Internal Medicine Wards Research Articles

Knowledge, Attitude and Practice of Hepatitis B among Informal Caregivers at Ndola Teaching Hospital

Introduction: Hepatitis B is a highly contagious infection. It is 50 to 100 times more infectious than HIV. It is the world’s most common liver infection, which is caused by a DNA-virus, the hepatitis B virus and is transmitted between people through blood, semen, vaginal fluids and mucous membranes. Basic knowledge about hepatitis B is necessary; with more knowledge people take preventive actions against hepatitis B, such as using stick proof cannulas. The general objective of this study was to assess the knowledge, attitude and practice of HBV infection among informal caregivers at Ndola Teaching Hospital, Ndola, Zambia. Method: A Cross sectional study was carried out at Ndola Teaching Hospital from June 2020 to September 2020. Systematic random sampling was used using questionnaire based interviews to consenting informal caregivers above the age of 18 years who were waiting for their patients in Gynecological ward, surgical wards and internal medicine wards. Results: A total number of 165 informal caregivers at Ndola Teaching Hospital were interviewed using a pretested questionnaire. The highest age group (44.2%) interviewed was between 25 to 34 years of age. The majority of informal caregivers (52.1%) went up to secondary education level and 63.0% of the informal caregivers were females. Most informal caregivers (53.3%) only had an average knowledge about hepatitis B infection. Informal caregiver’s education level was directly associated with the level of knowledge about Hepatitis B (p-value<0.001). Majority (87.3%) of the informal caregivers had good attitude towards hepatitis B. There was a direct association (p value <0.001) between informal caregiver’s knowledge on hepatitis B with their attitude. All the informal caregivers (100%) had bad practices on Hepatitis B and majority of the respondents 159 (96.4%) were not vaccinated only 6 (3.6%) were vaccinated against HBV. Conclusion: Hepatitis B is a major health problem globally casting an enormous burden on the health-care system a major source of patient’s misery. This illness or disease is preventable. In this study, the majority of the participants had good attitudes making knowledge as the main determinant of their practices. Therefore, primary prevention approach be taken by extensively and frequently teaching all informal care givers in all hospitals and clinics on how to protect themselves from the disease. Pictorial Posters depicting the proper way of handling patients by informal caregivers be displayed in health centers (wards and OPDs).

Associations of Chronic Medication Adherence with Emergency Room Visits and Hospitalizations.

Good medication adherence is associated with decreased healthcare expenditure; however, adherence is usually assessed for single medication. We aim to explore the associations of adherence levels to 23 chronic medications with emergency room (ER) visits and hospitalizations. The primary endpoints are ER visits and hospitalizations in internal medicine and surgical wards. Individuals aged 50-74 years, with a diagnosis of diabetes mellitus or hypertension, treated with at least one antihypertensive or antidiabetic medication during 2017 were included. We determined personal adherence rates by calculating the mean adherence rates of the medications prescribed to each individual. Adherence rates were stratified into categories. We retrieved information about all the ER visits, and hospitalizations in internal medicine and surgical wards during 2016-2018. Of 268,792 persons included in the study, 50.6% were men. The mean age was 63.7 years. Hypertension was recorded for 217,953 (81.1%), diabetes for 160,082 (59.5%), and both diabetes and hypertension for 109,225 (40.6%). The mean number of antihypertensive and antidiabetic medications used was 2.2 ± 1.1. In total, 51,301 (19.1%) of the cohort visited the ER at least once during 2017, 21,740 (8.1%) were hospitalized in internal medicine wards, and 10,167 (3.8%) in surgical wards during 2017. Comparing the highest adherence category to the lowest, adjusted odds ratios were 0.64 (0.61, 0.67) for ER visits, 0.56 (0.52, 0.60) for hospitalization in internal wards, and 0.63 (0.57, 0.70) for hospitalization in surgical wards. Odds ratios were similar for the three consecutive years 2016-2018. Better medication adherence was associated with fewer ER visits and hospitalizations among persons with diabetes and hypertension. Investing in improving medication adherence may reduce health costs and improve patients' health.

Developing a predictive model for hospital-associated disability among older patients hospitalized for an acute illness: the HAD-FREE Score.

