Moshe Vardi

Assessment of disease-severity scoring systems for patients with sepsis in general internal medicine departments

IntroductionDue to the increasing burden on hospital systems, most elderly patients with non-surgical sepsis are admitted to general internal medicine departments. Disease-severity scoring systems are used for stratification of patients for utilization management, performance assessment, and clinical research. Some widely used scoring systems for septic patients are inappropriate when rating non-surgical patients in a non-intensive care unit (ICU) environment mainly because their calculations require types of data that are frequently unavailable. This study aimed to assess the fitness of four scoring systems for septic patients hospitalized in general internal medicine departments: modified early warning score (MEWS), simple clinical score (SCS), mortality in emergency department sepsis (MEDS) score, and rapid emergency medicine score (REMS).MethodsWe prospectively collected computerized data of septic patients admitted to general internal medicine departments in our community-based university hospital. We followed 28-day in-hospital mortality, overall in-hospital mortality, and 30- and 60-day mortality. Using a logistic regression procedure we calculated the area under ROC curve (AUC) for every scoring system.ResultsBetween February 1st, 2008 and April 30th, 2009 we gathered data of 1,072 patients meeting sepsis criteria on admission to general internal medicine departments. The 28-day mortality was 19.4%. The AUC for the MEWS was 0.65-0.70, for the SCS 0.76-0.79, for the MEDS 0.73-0.75, and for the REMS, 0.74-0.79. Using Hosmer-Lemeshow statistics, a lack of fit was found for the MEDS model. All scoring systems performed better than calculations based on sepsis severity.ConclusionsThe SCS and REMS are the most appropriate clinical scores to predict the mortality of patients with sepsis in general internal medicine departments.

Vitamin E therapy results in a reduction in HDL function in individuals with diabetes and the haptoglobin 2-1 genotype

OBJECTIVE Vitamin E provides cardiovascular protection to individuals with diabetes and the haptoglobin 2-2 genotype but appears to increase cardiovascular risk in individuals with diabetes and the haptoglobin 2-1 genotype. We have previously demonstrated that the haptoglobin protein is associated with HDL and that HDL function and its oxidative modification are haptoglobin genotype dependent. We set out to test the hypothesis that the pharmacogenetic interaction between the haptoglobin genotype on cardiovascular risk might be secondary to a parallel interaction between the haptoglobin genotype and vitamin E on HDL function. RESEARCH DESIGN AND METHODS Fifty-nine individuals with diabetes and the haptoglobin 2-1 or 2-2 genotypes were studied in a double-blind placebo controlled crossover design. Participants were treated with either vitamin E (400IU) or placebo for 3 months and crossed over for an equivalent duration. Serum was collected at baseline and after the completion of each treatment. HDL functionality as well as HDL associated markers of oxidation and inflammation were measured after each interval in HDL purified from the cohort. RESULTS Compared to placebo, vitamin E significantly increased HDL function in haptoglobin 2-2 but significantly decreased HDL function in haptoglobin 2-1. This pharmacogenetic interaction was paralleled by similar non-significant trends in HDL associated lipid peroxides, glutathione peroxidase, and inflammatory cargo. CONCLUSION There exists a pharmacogenetic interaction between the haptoglobin genotype and vitamin E on HDL function (clinicaltrials.gov NCT01113671).

Mushroom poisoning from species of genus Inocybe (fiber head mushroom): a case series with exact species identification

Background. Many species of the genus Inocybe (family Cortinariaceae, higher Basidiomycetes) are muscarine-containing mycorrhizal mushrooms, ubiquitous around the world. The few published reports on the poisonous Inocybe mushrooms are often limited by the inadequate identification of the species. The clinical course of patients with typical muscarinic manifestations, in whom Inocybe spp. was unequivocally identified, is reported. Case series. Between November 2006 and January 2008 14 consecutive patients with typical muscarinic syndrome after mushroom ingestion were recorded. The clinical manifestations included combinations of nausea, vomiting, diarrhea, abdominal pain, hypersalivation, diaphoresis, tachycardia, bradycardia, hypotension, lacrimation, blurred vision, miosis, tremor, restlessness, flushing, and syncope. Time to onset of toxicity ranged between 15 min and 2 h after consumption, 5 h in one patient. Treatment was supportive, including intravenous fluids, antiemetics, and 1 mg atropine intravenously. Full recovery ensued within 12 h. In all the cases, an expert mycologist unequivocally identified the leftovers of the consumed mushrooms as Inocybe fastigiata, Inocybe geophylla, and Inocybe patouillardii. Conclusion. In this case series of patients who ingested identified muscarine-containing mushrooms supportive treatment and atropine resulted in recovery in all cases.

