Internal and Emergency Medicine

Ảnh hưởng của việc sàng lọc bệnh động mạch vành không triệu chứng (CAD) tới dự đoán tim mạch ở bệnh tiểu đường còn gây tranh cãi. Mục tiêu của nghiên cứu này là điều tra xem sàng lọc bệnh động mạch vành không triệu chứng có thể ảnh hưởng đến bệnh tật và tỷ lệ tử vong tim mạch trong bệnh tiểu đường hay không. Trong nghiên cứu nhóm không ngẫu nhiên này, 1.189 bệnh nhân tiểu đường type 2 liên tiếp không có tiền sử CAD đã được đánh giá. Họ được chia thành hai nhóm dựa trên việc có được sàng lọc (nhóm sàng lọc, n = 921) hay không (nhóm không sàng lọc, n = 268) đối với CAD không triệu chứng. Trong số các bệnh nhân được sàng lọc, 386 người có CAD được chứng minh bằng hình ảnh động mạch (nhóm CAD) và 535 người không có CAD âm thầm (nhóm không-CAD). Trong khoảng thời gian theo dõi trung bình 4.3 ± 1.9 năm, 130 bệnh nhân đã trải qua các sự kiện tim mạch nghiêm trọng (MACE). Tỷ lệ MACE cao hơn đáng kể ở nhóm không sàng lọc so với nhóm sàng lọc (22.0 so với 7.7%; p = 0.001). Phương pháp Kaplan–Meier cho thấy: (1) việc sàng lọc có liên quan đến tỷ lệ MACE thấp hơn (kiểm định log-rank, 3–95; p = 0.047); (2) nhóm không sàng lọc có hồ sơ nguy cơ tương tự như nhóm CAD (kiểm định log-rank, 2.02; p = 0.154); và (3) dự đoán tim mạch tốt hơn đáng kể ở nhóm không-CAD so với nhóm không sàng lọc (kiểm định log-rank, 4.27; p = 0.039). Phân tích hồi quy Cox đa biến cho thấy việc sàng lọc CAD (HR 0.2; 95% CI 0.2-0.3; p = 0.000) có tác dụng bảo vệ đáng kể chống lại sự xuất hiện của MACE. Dữ liệu của chúng tôi gợi ý rằng sàng lọc CAD không triệu chứng có thể làm giảm đáng kể bệnh tật và tỷ lệ tử vong tim mạch ở bệnh nhân tiểu đường type 2. Điều này có thể do các can thiệp chẩn đoán và điều trị cụ thể ở những bệnh nhân tiểu đường có CAD đã được chứng minh tại thời điểm sàng lọc.

We examined the characteristics of pro-calcitonin (PCT) in hospitalized COVID-19 patients (cohort 1) and clinical outcomes of antibiotic use stratified by PCT in non-critically ill patients without bacterial co-infection (cohort 2). Retrospective reviews were performed in adult, hospitalized COVID-19 patients during March–May 2020. For cohort 1, we excluded hospital transfers, renal disease and extra-pulmonary infection without isolated pathogen(s). For cohort 2, we further excluded microbiologically confirmed infection, ‘do not resuscitate ± do not intubate’ status, and intensive care unit (ICU). For cohort 1, PCT was compared between absent/low-suspicion and proven bacterial co-infections. Factors associated with elevated PCT and sensitivity/specificity/PPV/NPV of PCT cutoffs for identifying bacterial co-infections were explored. For cohort 2, clinical outcomes including mechanical ventilation within 5 days (MV5) were compared between the antibiotic and non-antibiotic groups stratified by PCT ≥ 0.25 µg/L. Nine hundred and twenty four non-ICU and 103 ICU patients were included (cohort 1). The median PCT was higher in proven vs. absent/low-suspicion of bacterial co-infection. Elevated PCT was significantly associated with proven bacterial co-infection, ICU status and oxygen requirement. For PCT ≥ 0.25 µg/L, sensitivity/specificity/PPV/NPV were 69/65/6.5/98% (non-ICU) and 75/33/8.6/94% (ICU). For cohort 2, 756/1305 (58%) patients were included. Baseline characteristics were balanced between the antibiotic and non-antibiotic groups except PCT ≥ 0.25 µg/L (antibiotic:non-antibiotic = 59%:24%) and tocilizumab use (antibiotic:non-antibiotic = 5%:2%). 23% (PCT < 0.25 µg/L) and 58% (PCT ≥ 0.25 µg/L) received antibiotics. Antibiotic group had significantly higher rates of MV5. COVID-19 severity inferred from ICU status and oxygen requirement as well as the presence of bacterial co-infections were associated with elevated PCT. PCT showed poor PPV and high NPV for proven bacterial co-infections. The use of antibiotics did not show improved clinical outcomes in COVID-19 patients with PCT ≥ 0.25 µg/L outside of ICU when bacterial co-infections are of low suspicion.