To develop a predictive model to identify hospitalized older patients at risk of functional decline. This retrospective cohort study recruited participants aged 65years and over admitted to internal medicine wards of a tertiary medical center in Taiwan during May to October 2017 for developing predictive model (n = 1698) and those admitted during November to December 2017 for validation study (n = 530) of the model. Demographic data, geriatric assessments and hospital conditions (admission route and length of hospital stay) were collected for analysis. Overall, of the 1698 participants (mean age 75.8 ± 7.9years, 60.9% male) enrolled in the development study, 20.1% had functional decline. Results of multivariate logistic regression showed that older age, hearing impairment, history of falls within one year, risk of malnutrition, physical restraint, admission via emergency department and hospital stay ≥ 5days were independent predictive factors for decline. A scoring system, HAD-FREE Score, constructed from the above predictive factors ranged from 0 to 18 points and ≥ 6 points was chosen as the cut-off point. The area under the receiver operating characteristic analysis was 0.748 (95% confidence interval: 0.720-0.776), the sensitivity was 65.3% and the specificity was 71.3%. Validation of the HAD-FREE Score showed moderate discriminative ability in the validation study. A HAD-FREE Score developed from seven independent factors could predict functional decline with moderate discriminative ability and good validation. This scoring system can be the basis of an automatic dynamic tracking within the electronic medical record to identify those older patients at risk of functional decline during hospitalization.

69. RELATIONSHIP BETWEEN AGE AT MENARCHE AND HYPERTENSION IN RSUP PROF. DR. R. D. KANDOU MANADO

Introduction: The age at menarche (AAM) is the first onset of the menstrual cycle in women, which represents the beginning of the capacity to reproduce, and can affect health later. Previous research has shown that early and late menarches were associated with hypertension. Some studies have shown in group of AAM <11 years and >15 years, the risk of hypertension increased. Objective: This study aims to assess the correlation between AAM and hypertension. Methods: This was an observational cross-sectional study. The subjects were women aged 18-70 years who were treated in the Internal Medicine ward of RSUP Prof. Dr. R. D. Kandou from December 2020–January 2021. Data was collected through interview, blood pressure examination, and medical record. The data were grouped into AAM <11 years, 11–15 years, >15 years; hypertension and non-hypertension, and were processed using SPSS. Results: This study included 65 female subjects, aged 22–66 years old. The mean age was 39.57 years. From 65 subjects, 32 (49.24%) were hypertensive and 33 (50.76%) were non-hypertensive. The mean age at menarches was 13.29 years. The Pearson chi square test showed that there was a correlation between AAM with hypertension (p = 0.004). The odds ratio (OR) (CI 95%) showed the AAM >15 years had higher risk of developing hypertension compared to 11–15 years. There was no difference in risk of hypertension in group of AAM <11 years compared to AAM 11–15 years. Conclusion: There is a correlation between AAM with hypertension. AAM >15 years is related to risk of hypertension.

Outcome of noncritical COVID-19 patients with early hospitalization and early antiviral treatment outside the ICU

Background/aimDespite the fact that the COVID-19 pandemic has been going on for over 5 months, there is yet to be a standard management policy for all patients including those with mild-to-moderate cases. We evaluated the role of early hospitalization in combination with early antiviral therapy with COVID-19 patients in a tertiary care university hospital. Materials and methodsThis was a prospective, observational, single-center study on probable/confirmed COVID-19 patients hospitalized in a tertiary care hospital on COVID-19 wards between March 20 and April 30, 2020. The demographic, laboratory, and clinical data were collected. ResultsWe included 174 consecutive probable/confirmed COVID-19 adult patients hospitalized in the Internal Medicine wards of the University Adult Hospital between March 20 and April 30, 2020. The median age was 45.5 (19–92) years and 91 patients (52.3%) were male. One hundred and twenty (69%) were confirmed microbiologically, 41 (23.5%) were radiologically diagnosed, and 13 (7.5%) were clinically suspected (negative microbiological and radiological findings compatible with COVID-19); 35 (20.1%) had mild, 107 (61.5%) moderate disease, and 32 (18.4%) had severe pneumonia. Out of 171 cases, 130 (74.3%) showed pneumonia; 80 were typical, and 50 showed indeterminate infiltration for COVID-19. Patients were admitted within a median of 3 days (0-14 days) after symptoms appear. The median duration of hospitalization was 4 days (0-28 days). In this case series, 13.2% patients were treated with hydroxychloroquine alone, 64.9% with hydroxychloroquine plus azithromycin, and 18.4% with regimens including favipiravir. A total of 15 patients (8.5%) were transferred to the ICU. Four patients died (2.2%).ConclusionIn our series, 174 patients were admitted to the hospital wards for COVID-19, 69% were confirmed with PCR and/or antibody test. At the time of admission, nearly one fifth of the patients had severe diseases. Of the patients, 95.4% received hydroxychloroquine alone or in combination. The overall case fatality rate was 2.2%.

