Department Of Internal Medicine Research Articles

Special Issue on Informatics Education A Longitudinal Graduate Medical Education Curriculum in Clinical Informatics: Function, Structure, and Evaluation.

There is a need to integrate informatics education into medical training programs given the rise in demand for health informaticians and the call on the Accreditation Council for Graduate Medical Education (ACGME) and the body of undergraduate medical education (UGME) for implementation of informatics curricula. This report outlines a 2-year longitudinal informatics curriculum now currently in its seventh year of implementation. This report is intended to inform United States (US) Graduate Medical Education (GME) program leaders of the necessary requirements for implementation of a similar program at their institution. The curriculum aligns with the core content for the subspecialty of clinical informatics (CI) and is led by a multidisciplinary team with both informatics and clinical expertise. This educational pathway has a low direct cost and is a practical example of the academic learning health system (aLHS) in action. The pathway is housed within an internal medicine department at a large tertiary academic medical center. The curriculum has yielded 13 graduates from both internal medicine (11, 85%) and pediatrics (2, 15%) whose projects have spanned acute and ambulatory care and multiple specialties. Projects have included Clinical Decision Support (CDS) tools, of which some will be leveraged as substrate in applications seeking extramural funding. Graduates have gone on to CI board certification and fellowship, as well as several other specialties, creating a distributed network of clinicians with specialized experience in applied CI. An informatics curriculum at the GME level may increase matriculation to CI fellowship and more broadly increase development of the CI workforce through building a cadre of physicians with HIT expertise across specialties without formal CI board certification. We offer an example of a longitudinal pathway which is rooted in aLHS principles. The pathway requires a dedicated multidisciplinary team and departmental and IT leadership support.

Assessment of renal response in Tunisian patients with proliferative lupus nephritis under three different induction immunosuppressive agents: A prognostic retrospective study.

The aim of our study was to evaluate the renal response (RR) of three immunosuppressive protocols in the induction treatment of proliferative lupus nephritis (PLN) in a Tunisian population. We performed a retrospective prognostic cohort study in the Internal Medicine Department of the Habib Thameur University Hospital in Tunis from January 2000 to December 2023, and included kidney biopsy proven proliferative lupus nephritis patients. Three induction treatments were compared: High CYP regimen: glucocorticoids (GC) + IV cyclophosphamide (CYP) in monthly pulses of 0.7g/m2 for 6 months; Low CYP regimen: GC + IV CYP in biweekly pulses of 500mg for 3 months; and MMF regimen: GC + oral MMF 1.5g twice daily for 6 months. The primary endpoint was the incidence of RR (complete and partial remission) at one year post-diagnosis. The additional outcomes were end-stage kidney disease (ESKD), severe adverse events (AEs) and death. Our study included 78 PLN patients (High CYP: 17, Low CYP: 40, MMF: 21). The study found that 94.1% of patients receiving High CYP achieved the primary endpoint, RR, compared to 67.5% of those receiving Low CYP and 61.9% in the MMF group. For the additional outcomes, there were 3 cases of ESKD, all in the Low CYP group, 5 cases of death (4 in the Low CYP group and 1 in the MMF group), and 20 cases of severe AEs, all of which were severe infections (5 in the High CYP group, 12 in the Low CYP group, and 3 in the MMF group). Multivariate analysis showed that the High CYP regimen was more associated with RR than the MMF regimen, with an adjusted OR of 9.846 (95% CI: 1.087-98.210); p = 0.042. Multivariate analysis did not show statistically significant differences between the High CYP regimen and the Low CYP regimen in terms of RR. As an induction treatment for PLN, the High CYP regimen was strongly associated with a higher rate of RR than the MMF regimen. There were no statistically significant differences between the High CYP regimen and the Low CYP regimen in terms of RR.

The Prevalence and Impact of Migraine Among Physicians in Saudi Arabia: A Cross-Sectional Study.

