Prediction of five-year survival for patients admitted to a department of internal medicine

OBJECTIVE: The effect of many common forms of therapy, as medication for mild hypertension or hypercholesterolaemia, only reaches clinical significance after years of treatment. The meaningful application of such therapy presupposes that physicians can, at least to some extent, predict the remaining lifetime of patients. We investigated whether clinicians from different disciplines were able to predict the 5-year survival of patients admitted to a department of internal medicine. DESIGN: The members of two groups, each consisting of an internist, a surgeon and a general practitioner, made individual predictions of the expected remaining lifetime of discharged patients from written summaries of clinical information. Each patient was randomized to be assessed by the members of either of the two groups. The predictions were compared with actual 5-year survival. SETTING: Department of internal medicine at a university hospital. SUBJECTS: Patients admitted consecutively during a 6-week period. MAIN OUTCOME MEASURES: Sensitivity, specificity, positive and negative predictive values and areas under the receiver operating characteristic (ROC) curves for predictions of 5-year survival for each of the six experts. RESULTS: A total of 402 patients were included. Five-year survival was 0.63. The sensitivity of the predictions ranged from 0.81 to 0.95, the specificity from 0.61 to 0.77, the positive predictive value from 0.78 to 0.87 and the negative predictive value from 0.68 to 0.87. The areas under the ROC curves ranged from 0.84 to 0.91. CONCLUSION: The quality of predictions of 5-year survival made by experienced clinicians should permit the rational use of treatments with long-term effects.     

Effect of postural changes on aldosterone to plasma renin ratio in patients with suspected secondary hypertension

AimsTo study the influence of postural changes on aldosterone to renin ratio (ARR) in patients with suspected secondary hypertension and to evaluate the sensitivity and specificity of the recommended seated ARR compared to supine and upright ARR for primary aldosteronism screening.MethodsFifty-three hypertensive patients were prospectively hospitalized for secondary hypertension exploration (age: 51 ± 12, 66% males). After withdrawal of drugs interfering with renin angiotensin system, plasma aldosterone and direct renin concentration were measured in the morning, at bed after an overnight supine position, then out of bed after 1 hour of upright position and finally 2 hours later after 15 minutes of seating. Minimal renin value was set at 5 μUI/mL.ResultsReferring to ARR cut-off of 23 pg/μUI, the sensitivity of seated ARR was 57.1% and specificity was 92.3%. The negative and positive predictive values were 95.1% and 45.2% respectively. Compared to these results, a cut-off of 19 improved sensitivity to 85.7% with a specificity of 89.7%. Negative and positive predictive values were 98.3% and 41.1% respectively. Seated ARR mean value was lower than supine and upright ARR mean values, due to an overall increase in renin at seating compared to the supine position by factor 1.9 while aldosterone just slightly increased by factor 1.2. Seated ARR correlated to supine and upright ARR: correlation coefficients (r) 0.90 and 0.93 respectively (P < 0.001).ConclusionsCurrent recommended measurement of ARR in the seating position is fairly correlated to supine and upright ARR. A suggested cut-off value of 19 instead of 23 pg/μUI increased the discriminating power of this test.     

The diagnostic accuracy of plasma BNP and NTproBNP in patients referred from primary care with suspected heart failure: results of the UK natriuretic peptide study

OBJECTIVES: To determine the diagnostic accuracy of the measurement of plasma B-type natriuretic peptide (BNP) and N-terminal pro-BNP (NTproBNP) in patients referred by their general practitioners (GPs) with symptoms suggestive of heart failure. Additionally, to compare the diagnostic accuracy of the resting 12-lead electrocardiogram (ECG) with that of the peptides. DESIGN: A diagnostic accuracy study. SETTING: Rapid-access heart failure clinics in five hospitals. PARTICIPANTS: 306 patients referred by their GPs with suspected heart failure. MAIN OUTCOME MEASURES: Sensitivity, specificity, positive and negative predictive values (PPV and NPV) and positive and negative likelihood ratios for BNP, NTproBNP and the ECG for the diagnosis of heart failure. Area under the receiver operating characteristics (ROC) curves for the two natriuretic peptides. RESULTS: The diagnosis of heart failure was confirmed in 104 (34%) patients. The area under the ROC curve was 0.84 [95% CI 0.79-0.89] for BNP and 0.85 [0.81-0.90] for NTproBNP. At the manufacturers' recommended decision cut-points, NTproBNP provided a higher NPV (0.97) than BNP (0.87), but at lower PPV (0.44 versus 0.59). An abnormal ECG did not add any further predictive value to that of NTproBNP. CONCLUSIONS: We have confirmed the value of the measurement of plasma BNP or NTproBNP as a 'rule-out' test for heart failure in patients currently referred by GPs to rapid access diagnostic clinics. A simple classification of the 12-lead ECG into 'normal' or 'abnormal' adds little value to ruling out heart failure in these circumstances. Further work is necessary to establish the best decision cut-points for use in clinical practice.     

