A simple index predicting mortality in acutely hospitalized patients.

BACKGROUND: Mortality rates used to evaluate and improve the quality of hospital care are adjusted for comorbidity and disease severity. Comorbidity, measured by International Classification of Diseases codes, do not reflect the severity of the medical condition, that requires clinical assessments not available in electronic databases, and/or laboratory data with clinically relevant ranges to permit extrapolation from one setting to the next. AIM: To propose a simple index predicting mortality in acutely hospitalized patients. DESIGN: Retrospective cohort study with internal and external validation. METHODS: The study populations were all acutely admitted patients in 2015-16, and in January 2019-November 2019 to internal medicine, cardiology and intensive care departments at the Laniado Hospital in Israel, and in 2002-19, at St. James Hospital, Ireland. Predictor variables were age and admission laboratory tests. The outcome variable was in-hospital mortality. Using logistic regression of the data in the 2015-16 Israeli cohort, we derived an index that included age groups and significant laboratory data. RESULTS: In the Israeli 2015-16 cohort, the index predicted mortality rates from 0.2% to 32.0% with a c-statistic (area under the receiver operator characteristic curve) of 0.86. In the Israeli 2019 validation cohort, the index predicted mortality rates from 0.3% to 38.9% with a c-statistic of 0.87. An abbreviated index performed similarly in the Irish 2002-19 cohort. CONCLUSIONS: Hospital mortality can be predicted by age and selected admission laboratory data without acquiring information from the patient's medical records. This permits an inexpensive comparison of performance of hospital departments.

Older age is risk for an international normalized ratio (INR) of 5 or more.

The elderly have higher INR values, but this may be due to factors such as inter-current illnesses or drug changes. In the following case-controlled study we contacted 304 patients receiving warfarin treatment, one group with an INR of 5 or more, and three control groups (INR < 2, 2-3.9, 4-4.9). Variables that significantly predicted an INR of 5 or more in a logistic regression model included age, the use of antibiotics, stopping of a chronic drug, and the lack of knowledge of the target INR. After forcing in other variables associated with age (less valve disease, more use of multivitamins, and a lower dose of warfarin) the increased risk was 1.6 (1.12-2.28) per 10 years of age. We conclude that age is an independent risk factor for INR values of 5 or more.

Reasons patients present to the emergency department might change during epidemics and be a valuable component of a disease surveillance system.

We hypothesize that the frequency of reasons patients present to the emergency department will change during epidemics and might be a valuable component of a disease surveillance system. We found support for this hypothesis over a two-year period with high frequency days of fever clustering during two periods of increased hospital influenza activity, but not during any other period during the two-years. This methodology appears to be superior to the previous use of triage nurses defining patients with symptom complexes. Such a system could result in online monitoring, be independent of the medical personnel (use of admission secretary), and might be able to identify various epidemics including increased hospital disease activity due to bio-terror attacks, influenza, and food poisoning. This would have important implications for limiting the spread of disease and for the acute planning of distribution of medical resources. Studies are warranted in various settings to determine whether or not changes in the daily frequencies of reasons patients present to the ED will allow identification of epidemics.

The effect of a structured personalized ergonomic intervention program for hospital nurses with reported musculoskeletal pain: An assigned randomized control trial.

BACKGROUND: Intervention programs for hospital nurses with musculoskeletal pain present a challenge for the health professions. OBJECTIVE: To examine the effect of a structured personalized ergonomic intervention program for hospital nurses with musculoskeletal pain. METHODS: In a randomised controlled trial, 31 nurses from one central hospital with musculoskeletal pain were observed at work. A multi-stage study that included the Nordic Musculoskeletal Questionnaire, Karasek's questionnaire, The Rapid Entire Body Assessment, and an intervention program was completed with 14 nurses, while the remaining 17 were assigned to a control group. The intervention program was carried out by one physiotherapist and included four meetings over three months. The control group received only instruction sheets. Data on body posture and frequency and intensity of pain were collected before and at three months after the termination of the intervention program. RESULTS: Compared with the control group, the intervention group showed an improvement in REBA scores and in posture that is considered risk factor for work-related musculoskeletal discomfort disorders [p < 0.001], but there were no significant differences in the number of body parts in pain or in the level of musculoskeletal pain. CONCLUSIONS: The intervention was shown to be effective in reducing risk factors for work-related musculoskeletal disorders over a short follow-up period. A long-term study is required to determine if this effect is preserved over a longer period and to determine whether the intervention can reduce musculoskeletal symptoms.