Background Migraine is a primary headache disorder and one of the most common causes of disability worldwide. Prior reports showed a higher prevalence of migraine among physicians. We conducted this study to estimate the prevalence of migraine among physicians in Saudi Arabia, as well as its impact on quality of life. Methods A cross-sectional study was conducted using a validated online questionnaire that was distributed among physicians in various medical and surgical specialties in Saudi Arabia from January to June 2023. The inclusion criteria involved physicians in all specialties, who worked in governmental or private hospitals in Saudi Arabia. Employed or healthcare workers other than physicians were excluded. To measure the impact of headache on a person's quality of life, the Migraine Disability Assessment (MIDAS) test was applied. Statistical analysis of the study was conducted using the Statistical Package for the Social Sciences (SPSS) Version 24 (IBM Corp., Armonk, NY). Results We had 387 respondents, of whom 362 fulfilled the inclusion criteria. The mean age was 33.02 ± 9.07 years, and genders were distributed equally. Most physicians worked in departments of internal medicine, family medicine, general practice, and general surgery. The prevalence of migraine was recorded in 17.1% (62 patients) of all the included participants, with a female predominance. MIDAS revealed a total mean score of 16.823±14.149. The severity grades were classified as moderate (37.1%), severe (35.5%), or little to no (21.0%). Stress and light were cited as the top factors that trigger or worsen migraine, while sleep, rest, and quiet and darknesswere cited as the top relieving factors. The average number of headache attacks (month) was 6.823. Most patients with migraine were board residents (27.4%), living in the western region (53.2%), and working in a governmental hospital (38.7%). Conclusion Migraine is a common disorder among physicians in Saudi Arabia, with significant moderate-to-severe disability. Stress is identified as a major trigger. Proper awareness, stress management programs, and therapeutic intervention may mitigate the untoward consequences of migraine.

Circadian pattern of blood pressure in patients with stable COPD

ObjectiveTo describe the circadian blood pressure (BP) pattern in stable COPD patients. MethodsWe included stable COPD patients from Internal Medicine Departments. Office BP and ambulatory BP monitoring were performed. Patients were classified as BP reducers (dipper or extreme dipper) or non-reducers (non-dipper or riser). ResultsWe included 43 patients (5 women, mean age 69.5 ± 9.5 years). Among them, 11 had sustained normotension, 13 sustained hypertension, 2 white coat hypertension, and 17 masked hypertension. Arterial stiffness was observed in 12 (27.9%) patients. Overall, 26 (60.5%) exhibited a non-reducer BP profile. Non-reducers had a higher frequency of previous major cardiovascular events (50% vs. 11.8%, p = 0.020) and long-acting muscarinic antagonist use (84.6% vs. 47.1%, p = 0.009). ConclusionsHypertension is often masked in COPD patients, who frequently display an altered circadian BP pattern. Longitudinal studies with larger samples are needed to evaluate the impact of these patterns on COPD progression.

Impact of Chronic Organ Disorder Staging on Hospitalization Risk in Elderly Patients With Multimorbidity: A Retrospective Cohort Study.

Introduction Multimorbidity, defined as the coexistence of two or more chronic conditions, is increasingly prevalent in the aging population and is linked to adverse health outcomes, including hospitalization. Chronic organ disorder (COD) is a proposed framework in Japan to assess multimorbidity by categorizing organ dysfunction stages. This study investigates the association between COD stages and hospitalization rates in elderly patients with multimorbidity. Method A retrospective cohort study was conducted at the Internal Medicine Department of Unnan Municipal Hospital. Patients aged 18 and older with multimorbidity, defined as having two or more chronic diseases, who visited the clinic from April to September 2022 were included. COD stages were classified from A to E, representing increasing severity. Logistic regression analysis was used to evaluate hospitalization-related factors, including age, BMI, serum albumin, and COD stages. Results Among 568 patients, 66 (11.6%) were hospitalized. Hospitalized patients were older (75.5 vs. 58.8 years, p < 0.001), had lower BMI (20.65 vs. 22.21 kg/m², p = 0.003), and lower serum albumin levels (3.70 vs. 3.96 g/dL, p < 0.001). Advanced COD (Stage B or above) was associated with an increased risk of hospitalization (OR: 1.86, 95% CI: 1.01-3.45, p = 0.048). Age ≥75 years (OR: 2.93, 95% CI: 1.55-5.54, p < 0.001) and low BMI were also significant predictors. Conclusion This study demonstrates that advanced COD stages, age, and low BMI are significant predictors of hospitalization in patients with multimorbidity. Comprehensive COD assessment aids in identifying high-risk patients and potentially guides preventive interventions to reduce hospital admissions.