Skin Ulcers are Predictors of 30-Day Hospital Readmission, But are Under-represented in the DRG Coding: A Retrospective Case-Control Study From an Italian Internal Medicine Unit.

This study retrospectively analyzes all consecutive patients who underwent during a year hospital readmissions, defined as an admission to a hospital within 30 days of discharge, to an Italian Internal Medicine ward. All these data were compared with those from patients who underwent only 1 hospital admission in the same period. The aim of this study was to identify potential novel risk factors for hospital readmissions. In 2018, a total of 3012 patients were hospitalized. Among these, 14.1% (n = 426; mean age, 79.7 ± 11.9; range, 23-100) were defined as readmissions; data were compared with controls (n = 420; 13.9%; mean age, 75.9 ± 14.7; range, 22-99) who had only 1 hospitalization. Cases showed a significantly higher prevalence than controls regarding cerebrovascular disease (77.2% vs 48.1%), cognitive impairment (51.8% vs 26.9%), congestive heart failure (47.6% vs 20.2%), chronic kidney disease (31.7% vs 13.1%), and chronic obstructive pulmonary disease (23.0% vs 14.5%). Skin ulcers were significantly more prevalent among cases (45.1% vs 17.6%). Diagnosis-related group (DRG) analysis showed a higher proportion of "infectious disease" (24.4% vs 15.0%) among the cases than in controls. Despite skin ulcers were very frequent among cases and controls (45.1% vs 17.6%), they were codified as "skin wound" DRG only in 1.4% and 0.2%, respectively. At the DRGs analysis, sepsis (31.6% vs 19.1%), pneumonia (17.1% vs 7.6%), and kidney failure (9.6% vs 3.8%) represented the main significant cause of death in cases compared to controls. Our study confirms that readmissions to Internal Medicine departments are related to the severity of chronic diseases affecting patients. Skin ulcers are present in about half of patients who will be early readmitted within 30 days, but they are almost never reported in DRGs, so more accurate coding is needed. Key challenges for the future are sepsis prevention measures and investing resources in chronic disease assistance, including skin ulcer chronic management.

Clinical factors associated with death in 3044 COVID-19 patients managed in internal medicine wards in Italy: results from the SIMI-COVID-19 study of the Italian Society of Internal Medicine (SIMI).

During the COVID-19 2020 outbreak, a large body of data has been provided on general management and outcomes of hospitalized COVID-19 patients. Yet, relatively little is known on characteristics and outcome of patients managed in Internal Medicine Units (IMU). To address this gap, the Italian Society of Internal Medicine has conducted a nationwide cohort multicentre study on death outcome in adult COVID-19 patients admitted and managed in IMU. This study assessed 3044 COVID-19 patients at 41 referral hospitals across Italy from February 3rd to May 8th 2020. Demographics, comorbidities, organ dysfunction, treatment, and outcomes including death were assessed. During the study period, 697 patients (22.9%) were transferred to intensive care units, and 351 died in IMU (death rate 14.9%). At admission, factors independently associated with in-hospital mortality were age (OR 2.46, p = 0.000), productive cough (OR 2.04, p = 0.000), pre-existing chronic heart failure (OR 1.58, p = 0.017) and chronic obstructive pulmonary disease (OR 1.17, p = 0.048), the number of comorbidities (OR 1.34, p = 0.000) and polypharmacy (OR 1.20, p = 0.000). Of note, up to 40% of elderly patients did not report fever at admission. Decreasing PaO2/FiO2 ratio at admission was strongly inversely associated with survival. The use of conventional oxygen supplementation increased with the number of pre-existing comorbidities, but it did not associate with better survival in patients with PaO2/FiO2 ratio < 100. The latter, significantly benefited by the early use of non-invasive mechanical ventilation. Our study identified PaO2/FiO2 ratio at admission and comorbidity as the main alert signs to inform clinical decisions and resource allocation in non-critically ill COVID-19 patients admitted to IMU.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11739-021-02742-8.