Soluble factors from peripheral blood T-cells of patients with polycythemia vera stimulate normal BFU-E.

T cells and monocytes from patients with polycythemia vera (PV) were isolated and grown in culture. The conditioned medium was tested for the presence of soluble factors that promote proliferation of erythroid colonies from the blood of healthy donors. We show that T cells from all 14 PV patients that were examined secrete factor/s that stimulate the proliferation of erythroid burst-forming units (BFU-E) in the absence of an external source of erythropoietin and BPA. Addition of cyclosporin A to the culture did not inhibit the production of this activity. The conditioned medium from monocytes of PV patients can also stimulate normal BFU-E but to a much lesser extent than T-cell conditioned medium. Such stimulation was not observed with control T cells or monocytes. We observed that the fraction of DR-positive T cells was significantly higher in PV patients comparing to normal. These results suggest that PV patients possess an abnormally high level of circulating activated T cells which may in turn be the source of the putative factor that facilitates uncontrolled erythroid differentiation.

Blood pressure response to exercise as a predictor of hypertension.

Published studies of the blood pressure response to exercise were reviewed to assess the probability of future hypertension in a subject with a "hypertensive" response to exercise. The reviewed data indicate that the sensitivity of a hypertensive response to exercise for future hypertension varied between 16% and 60%, and the specificity between 53% and 95%. The prevalence of hypertension on follow-up among normotensive subjects with a hypertensive response to exercise testing was 2.06 to 3.39 times higher than that among subjects with a normotensive response. Therefore, blood pressure response to exercise does have a predictive value for future hypertension. However, this predictive value is limited, since 38.1% to 89.3% of those with a hypertensive response to exercise did not have hypertension on follow-up, and a normotensive response only marginally reduced the risk of future hypertension. The use of exercise testing as a predictor of hypertension is still in need of experimental development and confirmation.

The importance of leukocyturia in young adults.

The records of 1,000 asymptomatic male air force personnel were examined retrospectively for the results of 15 yearly examinations (1968 through 1983) of urinary sediment, beginning with subjects aged 18 to 33 years. The cumulative incidence of four to six or more WBCs per high-power field on one or more examinations was 31.8% after an average of 12.2 examinations per person over the 15-year period. In 107 subjects the WBCs were found on two or more occasions within five consecutive examinations. In 106 subjects, 140 urine cultures were sterile. In 28 cases the urine was also sterile after culture for Mycobacterium tuberculosis. Intravenous pyelograms, obtained in eight cases, were normal. Renal biopsy in one case with recurrent hematuria and trace proteinuria showed focal glomerulonephritis. All subjects are currently active and free of urinary symptoms an average of 7.6 years after detection of leukocyturia.

The effect of desmopressin on massive gastrointestinal bleeding in hereditary telangiectasia unresponsive to treatment with cryoprecipitate.

A patient with hereditary hemorrhagic telangiectasia and reduced levels of von Willebrand factor had severe recurrent gastrointestinal bleeding. Treatment with either desmopressin acetate or cryoprecipitate normalized both bleeding time and kaolin-activated partial thromboplastin time. Hematochezia (five episodes) continued, however, for a week despite daily treatment with cryoprecipitate, whereas treatment with desmopressin at the onset of three later episodes of hematochezia resulted in the prompt cessation of bleeding. After an episode of life-threatening gastrointestinal bleeding, desmopressin administration allowed a total colectomy without excessive bleeding. During the 3 years after colectomy, no further gastrointestinal bleeding occurred. In the past year, however, three episodes of severe epistaxis responded promptly to intravenous infusion of desmopressin. We conclude that desmopressin may be useful in the management of bleeding in patients with hereditary hemorrhagic telangiectasia with or without von Willebrand factor deficiency.

Autovalidation rates in an outpatient coagulation laboratory.

INTRODUCTION: To determine the rates of autovalidation in our outpatient coagulation laboratory. METHODS: We retrospectively identified all coagulation tests analyzed during the month of January 2014 from our laboratory information system (LIS) (N = 16 116), from around 800 000 active members of Clalit Health Services (a health maintenance organization). The integrated system includes a single centrifugation of all collection tubes, analyzers that rerun or reflex tests according to the test results, and a laboratory information system that sends orders to the analyzer, autovalidates test results, and automatically sends critical value results to a list for immediate physician communication. Reasons for technician validation are tests rerun for confirmation or because of analyzer errors and test results that require reflex testing. All other test results are sent automatically to the laboratory information system without the need for technician review. RESULTS: There were 362 test results with analyzer errors, 91 results rerun for confirmation (thrombophilia test results outside the reference interval), and 50 tests with mixing studies and reflex testing for factor XI activity levels (total = 3.1%, 503/16116), resulting in an autovalidation rate of 96.9% (95% confidence interval - 96.6-97.2%). CONCLUSIONS: We conclude that an integrated system can result in a high autovalidation rate in a high-volume outpatient coagulation laboratory.