Reflection of Violence in Health to Physicians, Its Effect on Anxiety and Depression Levels

Objective: The aim of this study is to examine the impact of violence on health and the effect of violence on anxiety and depression levels in physicians. Methods: 442 physicians working in internal medicine and surgery departments were included in this cross-sectional study. The collected data were analysed using IBM SPSS Statistics, version 27.0. Results: It was found that 63.1% of the physicians were exposed to violence from patients/patient relatives. Anxiety and depression scores were significantly higher among those exposed to violence and those who reported that health-related violence negatively affected their approach to patients. Conclusions: All forms of violence experienced by research assistants, who play an important role in the provision of health care, in the course of their work have a negative impact on their professional and social lives.

A Study on the Correlation between Xerostomia, Yin Deficiency, and Heart Rate Variability in Halitosis Patients

Objectives: The purpose of this study was to analyze the correlation between the level of xerostomia and Yin deficiency as well as heart rate variability in patients with halitosis.Methods: A survey was conducted on 30 patients who visited the Department of Internal Medicine at Dongsin University Oriental Hospital from March 2021 to February 2022. A questionnaire regarding halitosis and xerostomia was administered using the Visual Analogue Scale (VAS) scores, and Yin deficiency was assessed using 10 specific items. Oral moisture was measured using the Oral Moisture Checking Device (Mucus) under unstimulated conditions, while heart rate variability was measured with the SA-6000 equipment.Results: A significant positive correlation was found between VAS scores for halitosis and xerostomia and Yin deficiency. However, there was no correlation between xerostomia and the Mucus scores. The low Mucus score group showed a significant negative correlation with LF values compared to the normal Mucus score group.Conclusion: Patients with halitosis who experience xerostomia are likely to be in a state of Yin deficiency.

Hyperreflexia in outpatients with Parkinson’s disease and coexisting cervical spinal stenosis: A retrospective cohort study

Background. Degenerative cervical myelopathy (DCM) is poorly recognized and infrequently diagnosed. Objectives. To identify symptoms and signs in the lower extremities physically and radiologically in outpatients with idiopathic Parkinson’s disease (PD) and coexisting DCM. Methods. In 2023, a retrospective cohort study was performed to review the medical records from 2016 to 2020 at the outpatient clinic of the Department of Internal Medicine. As a result, 8 women with PD were diagnosed based on the presence of cardinal features, asymmetry, and a good response to levodopa. Brain and cervical magnetic resonance imaging (MRI) was conducted in 4 patients (group A): 3 with hyperreflexia of the patellar tendon, and 1 with Babinski’s sign. Results. The motor subtype of the 8 patients aged 69 to 90 was a tremor-dominant type of PD. The Hoehn and Yahr (H&amp;Y) stages were II (1) and III (3) in group A, and III (3) and IV (1) in those without hyperreflexia of the patellar tendon. Hyperreflexia and Babinski’s sign were predominant on the tremor-dominant side in group A. Radiologically, their anteroposterior diameters at the most stenotic level (C5-6) were 6.0, 7.1, 7.1, and 10.4 mm. They developed muscular rigidity and spasticity involving the lower extremities. The gait and balance performance were particularly affected compared with the upper extremity function. Conclusion. Hyperreflexia of the patellar tendon and imbalance of gait performance due to coexisting DCM were the important factors affecting gait in older women with tremor-dominant PD.

