Diagnostic and prognostic value of thrombocytosis in admitted medical patients.

Am J Med Sci. 2011 Nov;342(5):395-401

Authors: Tchebiner JZ, Nutman A, Boursi B, Shlomai A, Sella T, Wasserman A, Guzner-Gur H

Abstract
INTRODUCTION: Whether secondary thrombocytosis is a distinguishing clinical biomarker of various diseases, and whether it is an independent predictor of short-term outcome of admitted medical patients is unknown and has never been examined.
METHODS: A cohort of all 138 patients with secondary thrombocytosis (platelets count ? 5 x 105/?L) admitted to the department of medicine during the last 2 years was analyzed. Epidemiological and clinical data, and the final diagnosis and outcome were recorded and compared with a cohort of 684 consecutive admitted patients without thrombocytosis.
RESULTS: Thrombocytosis was not a non-specific marker of inflammation, because uncomplicated infections and most admission causes were not associated with thrombocytosis, except for inflammatory rheumatic diseases (6% versus 1%), along with anemia (9.4% versus 2.5%) and tumor comorbidity (25% versus 14%). In contrast, thrombocytosis was a distinguishing biomarker for severe pyogenic infections, especially empyema (5% vs. 0%), any abscesses (14% versus 3%), and soft tissue infections (7% versus 3%). Moreover, the thrombocytosis group had significantly more admission days, infections (45% versus 33%), sepsis (21% versus 6%), in-hospital major complications (15% versus 3%) and mortality (19% versus 5%). Finally, thrombocytosis was found to be an independent predictor of mortality, in a multivariate regression analysis.
CONCLUSIONS: Thrombocytosis is not a simple marker of inflammation. Its presence warrants thorough investigation for the presence of severe underlying disease, mostly complicated pyogenic infections, inflammatory rheumatic diseases and malignancy. Moreover, thrombocytosis is a marker for major complications and is an independent predictor of mortality in admitted medical patients.

PMID: 21681080 [PubMed - indexed for MEDLINE]

Short-term effects of hypertonic saline solution in acute heart failure and long-term effects of a moderate sodium restriction in patients with compensated heart failure with New York Heart Association class III (Class C) (SMAC-HF Study).

Am J Med Sci. 2011 Jul;342(1):27-37

Authors: Paterna S, Fasullo S, Parrinello G, Cannizzaro S, Basile I, Vitrano G, Terrazzino G, Maringhini G, Ganci F, Scalzo S, Sarullo FM, Cice G, Di Pasquale P

Abstract
INTRODUCTION: Hypertonic saline solution (HSS) and a moderate Na restriction plus high furosemide dose showed beneficial effects in compensated heart failure (HF), in short and long terms. The study was aimed to verify the effects of this combination on hospitalization time, readmissions and mortality in patients in New York Heart Association (NYHA) class III.
METHOD: Chronic ischemic or nonischemic cardiomyopathy uncompensated patients with HF in NYHA III functional class with ejection fraction <40%, serum creatinine <2.5 mg/dL, blood urea nitrogen <60 mg/dL and reduced urinary volume were single-blind randomized in 2 groups: the first group received a 30-minute intravenous infusion of furosemide (250 mg) plus HSS (150 mL) twice daily and a moderate Na restriction (120 mmol); the second group received furosemide intravenous bolus (250 mg) twice a day, without HSS and a low Na diet (80 mmol); both groups received a fluid intake of 1000 mL/d. After discharge, the HSS group continued with 120 mmol Na/d; the second group continued with 80 mmol Na/d.
RESULTS: A total of 1771 patients (881 HSS group and 890 without HSS group) met inclusion criteria: the first group (881 patients), compared with the second (890 patients), showed an increase in diuresis and serum Na levels, a reduction in hospitalization time (3.5 + 1 versus 5.5 + 1 days, P < 0.0001) and, during follow-up (57 + 15 months), a lower rate in readmissions (18.5% versus 34.2%, P < 0.0001) and mortality (12.9% versus 23.8%, P < 0.0001); the second group also showed a significant increase in blood urea nitrogen and serum creatinine.
CONCLUSION: This study suggests that in-hospital HSS administration, combined with moderate Na restriction, reduces hospitalization time and that a moderate sodium diet restriction determines long-term benefit in patients with NYHA class III HF.