Hyperglycemia at admission, comorbidities, and in-hospital mortality in elderly patients hospitalized in internal medicine wards: data from the RePoSI Registry

AimsThe association between hyperglycemia at hospital admission and relevant short- and long-term outcomes in elderly population is known. We assessed the effects on mortality of hyperglycemia, disability, and multimorbidity at admission in internal medicine ward in patients aged ≥ 65 years.MethodsData were collected from an active register of 102 internal medicine and geriatric wards in Italy (RePoSi project). Patients were recruited during four index weeks of a year. Socio-demographic data, reason for hospitalization, diagnoses, treatment, severity and comorbidity indexes (Cumulative Illness rating Scale CIRS-SI and CIRS-CI), renal function, functional (Barthel Index), and cognitive status (Short Blessed Test) and mood disorders (Geriatric Depression Scale) were recorded. Mortality rates were assessed in hospital 3 and 12 months after discharge.ResultsOf the 4714 elderly patients hospitalized, 361 had a glycemia level ≥ 250 mg/dL at admission. Compared to subjects with lower glycemia level, patients with glycemia ≥ 250 mg/dL showed higher rates of male sex, smoke and class III obesity. These patients had a significantly lower Barthel Index (p = 0.0249), higher CIRS-SI and CIRS-CI scores (p = 0.0025 and p = 0.0013, respectively), and took more drugs. In-hospital mortality rate was 9.2% and 5.1% in subjects with glycemia ≥ 250 and < 250 mg/dL, respectively (p = 0.0010). Regression analysis showed a strong association between in-hospital death and glycemia ≥ 250 mg/dL (OR 2.07; [95% CI 1.34–3.19]), Barthel Index ≤ 40 (3.28[2.44–4.42]),CIRS-SI (1.87[1.27–2.77]), and male sex (1.54[1.16–2.03]).ConclusionsThe stronger predictors of in-hospital mortality for older patients admitted in general wards were glycemia level ≥ 250 mg/dL, Barthel Index ≤ 40, CIRS-SI, and male sex.

Decontamination effect of neutral electrolysed water for spray nozzles of electric warm-water bidet toilet seats in the healthcare setting

SummaryBackgroundThere has been an increasing demand for more sanitary bidet seats in many healthcare settings because of concerns regarding potential contamination of the spray nozzles of warm-water bidet toilet seats. This contamination is thought to possibly serve as a reservoir for horizontal transmission of drug-resistant bacteria.AimThis study was performed to determine the optimal Pseudomonas aeruginosa decontamination conditions and verify the effectiveness of these decontamination conditions.MethodsAn in vitro test of rinsing with neutral electrolysed water was performed using seven strains of P. aeruginosa. The decontamination effect of the neutral electrolysed water was verified by a field test involving an analysis of the number of bacteria isolated from samples collected from the spray nozzles and the sprayed water from 10 toilet seats at the internal medicine ward of Juntendo University Hospital.FindingsThe in vitro test results showed that the decontamination effect of neutral electrolysed water tended to be higher with higher free chlorine concentrations in the nozzle-cleaning water and shorter intervals of rinsing. The field test involving the hospital ward toilets showed that routine physical cleaning was satisfactorily effective.ConclusionThe study results suggest that the risk of horizontal transmission of drug-resistant bacteria via the use of bidet toilet seats in hospitals can be reduced by general cleaning and appropriate control of the free chlorine concentration in the nozzle-cleaning water.

Translating evidence-based nursing clinical handover practice in an acute care setting: A quasi-experimental study.

Effective transfer of information during the nursing handover contributes to patient safety. This study aimed to translate the best practice nursing shift handover recommendations in an acute care setting using the Ottawa Model for Research Use and to explore its effect on patient adverse outcomes (falls, pressure injuries, and medication errors). Using a quasi-experimental design, the study was conducted in four internal medicine wards in a major tertiary hospital. A total of 88 nurses and 110 patients participated in 152 handover observations. The findings showed clinically important increases in percentages and odds of nurses' compliance with shift handover recommendations after the intervention. The patient adverse outcomes after the intervention were compared to the corresponding period of previous year. A reduction was observed for all adverse patient outcomes with incident rate ratios of 0.762 (p=0.027) for falls, 0.624 for pressure injuries (p=0.010), and 0.782 for medication errors (p=0.023). Replicating this study's methodology across multiple clinical settings will increase the generalizability of findings and provide further evidence to inform nursing practice and policy.