CLINICAL PATTERNS AND OUTCOMES IN CIRRHOTIC YEMENI PATIENTS WITH ACUTE-ON-CHRONIC LIVER FAILURE

Acute-on-chronic liver failure (ACLF) is a clinical condition of abrupt hepatic decompensation in chronic liver disease patients that is associated with extra-hepatic organ failures and a higher mortality rate. This study aimed to identify the clinical patterns and outcomes in cirrhotic Yemeni patients with ACLF. This prospective cohort study was carried out on 160 cirrhotic patients admitted between May 2023 and May 2024 to the Internal Medicine Department in Al-Sadaqah General Teaching Hospital in Aden governorate, Yemen. Based on the European Association for Study of Liver's Chronic Liver Failure Consortium EASL-CLIF criteria, patients were divided into Group A: 54 patients with ACLF. Group B: 106 patients without ACLF. The prevalence of ACLF is 33.8%. The mean age was 41.54± 8.11 years in ACLF and 39.22± 8.14 years in non-ACLF patients. The proportion of males in ACLF was 51.9% vs. 57.5% in non-ACLF patients. The most common causes of cirrhosis were cryptogenic (58.8%) and autoimmune hepatitis (25.6%). A significant correlation was found between prior hospitalization, decompensation, and the increased risk of developing ACLF. The most common complications were jaundice, hepatic encephalopathy, renal failure, signs of bacterial infection, ascites, and gastrointestinal bleeding, respectively. The main precipitating events for ACLF were bacterial infection, especially SBP (48.1%), GIT bleeding (24.1%), and no identified precipitating events (24.1%). The most common organ failures were renal (70.4%), liver (42.6%), and cerebral (31.5%). ACLF patients showed higher levels of WBCs, bilirubin, and serum creatinine. Mortality rates were significantly higher in ACLF patients compared to non-ACLF at both 28 days (33.3% vs. 5.7%) and 90 days (685% vs. 23.6%). This study demonstrated that ACLF patients have worse prognoses, higher mortality rates, increased ICU admission, lower survival, and higher rates of organ failure than non-ACLF patients.

Survival of patients affected with multiple myeloma at the Department of Internal Medicine and Haematology of Semmelweis University

Survival of patients affected with multiple myeloma at the Department of Internal Medicine and Haematology of Semmelweis University

Thromboangiitis Obliterans (Buerger's Disease): A Young Woman's Rare Case and Current Knowledge

AbstractIn this paper, we described the clinical features and the typical vascular imaging picture of a rare case of thromboangiitis obliterans (TAO) in a 47-year-old, young, Caucasian woman without relevant medical records except for smoking habits and admitted to our Department of Internal Medicine with a necrotic lesion of the first and third toes of the right foot. After a rapid clinical and instrumental evaluation, necrotic tissue debridement was performed and the patient was treated with Iloprost infusion and antibiotics (for overlapping infection) with clinical improvement. Moreover, we summarized the current knowledge about the disease making an update and critical examination of the literature. TAO, also known as Buerger's disease, is a rare disease. In recent decades, the incidence of TAO has decreased in Europe and the United States in men but several studies have reported an increase in the prevalence of disease in women. TAO is a segmental nonatherosclerotic inflammatory disorder that involves primarily small and medium arteries, veins, and nerves of the extremities with limb ischemia, pain, claudication, ulcers, and necrosis that can lead to amputation. Smoking is considered the main risk factor, but despite that, more than 100 years have passed since the first description of the disease by Leo Buerger, and knowledge on pathogenesis, precipitating factors, and therapy remain still unclear.

