Pulse dose steroid experience among hospitalized patients with systemic lupus erythematosus: a single-center feasibility study

Clinical Rheumatology - Introduction/objectives: Pulse intravenous (IV) methylprednisolone (MEP) is often used for severe SLE manifestations requiring hospitalization. However, the accuracy of...     

医院下呼吸道感染的病原菌分布及其药物敏感性分析

目的 了解医院医院下呼吸道感染的病原菌分布及药物敏感情况.方法 对我院医院下呼吸道感染的痰标本行病原菌培养,并对致病菌的药物敏感性进行分析.结果 共分离致病菌249株G+球菌占37.3%,G-杆菌占49.0%,真菌占13.7%.G+球菌中前四位分别是金黄色葡萄球菌(33株)、表皮葡萄球菌(19株)、链球菌(14株)和腐生葡萄球菌(13株).G-杆菌前四位分别是鲍氏不动杆菌(29株)、铜绿假单胞菌(21株)、阴沟肠杆菌(18株)和肺炎克雷伯杆菌(16株).所分离的细菌对多种抗菌药的敏感性均较低,但主要G+球菌对万古霉素敏感率100%.四种主要G-杆菌中除铜绿假单胞菌外对亚胺培南、美罗培南的敏感率均在75%以上.真菌以白假丝酵母菌为主(22株),对抗真菌药物敏感率较高.结论 我院院内下呼吸道感染的病原菌构成复杂,以G-杆菌为主.     

Symptoms in hospitalized patients: outcome and satisfaction with care

PURPOSE: Physical symptoms are responsible for substantial morbidity in outpatients. We assessed symptoms in patients admitted to a hospital to determine their frequency, persistence at discharge, and the relation between symptom outcome and satisfaction with care. METHODS: During a 12-month period, 2,126 hospitalized medical patients completed a study interview within 2 hours of admission. More than half (n = 1,168) of the patients were re-interviewed within 24 hours of discharge. We ascertained the presence and severity of 11 physical symptoms, as well as activities of daily living, mobility, mood, self-rated health, physiologic severity of illness, satisfaction with care, and length of stay. RESULTS: Symptoms were common at the time of hospital admission, particularly fatigue (80% of patients), dyspnea (60%), cough (51%), dizziness (51%), headache (47%), chest pain (46%), and nausea or vomiting (43%). Individual symptoms failed to resolve by hospital discharge approximately 25% to 50% of the time. The three most prominent predictors of persistence of symptoms were shorter length of stay, severity of the symptom on admission, and total symptom count. Patient satisfaction with care was associated with total symptom severity score at discharge and the degree of symptomatic improvement that had occurred during hospitalization. CONCLUSION: Because symptoms are common at discharge and associated with decreased satisfaction with care, asking about them would be a reasonable way to enhance patient-oriented care.     

Fever in hospitalized medical patients

The occurrence of fever and the clinical profile of febrile patients on the medical service of a teaching hospital were studied prospectively. Thirty-six per cent of 972 patients developed fever (temperature exceeding 38°C). Their 13% mortality rate and 13.2-day average hospital stay exceeded the 3% mortality and seven-day hospitalization for afebrile patients (p<0.0001 for both). Most fever episodes occurred during the first two hospital days. Approximately 30% of first and subsequent fever episodes were caused by bacterial infections; illnesses involving tissue necrosis (e.g., stroke, myocardial infarction) accounted for 20%. Five conditions comprised 53% of diagnoses: respiratory and urinary tract infections, neoplasm, myocardial infarction, and drug reaction. Only one patient had a fever of uncertain origin. Several clinical clues used frequently to identify bacterial infections were reevaluated. Patients with bacterial infections had higher temperatures on the first febrile day (mean 38.9°C) and were more likely to have had prior infections than those with other causes of fever (mean 38.3°C, p<0.001). Older patients (>75 years) had a lower febrile response to bacterial infections than younger patients. Fever in hospitalized medical patients is a common and important concomitant of increased mortality and length of hospitalization. Supported in part by grants from the National Center for Health Services Research (HS 02063 and HS 04066) and by a grant from the Henry J. Kaiser Family Foundation. The work was performed, in part, while Dr. Bor was a Henry J. Kaiser Fellow in General Medicine, Harvard Medical School.     