PMID: 21701268 [PubMed - indexed for MEDLINE]

The effect of urinary bladder catheterization on patient care in an internal medicine department.

Am J Med Sci. 2011 Jun;341(6):474-7

Authors: Shimoni Z, Mullerad M, Niven M, Feuchtwanger Z, Froom P

Recommendations for urinary catheterization in newly hospitalized patients are inconsistent and unclear.

PMID: 21412136 [PubMed - indexed for MEDLINE]

Primary care management of chronic obstructive pulmonary disease to reduce exacerbations and their consequences.

Am J Med Sci. 2010 Oct;340(4):309-18

Authors: Anzueto A

Exacerbations of chronic obstructive pulmonary disease (COPD)-acute worsenings of dyspnea, cough and/or sputum production beyond daily symptom variations, necessitating a change in treatment-account for most COPD-related morbidity, care burden and direct costs. Frequent exacerbations (especially those requiring emergency, inpatient or intensive care) reduce physical activity, accelerate lung function decline and increase mortality. This review profiles exacerbation diagnosis, treatment and reduction measures for primary care physicians. Chronic maintenance pharmacotherapy is important to reduce exacerbations. Tiotropium, a long-acting anticholinergic, and salmeterol/fluticasone, a long-acting ?-agonist/inhaled corticosteroid combination, are Food and Drug Administration-approved maintenance therapies to reduce exacerbations of COPD. Influenza and pneumonia vaccinations reduce infectious triggers; pulmonary rehabilitation reduces exacerbation recurrence. Acute exacerbation treatment (short-acting bronchodilators, systemic corticosteroids and/or antibiotics) should be complemented by long-term COPD maintenance therapy to reduce future exacerbations. Recognition of a COPD exacerbation signals primary care physicians to establish long-term COPD management to reduce morbidity, disability and mortality.

PMID: 20625276 [PubMed - indexed for MEDLINE]

Predictors of timely antibiotic administration for patients hospitalized with community-acquired pneumonia from the cluster-randomized EDCAP trial.

Am J Med Sci. 2010 Apr;339(4):307-13

Authors: Hsu DJ, Stone RA, Obrosky DS, Yealy DM, Meehan TP, Fine JM, Graff LG, Fine MJ

INTRODUCTION: To identify factors associated with timely initiation of antibiotic therapy for patients hospitalized with pneumonia. DESIGN: Secondary analysis of a cluster-randomized, controlled trial. SETTING: Thirty- two emergency departments (EDs) in Pennsylvania and Connecticut. SUBJECTS: Patients with a clinical and radiographic diagnosis of community-acquired pneumonia. INTERVENTIONS: From January to December 2001, EDs were randomly allocated to guideline implementation strategies of low (n = 8), moderate (n = 12), and high intensity (n = 12) to improve the initial site of treatment and the performance of evidence-based processes of care. Our primary outcome was antibiotic initiation within 4 hours of presentation, which at that time was the recommended process of care for inpatients. RESULTS: Of the 2076 inpatients enrolled, 1632 (78.6%) received antibiotic therapy within 4 hours of presentation. Antibiotic timeliness ranged from 55.6% to 100% (P < 0.001) by ED and from 77.0% to 79.7% (P = 0.2) across the 3 guideline implementation arms. In multivariable analysis, heart rate > or =125 per minute (OR = 1.6, 95% CI 1.1-2.3), respiratory rate > or =30 per minute (OR = 2.3, 95% CI 1.6-3.4), and aspiration pneumonia (OR = 3.7, 95% CI 1.1-12.7) were positively associated with timely initiation of antibiotic therapy, whereas a hematocrit <30% (OR = 0.6, 95% CI 0.4-1.0) was negatively associated with this outcome. CONCLUSIONS: Timely initiation of antibiotic therapy is associated primarily with patient-related factors that reflect severity of illness at presentation. Although this study demonstrates an opportunity to improve performance on this quality measure in nearly one quarter of inpatients with pneumonia, we failed to identify any modifiable patient, provider, or hospital level factors to target in such quality improvement efforts.

