Prospective determination of the incidence and severity of hyponatraemia in older hospitalised patients with acute urinary tract obstruction.

INTRODUCTION: acute urinary tract obstruction (aUTO) is a common finding in older hospitalised patients. Anecdotal reports described hyponatraemia in patients with aUTO, which subsides rapidly with relief of the obstruction.The aim of this study was to determine the incidence, severity and subsequent correction of hyponatraemia in patients with aUTO. METHODS: this is a prospective, single-centre, observational study including inpatients in the internal medicine and geriatric wards. A total of 204 patients were investigated, 104 with aUTO and 100 controls. The prevalence, severity and associations of hyponatraemia between aUTO and control patients were compared. RESULTS: the incidence of hyponatraemia was similar in aUTO and control groups 28% versus 22%, respectively (P = 0.42). However, the incidence of severe hyponatraemia was significantly higher in the study group 7% versus 1% (P = 0.04). Mean sodium level was lower in hyponatremic patients with aUTO 127.7 ± 5.9 mEq/l versus 130.8 ± 3 mEq/l (P = 0.013). Serum sodium remained largely unchanged in the control group (∆Na 1.5 ± 2.3 mEq/l) but increased significantly within 48 hours following catheter insertion in patients with urinary retention (∆Na 5.3 ± 4.2 mEq/l overall in the aUTO group and 9.6 ± 3 mEq/l in those with urinary retention and severe hyponatraemia (P = 0.002)).

Safety of oesophagogastroduodenoscopy in a nonagenarian population.

BACKGROUND: invasive gastrointestinal (GI) procedures are increasingly performed on much older patients but data regarding oesophagogastroduodenoscopy (OGD) in this population are limited. We compared the indications, safety and benefits of OGD for nonagenarians compared to octogenarians. METHODS: an observational retrospective review of patients who underwent OGD between 2013 and 2018 at a gastroenterology institute in one large hospital. Patients aged 90 and above 'nonagenarians' were compared to those aged 80-89 'octogenarians'. RESULTS: 472 patients (231 nonagenarians and 241 octogenarians), median age of 91 for nonagenarians (201 aged 90-94, 30 aged 95 and older) and 82 (174 aged 80-84, 67 aged 85-89) for octogenarians. GI bleeding was a more common and dyspepsia, a less common, indication for nonagenarians compared to octogenarians (55 and 7%, versus 43 and 18%). Significant findings and need for endoscopic treatments were both more commonly found in nonagenarians compared to octogenarians (25 and 24% versus 15 and 8%, respectively). General anaesthesia was more commonly given to nonagenarians (35 versus 10%). Immediate complications and 30-day mortality rate were similar between the groups: (2.6% of nonagenarians versus 1.6% of octogenarians). Of 30 patients aged 95 and older, 13% had late adverse events, compared to 1% of the overall cohort. CONCLUSIONS: OGD appears safe in nonagenarians. Pathological findings and endoscopic interventions are more common. Decisions regarding OGD should not be based on age alone.

[PREVALENCE OF AND POSSIBLE RISK FACTORS FOR PROLONGED HOSPITAL STAY IN DEPARTMENTS OF INTERNAL MEDICINE].

BACKGROUND: Prolonged hospitalization (PH) is associated with increasing rates of complications and cost. OBJECTIVES: To detect and quantify causes and predictors for PH in current practice. METHODS: PH was defined as higher than the 70th percentile of the mean hospitalization duration for each department (two medical departments and one acute geriatric ward). Demographic and clinical data were collected on admission in order to determine predictive factors for PH. Actual causes for PH were tested on the 4th day of hospitalization for all patients by: (1) questioning the patients' attending physicians using a structured questionnaire; (2) assessing the patients' charts using a validated tool. RESULTS: Data were collected during a 5-month study period for all 1092 consecutively admitted patients hospitalized in the three departments in the study of whom 337 (30%) had a PH. In the multivariate analysis we detected the following independent predictors for PH: (1) unmarried patients; (2) dependent-patients; (3) hospitalization in the geriatric versus medical department; (4) an expected high mortality rate according to a validated prediction score; (5) renal failure on admission; (6) prior admission in the previous 6 months. The disease leading to the current admissions was the reason for continued admission on day 4 in the patients with eventual PH in 85% of the cases, as compared to 93% in the control group with regular-duration of hospitalization (p=0.014). On day 4, non-medical reasons for prolonged duration were detected in 7% of those with eventual PH as compared to 1% in the control group (p=0.018). CONCLUSIONS: We already detected demographic and clinical predictors for PH on admission, some of which may be amenable to intervention.