Acute leukemia detection rate by automated blood count parameters and peripheral smear review.

INTRODUCTION: It is unclear what minimal criteria will identify all new cases of acute leukemia in adults in various settings. METHODS: To determine the adult acute leukemia detection rate of the various criteria, we recorded complete blood count (CBC) test results from consecutive patients with leukemia (130 hospitalized patients and 96 outpatients) and from consecutive patients without leukemia (34,827 hospitalized and 33,695 outpatients). RESULTS: Basic criteria for a reflex review (hemoglobin, platelets, and a five-part differential) detected 91% of new hospital leukemia patients (118 of 130) compared to 75% (72 of 96) outpatients. No cases were missed if we did reflex testing when there was either one of the basic criteria or an increased proportion of large unstained cells (LUC), but five cases were missed using the blast flag instead of the LUC. Adding the LUC to basic criteria resulted in the detection of all cases of acute leukemia. The cost of detection of one case of acute leukemia was 1029 and 425 peripheral smear reviews in hospital and outpatients, respectively. CONCLUSION: We conclude that basic criteria available on most hematology analyzers along with the LUC identify all adult patients with acute leukemia in both hospital and outpatient settings with minimal peripheral smear review rates.

Association of calcitriol and blood pressure in normotensive men.

The purpose of this study was to clarify the possible associations between the serum 1,25-dihydroxyvitamin D (calcitriol) level and blood pressure. Cross-sectional analysis of data was performed. Data collected included levels of serum calcitriol, parathyroid hormone, serum calcium, and blood lead; blood pressure; dietary history; and demographic and anthropometric variables. One hundred normotensive male industrial employees made up the study population. Systolic blood pressure and diastolic blood pressure were main outcome measures. After possible confounders were controlled for, multivariate analyses yielded an inverse, independent, and statistically significant association between calcitriol level and systolic blood pressure (standardized beta= -0.2704, P=.0051). A similar trend of borderline significance was found for the association between calcitriol and diastolic blood pressure (standardized beta= -0.1814, P=.0611). Parathyroid hormone, serum calcium, and blood lead levels were not associated with blood pressure. When subjects were divided into four groups by calcitriol level, those in the lowest quartile showed significantly higher systolic and diastolic blood pressures than those in the upper quartile (difference=11 mmHg, P=.007, and difference=4 mmHg, P=.071, respectively). There is an inverse association between serum calcitriol level and blood pressure. This suggests that in addition to its role in calcium homeostasis, the active metabolite of vitamin D may play a role in determining blood pressure. The differences in both systolic and diastolic blood pressures between the upper and lower quartiles of serum calcitriol were substantial and may be of clinical significance.

Apolipoprotein E-epsilon4 genotype predicts a poor outcome in survivors of traumatic brain injury.

OBJECTIVE: To determine the ability of apolipoprotein E (APOE) genotypes to predict days of unconsciousness and a suboptimal functional outcome in traumatic brain injury (TBI) survivors. BACKGROUND: TBI is known to be associated with neuropsychological deficits and functional disability. Recent evidence indicates that APOE plays a pivotal role in CNS response to injury. METHODS: In this prospective study the authors determined the APOE genotypes and tested their ability to predict days of unconsciousness and functional outcome after at least 6 months in 69 survivors of TBI. A good functional outcome was defined as no dysarthria, behavioral abnormalities, or dysphasia; no severe cognitive abnormalities; and the ability to live independently. RESULTS: The odds ratio of more than 7 days of unconsciousness was 5.69 in those with the APOE-epsilon4 allele compared with those without the epsilon4 allele (95% CI, 1.69 to 20.0; p = 0.001). Only 1 of 27 subjects (3.7%) with the epsilon4 allele had a good functional outcome compared with 13 of 42 (31.0%) of those without the epsilon4 allele (p = 0.006). The OR of a suboptimal outcome (fair or unfavorable) was 13.93 for those with the epsilon4 allele compared with those without the allele after controlling for age and time of unconsciousness (95% CI, 1.45 to 133.97; p = 0.02). CONCLUSION: The results demonstrate a strong association between the APOE-epsilon4 allele and a poor clinical outcome, implying genetic susceptibility to the effect of brain injury. Additional studies of TBI patients are warranted to confirm their findings.

