Frailty and Sarcopenia Assessment upon HospitalAdmission to Internal Medicine Predicts Length ofHospital Stay and Re-Admission: A ProspectiveStudy of 980 Patients.

BACKGROUND: Frailty and sarcopenia are associated with frequent hospitalizations and poor clinical outcomes in geriatric patients. Ascertaining this association for younger patients hospitalized in internal medicine departments could help better prognosticate patients in the realm of internal medicine. METHODS: During a 1-year prospective study in an internal medicine department, we evaluated patients upon admission for sarcopenia and frailty. We used the FRAIL questionnaire, blood alanine-amino transferase (ALT) activity, and mid-arm muscle circumference (MAMC) measurements. RESULTS: We recruited 980 consecutive patients upon hospital admission (median age 72 years (IQR 65-79); 56.8% males). According to the FRAIL questionnaire, 106 (10.8%) patients were robust, 368 (37.5%) pre-frail, and 506 (51.7%) were frail. The median ALT value was 19IU/L (IQR 14-28). The median MAMC value was 27.8 (IQR 25.7-30.2). Patients with low ALT activity level (<17IU/L) were frailer according to their FRAIL score (3 (IQR 2-4) vs. 2 (IQR 1-3); p < 0.001). Higher MAMC values were associated with higher ALT activity, both representing robustness. The rate of 30 days readmission in the whole cohort was 17.4%. Frail patients, according to the FRAIL score (FS), had a higher risk for 30 days readmission (for FS > 2, HR = 1.99; 95CI = 1.29-3.08; p = 0.002). Frail patients, according to low ALT activity, also had a significantly higher risk for 30 days readmission (HR = 2.22; 95CI = 1.26-3.91; p = 0.006). After excluding patients whose length of stay (LOS) was ≥10 days, 252 (27.5%) stayed in-hospital for 4 days or longer. Frail patients according to FS had a higher risk for LOS ≥4 days (for FS > 2, HR = 1.87; 95CI = 1.39-2.52; p < 0.001). Frail patients, according to low ALT activity, were also at higher risk for LOS ≥4 days (HR = 1.87; 95CI = 1.39-2.52; p < 0.001). MAMC values were not correlated with patients' LOS or risk for re-admission. CONCLUSION: Frailty and sarcopenia upon admission to internal medicine departments are associated with longer hospitalization and increased risk for re-admission.

Beneficial effect of awake prone position in hypoxaemic patients with COVID-19: case reports and literature review.

We hereby present two case reports of moderate coronavirus disease patients, suffering from profound hypoxaemia, further deteriorating later on. A schedule pre-planned awake prone position manoeuvres were executed during their hospital stay. Following this, the patients' saturation improved, later to be weaned from oxygen support. Paucity of evidence and data regarding this topic led us to review the concept of awake prone position.

Clinical Characterization of 162 COVID-19 patients in Israel: Preliminary Report from a Large Tertiary Center.

BACKGROUND: In February 2020, the World Health Organisation designated the name COVID-19 for a clinical condition caused by a virus identified as a cause for a cluster of pneumonia cases in Wuhan, China. The virus subsequently spread worldwide, causing havoc to medical systems and paralyzing global economies. The first COVID-19 patient in Israel was diagnosed on 27 February 2020. OBJECTIVES: To present our findings and experiences as the first and largest center for COVID-19 patients in Israel. METHODS: The current analysis included all COVID-19 patients treated in Sheba Medical Center from February 2020 to April 2020. Clinical, laboratory, and epidemiological data gathered during their hospitalization are presented. RESULTS: Our 162 patient cohort included mostly adult (mean age of 52 ± 20 years) males (65%). Patients classified as severe COVID-19 were significantly older and had higher prevalence of arterial hypertension and diabetes. They also had significantly higher white blood cell counts, absolute neutrophil counts, and lactate dehydrogenase. Low folic acid blood levels were more common amongst severe patients (18.2 vs. 12.9 vs. 9.8, P = 0.014). The rate of immune compromised patients (12%) in our cohort was also higher than in the general population. The rate of deterioration from moderate to severe disease was high: 9% necessitated non-invasive oxygenation and 15% were intubated and mechanically ventilated. The mortality rate was 3.1. CONCLUSIONS: COVID-19 patients present a challenge for healthcare professionals and the whole medical system. We hope our findings will assist other providers and institutions in their care for these patients.

A Stroke in the Young with Surprising Recovery.

INTRODUCTION: The differential diagnosis of stroke in a comparatively young adult should always include cardiovascular aetiologies as well as central nervous system infection. CASE PRESENTATION: A 56-year-old man, with no significant medical history, presented with headache, nausea and vomiting, and right hemiparesis. Routine stroke investigation was initiated, while CNS infection was also sought. Diagnoses of HIV infection, neurosyphilis, HCV and HBV were established. Targeted therapy resulted in prompt clinical improvement. CONCLUSION: This case highlights the importance of considering CNS infection as a cause of neurological deficits in parallel with other investigations in cases of stroke in a comparatively young adult. LEARNING POINTS: The differential diagnosis should be wide for all patients presenting with stroke.Neurosyphilis should be included in the differential diagnosis of stroke in the young and middle-aged.Newly diagnosed HIV patients should be screened for other, sexually transmitted coinfection.

The 'SILENT Alarm': When History Taking Reveals a Potentially Fatal Toxicity.

INTRODUCTION: The combination of acute/sub-acute neurological and metabolic derangements should always raise the suspicion of toxicity, either endogenous or exogenous. The adverse effects of psychiatric medications are especially difficult to determine since the psychiatric background of patients is often inaccessible. CLINICAL PRESENTATION: A 66-year-old man presented to the emergency department with dysarthria and uncontrolled tremor, rapidly deteriorating into a complex of severe neurological and metabolic derangements. Only after repeated attempts to take a thorough history was lithium toxicity identified. CONCLUSION: Thorough, comprehensive history taking, including chronic medications and their substitutes, is essential and lifesaving when potentially lethal medications are involved. LEARNING POINTS: Meticulous direct and collateral history taking is essential for correct diagnosis and to reveal psychiatric diagnoses and medications not reported by patients and caregivers.As drug interactions can cause potentially fatal side effects, it is of the utmost importance to gain access to the patient's full medication list.It is important to educate patients about the potential toxicity of their prescribed medications and to encourage them to seek medical attention when serious manifestations of toxicity are present.