Proton pump inhibitor use and appropriateness analysis: a snapshot from a secondary care hospital

Abstract Objectives Proton pump inhibitors (PPIs) have become one of the most frequently prescribed drugs since their introduction 30 years ago. Effectiveness and safety profile of PPIs has led to their overutilization and has exposed patients to a number of potential risks. The objective of this study was to evaluate the use of PPIs in a secondary care hospital in the United Arab Emirates. Methods This prospective observational drug-utilization study was conducted in patients receiving treatment with PPIs and admitted to internal medicine wards of the study site. Electronic patient case records were reviewed and data on PPI prescribing was collected and analysed. Appropriateness of PPI use was assessed as per international guidelines. Key findings Out of 172 patients enrolled, 53.5% were females with median age of 57 years (34.3, 71.0). Four different PPIs were prescribed to study patients, pantoprazole (86.6%), esomeprazole (5.8%), rabeprazole (4.1%) and omeprazole (3.5%). Ninety-two (53.5%) patients were prescribed intravenous PPI, whereas 80 (46.5%) patients were given PPI in oral form. Overall, 103 (59.9%) patients had inappropriate PPI prescriptions. Of these inappropriate prescriptions, 22 patients had no clear indication for PPI use and for 16 patients; PPIs were indicated for stress ulcer prophylaxis in low-risk category. Corticosteroid use [odds ratio (OR): 4.34, 95% confidence interval (CI): 1.22–15.46; P = 0.023] was significantly associated with greater odds of inappropriate PPI use. Conclusions We report a high prevalence of inappropriate PPI prescribing among the hospitalized patients in our study. Inappropriate PPI prescribing is a concerning issue and collective efforts should be made to check and minimize the same.

WHAT IS IN THE SHADOW – A CASE OF SECONDARY HYPERTENSION

Objective: To present a case of secondary hypertension, to rule the importance of having evidence based recommendations. Design and method: We describe the case of a diabetic, dyslipidemic 63 years old man, with coronary artery disease-percutaneous coronary intervention (PCI) of right coronary artery (RCA) and of circumflex coronary artery(CCA) in 2016, hypertensive (ambulatory treatment: angiotensin-enzyme inhibitor, a calcium channel blocker, beta blocker and alpha2 central receptors) admitted in internal medicine ward with fronto-occipital headache, dizziness, hypertension (with a blood pressure value of 170/110 mmHg), hypokalemia (K 1.76 mmol/l). Taking into consideration the characteristics of the particularly case presented above, the patient is considered to meet the admission criteria. The abdominal CT scan revealed adrenal gland adenoma (1.8/1.4 cm). The diagnose of primary hiperaldosteronism is confirmed by the value of aldosteron/renine ratio (ARR 17). The patient's blood pressure and hypokalemia was influenced by the dose adjustment to the patient's ambulatory treatment and the administration of antimineralocorticoid and potassium supplement. Results: The new regimen reduced the blood pressure values, normalized the blood pressure and partially increased the potassium level (K 2.82 mmol/l). Conclusions: Although the prevalence of secondary hypertension is approximately 10 % the risks associated with are significantly higher. We reported a case of secondary hypertension with a good outcome despite it's severity.

Delta-Procalcitonin and Vitamin D Can Predict Mortality of Internal Medicine Patients with Microbiological Identified Sepsis.