PMID: 20224313 [PubMed - indexed for MEDLINE]

New onset atrial fibrillation developing in medical inpatients.

Am J Med Sci. 2009 Mar;337(3):169-72

Authors: Chen SX, Amir KA, Bobba RK, Arsura EL

BACKGROUND: The outcome of patients who develop new onset atrial fibrillation (AF) after admission to an Internal Medicine service for acute medical illnesses is unknown. METHODS: In a retrospective review, we compared patients in the study group: patients who were admitted to hospital for acute medical illnesses and subsequently developed new onset AF during hospitalization, with a control group 1: patients whose admitting diagnosis was new onset AF and a control group 2: patients who were admitted for acute medical illnesses and never developed AF. We analyzed clinical characteristics and all-cause mortality rate during the first 30 days, 6 months, and 1 year after admission. RESULTS: The 1-year mortality rates in study group were significantly higher than control group 1 (62% versus 8%, P < 0.001) and control group 2 (62% versus 29%, P < 0.05). These results suggest that AF and acute medical illness both are risk factors for increased mortality. The odds ratios were 4.05 (P = 0.023) and 18.33 (P = 0.001) for AF and acute medical illnesses, respectively, indicating that acute medical illness is the better predictor for mortality. Troponin I levels were elevated in 46% of patients in study group versus 12% in control group 1 and 42% in control group 2 (P < 0.05). CONCLUSIONS: Medical inpatients who develop new onset AF during hospitalization for acute medical illnesses have an increased mortality when compared with patients who were admitted solely for new onset AF. Acute medical illness rather than AF plays a more important role on the increased mortality in this subset of patient population.

PMID: 19204559 [PubMed - indexed for MEDLINE]

Austrian syndrome (pneumococcal pneumonia, meningitis, and endocarditis): a case report.

Am J Med Sci. 2008 Oct;336(4):354-5

Authors: Dalal A, Ahmad H

This report describes a case of Austrian syndrome (pneumonia, meningitis, and endocarditis, as a result of Streptococcus pneumoniae infection). A computerized medline search was performed for review of literature. In the review of literature, 54 cases including our case were found. Complete clinical and microbiological information was available only for 20 cases. Most invasive pneumococcal infections occurred in debilitated middle aged men with chronic alcoholism. Native aortic valve insufficiency was the commonest cause of cardiac failure among these patients, requiring valve replacement. Austrian syndrome is seen infrequently in this antibiotic era but is still associated with a poor outcome. Hence early recognition and appropriate medical or combined medical-surgical treatment needs to be considered promptly.

PMID: 18854681 [PubMed - indexed for MEDLINE]

The value of pleural fluid analysis.

Am J Med Sci. 2008 Jan;335(1):7-15

Authors: Sahn SA

Pleural fluid analysis in isolation may have clinical value. To have the greatest diagnostic impact, the clinician must formulate a prethoracentesis diagnosis based on the clinical presentation, blood tests, and radiographic imaging. With this approach, a definitive or confident clinical diagnosis can be expected in up to 95% of patients. The information in this report should allow the clinician to achieve this goal.

PMID: 18195577 [PubMed - indexed for MEDLINE]

Fluoroquinolones in community-acquired pneumonia when tuberculosis is around: an instructive case.

Am J Med Sci. 2008 Feb;335(2):141-4

Authors: Grupper M, Potasman I

Fluoroquinolones are increasingly used for the treatment of community-acquired pneumonia. However, their use has been associated with a delay in the diagnosis and treatment of pulmonary tuberculosis. We describe the clinical and insightful bacteriological course of a 39-year-old patient with pulmonary tuberculosis who had presented as having community-acquired pneumonia and was treated empirically with levofloxacin. The case highlights a major problem associated with the indiscriminate use of fluoroquinolones.

PMID: 18277123 [PubMed - indexed for MEDLINE]