[AN EDUCATIONAL INTERVENTION TO REDUCE THE RATE OF CONTAMINANTS IN BLOOD CULTURES AND IMPROVE APPROPRIATE ANTIBIOTIC TREATMENT].

INTRODUCTION: Blood cultures' contamination (BCC) is associated with unnecessary processing of cultures, higher cost, and occasionally, unjustified antibiotic treatment. We aimed to reduce the rate of BCC by educational intervention. In parallel, we also strove to expand the use of aminoglycosides (AMG) and reduce the utilization of beta-lactam antibiotics. The rate of BCC was assessed prospectively in the study department - the Emergency Department (ED) and in control departments - Medical Departments A, B and Geriatrics. Data was collected continuously during the study period and educational interventions were performed in the ED but not in the control departments. The intervention included meetings with ED staff, emphasizing proper blood culture collection technique, and post-intervention result updates. The utilization of AMG was encouraged in cases of suspected gram-negative bacteremia. The empirical and definitive antibiotic regimen was assessed. During the study period, a 30% decrease in BCC rate [33/564 (5.9%) to 30/734 (4.1%), p=0.143] was noted in the study department whereas a small increase in BCC rate was noted in the control departments. Logistic regression analysis revealed significantly different trends in BCC rate between the study and control departments (p<0.001). Additionally, an increase in AMG utilization was observed (7% to 40%) in patients with suspected gram-negative bacteremia with normal renal function (p=0.16). Educational intervention was successful in reducing the rate of BCC and in parallel, increasing the utilization of AMG. Repeat and frequent interventions are required to maintain such achievements.

Can Procalcitonin Contribute to the Diagnosis of Clostridium difficile Colitis?

BACKGROUND: It is a challenge to diagnosis Clostridium difficile colitis. OBJECTIVES: To determine, among patients who developed nosocomial diarrhea, whether serum procalcitonin (PCT) can distinguish between C. difficile toxin (CDT)-positive and CDT-negative patients. METHODS: This prospective study included 50 adults (>18 years) who developed diarrhea during hospitalization, 25 with a positive fecal test for CDT (study group) and 25 CDT negative (control group). RESULTS: Baseline demographic and underlying illnesses were similar in both groups. Duration of diarrhea was 6 ± 4 days and 3 ± 1 in the study and control groups, respectively (P = 0.001). Mean blood count was 20 ± 15 and 9.9 ± 4, respectively (P = 0.04). CRP level was higher in the study than in the control group (10.9 ± 7.4 and 6.6 ± 4.8, P = 0.028). PCT level was higher in the study group (4.4 ± 4.9) than the control group (0.3 ± 0.5, P = 0.102). A PCT level > 2 ng/ml was found in 7/25 patients (28%) and 1/25 (4%), respectively [odds ratio 9.33, 95% confidence interval (0.98 to 220), P = 0.049]. Multivariate analysis showed that only duration of diarrhea and left shift of peripheral leucocytes were significant indicators of CDT (P = 0.014 and P = 0.019, respectively). The mortality rate was 12/25 (48%) vs. 5/25 (20%), respectively (P = 0.04). CONCLUSIONS: We found a non-significant tendency to higher PCT levels in patients with CDT-positive vs. CDT-negative nosocomial diarrhea. However, a PCT level > 2 ng/ml may help distinguish between these patients.

[MONITORING UNITS IN DEPARTMENTS OF INTERNAL MEDICINE: FREQUENCY, IMPACT AND SATISFACTION].

BACKGROUND: Due to increasing numbers of elderly, seriously ill patients and shortage of ICU beds, many hospitals have established monitoring units (MU) in their medical departments. OBJECTIVES: (1) To assess the national prevalence of MUs in medical departments; (2) to determine the outcome of consecutively admitted MU patients; (3) to evaluate patient/ family satisfaction with care. METHODS: The case control study included all 123 patients hospitalized in the MU during a 5-month period, compared with two control groups: (1) 123 patients admitted to medical departments, matched at a ratio of 1:1 by gender, age±10 years and mechanical ventilation; (2) all 52 medical patients treated in the ICU. The main endpoint was 28-day survival. RESULTS: A total of 76/99 (77%) directors of medical departments in Israel responded: 70 (92%) reported the presence of a MU, 64 (92%) have 5-7 beds and 47 (67%) have one nurse per shift. Baseline characteristics of enrolled MU and medical department patients were similar, although 52 medical ICU patients were younger (56±21 vs. 73±14, p<0.001) and had a lower incidence of kidney failure (11.5% vs. 41.5%, p<0.001). The predicted mortality rates were higher for MU patients compared to medical department patients, but 28-day survival rates were similar (64-70%, NS). The questionnaire showed high rates of satisfaction (from 0=low to 5=high): highest with MU care: (4.79±0.48), followed by ICU (4.41±1.06) and lowest for medical department nursing care (4.27±0.84)(p=0.017). CONCLUSIONS: Monitoring units are ubiquitous in Israeli hospitals and contribute to survival and satisfaction with care.