High prevalence of autoimmune thyroid diseases in patients with prolactinomas: A cross-sectional retrospective study in a single tertiary referral centre

BackgroundProlactin has been shown to exert potent immunomodulatory activities.DesignRetrospective cross-sectional study examining the prevalence of autoimmune thyroid diseases (AITD) in patients with prolactinomas. The medical files of 462 patients (367 women and 95 men) followed up at a single tertiary referral centre were analyzed.ResultsThe prevalence of AITD among prolactinoma patients was estimated at 21.0% (23.2% in females and 12.6% in males). In 51.5% of the patients, diagnosis of prolactinoma preceded the development of AITD; in 37.2%, both diseases were simultaneously diagnosed and 11.3% of patients were diagnosed first with AITD. Hyperthyroidism was observed in 1.24% of the investigated subjects. Primary hypothyroidism was detected in 15.6% of all patients (16.4% in women; 10.7% in men) with a mean incidence of 24 cases/1000/year.ConclusionsOur results demonstrate the high frequency of AITD in patients with prolactinomas. The prevalence rate of hyperthyroidism is comparable with the literature data from community-based studies. In contrast, the prevalence of the spontaneous hypothyroidism due to autoimmune thyroiditis is significantly higher in female and male subgroups of patients with prolactinomas in comparison with the general population. A possible role of supraphysiologically increased prolactin levels in the pathogenesis and the clinical course of AITD in patients with prolactinomas can be suggested. Based on these findings we recommend routine screening for AITD with simple thyroid tests (TSH, TPO-Abs and ultrasound examination) in all patients diagnosed with prolactinoma.     

A novel organizational model to face the challenge of multimorbid elderly patients in an internal medicine setting: a case study from Parma Hospital,Italy

Continuous increase of elderly patients with multimorbidity and Emergency Department (ED) overcrowding are great challenges for modern medicine. Traditional hospital organizations are often too rigid to solve them without consistently rising healthcare costs. In this paper we present a new organizational model achieved at Internal Medicine and Critical Subacute Care Unit of Parma University Hospital, Italy, a 106-bed internal medicine area organized by intensity of care and specifically dedicated to such patients. The unit is partitioned into smaller wards, each with a specific intensity level of care, including a rapid-turnover ward (mean length of stay <4 days) admitting acutely ill patients from the ED, a subacute care ward for chronic critically ill subjects and a nurse-managed ward for stable patients who have socio-economic trouble preventing discharge. A very-rapid-turnover (“come’n’go”) ward has also been instituted to manage sudden ED overflows. Continuity, effectiveness, safety and appropriateness of care are guaranteed by an innovative figure called “flow manager,” with skilled clinical experience and managerial attitude, and by elaboration of an early personalized discharge plan anticipating every patient’s needs according to lean methodology principles. In 2012–2014, this organizational model, compared with other peer units of the hospital and of other teaching hospitals of the region, showed a better performance, efficacy and effectiveness indexes calculated on Regional Hospital Discharge Records database system, allowing a capacity to face a massive (+22 %) rise in medical admissions from the ED. Further studies are needed to validate this model from a patient outcome point of view.     

Predictors of clock drawing test (CDT) performance in elderly patients attending an internal medicine outpatient clinic: a pilot study on sun exposure and physical activity

Influence of sun exposure and physical activity on cognition has not been evaluated simultaneously. We aimed to evaluate predictors of clock drawing test (CDT) performance on n = 125 patients attending an internal medicine outpatient clinic. Interview data was gathered on sociodemographic, health-related and lifestyle factors referring to the last year. Factors associated with obtaining a score >0 and a full score (10/10) were analyzed by univariate (UVA) and multivariate (MVA) logistic regression analyses. Mean age of the participants was 72 ± 5, 58% were women and 17% were illiterate. Mean CDT score was 4.70 ± 2.27, 61.6% scored >0 and 21.6% scored 10/10. Both duration of walking and summer sun exposure predicted a CDT score >0 in UVA. However only summer sun exposure was an independent predictor (odds ratio = OR = 1.73, 95% confidence interval = CI = 1.16-2.57). Other factors independently associated with obtaining a score >0 were education level (OR = 2.70, 95%CI = 1.77-4.12) and cerebrovascular disease (CVD) history (OR = 0.08, 95%CI = 0.008-0.78). Factors independently associated with obtaining a full score were weight (OR = 1.05, 95%CI = 1.00-1.10), education level (OR = 2.04, 95%CI = 1.38-3.00) and visiting the clinic alone (OR = 3.92, 95%CI = 1.354-11.39). Our study shows that CDT can be utilized to unravel the lifestyle factors associated with cognitive function. To our knowledge, this is the first study to suggest an association between sun exposure and cognition.     