Medical divisions are at high risk of Clostridioides difficile infection (CDI) due to patients’ frailty and complexity. This sub-analysis of the FADOI-PRACTICE study included patients presenting with diarrhea either at admission or during hospitalization. CDI diagnosis was confirmed when both enzyme immunoassay and A and B toxin detection were found positive. The aim of this sub-analysis was the identification of a new score to predict CDI in hospitalized, medical patients. Five hundred and seventy-two patients with diarrhea were considered. More than half of patients was female, 40% on antibiotics in the previous 4 weeks and 60% on proton pump inhibitors (PPIs). CDI diagnosis occurred in 103 patients (18%). Patients diagnosed with CDI were older, more frequently of female sex, recently hospitalized and bed-ridden, and treated with antibiotics and PPIs. Through a backward stepwise logistic regression model, age > 65 years, female sex, recent hospitalization, recent antibiotic therapy, active cancer, prolonged hospital stay (> 12 days), hypoalbuminemia (albumin < 3 g/dL), and leukocytosis (white blood cells > 9 × 10^9/L) were found to independently predict CDI occurrence. These variables contributed to building a clinical prognostic score with a good sensitivity and a modest specificity for a value > 3 (79% and 58%, respectively; AUC 0.75, 95% CI 0.71–0.79, p < 0.001), that identified low-risk (score ≤ 3; 42.5%) and high-risk (score > 3; 57.5%) patients. Although some classical risk factors were confirmed to increase CDI occurrence, the changing landscape of CDI epidemiology suggests a reappraisal of common risk factors and the development of novel risk scores based on local epidemiology.

Medical specialty usage of COVID-19 survivors after hospital discharge is poorly understood. This study investigated medical specialty usage at 1–12 and 13–24 months post-hospital discharge in critically ill and non-critically ill COVID-19 survivors. This retrospective study followed ICU (N = 89) and non-ICU (N = 205) COVID-19 survivors who returned for follow-up within the Stony Brook Health System post-hospital discharge. Follow-up data including survival, hospital readmission, ongoing symptoms, medical specialty care use, and ICU status were examined 1–12 and 13–24 months after COVID-19 discharge. “New” (not previously seen) medical specialty usage was also identified. Essentially all (98%) patients survived. Hospital readmission was 34%, but functional status scores at discharge were not associated with hospital readmission. Many patients reported ongoing [neuromuscular (50%) respiratory (39%), chronic fatigue (35%), cardiovascular (30%), gastrointestinal (28%), neurocognitive (22%), genitourinary (22%), and mood-related (13%)] symptoms at least once 1–24 months after discharge. Common specialty follow-ups included cardiology (25%), vascular medicine (17%), urology (17%), neurology (16%), and pulmonology (14%), with some associated with pre-existing comorbidities and with COVID-19. Common new specialty visits were vascular medicine (11%), pulmonology (11%), and neurology (9%). ICU patients had more symptoms and follow-ups compared to the non-ICU patients. This study reported high incidence of persistent symptoms and medical specialty care needs in hospitalized COVID-19 survivors 1–24 months post-discharge. Some specialty care needs were COVID-19 related or exacerbated by COVID-19 disease while others were associated with pre-existing medical conditions. Longer follow-up studies of COVID-19 survivor medical care needs are necessary.

Hypoalbuminemia is frequently observed in hospitalized patients and it can be associated with several different diseases, including cirrhosis, malnutrition, nephrotic syndrome and sepsis. Regardless of its cause, hypoalbuminemia has a strong predictive value on mortality and morbidity. Over the years, the rationale for the use of albumin has been extensively debated and the indications for human serum albumin supplementation have changed. As the knowledge of the pathophysiological mechanisms of the pertinent diseases has increased, the indications for intravenous albumin supplementation have progressively decreased. The purpose of this brief article is to review the causes of hypoalbuminemia and the current indications for intravenous administration of albumin. Based on the available data and considering the costs, albumin supplementation should be limited to well-defined clinical scenarios and to include patients with cirrhosis and spontaneous bacterial peritonitis, patients with cirrhosis undergoing large volume paracentesis, the treatment of type 1 hepatorenal syndrome, fluid resuscitation of patients with sepsis, and therapeutic plasmapheresis with exchange of large volumes of plasma. While albumin supplementation is accepted also in other clinical situations such as burns, nephrotic syndrome, hemorrhagic shock and prevention of hepatorenal syndrome, within these contexts it does not represent a first-choice treatment nor is its use supported by widely accepted guidelines.