The role of cardiac troponin I as a prognosticator in critically ill medical patients: a prospective observational cohort study

INTRODUCTION: Myocardial injury is frequently unrecognized in intensive care unit (ICU) patients. Cardiac troponin I (cTnI), a surrogate of myocardial injury, has been shown to correlate with outcome in selected groups of patients. We wanted to determine if cTnI level measured upon admission is an independent predictor of mortality in a heterogeneous group of critically ill medical patients. METHODS: We conducted a prospective observational cohort study; 128 consecutive patients admitted to a medical ICU at a tertiary university hospital were enrolled. cTnI levels were measured within 6 h of admission and were considered positive (>0.7 ng/ml) or negative. A variety of clinical and laboratory variables were recorded. RESULTS: Both cTnI positive and negative groups were similar in terms of age, sex and pre-admission co-morbidity. In a univariate analysis, positive cTnI was associated with increased mortality (OR 7.0, 95% CI 2.44–20.5, p < 0.001), higher Acute Physiology and Chronic Health Evaluation (APACHE) II scores and a higher rate of multi-organ failure and sepsis. This association between cTnI and mortality was more pronounced among elderly patients (>65 years of age). Multivariate analysis controlling for APACHE II score revealed that elevated cTnI levels are not independently associated with 28-day mortality. CONCLUSION: In critically ill medical patients, elevated cTnI level measured upon admission is associated with increased mortality rate. cTnI does not independently contribute to the prediction of 28-day mortality beyond that provided by APACHE II

Case series: Point-of-Care Ultrasound Conducted by Medical Students During their First Clinical Rotation Changes Patients’ Primary Diagnosis and Management

Background: As point-of-care ultrasound (POCUS) becomes a standard of care procedure, medical schools around the world have started to seek the integration of POCUS courses into their curricula. This puts medical students in a unique position as they are trained in an area in which many physicians lack knowledge. This case series provides a glimpse into the capabilities of POCUS even when used by medical students. Methods: Fourth-year medical students at Ben-Gurion University of the Negev performed numerous POCUS exams during their first clinical rotation at Soroka University Medical Center in Israel. All students completed a course in basic POCUS training and were evaluated in a brief practical exam before entering their first clinical rotation. Four of the cases in which the students took part are presented in this case series. Results: The POCUS exam in the first case discovered pulmonary embolism in addition to the diagnosis of Cushing disease. In the second case, endocarditis could have been diagnosed three days earlier had a POCUS exam been performed. Case 3 demonstrates the additional contribution of POCUS to the decision-making process carried out by physicians and its superiority in quantifying and diagnosing pleural effusion compared to chest X-Ray. Case 4 indicated that POCUS is preferable over chest X-ray and auscultation for the diagnosis of pulmonary edema. Conclusion: This case series may emphasize the capabilities POCUS has when utilized in the standard physical examination and the importance of incorporating POCUS instruction in medical schools for new physicians to acquire this skill

Pocket Size Ultra-Sound versus Cardiac Auscultation in Diagnosing Cardiac Valve Pathologies: A Prospective Cohort

Background: Pocket-size ultrasound devices are used to perform focused ultrasound studies (POCUS). We compared valve malfunction diagnosis rate by cardiac auscultation to POCUS (insonation), both conducted by medical students. Methods: A prospective cohort study was conducted among subjects with and without clinically relevant valve dysfunction. Inclusion criteria for subjects with a clinically relevant valve dysfunction was based on the presence of at least one moderate severity valve pathology identified by echocardiography. Three final-year medical students examined the patients. Each subject underwent auscultation and a POCUS using a pocket-size ultrasound machine. Sensitivity and specificity were calculated. Results: The study included 56 patients. In 18 patients (32%) no valve pathology was found. Nineteen patients (34%) had at least two valvular pathologies. Sixty valve lesions were present in the entire cohort. Students' sensitivity for detecting any valve lesion was 32% and 64% for auscultation and insonation, respectively, and specificity was similar. The sensitivity for diagnosing mitral regurgitation, mitral stenosis, and aortic regurgitation rose significantly by using POCUS compared to auscultation alone. When using POCUS, students identified valvular pathologies in 22 cases (39%) from the patients with at least two valve dysfunctions, and none when using auscultation. Conclusions: Final-year medical students' competency to detect valve dysfunction by performing cardiac auscultation is poor. Cardiac ultrasound-focused training significantly improved medical students' sensitivity for diagnosing a variety of valve pathologies