Evaluation of Clinical Education Based on Cognitive Apprenticeship Model Using Maastricht Clinical Education Questionnaire

Introduction: One of the main aspects of medical students is clinical education. The cognitive apprenticeship model is one of the principles of clinical education and contains six dimensions, including modeling, coaching, scaffolding, articulation, reflection, and exploration. This research aimed to evaluate the clinical education at Kerman University of Medical Sciences based on the cognitive apprenticeship model in 2021. Method: In this descriptive-analytical cross-sectional research, the Maastricht Clinical Education Questionnaire was separated among 150 students, and with a response rate of 74%, 112 of them completed this. Results: In the evaluation of the clinical education at Kerman University of Medical Sciences, the score of the articulation domain was higher than others, and the lowest score was given to the reflection domain. Clinical education in the internal medicine department was the most consistent with the cognitive apprenticeship model. Conclusion: Identifying the strengths and weaknesses of clinical education is the first step toward improving the quality of medical education. In the subsequent steps, the practitioners and planners of the faculty member empowerment programs should design, implement, and evaluate educational empowerment programs for clinical faculty members to improve their academic skills in the clinical education environment.

Magnetic resonance spectroscopy as a diagnostic model for assessment of liver steatosis in metabolic dysfunction-associated steatotic liver disease in non-diabetic patients

BackgroundMetabolic dysfunction-associated steatotic liver (MASLD) disease is the commonest hepatic cause of liver fibrosis and cirrhosis after the introduction of the direct acting antivirals and eradication of hepatitis C. MASLD is usually associated with metabolic syndrome and elevated inflammatory markers. Magnetic resonance spectroscopy (MRS) offers a non-invasive diagnostic, alternative to liver biopsy. This is a case–control diagnostic-accuracy study conducted on 40 patients in the Hepato-gastroenterology Unit in the Internal Medicine Department, Ain Shams University Hospitals, to study the role of MRI spectroscopy as a new diagnostic model for assessment of liver steatosis in non-diabetic MASLD patients compared to the standard ultrasound and clinical criteria. MASLD was diagnosed by a combination of a validated ultrasound hepatic steatosis score grading system and hepatic steatosis index using clinical and laboratory parameters. MRS was performed in all patients and fat peak, water peak, and fat fraction % were measured, and diagnostic accuracy of different MRS is compared to the US scoring and different laboratory and clinical parameters. To our knowledge this is the first study conducted on MRS in our region and Egypt.ResultsThis study revealed no statistically significant difference between the two groups regarding HbA1C, creatinine, while there was highly statistically significant difference regarding fasting blood sugar, 2 h post-prandial glucose level, urine albumin, and low-density lipoprotein levels. Hepatic steatosis score grading by abdominal ultrasound on the 20 controls showed no fatty changes with grade 0 (50%), and on the 20 MASLD patients showed that 2 cases were grade 1 steatosis (5%), 9 cases were grade 2 steatosis (22.5%), and 9 cases were grade 3 steatosis (22.5%). The diagnostic accuracy of predicting hepatic steatosis using different MRS parameters: fat peak, water peak, and fat fraction had area under the curve of 99.9%, 88.6%, and 100%, respectively. The sensitivity and specificity of fat fraction in detecting hepatic steatosis were 100%. The sensitivity and specificity of the fat peak in detecting hepatic steatosis were 100% and 95%, respectively. Moreover, the sensitivity and specificity of the water peak in detecting the hepatic steatosis were 88.6% and 85%, respectively. There is a statistically significant correlation between the three MRS parameters and the abdominal ultrasound hepatic steatosis score grades.ConclusionMRS parameters: fat fraction, fat peak, and water peak, have high diagnostic accuracy for predicting the liver steatosis. Moreover, MRS has the added advantage of being a non-invasive and a tool with low radiation risk. MRS also shows the metabolic changes in the liver and could be an eligible outcome in therapeutic clinical trials.