Hypovitaminosis C in hospitalized patients

BACKGROUND: In recent years, cases of scurvy have mainly been described in populations at risk. The prevalence and risk factors for hypovitaminosis C among hospitalized patients in a department of internal medicine are largely unknown. METHODS: We determined serum ascorbic acid level (SAAL) and searched for clinical and biological signs of scurvy in 184 patients hospitalized during a 2-month period. RESULTS: The prevalence of hypovitaminosis C (depletion: SAAL<5 mg/l or deficiency: SAAL<2 mg/l ) was 47.3%. Some 16.9% of the patients had vitamin C deficiency. There was a strong association between hypovitaminosis C and the presence of an acute phase response (p=0.002). Other univariate risk factors for vitamin C depletion were male sex (p=0.02), being retired (p=0.037), and infectious diseases (p=0.002). For vitamin C deficiency, the significant univariate risk factors included the same ones found for vitamin C depletion, plus being unemployed (p=0.003) and concomitant excessive alcohol and tobacco consumption (p<0.0001). Logistic regression showed that being retired (p=0.015) and concomitant excessive alcohol and tobacco consumption (p=0.0003) were significant independent risk factors. Hemorrhagic syndrome and edema were described more often in patients with vitamin C deficiency than in those with vitamin C depletion or without hypovitaminosis. Clinical signs were more frequent for an ascorbic acid level below 2.5 mg/l. CONCLUSION: Hypovitaminosis C is frequent in hospitalized patients but should be interpreted according to the presence or absence of an acute phase response. The main risk factors are living conditions and excessive alcohol and tobacco consumption.     

Death in shigellosis: incidence and risk factors in hospitalized patients

The total number of admissions and deaths of patients with shigellosis were ascertained at the Dhaka Treatment Centre of the International Centre for Diarrhoeal Disease Research, Bangladesh, 1974-1988, and the characteristics of 67 patients who died were compared with those of 134 discharged alive. Of 9780 Shigella-infected inpatients, 889 (9.1%) died; 32.3% of deaths occurred in children less than 1 year of age. Fatality rates were highest (10.3%) in Shigella sonnei-infected patients and lowest (6.7%) in Shigella dysenteriae type 1-infected patients. Age less than 1 year, lack of breast feeding in patients 1-2 years of age, hypothermia, severe malnutrition, severe dehydration, altered consciousness, abdominal distension, thrombocytopenia, hypoproteinemia, hyponatremia, hypoglycemia, renal failure, and bacteremia were all significantly more common in case patients. In a multivariate analysis, younger age, decreased serum protein, altered consciousness, and thrombocytopenia were predictive of death. Thus in Bangladesh the fatality rate for hospitalized patients infected with any species of Shigella remains high despite relatively intensive inpatient care, and young, hypoproteinemic patients are at greatest risk of fatal illness.     

Candida-associated diarrhea in hospitalized patients

Ten hospitalized patients with severe diarrhea associated with intestinal Candida overgrowth are reported. Candida-associated diarrhea is predominantly of the secretory type, characterized by frequent watery stools, usually without blood, mucus, tenesmus, or abdominal pain. The patients were elderly, malnourished, and critically ill, or suffered from chronic debilitating illness. Their hospital stays were prolonged, and the majority were being treated with multiple antibiotics or chemotherapeutic agents. Diarrhea often led to dehydration, prerenal azotemia, hyperchloremic metabolic acidosis, and electrolyte imbalance. Stool culture most frequently isolated Cand. albicans in association with decreased normal flora. Colonoscopy showed no evidence of colitis. Diagnosis was made based on the absence of diarrhea-producing medications, the continuation of diarrhea despite fasting, the exclusion of other infections, inflammatory conditions and other causes of secretory diarrhea, and a dramatic response to a short course of nystatin.     

Undiagnosed tuberculosis in hospitalized patients

Eighty-two cases of active tuberculosis (TB) were diagnosed only at autopsy in patients hospitalized in the Chaim Sheba Medical Center during a 21-year period (1960 to 1980). Some 75 percent of the patients were over 50 years old and a large number of them suffered from accompanying diseases or drug therapy which suppresses the immune system. Diagnostic measures for the confirmation of tuberculosis (skin tests; cultures of sputum, urine, gastric juice; liver biopsy) were not taken in 75 percent of the cases. In those taken, skin tests were negative in 75 percent of cases, most probably as a sign of anergy. The rest were borderline cases in whom the diagnosis of TB was not accepted affirmatively.     