Von Willebrand factor and mitral valve prolapse.

The levels of von Willebrand factor (vWF:Ag) were measured in 27 patients with mitral valve prolapse (MVP) and compared to 27 age matched controls. Decreased levels of vWF:Ag (less than 80%) were found in 59% (16/27) of those with MVP compared to only 7% (2/27) of the controls (p less than 0.001). Mean vWF: Ag levels were also significantly lower in those with MVP (68 +/- 30% versus 100 +/- 23%, p less than 0.001). In those with MVP and congestive heart failure secondary to rupture chordae tendineae, however, the mean level of vWF: Ag was not significantly different from control values (95 +/- 32). There was an increased incidence of recurrent nose bleeds in those with MVP and low levels of vWF:Ag. We conclude that there is a relationship between MVP and low levels of vWF:Ag which may explain the increased incidence of epistaxis in such patients. Increased release of vWF:Ag in those with MVP and concomitant congestive heart failure may account for the normal levels found in this subgroup.

Usefulness of echocardiographically determined mitral leaflet motion for diagnosis of mitral valve prolapse in 17- and 18-year-old men.

Mitral leaflet motion during systole was studied by echocardiography in 102 healthy young men. Mean posterior maximal leaflet motion was 2 +/- 1 mm behind the CD line on 2-dimensionally (2-D) directed M-mode examination. On the apical 4-chamber cross-sectional view a mean area of 0.34 +/- 0.24 mm2 was contained by the mitral leaflets above the plane of the mitral anulus. Elevated values on the M-mode view (greater than or equal to 4 mm) compared with the 2-D 4-chamber view (greater than or equal to 0.70 mm2) were discordant, with 90% (18 of 20) of the elevated values found in 1 view only. Thus, there is a wide spectrum of mitral leaflet motion in asymptomatic young men. The value of the echocardiogram in diagnosis of mitral valve prolapse is questionable because any cutoff point between normal and abnormal is arbitrary and the degree of motion has not been shown to correlate with morbidity or mortality.

Reduced natural killer activity in patients with Fanconi's anemia and in family members.

Natural killer (NK) activity was measured in the peripheral blood of a family with Fanconi's anemia (FA) and compared to normal controls. One of two children with FA, and 6 of 11 family members had reduced NK activity (less than 30% with an E:T ratio of 25:1) compared to none of 40 controls (p less than 0.001). On retesting 5 of 8 family members and both children with FA had reduced endogenous NK activity compared to 0 of 5 controls (p less than 0.02). The number of NK cells determined by Leu 11b antibody was not reduced in any of the family members. Augmentation with interleukin-2 (IL-2) and alpha interferon (IFN) in those with low endogenous activity was variable. Three demonstrated no response to the 2 immunomodulators, while the 4 others increased to low normal levels. We conclude that some patients with FA and their apparently healthy relatives have reduced NK activity, which appears to be secondary to an intrinsic cell defect.

Deficiencies in structured medical abstracts.

This study was carried out to determine if the content of structured abstracts conforms with recommendations of the Ad Hoc Working Group for the critical appraisal of the medical literature as adopted by the Annals of Internal Medicine. The study design was a survey. All articles published in Annals of Internal Medicine in 1991, excluding editorials, case-reports, literature reviews, decision analysis, studies in medical education, descriptive studies of clinical and basic phenomena, and papers lacking a structured abstract, were studied. Of a total of 150 articles, 20 were excluded. The abstract and text of each article were assessed for the presence of the following items; patient selection criteria, statements concerning extrapolation of findings, need for further study, and whether or not the information should be used now. Number of refusers, drop outs and reason(s) for drop outs were assessed for intervention and prospective cohort studies only. Deficiencies of assessed items were noted in both abstracts and texts. For abstracts, patient selection criteria, numbers of refusers, number of drop outs and reason(s) for drop outs were reported in 44.6% (58/130), 3.1% (4/130), 16.9% (14/83) and 2.4% (2/83) respectively. These items were reported more frequently in the texts 87.7% (114/130), 9.2% (12/130), 60.2% (50/83) and 37.3% (31/83) respectively (p < 0.05). Statements concerning extrapolation of findings, need for further study and use of information now were also more frequent in texts than abstracts (p < 0.0001). A large number of structured abstracts published in the Annals of Internal Medicine in 1991, lack information recommended by the Ad Hoc Working Group. Our findings should not be extrapolated to other journals requiring structured abstracts.