Clinical Characteristics and Outcomes of Patients with Clinically Unsuspected Pulmonary Embolism versus Patients with Clinically Suspected Pulmonary Embolism

Background: The routine use of multidetector computed tomography has led to increased detection of unsuspected pulmonary embolism (UPE), with questionable benefit for diagnosis and treatment. Objective: The purpose of this work was to compare the clinical characteristics and prognosis of patients with UPE to patients with suspected PE (SPE). Methods: We retrospectively reviewed the charts of patients diagnosed with PE in a community-based university hospital between the years 2002 and 2007. UPE was defined as PE detected on CT scans performed for indications other than suspicion of PE. We compared patients with UPE to patients with SPE for differences in clinical features, electrocardiogram, imaging and echocardiographic findings. We also assessed the long-term outcomes using electronic patient records. Results: Of 500 patients with PE, 408 had SPE and 92 had UPE. Patients with UPE were similar to patients with SPE regarding age and sex distribution. Malignancy was more prevalent in UPE patients (39 vs. 23%, p < 0.0068). UPE patients had significantly less tachypnea (37 vs. 57%, p = 0.0005), dyspnea (47 vs. 87%, p < 0.0001), chest pain (19 vs. 42%, p < 0.0001) and hypoxemia (36 vs. 55%, p = 0.0011). Mortality was higher in UPE patients (70.3 vs. 53%, p = 0.0029). The hazard ratio after adjustment for confounders including age, sex and malignancy was 1.546 (95% CI: 1.139–2.099, p = 0.0052). Conclusions: We suggest that UPE is more prevalent in patients with a malignancy and is associated with higher mortality despite a less severe clinical presentation. UPE may be a marker of poor prognosis.

The practice of internal medicine in Europe: organisation, clinical conditions and procedures

BACKGROUND Current information on the role of internists in the European countries is scarce. This report describes the results of a survey of the practice of internists in Europe. METHODS Two online questionnaire-based surveys were carried out by the European Board of Internal Medicine, one on the practice of internists and the other on postgraduate training in internal medicine. The national internal medicine societies of all 30 member countries of the European Federation of Internal Medicine were invited to participate. The responses were reviewed by internal medicine trainees from the respective countries and summaries of the data were sent to the national societies for approval. Descriptive analysis of the data on the practice of internists was carried out. RESULTS Twenty-seven countries (90%) completed the questionnaire and approved their datasets. In 8 European countries, most internists practised internal medicine alone and in 7 countries at least half of physicians practised internal medicine together with a subspecialty. Internal medicine was considered a hospital-based specialty in most countries. The majority of selected presenting problems and diagnoses were rated as commonly encountered in all countries. More variability between countries was observed in the performance of diagnostic and therapeutic procedures. CONCLUSION Many similarities exist in the practice of internal medicine between the European countries, while some differences are present that likely reflect the variable impact of subspecialisation. The results of the survey should prove valuable for the definition of specific competencies and development of a common curriculum for internal medicine at the European level.

Attitudes towards and practice of venous thromboembolism prevention in general internal medicine wards: a multinational survey from member countries of the European Federation of Internal Medicine.