Background: The management of septic patients hospitalized in Internal Medicine wards represents a challenge due to their complexity and heterogeneity, and a high mortality rate. Among the available prognostic tools, procalcitonin (PCT) is considered a marker of bacterial infection. Furthermore, an association between vitamin D deficiency and poor sepsis-related outcomes has been described. Objectives: To evaluate the prognostic accuracy of two consecutive PCT determinations (Delta-PCT) and of vitamin D levels in predicting mortality in a population of patients with microbiological identified sepsis admitted to Internal Medicine wards. Methods: This is a sub-analysis of a previous prospective study. A total of 80 patients had at least two available consecutive PCT determinations, while 63 had also vitamin D. Delta-PCT was defined as a reduction of PCT > 50% after 48 h, >75% after 72 h, and >85% after 96 h. Mortality rate at 28- and 90-days were considered as main outcome. Results: Mortality rate was 18.7% at 28-days and 30.0% at 90-days. Baseline PCT levels did not differ between survived and deceased patients (28-days: p = 0.525; 90-days: p = 0.088). A significantly higher proportion of survived patients showed Delta-PCT (28-days: p = 0.002; 90-days: p < 0.001). Delta-PCT was associated with a lower 28-days (p = 0.007; OR = 0.12, 95%CI 0.02–0.46) and 90-days mortality (p = 0.001; OR = 0.17, 95%CI 0.06–0.48). A significantly higher proportion of deceased patients showed severe vitamin D deficiency (28-days: p = 0.047; 90-days: p = 0.049). Severe vitamin D deficiency was associated with a higher 28-days (p = 0.058; OR = 3.95, 95%CI 1.04–19.43) and 90-days mortality (p = 0.054; OR = 2.94, 95%CI 1.00–9.23). Conclusions: Delta-PCT and vitamin D represent two useful tests for predicting prognosis of septic patients admitted to Internal Medicine wards.

Oral anticoagulation on patients with atrial fibrillation: are we doing a good job?

Introduction Atrial fibrillation (AF) is one of the major causes of stroke and cardiovascular morbidity in the world [1]. Oral anticoagulation (OAC) with vitamin K antagonists (VKAs) or non-VKA oral anticoagulants (NOACs) reduces the risk of such events in AF patients [1–3]. Our aim was to evaluate if AF patients were correctly hypocoagulated and the prevalence of acute ischaemic stroke (IS) and acute transient ischaemic attack (TIA) among these patients. Materials and methods A cross-sectional study was undertaken in a Portuguese hospital in Beja in the last three months. Patients (aged 18 years or older) with previous history of AF admitted to internal medicine ward were included. Data was extracted from medical charts, which included sociodemographic and clinical variables. To assess if patients were correctly medicated or in need for OAC, we calculated CHA2DS2-VASc (if <2: no need for OAC; if ≥2 (male) or ≥ 3 (female): need for OAC), assessed renal function (creatinine value; creatinine clearance using Cockcroft-Gault Equation), INR, and the type of OAC and doses. The informed consent of the subjects and acceptance of the study protocol by a local ethics committee has been obtained. Data analysis was performed using univariate statistics (IBM SPSS v.20.0). Results A total of 150 patients were included, with a mean age of 81.8 ± 7.7 years old and 52.7% (n = 79) were female. Almost half of the sample was not on OAC (48.0%, n = 72). From the ones on OAC, 60.3% (n = 47) were on NOAC, with apixaban as the most prescribed drug (55.3%; n = 26), followed by rivaroxaban (31.9%; n = 15). A considerable proportion of patients was using warfarin (38.5%; n = 30). Almost 60% of the cases were incorrectly hypocoagulated, either due to lack of OAC prescription in patients that should be on that medication (80.7%; n = 71) or to incorrect dose (19.3%; n = 17). From patients who should be on OAC, 74.6% (n = 53) were aged 80 or older and 15.5% (n = 11) were admitted to internal medicine ward with acute IS (63.6%; n = 7) or acute TIA (36.4%; n = 4). Acute IS has been also registered in 4 patients (5.1%) correctly medicated (NOAC: n = 3; VKA: n = 1). Discussion and conclusions Data suggest that almost half of the patients were not on OAC and 15.5% of these experienced an acute cerebrovascular event. Almost 75% of patients who should be on OAC were aged 80 or older. The considerable stroke risk without OAC often exceeds the bleeding risk even in the elderly, in patients with cognitive dysfunction, or in patients with frequent falls or frailty and these should not be the reasons for withholding, ending or do not initiate OAC.

More severe hypercoagulable state in acute COVID-19 pneumonia as compared to other pneumonia.