Severe hypophosphatemia in hospitalized patients

Severe hypophosphatemia (serum phosphorus less than or equal to 0.48 mmol/L [less than or equal to 1.5 mg/dL]) was found in 120 patients admitted to a major university hospital, during a period of 16 months. Fifty-one patients (42.5%) developed hypophosphatemia postoperatively. Medications known to precipitate hypophosphatemia were a causative factor in 82% of the patients, with glucose administered intravenously, antacids, diuretics, and steroids being the most common agents associated with profound hypophosphatemia. Gram-negative septicemia was observed in 16 patients, and it was the second most common cause of severe hypophosphatemia. The mortality rate was 20% in patients with a serum phosphorus concentration between 0.36 and 0.48 mmol/L (1.1 and 1.5 mg/dL) (group A) and 30% in patients with a serum phosphorus concentration of less than or equal to 0.32 mmol/L (less than or equal to 1.0 mg/dL) (group B). The cause of death and its temporal association with the lowest observed values of phosphorus concentration indicate that severe hypophosphatemia might be a contributory factor to mortality. Our data indicate that severe hypophosphatemia in hospitalized patients is the result of a combination of factors. Surgery, followed by a period of fasting with intravenous administration of glucose, and gram-negative septicemia are the most common causes.     

Homocysteine and disability in hospitalized geriatric patients

Elevated total homocysteine (tHcy) concentrations have been found to be associated with cardiovascular disease and dementia in old age. The present study was performed to identify the prevalence of hyperhomocysteinemia (HHcy) and to analyze the association between tHcy concentration and sociodemographic characteristics, nutritional parameters, and cognitive and functional status in this sample of hospitalized geriatric patients. A total of 214 patients (77% females) 65+ years old admitted into an acute care geriatric ward of an internal medical department in the Northern Italy were studied. tHcy concentration was measured using a high-performance liquid chromatography with fluorescence detection (HPLC-F). Information about nutrition (body mass index [BMI], serum albumin, cholesterol, and transferrin) was collected on admission. Functional status was investigated with the Basic Activities of Daily Living scale (ADL) and the Instrumental Activities of Daily Living scale (IADL); cognitive and affective status were assessed by the Mini-Mental State Evaluation (MMSE) and the Geriatric Depression Scale (GDS). The mean tHcy concentration was 18.4 +/- 13.1 micromol/L; 74.2% of males and 68.9% of females had HHcy (> 12 micromol/L). Sixty-four percent of patients with normal serum vitamin B12 and folate concentrations had HHcy. Elevated tHcy concentrations were associated with older age, male gender, increasing serum creatinine, lower MMSE score, and disability. The mean tHcy concentration depended on the occurrence of different diseases. Patients affected by atherosclerotic diseases, such as ischemic heart diseases, cerebrovascular diseases, and dementia had higher mean tHcy concentration than those without diagnosed vascular diseases. In multivariate analysis, vitamin B12, folate, serum albumin, creatinine, and disability emerged as factors associated with tHcy, adjusted for age, gender, education, MMSE score, and atherosclerotic diseases. Our results suggest that the prevalence of HHcy in hospitalized patients is very high, even in subjects with normal cobalamin and folate concentrations. High Hcy concentration can be associated with functional impairment.     

Validity,test-retest reliability,sensitivity to change and feasibility of motor-cognitive dual task assessments in patients with dementia