Asymptomatic microscopic hematuria--is investigation necessary?

Microscopic hematuria is common in asymptomatic adults, but the benefit of screening the general population for blood in the urine has not been established. On the other hand, most studies of referred patients with putatively asymptomatic microscopic hematuria have reported a 2-11% prevalence of urothelial malignancies, leading to the recommendation that all patients with microscopic hematuria be thoroughly investigated. Urinalysis is inexpensive and highly acceptable to the general population, but is neither a sensitive, nor specific test, and has poor predictive value for urothelial malignancies, and nephrological diseases. Furthermore the benefits of early detection of such diseases has not been established. We conclude that screening urinalysis cannot be recommended. Studies are needed to determine which constellation of findings primary physicians use to select patients for referral to centers with urological and nephrological expertise.

Healthy volunteer effect in industrial workers.

Volunteers for epidemiological research, have lower mortality rates than non-volunteers, thereby producing a bias referred to as the "healthy volunteer effect" (HVE). Occupationally active persons have been similarly shown to have a reduced mortality relatively to the general population (the "healthy worker effect"). To determine whether a HVE exists in occupationally active persons, we followed for 8 years a cohort of Israeli male industrial employees, of whom 71.6% agreed to participate in 1985 in screening examinations for cardiovascular disease. We calculated standardized mortality ratios (SMRs) of the entire cohort relative to the general population, and compared the mortality among participants with that of the non-participants. Over 8 years follow up, SMRs were 78% for the entire cohort, 71% for participants and 99% for non-participants. Participants were older than non-participants and worked more commonly in smaller factories. A proportional hazard model indicated that after adjusting for these variables, the all cause mortality hazard ratio among participants and non-participants was 0.69 (95% CI = 0.51-0.94). During the first and last two years of the 8-year follow-up there were 39.6 and 30.0 age-adjusted deaths per 10,000 person-years among participants, and 58.6 and 51.5 respectively among non-participants. We conclude that the HVE occurs in occupationally active persons, and that it may persist for up to 8 years follow-up.

Spontaneous pneumothorax and mitral valve prolapse.

We searched for mitral valve prolapse in patients with spontaneous pneumothorax to test the hypothesis that both may be part of a common disorder of connective tissue. Echocardiographic mitral valve prolapse was found in 11 (50 percent) of 22 patients who had suffered spontaneous pneumothorax compared to four (10 percent) of 40 age-matched control subjects (p less than 0.01). The body mass index (BMI) (weight/height2) was lower (p less than 0.001) in the group with pneumothorax; in five patients who were the thinnest in the study (BMI less than 2 standard deviations lower than mean normal value), mitral valve prolapse was present in four. The finding of a strong association of spontaneous pneumothorax with mitral valve prolapse, especially in subjects with an abnormal body build, suggests that in many patients, spontaneous pneumothorax may be a manifestation of a systemic abnormality of connective tissue.

The mean leukocyte myeloperoxidase index in hematological patients.

A Technicon H-1 hematologic analyzer was used to measure the mean leukocyte myeloperoxidase (MPX) in 160 patients seen in a hematology clinic. The normal range was -15 to +10, which included 95% of 300 consecutive hospitalized patients. No abnormalities in the MPX were found in 35 patients with beta-thalassemia minor, 8 with iron deficiency, 14 with myeloproliferative disorders, 17 with autoimmune disorders, and 37 patients with lymphoma in complete remission. On the other hand 36% (10/28) of lymphoma patients with active disease either at diagnosis or relapse had a MPX of greater than 10 compared to only 2.3% (7/300) in hospitalized patients (P less than 0.001). Increased levels of MPX were found primarily in patients with non-Hodgkin's lymphoma (NHL) of intermediate or high grades, or Hodgkin's disease [56% (9/16) compared to only 8.3% (1/12) in those with low grade NHLs, P less than 0.05]. The MPX levels returned to normal after successful treatment. Of the various chemotherapeutic agents used, only hydroxyurea led to a consistent elevation of the MPX. The authors conclude that MPX is commonly increased in patients with lymphoma and in those receiving hydroxyurea. Further studies are required to determine if the MPX is a sensitive test for relapse in patients with lymphomas who had an elevated pretreatment value.