Derivation and external validation of a simple risk score to predict in-hospital mortality in patients hospitalized for COVID-19: A multicenter retrospective cohort study

As severe acute respiratory syndrome coronavirus 2 continues to spread, easy-to-use risk models that predict hospital mortality can assist in clinical decision making and triage. We aimed to develop a risk score model for in-hospital mortality in patients hospitalized with 2019 novel coronavirus (COVID-19) that was robust across hospitals and used clinical factors that are readily available and measured standardly across hospitals.In this retrospective observational study, we developed a risk score model using data collected by trained abstractors for patients in 20 diverse hospitals across the state of Michigan (Mi-COVID19) who were discharged between March 5, 2020 and August 14, 2020. Patients who tested positive for severe acute respiratory syndrome coronavirus 2 during hospitalization or were discharged with an ICD-10 code for COVID-19 (U07.1) were included. We employed an iterative forward selection approach to consider the inclusion of 145 potential risk factors available at hospital presentation. Model performance was externally validated with patients from 19 hospitals in the Mi-COVID19 registry not used in model development. We shared the model in an easy-to-use online application that allows the user to predict in-hospital mortality risk for a patient if they have any subset of the variables in the final model.Two thousand one hundred and ninety-three patients in the Mi-COVID19 registry met our inclusion criteria. The derivation and validation sets ultimately included 1690 and 398 patients, respectively, with mortality rates of 19.6% and 18.6%, respectively. The average age of participants in the study after exclusions was 64 years old, and the participants were 48% female, 49% Black, and 87% non-Hispanic. Our final model includes the patient''s age, first recorded respiratory rate, first recorded pulse oximetry, highest creatinine level on day of presentation, and hospital''s COVID-19 mortality rate. No other factors showed sufficient incremental model improvement to warrant inclusion. The area under the receiver operating characteristics curve for the derivation and validation sets were .796 (95% confidence interval, .767–.826) and .829 (95% confidence interval, .782–.876) respectively.We conclude that the risk of in-hospital mortality in COVID-19 patients can be reliably estimated using a few factors, which are standardly measured and available to physicians very early in a hospital encounter.     

Advantages of serum pepsinogen A combined with gastrin or pepsinogen C as first-line analytes in the evaluation of suspected cobalamin deficiency: a study in patients previously not subjected to gastrointestinal surgery

Lindgren A, Lindstedt G, Kilander AF (Borås Central Hospital and Sahlgrenska University Hospital, Göteborg, Sweden). Advantages of serum pepsinogen A combined with gastrin or pepsinogen C as first-line analytes in the evaluation of suspected cobalamin deficiency: a study in patients previously not subjected to gastrointestinal surgery. J Intern Med 1998; 244 : 341–349.

Objectives

Since there is a significant overlap in serum cobalamin concentrations between healthy and cobalamin-deficient individuals, we wanted to compare two different principles for use as supplementary tests to serum cobalamin concentration in patients with suspected cobalamin malabsorption and deficiency.

Design

Clinical study of consecutive patients.

Setting

The catchment area of Sahlgrenska University Hospital, Göteborg.

Subjects

A total of 112 patients with suspected cobalamin deficiency who had not previously undergone gastrointestinal surgery.

Interventions

Gastroduodenoscopy with biopsies taken from the gastric body and the duodenum, Schilling test, and measurement of serum methylmalonic acid (MMA), total homocysteine (Hcy), pepsinogens A and C, and gastrin.

Main outcome measures

Number of patients with gastric body atrophy identified with the combination of MMA and Hcy, and pepsinogen A combined with pepsinogen C or gastrin.

Results

About 95% of the patients with severe gastric body atrophy had abnormal concentrations of serum pepsinogen A and/or gastrin or pepsinogen A/C ratio, whereas 65% had abnormal metabolite concentrations. Serum pepsinogen A combined with pepsinogen C identified 100%, and combined with gastrin 88%, of the patients with gastric body atrophy and elevated metabolite tests, and 67 and 75%, respectively, of those who had not yet developed elevated metabolite tests.

Conclusions

Pepsinogen A, combined with pepsinogen C or gastrin, should be the first option in evaluating patients with suspected cobalamin deficiency who have not previously undergone gastrointestinal surgery.