ObjectiveTo investigate validity, test-retest reliability, sensitivity to change, and feasibility of dual task (DT) assessments in patients with dementia.DesignValidation study.SettingPost ward-rehabilitation.ParticipantsGeriatric patients (n = 105) with dementia (age 82.7 ± 5.9, MMSE score 21.9).Main outcome measuresPsychometric quality of DT performance of different DT-tests. Analyses were performed for motor and cognitive performance, and relative DT costs (DTCs).ResultsSpearman’s rank correlations (r_s) between examined DT-tests were moderate-high for motor tasks (r_s = 0.29–0.90), small-high for cognitive tasks (r_s = 0.12–0.55) and small-high for relative DTCs (motor DTCs r_s = 0.02-0.61, cognitive DTCs r_s = −0.19 to 0.06, combined DTCs r_s = −0.11 to 0.31). Correlations with external assessment were moderate-high for motor tasks (r_s = 0.25–0.84), small-moderate for cognitive tasks (r_s = −0.10 to 0.46) and small-moderate for relative DTCs (motor DTCs r_s = −0.09 to 0.17, cognitive DTCs r_s = −0.03 to 0.21, combined DTCs r_s = −0.07 to 0.26).Test-retest reliability was excellent for motor tasks (ICC = 0.75–0.96), fair-excellent for cognitive tasks (ICC = 0.51–0.88) and poor-good for relative DTCs (motor DTCs ICC = 0.10–0.74, cognitive DTCs ICC = 0.05–0.65, combined DTCs ICC = 0.15–0.71).Sensitivity to change was acceptable-excellent for trained DT-tests (p ≤ 0.01). Effect sizes were small-large for gait parameters (SRM = 0.30–1.12), large for cognitive tasks (SRM = 0.82–0.95) and small-large for relative DTCs (motor DTCs SRM = 0.15–0.77, cognitive DTCs SRM = 0.56-0.98, combined DTCs SRM = 0.40–1.10).Completion time ranged from 13.1 to 16.9 min.ConclusionsAll DT-tests showed acceptable-excellent psychometric properties in patients with dementia with highest quality for the gait-based tests ‘Walking & Counting’ and ‘Walking & reciting ABC’.     

Resuscitation of hospitalized patients

Effects of in-hospital resuscitations performed by a trained resuscitation team were studied over a 20-month period during which 1653 deaths were registered. Resuscitative attempts were made in 61 patients with a mean age of 71 years (range 0-86 years). The underlying disease was ischaemic heart disease in 38 cases and most arrests occurred in general wards. Twenty-one patients were initially resuscitated; 12, however, died after an average of 3.2 days while still in hospital. Nine patients were discharged and seven are still alive after two and a half years.     

Vitamin D deficiency in hospitalized patients

Vitamin D deficiency is one of the important risk factors for the development of osteoporosis and fractures. The high prevalence of hypovitaminosis in elderly people in old age pnesioners homes was proved in several investigations, similarly as the favourable effect of vitamin D (800 IU/day) and calcium supplementation on a decline of fracture risk. Risk factors of hypovitaminosis such as an inadequately varied diet; low exposure to sunlight, chronic liver and kidney disease and treatment affecting the metabolism and clearance of vitamin D are very frequent in elderly patients hospitalized in medical departments. In the submitted trial the authors assessed in a group of 38 patients, mean age 70 years, hospitalized at the medical department at the end of the winter period the vitamin D3 serum level. They found a significant reduction of the concentration of 1.25 hydroxyvitamin D3 (p < 0.01) in the investigated group. The results of the trial, along with data in the literature on the high prevalence of hypovitaminosis D in the European population, indicate the need to introduce this simple cheap and safe therapeutic modality into routine practice.     

Protein-calorie undernutrition in hospitalized cancer patients

A survey of the nutritional status of hospitalized cancer patients was conducted in two phases. In phase 1, protein-calorie nutrition was evaluated in 54 ward patients by anthropometries, creatinine excretion and serum albumin. In phase two, 30 cancer patients with protein-calorie undernutrition were transferred to the Clinical Research Unit for study of the underlying mechanisms. Evaluation in this group included anthropometries, serum albumin, creatinine excretion, vitamin levels, caloric intake, basal metabolic rate and stool fat content. Duration of survival from study was recorded in both phases.We found a nearly universal prevalence of protein-calorie undernutrition in advanced cancer, with loss of adipose tissue, visceral protein and skeletal muscle varying unpredictably from patient to patient. The creatinine to height ratio was the most sensitive indicator of protein-calorie undernutrition; 88 per cent of the patients in both phases had a creatinine to height ratio less than 80 per cent of standard, whereas only 42 per cent and 23 per cent of these patients had values less than 80 per cent of standard for triceps skin fold and mid-arm muscle area, respectively. In phase 2, plasma folate, ascorbic acid and vitamin A levels were low in 20 to 45 per cent. Steatorrhea was rare. Neither the basal metabolic rate nor caloric intake differed from expected values for normal sedentary subjects of comparable size.The degree of malnutrition significantly correlated with survival. Patients who died within 70 days of study generally had a creatinine to height ratio <60 per cent of standard (18 of 19 patients), albumin <3.5 g/dl (16 of 23 patients) and/or triceps skin fold thickness <60 per cent of standard (12 of 19 patients).We conclude that protein-calorie undernutrition is present in most hospitalized cancer patients but that it varies widely in degree between subjects and is often obscured at the bedside by residual obesity. The creatinine to height ratio, however, is a sensitive quantitative indicator of this condition. There appear to be nutritional thresholds below which survival is decreased. Survival might be enhanced if nutrition could be maintained above these critical levels.     