The Publisher regrets that this article is an accidental duplication of an article that has already been published, http://doi.org/10.1016/j.mayocpiqo.2020.09.002. The duplicate article has therefore been withdrawn.The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal

WHEN WE DON’T HAVE ENOUGH-A CASE OF SECONDARY HYPERTENSION

Objective: Diabetic nephropathy (DN) is a significant cause of chronic kidney disease (CKD) and end-stage renal failure globally. Hypertension is approximately twice as prevalent in patients with diabetes compared to the general population. The major causes of hypertension in DN include activation of local (renal) renine-angiotensin-aldosterone system (RAAS), increased or abnormal sympathetic nervous system (SNS) activity, oxidative stress and abnormal nitric oxide (NO) metabolism. These mechanisms are responsible for the onset and worsening of hypertension in this population. Design and method: We report the case of a type I diabetic 47 years old man, with multiple complications (retinopathy, nephropathy, polineuropathy), stage 5 chronic kidney disease in hemodialysis program, hypertensive (ambulatory treatment: calcium channel blocker, and alpha2 central receptors), presented to the emergency department with tonic-clonic seizure, hypertension (with a blood pressure value of 185/98 mmHg), hyperglycemia (glycemia over 750 mg/dl), metabolic acidosis (ph 7.23), moderate hyponatremia (Na 124 mmol/l). Taking into consideration the characteristics of the particularly case presented above, the patient is considered to meet the admission criteria for intensive care unit (ICU). The evolution was favorable with insulin, acid-base and hydro electrolytic re equilibration, prevention of stress ulcer, venous thromboembolism prophylaxis and anti-hypertensive treatment (nitroglycerine, alpha1-adrenoreceptor blocker- urapidil, angiontensin-converting enzyme inhibitor, calcium channel blocker, loop diuretic) and the patient was transferred to internal medicine ward. Results: Despite the use of the treatment to the maximum tolerated plus the addition of alpha2 central receptors blocker (clonidine), the patient's blood pressure was uncontrolled (maximum 260/130 mm Hg), far from the target. The new regimen reduced the blood pressure values by systolic blood pressure 170 mm Hg. Conclusions: Although the prevalence of secondary hypertension is approximately 10 % the risks associated with are significantly higher. We reported a case of secondary hypertension with uncontrolled values of blood pressure despite maximal treatment.

Frequency and associated factors for carbapenem-non-susceptible Bacteroides fragilis group bacteria colonization in hospitalized patients: Case control study in a university hospital in Turkey

PurpuseThe carbapenem-resistant Bacteroides fragilis group (CR-BFG) bacteria have been reported in several countries recently with increasing global attention. The high incidence of CR-BFG isolated from our hospitalized patients has become an important problem. Therefore, we aimed to determine the frequency and associated factors for intestinal colonization by carbapenem-non-susceptible BFG (CNS-BFG) among adult patients hospitalized at intensive care units, neurosurgery and internal medicine wards in our hospital. MethodsRectal swabs (n = 1200), collected from 766 patients between February 2014 and March 2015, were inoculated onto kanamycin-vancomycin-leaked blood agar containing 0.125 mg/L meropenem. The isolates were identified by MALDI-TOF MS. Susceptibility testing was performed by agar dilution method. The carbapenemase gene (cfiA) was detected by PCR. Logistic regression analysis was used to evaluate the associated factors for intestinal colonization by CNS-BFG. ResultsA total 180 non-duplicate BFG isolates were obtained from 164 patients.Ten different species, including Parabacteroides distasonis (n = 46, 25.6%), and Bacteroides fragilis (n = 30; 16.6%), were identified. Twenty-five percent of the isolates were non-susceptible to meropenem (MIC >2 mg/L). The highest prevalence of meropenem resistant strains (MIC >8 mg/L) was detected among B. fragilis (n = 12), followed by Parabacteroides spp. (n = 4). All but one B. fragilis strains were cfiA gene positive. Hospital admission, increasing Charlson score, use of antibiotics; including carbapenems in past three months, colonization with other accompanying carbapenem-resistant Gram negative bacteria (Enterobacteriaceae, Acinetobacter baumannii and Pseudomonas aeruginosa), and having undergone surgical operations were significantly associated with RCS- BFG colonization. ConclusionsThe high carriage rate of CNS-BFG in hospitalized patients may lead to worse clinical outcomes, such as serious infections and mortality, and deserves attention.