Challenges and peculiarities of nursing activities in intermediate care units compared with internal medicine wards: A prospective study

AbstractBackgroundIntermediate Care Units (IMCs) are specialized facilities located within other departments in many Western countries. They are designed to manage patients with conditions that are not severe enough to require an intensive care unit. IMCs aim to fill the gap between regular wards and intensive care units, necessitating an adequate allocation of nursing resources.AimsThe aims of the study are to (1) evaluate and compare the nursing workload for patients admitted to a regular ward or to an IMC; (2) quantify nursing workload in terms of activities and time spent to perform them; and (3) evaluate which patient characteristics predict nursing work overload.Study Design and MethodsThis is an observational, prospective, single‐centre study. We included patients admitted to the Internal Medicine department in a general hospital in Italy, between 1 September and 31 December 2022, either in the regular ward or in the IMC. Clinical characteristics, comorbidity, functionality, frailty, severity and acuity of patients were recorded using validated assessment tools. Nursing activities in the first 3 days of hospitalization were recorded and standardized as activities/5 min/patient/day. An average number of nursing activities/5 min/patient/day exceeding the 85th percentile was considered nursing work overload. Multivariate logistic regression models were conducted to identify patient‐related risk factors associated with nursing work overload.ResultsWe included 333 patients, 55% (183/333) admitted to the IMC and 45% (150/333) to the regular ward. In the IMC, the average nursing activities were 32.4/5 min/patient/day compared with 22.6 in the regular ward. Nursing work overload was found in 6% (9/150) of patients admitted to the regular ward compared with 23% (42/183) in the IMC.ConclusionThere is a significantly higher demand for nursing care among patients in the IMC, with higher daily average of nursing activities.Relevance to Clinical PracticeThe allocation of nursing resources within the IMC should be greater than in the regular ward because of higher workload.

Platelet indices as a predictor in patients with aplastic anemia and immune thrombocytopenic purpura: a retrospective case–control study

Background and objectivesPlatelet indices are widely available and relatively cheap platelet parameters. The critical objective of this study is to assess the reliability of platelet indices as biomarkers for diagnosis and prognosis in adult thrombocytopenic patients.MethodsA retrospective case–control study, including 81 immune thrombocytopenia (ITP) cases, 50 aplastic anemia (AA) cases, and 150 participants as a control group. This study included patients admitted from 2016 to 2021 to the Clinical Hematology Unit, Department of Internal Medicine, University Hospital. The collected data included sociodemographic information, clinical data, laboratory data, and an assessment of the therapeutic response in the studied groups.ResultsFor the diagnosis of adult thrombocytopenic patients, platelet distribution width (PDW) showed the best diagnostic accuracy (85% for ITP and 91.9% for AA) at cutoff points of 14.9% and 17.2%, respectively. This was followed by mean platelet volume (MPV) with diagnostic accuracies of 77% for ITP and 89.3% for AA at a cutoff point of 9.4 fl. Platelet large cell ratio (PLCR) demonstrated insignificant accuracy in diagnosing either ITP or AA.ConclusionPlatelet indices can play a crucial influence in the diagnosis, not the prognosis, of adult thrombocytopenia.Trial registrationNCT05116033. https://classic.clinicaltrials.gov/ct2/show/NCT05116033

Comparison of Causes of Mortality Between Hospitalized Unsheltered Homeless Patients and Non-Homeless Sex and Age-Matched Controls: A Retrospective Case-Control Study.

Roofless individuals represent the most severe category of homelessness. Their clinical characteristics and mortality patterns in Central and Eastern Europe are little known. A single-center retrospective case-control study at the internal medicine department in Bratislava, Slovakia was conducted. 5694 mortality records from 2010 to 2023 were screened, and 141 (118 men, 23 women) roofless individuals were identified. Patients were sex- and age-matched, with 141 patients from the cohort of non-homeless deceased patients. Compared to controls, roofless people had a higher incidence of immobility (p = 0.02) and hypothermia (p < 0.0001) at admission. 83% of the roofless people were men, and 59% of the roofless people died before reaching old age (60+). Homeless men died more often from infectious disease (p = 0.02), pneumonia being the most common one (60%). Men from the control group died more often from liver diseases (p = 0.03). There were no significant differences in the causes of mortality between women. These findings could help to reduce the invisibility of the issue of massive premature mortality amongst homeless populations and roofless individuals, in particular.