Glatiramer Acetate-associated Refractory Immune Thrombocytopenic Purpura

We present a case of glatiramer acetate-associated refractory immune thrombocytopenic purpura (ITP) in a female patient with multiple sclerosis. A search of MEDLINE/PubMed did not find any connection between glatiramer acetate and thrombocytopenia, specifically ITP. The autoimmune reaction was resistant to conservative ITP treatment, and was eventually managed only by splenectomy. To the best of our knowledge, this is the first report of glatiramer acetate-associated ITP. Physicians should be aware of this condition, and consider performing routine blood counts at the beginning of glatiramer acetate treatment

Community-based serum chloride abnormalities predict mortality risk

Introduction This population-based study aimed to investigate the prognostic value of ambulatory serum chloride abnormalities, often ignored by physicians. Methods The study population included all non-hospitalized adult patients, insured by "Clalit" Health Services in Israel’s southern district, who underwent at least 3 serum chloride tests in community-based clinics during 2005–2016. For each patient, each period with low (≤97 mmol/l), high (≥107 mmol/l) or normal chloride levels were recorded. A Cox proportional hazards model was used to estimate the mortality risk of hypochloremia and hyperchloremia periods. Results 664,253 serum chloride tests from 105,655 subjects were analyzed. During a median follow up of 10.8 years, 11,694 patients died. Hypochloremia (≤ 97 mmol/l) was independently associated with elevated all-cause mortality risk after adjusting for age, co-morbidities, hyponatremia and eGFR (HR 2.41, 95%CI 2.16–2.69, pConclusion In the outpatient setting, hypochloremia is independently associated with an increased mortality risk. This risk is dose-dependent where the lower the chloride level, the higher is the risk

A Population-based Study of Peripartum Cardiomyopathy in Southern Israel: Are Bedouin Women a New High-risk Group?

Objectives Peripartum cardiomyopathy (PPCM) is a serious complication of pregnancy. Studies investigating the risk factors that worsen outcomes have yielded conflicting results. The goals of this study were to describe the clinical and echocardiographic characteristics of PPCM in a single tertiary center and to determine the prognostic factors associated with persistence of left ventricular (LV) dysfunction in these women. Study Design This retrospective cross-sectional population-based cohort study included all patients with PPCM confirmed by echocardiography who delivered at our center from 2004 to 2014. Two groups were compared to determine long-term maternal outcome: (1) those who recovered normal LV function; and (2) those with residual systolic LV dysfunction. Results There were 148,994 deliveries during the study period. Of these, 89,196 patients were Bedouin and 59,798 were non-Bedouin. Forty-six patients met the PPCM study inclusion criteria. The PPCM prevalence for the total deliveries was 1:3,239. The PPCM prevalence among Bedouin patients was 1:2,787 versus non-Bedouin patients of 1:4,983 (P=0.037). None of the women had pre-existing chronic hypertension, and there was no maternal death. Patients who had severe or moderate LV dysfunction at the clinical presentation of PPCM were less likely to regain normal LV function than those with mild dysfunction (81.2% versus 56.7%, P=0.009). Based on initial echocardiogram, a trend toward residual LV dysfunction was noted in patients with a dilated left ventricle as compared to those with a non-dilated left ventricle (18.8% versus 6.7%, P=0.32). A hypokinetic right ventricle was found in 15.2% of the women who suffered from PPCM. Conclusion In our cohort, Bedouin women may be at increased risk for PPCM, and patients with severe LV dysfunction have a lower chance of recovery from PPCM