INTRODUCTION Hospitalised patients in Internal Medicine departments are at risk of venous thromboembolism (VTE). Adherence to risk stratification methods is poor. We conducted a survey among Internists from member countries of the European Federation of Internal Medicine (EFIM) to assess current knowledge and attitude towards VTE prevention. METHODS A multinational survey of Internists affiliated to EFIM. RESULTS 226 physicians from 30 countries were included. Seventy nine percent of the physicians were aware of clinical guidelines to prevent VTE. Most considered their knowledge of the guidelines to be moderate. Many had not updated their knowledge recently. The magnitude of the clinical problem was over- and underestimated by many (12.2% and 40.1%, respectively). Only 46.7% thought their patients were mostly receiving proper prophylaxis. Sixty four percent worked in departments without a formal VTE prophylaxis program. Risk of bleeding, lack of awareness and lack of decision support systems were the three most common reasons for deferring treatment (88.6%, 32.3% and 27.9%, respectively). Most of the participants stated that they strongly believe in VTE prophylaxis as an intervention that prevents morbidity and mortality. CONCLUSIONS Despite general awareness of clinical guidelines, many medical wards do not have formal risk assessment methodologies incorporated into their operative workflow. This gap, as well as fear of complications, may be one of the reasons for the low rates of adherence reported by physicians. We speculate that perhaps current guidelines have not been accepted by Internists due to paucity of well defined and validated risk assessment tools.

O0014 ASSESMENT OF DISEASE-SEVERITY SCORING SYSTEMS FOR SEPTIC PATIENTS IN DEPARTMENTS OF INTERNAL MEDICINE

ultrasound. Only 22.5% of patients sent for imaging were positive for DVT. In low risk patients who had been sent for imaging (n=97), a D-Dimer threshold of 1.0 (Table 1) yielded a sensitivity of 95%, specificity of 47.4%, positive predictive value of 32% and negative predictive value of 97.4% for DVT. By adjusting D-Dimer thresholds in the low risk population, the projected sensitivities were calculated (Figure 2). Increasing D-Dimer thresholds up to 2.2 did not compromise sensitivity, but reduced the number of patients sent for imaging by 29%. In the high or indeterminate risk group, a D-Dimer level of 1 yielded sensitivities of 78.9% and 86.4% respectively (Figure 3). Throughout the 6 month period, no patients returned with a missed case of DVT. Discussion and conclusion: In high or unknown risk patients, a low D-Dimer level alone is insufficient to exclude DVT. In low risk patients, D-Dimer thresholds of 1.0, even up to 2.2, offers sufficient sensitivity (95%) to discharge patients without the need for imaging. Longer term data is required before a higher cut-off can be determined and safely applied. Our results highlight the importance of risk stratification in DVT assessment and suggest that our algorithm is a safe and effective method in reducing the number of patients sent for imaging.

Activated partial thromboplastin time monitoring in patients receiving unfractionated heparin for venous thromboembolism in relation to clinical outcomes

Venous thromboembolism (VTE) is a prevalent and serious condition, which requires anticoagulation treatment for prolonged time duration. The use of unfractionated heparin administered intravenously or subcutaneously for acute management of VTE has been studied with favourable clinical results. Most physicians use activated partial thromboplastin time to monitor the treatment effect, in an effort to obtain better efficacy with less bleeding complications. Recent data however does not support this practice. We set to explore the medical literature for the correlation between the level of anticoagulation and the clinical outcomes. Randomised controlled trials comparing subcutaneous unfractionated heparin to any other treatment modality in patients with venous thromboembolism were obtained and a meta-analysis was performed. Seventeen reports from 15 randomised controlled trials were included. Of these, eleven included anticoagulation measurements. Seven and six trials were included in our analysis for subcutaneous and intravenous modes of administration, respectively. No correlation between the anticoagulation level and the major clinical outcomes were found, except for the initial anticoagulation measurement and the total mortality at three months, but not to death related to treatment or disease progression. In conclusion, weight-adjusted subcutaneous unfractionated heparin without anticoagulation monitoring may be feasible for patients with acute venous thromboembolism. No differences exist between intravenous and subcutaneous modes of administration with regards to the correlation between anticoagulant measures and the clinical outcomes. More research is needed to substantiate this observation.

Contents Vol. 84, 2012

J. Hammer, Basel F.J.F. Herth, Heidelberg J. Johnston, Vancouver, B.C. C. Kroegel, Jena F. Kummer, Vienna P.N. Mathur, Indianapolis, Ind. M. Miravitlles, Barcelona J. Müller-Quernheim, Freiburg L.P. Nicod, Lausanne M. Noppen, Brussels D. Olivieri, Parma C. Page, London W. Randerath, Solingen S. Siddiqui, Leicester T. Terashima, Ichikawa O.S. Usmani, London S. van Eeden, Vancouver, B.C. K. Yasufuku, Toronto, Ont. Official Journal of