Ocular Sarcoidosis as Initial Presentation of the Disease: Clinical Characteristics and Risk Factors Associated with Disease Recurrence

ABSTRACT Purpose To review the clinical presentation and diagnostic workup of patients presenting with ocular sarcoidosis as initial manifestation of the disease and identify risk factors for disease recurrence. Methods All cases of sarcoidosis followed in our departments of Ophthalmology and Internal Medicine were retrospectively reviewed. Among 177 patients, 50 had ocular sarcoidosis as initial presentation of the disease. Clinical, biological, radiological, and treatment data were collected. Logistic regression analysis was conducted to identify risk factors for recurrence. Results Mean age of patients was 51 years, with an equal M/F ratio. Bilateral ocular involvement was present in 86% of cases, with granulomatous panuveitis being the most common manifestation (48%). Two-thirds of patients had extraocular symptoms related to the disease, mostly fatigue. The most frequently involved extraocular site was the supradiaphragmatic lymph nodes, identified in 84% of cases. CRP was normal in 68% of patients, while ACE and lysozyme were elevated in 19% and 64% of cases, respectively. Histopathological confirmation was obtained in 68% of patients. Female sex (odds ratio [OR] 6.66, 95% confidence interval [CI] 1.50–40.40, p = 0.021) and granulomatous panuveitis (OR 7.23, 95% CI 1.70–40.99, p = 0.013) were identified as significant risk factors for disease recurrence. Conclusion Ocular sarcoidosis is a common initial presentation of systemic sarcoidosis. Diagnosis should be suspected in the presence of bilateral granulomatous panuveitis. Chest CT scan or 18F-FDG PET/CT is mandatory for systemic workup and biopsy is necessary for definite diagnosis. Female sex and a panuveitis presentation are significantly associated with disease recurrence.

Rate and predictors of thromboprophylaxis in internal medicine wards: Results from the AURELIO study