A rare cause of postpartum acute hyponatremia

A previously healthy 24-year-old female underwent an emergent caesarean section without a major bleeding described. During the first post-operative days (POD) she complained of fatigue, headache and a failure to lactate with no specific and conclusive findings on head CT. On the following days, fever rose with a suspicion of an obstetric surgery-related infection, again with no evidence to support the diagnosis. On POD5 a new-onset hyponatremia was documented. The urine analysis suggested SIADH, and following a treatment failure, further investigation was performed and demonstrated both central hypothyroidism and adrenal insufficiency. The patient was immediately treated with hydrocortisone followed by levothyroxine with a rapid resolution of symptoms and hyponatremia. Further laboratory investigation demonstrated anterior hypopituitarism. The main differential diagnosis was Sheehan’s syndrome vs lymphocytic hypophysitis. Brain MRI was performed as soon as it was available and findings consistent with Sheehan’s syndrome confirmed the diagnosis. Lifelong hormonal replacement therapy was initiated. Further complaints on polyuria and polydipsia have led to a water deprivation testing and the diagnosis of partial central insipidus and appropriate treatment with DDAVP

The Risk of Rectal Temperature Measurement in Neutropenia

Background: Avoiding rectal thermometry is recommended in patients with neutropenic fever. Permeability of the anal mucosa may result in a higher risk of bacteremia in these patients. Still, this recommendation is based on only a few studies. Methods: This retrospective study included all individuals admitted to our emergency department during 2014–2017 with afebrile (body temperature <38.3°C) neutropenia (neutrophil count <500 cells/microL) who were over the age of 18. Patients were stratified by the presence or absence of a rectal temperature measurement. The primary outcome was bacteremia during the first five days of index hospitalization; the secondary outcome was in-hospital mortality. Results: The study included 40 patients with rectal temperature measurements and 407 patients whose temperatures were only measured orally. Among patients with oral temperature measurements, 10.6% had bacteremia, compared to 5.1% among patients who had rectal temperature measurements. Rectal temperature measurement was not associated with bacteremia, neither in non-matched (odds ratio [OR] 0.36, 95% confidence interval [CI] 0.07–1.77) nor in matched cohort analyses (OR 0.37, 95% CI 0.04–3.29). In-hospital mortality was also similar between the groups. Conclusions: Patients with neutropenia who had their temperature taken using a rectal thermometer did not experience a higher frequency of events of documented bacteremia or increased in-hospital mortality

Comparison of Clinical Characteristics and Prognosis in Patients with Right- and Left-sided Infective Endocarditis

Objective Right-sided endocarditis (RSE) accounts for 5%–10% of all cases of infective endocarditis (IE) and frequently has different etiological, pathogenetic, and clinical presentations compared with left-sided endocarditis (LSE). The aims of this study were to evaluate the epidemiologic and clinical characteristics and prognosis of RSE patients and to compare them with those of LSE patients. This study’s importance relates to the local understanding of RSE and LSE, since Israeli demographics are different compared to the Unites States and Europe with regard to intravenous drug abuse and rheumatic valvular disease prevalence. Material and Methods A retrospective cohort study of 215 patients with infective endocarditis was performed. The primary outcome was in-hospital mortality. The secondary outcomes were duration of hospitalization, recurrent hospitalization, recurrent infective endocarditis, and one-year mortality. Results Of the 215 patients in the study, 176 had LSE and 39 had RSE. The RSE patients were younger than the LSE patients (48.1±18.9 years versus 61.8±17.0 years, P<0.001). The most common pathogen in both groups was Staphylococcus aureus, which occurred more in the RSE group (51%) versus the LSE group (19%). In-hospital mortality was lower among patients with RSE (2.6% versus 17%, P<0.037). Conclusions Our study demonstrated an increasing percentage of RSE compared to LSE among patients with IE. Pacemaker lead infection has become the leading cause of RSE in intravenous drug users (IVDU), although less common in Southern Israel. The etiological and clinical differences between RSE and LSE are noteworthy. Patients with RSE have a better prognosis than those with LSE