Incidence of sepsis in hospitalized patients

In recent years, several epidemiological studies have helped expand our knowledge of the incidence of sepsis at the intensive care unit (ICU) and population levels. However, more data are needed from developing countries. Overall, even with a lack of standardized definitions—particularly of sepsis-associated organ dysfunction, hypoperfusion or hypotension, and septic-induced cardiovascular failure despite adequate fluid resuscitation—the incidence of sepsis seems higher in Brazil, the United Kingdom, and Portugal. In the future, in order to better identify patients that need early ICU admission, aggressive care, and new therapies, we must develop and apply better instruments for definition and risk stratification, especially for evaluating the risk of progressing from sepsis to severe sepsis and septic shock.     

Severe hypokalemia in hospitalized patients.

Profound hypokalemia was observed in 73 patients in a major university teaching hospital during a three-year period. When compared with hospitalized subjects used as controls, these patients experienced a greater mortality, were substantially more likely to be female, but were not more likely to suffer from cardiovascular disease. Use of a diuretic appeared to precipitate profound hypokalemia infrequently, and when it did, the clinical situation was extremely complex. Over 10% of the patients with hypokalemia had acute myeloid leukemia, an incidence 22 times greater than that expected. Hypokalemia should be sought in all patients with this disease, since it is an avoidable cause of death. Further studies into the mechanism of hypokalemia are required to explain its striking preponderance in women.     

Percutaneous endoscopic gastrostomy: high mortality rates in hospitalized patients

OBJECTIVE: Percutaneous endoscopic gastrostomy (PEG) is a widely used method for insertion of a gastrostomy tube in patients who are unable to eat but have a normally functioning gut. Complications have been described, especially in fragile, debilitated patients, and 30-day mortality rates of 4.1-26% have been reported. We assessed the outcome of PEG tube placement for inpatients and outpatients, based on morbidity, mortality, and long-term survival. METHODS: We reviewed the medical records of all patients who underwent PEG at our institution between January 1, 1995 and December 31, 1996. Four groups of patients were compared: Group 1, patients from nursing homes; Group 2, hospitalized patients; Group 3, hospitalized patients matched to Group 2 for diseases, except mental disorder, and not treated with PEG; and Group 4, the general hospital population matched for age. RESULTS: A total of 114 PEG tubes were inserted in 114 patients, 47 from Group 1, 67 from Group 2. Eighty-seven percent of patients in Group 1 underwent PEG because of dementia, versus 46% of Group 2 (p<0.001). The mortality rate was five times higher in Group 2 than in Group 3 (p<0.001). The 30-day mortality was seven times higher in Group 2 than in Group 1, twice that in Group 3, and five times higher than in Group 4 (p = 0.002 and p<0.001, respectively). When intention-to-treat analyses were applied to the data, 19/48 patients died (39.5%) in Group 1, and 60/83 (72.0%) died in Group 2, (p<0.001). CONCLUSIONS: Patients hospitalized with acute illness are at high risk for serious adverse events after PEG insertion and this procedure should be avoided.     

Acute-on-chronic kideny injury in hospitalized patients:a clinical survey

Objective To investigate the incidence and risk factors of acute-on-chronic kidney(A-on-C) in hospitalized patients. Methods We did a retrospective study on the clinical profiles of patients with A-on-C hospitalized in Affiliated Renji Hospital of Shanghai Jiaotong University