Communication Effort Score (CES) in patients hospitalized in internal medicine ward

Aims: There are more than thirty prognostic scoring systems defined in the literature for emergency patients up to now. The purpose of this study is to develop communication effort score (CES) to be used in internal medicine ward by considering it from a different angle, and also to examine the relation of this index with prognosis. Methods: The study had a prospective-observational study design, and was conducted on patients followed-up in the ward due to acute diseases. The patients were graded under 4 categories according to communication effort within the first 8 hours after referring to emergency department, between exhibiting active communication effort and being closed to communication.The prognostic performance of CES was tested comparatively with other scoring systems by using AUROC analysis. Results: Data were collected on 308 consecutive acute medical admissions, 55.2% of whom were men, with the mean age of 65.4 ± 15.6 years The mortality rate of the patients in hospital was 2% in CES-1, 4.8% in CES-2, 27.2% in CES-3; and 51.6% in CES-4.The CES model showed a good discrimination power for in-hospital mortality as 0.813 AUC(95% CI, 0.77–0.85). These results were better than the prognostic scoring systems (RAPS, MEWS, REMS, WPS, GAP, and NEWS) and the other specific and general descriptive scoring systems (ECOG, GCS, qSOFA, CCL). The sensitivity and specificity of CES for the optimal cut-off point (2.5) in predicting in-hospital mortality were 0.957 and 0.632, respectively. Conclusions: The present study showed that CES, which is a new definitive score, is a strong predictor of both inhospital mortality and short-term mortality.

Case Report: COVID-19 with cytokine storm in a 16-year-old patient: if heart failures comes think about levosimendan

Introduction: Our case is unique because the differential diagnosis was a challenge. At first, the patient presented with septic shock and multi-organ failure in the context of a suspected lymphoproliferative syndrome. Once the lymphoproliferative process had been ruled out, hemophagocytic syndrome due to COVID-19 infection was suspected, so he is probably one of the few patients with such an exhaustive study that could contribute to our understanding of COVID-19. We followed therapeutic guidelines that differ from the usual, using adrenalin and levosimendan. Corticosteroids helped to modulate the cytokine storm. Case report: A 16-year-old adolescent was admitted to the intensive care unit with fever, diarrhea, multiorgan failure and septic shock. He was IgG positive for COVID-19 and IgM negative. Thoraco-abdominal computed tomography demonstrated multiple para-aortic and peri-pancreatic lymphadenopathy and acute respiratory distress syndrome. The first suspected diagnosis was a lymphoproliferative syndrome and bacterial infection. The second possibility was a hemophagocytic syndrome in a patient recovering from COVID-19. He was treated with broad spectrum antibiotics because the differential diagnosis was difficult, and we removed them when the microbiological screening was negative. During the course of the disease he presented with severe biventricular dysfunction, probably due to the cytokine storm, so we used inotropic drugs (adrenaline, levosimendan). Infection with Salmonella species group B was diagnosed later, when the patient was in the Internal Medicine ward, although he was asymptomatic. Conclusion: The severity of COVID-19 infection ranges from mild to severe, causing serious disease in some people. Although the pathophysiology is not well known, it seems that in some cases an immune storm is triggered, and it is related to more serious and prolonged disease. In our case, heart failure was important, because it could have worsened the prognosis. Fortunately, the response to levosimendan and corticosteroids was adequate and he recovered favorably until discharge.

Ankle-Brachial Index Is a Predictor of In-Hospital Functional Status but Not of Complications in Hospitalized Elderly Patients

Introduction: Atherosclerosis causes a chronic reduction of vascularization with consequent impairment of the performance of organs, like the brain or muscles, which determines the functional and cognitive decline of the elderly and their ability to respond to acute stressful condition. Therefore, our aim was to evaluate if ankle brachial index (ABI) could effectively be a determinant of in-hospital functional status and complications in elderly hospitalized patients. Methods: This is a monocentric cross-sectional study of 189 patients aged 65 years or older. The study was undertaken at the Internal Medicine ward of Niguarda Hospital in Milan. ABI (BOSO ABY-System 100) and in-hospital status (activities of daily living, ADL and instrumental activities of daily living, IADL) were collected on the second day of hospitalization. Complications (falls and delirium episodes) were also recorded during the whole hospitalization period. Results: The average age of patients was 79.3 ± 6.9 years. Among outcomes, only ADL (r = 0.192, p = 0.007) and IADL score (r = 0.200, p = 0.005) showed significant correlation with ABI. Moreover, during the subsequent logistic regression, ABI remained among the statistically significant determinants of both scores (β = 0.231, p = 0.013 and β = 0.314, p = 0.001, respectively). Conclusions: The main result of our study is the finding of ABI as a significant determinant of acute in-hospital functional impairment (evaluated as ADL and IADL scores). The continuous exposure of the brain and muscles to the reduced perfusions induced by vascular atherosclerosis, probably determined the reduced ability to respond to stressful conditions.