BackgroundRandomized controlled trials suggest that prophylactic doses of anticoagulants effectively prevent venous thromboembolism (VTE) in hospitalized medical patients with high thromboembolic risk. However, no prospective studies exist regarding the real-world prevalence of prophylactic anticoagulant use. This prospective study aimed to determine the rate and predictors of thromboprophylaxis in an unselected population of patients hospitalized in medical departments. MethodsWe conducted a multicenter prospective observational study (AURELIO – rAte of venous thrombosis in acutely iLl patIents hOspitalized) to assess the rate of deep vein thrombosis (DVT) in unselected acutely ill patients hospitalized in medical wards using compression ultrasound (CUS) at admission and discharge. Additionally, we evaluated the rate of pharmacological thromboprophylaxis administration in this population and analyzed the thrombotic risk by assessing RAMs (Risk Assessment Models) such as the IMPROVE-VTE and PADUA scores following the clinician's decision to administer thromboprophylaxis. Patients with IMPROVE-VTE scores ≥3 and/or PADUA scores ≥4 were classified as high thrombotic risk; those with IMPROVE-VTE scores <3 and/or PADUA scores <4 were classified as low risk. ResultsWe recruited 2371 patients (1233 males [52 %] and 1138 females [48 %]; mean age 72 ± 16 years). The median length of hospitalization was 13 ± 12 days. Overall, 442/2371 (18.6 %) patients received prophylactic parenteral anticoagulants (subcutaneous low weight molecular heparin or fondaparinux once daily) at admission. Assessing the thrombotic risk of the population recruited 1016 (42.9 %) patients were classified as high risk and 1354 (57.1 %) were low risk. Among high-risk patients, 339/1016 (33.4 %) received anticoagulant prophylaxis compared to 103/1354 (7.6 %) low-risk patients. During hospitalization, 9 patients developed DVT, comprising 7 asymptomatic and 2 symptomatic cases of proximal DVT. Of these, 3 patients were on anticoagulant prophylaxis, while 6 were not. Among the high-risk population, 7 out of 1016 patients (0.7 %) experienced proximal DVT during hospitalization, with 2 out of these 7 (28 %) receiving anticoagulant thromboprophylaxis. In the low-risk population, 2 out of 1354 patients (0.2 %) developed DVT, with 1 out of these 2 (50 %) receiving anticoagulant thromboprophylaxis. Age, heart or respiratory failure, pneumonia, active neoplasia, previous VTE, reduced mobility, and absence of kidney failure were more frequent in patients receiving prophylaxis. Multivariable logistic regression identified age (RR 1.010; CI 95 % 1002–1019; p = 0.015), heart/respiratory failure (RR 1.609; CI 95 % 1248–2075; p < 0.0001), active neoplasia (RR 2.041; CI 95 % 1222–2141; p < 0.0001), pneumonia (RR 1.618; CI 95 % 1557–2676; p < 0.0001), previous VTE (RR 1.954; CI 95 % 1222–3125; p < 0.0001), and reduced mobility (RR 4.674; CI 95 % 3700–5905; p < 0.0001) as independent predictors of thromboprophylaxis. ConclusionsThis study, conducted without pre-established thromboembolic risk scores, offers a comprehensive view of venous thromboembolism prophylaxis in medical patients with acute conditions hospitalized in internal medicine departments. It reveals that advanced age, heart or respiratory failure, active cancer, pneumonia, previous VTE, and reduced mobility are predictors that may influence the decision to administer thromboprophylaxis in these patients.

A Simple Frailty Index Predicts Inhospital Mortality

Introduction: Comparing frailty models in different settings that predict inhospital 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 inhospital 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 inhospital mortality. Results: The mean patient age was 73 ± 19 years, and 49.1% (5,665/11,542) were males. A Laniado-4 scale performed better than the Norton scale for predicting inhospital mortality. A simple frailty index ranging from 0 to ≥8 points was associated with rates of inhospital 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 inhospital 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.

Clinical Phenotyping for Prognosis and Immunotherapy Guidance in Bacterial Sepsis and COVID-19.

It is suggested that sepsis may be classified into four clinical phenotypes, using an algorithm employing 29 admission parameters. We applied a simplified phenotyping algorithm among patients with bacterial sepsis and severe COVID-19 and assessed characteristics and outcomes of the derived phenotypes. Retrospective analysis of data from prospective clinical studies. Greek ICUs and Internal Medicine departments. We analyzed 1498 patients, 620 with bacterial sepsis and 878 with severe COVID-19. We implemented a six-parameter algorithm (creatinine, lactate, aspartate transaminase, bilirubin, C-reactive protein, and international normalized ratio) to classify patients with bacterial sepsis intro previously defined phenotypes. Patients with severe COVID-19, included in two open-label immunotherapy trials were subsequently classified. Heterogeneity of treatment effect of anakinra was assessed. The primary outcome was 28-day mortality. The algorithm validated the presence of the four phenotypes across the cohort of bacterial sepsis and the individual studies included in this cohort. Phenotype α represented younger patients with low risk of death, β was associated with high comorbidity burden, and δ with the highest mortality. Phenotype assignment was independently associated with outcome, even after adjustment for Charlson Comorbidity Index. Phenotype distribution and outcomes in severe COVID-19 followed a similar pattern. A simplified algorithm successfully identified previously derived phenotypes of bacterial sepsis, which were predictive of outcome. This classification may apply to patients with severe COVID-19 with prognostic implications.