Operating a Monitoring Unit in the Geriatric Department: Effects on Outcomes.

OBJECTIVES: To compare the effect of a five-bed geriatric monitoring unit (MU) on in-hospital mortality and length of stay with the effect of usual care in a geriatric hospital department and a medical MU. DESIGN: Prospective, case-control, noninterventional study. PARTICIPANTS: All individuals hospitalized for 24 hours or longer in the geriatric MU (n = 89, aged 53-101, mean age 82.2 ± 9.6) over a period of 5 months (January-May 2015); individuals admitted to the geriatric department (n = 178, aged 55-100, mean age 83.2 ± 9.8), matched at a ratio of 1:2 according to sex, age ±5 years, and need for mechanical ventilation; and individuals admitted to a similar five-bed medical MU (n = 95, aged 35-90, mean age 68.2 ± 14.4) during the same period. MEASUREMENTS: Primary outcome was in-hospital mortality. RESULTS: The predicted death rate was 49 ± 26 for participants in the geriatric MU, 39.6 ± 27 for those in the medical MU (P = .02), and 36.7 ± 27 for those in the geriatric department (P < .001). Observed in-hospital mortality was higher for geriatric MU participants (n = 40, 44.9%) than for the department control group (n = 48, 27%) (P = .002), although the mortality ratios (actual divided by predicted death rates) of these two groups were similar, indicating that the more severely ill participants in the geriatric MU did better than control participants in the departments, in particular those requiring hemodynamic pressure support and those with acute renal failure. CONCLUSION: For elderly, severely ill adults, care in a geriatric MU was associated with lower in-hospital mortality than care in the hospital geriatric ward and a longer stay and may be an alternative to medical MU admission.

Prosthetic valve endocarditis due to Streptococcus pneumoniae.

INTRODUCTION: In the pre-antibiotic era up 10% of cases of infective endocarditis were due to Streptococcus pneumoniae, but this association is currently exceedingly rare. CASE DESCRIPTION: Since 1997 we have diagnosed three patients, all aged >70, with endocarditis due to S. pneumoniae. One of these three cases involved a prosthetic valve, another a prosthetic ring. All three patients completely recovered with antibiotic treatment only. DISCUSSION AND EVALUATION: During the same period there were 1694 cases of pneumococcal bacteremia, of whom 395 (23%) after age 70. Therefore, after age 70 the prevalence of endocarditis out of all cases of pneumococcal bacteremia was 0.7%. A literature review detected another 16 cases of pneumococcal PVE. The mean age of these 17 patients was 64±14; 10 were female and 7 male. In most instances, symptom duration was short, < 6 days. Valve surgery was performed in 5 cases (29%) and 13 patients (76%) survived. CONCLUSIONS: Endocarditis due to S. pneumoniae is rare in the antibiotic era; even in patients with prosthetic valves its course is evidently not more virulent than with other low-virulent organisms.

[Shaare Zedek Medical Center's model of an integrated division of internal medicine].

BACKGROUND: The specialty and practice of internal medicine have been subject to serious challenges in the last two decades. METHODS: We describe the integrative model of internal medicine as developed in our hospital, providing solutions to some major challenges. RESULTS: Major components include: (1) Senior physicians and residents are employed by the Division rather than individual Departments of Medicine, allowing for balanced distribution of professional capabilities. (2) Two medical departments specialize in geriatric medicine, while the other departments take care of younger, more intellectually challenging patients. Senior and junior staff members rotate through these departments, allowing for exposure to different patient populations and professional expertise. (3) The backbone of senior physicians is rewarded by a set of incentives, including dedicated time for research. (4) Senior staff from the subspecialties contributes annually 1-2 months as senior physicians in the departments and receive academic and other compensation for their efforts. (5) In cases where medical departments elsewhere are flooded with corridor admissions (a source of frustration and burnout), a short admission unit in the emergency department relieves internal medicine pressures and shortens evaluation and therapy for many patients. CONCLUSION: Our integrative model of internal medicine allows for improved patient and staff distribution, greater satisfaction among patients and family members, greater professional satisfaction among physicians, while resident vacancies are filled with competent residents.

Prospective evaluation of colonization with extended-spectrum beta-lactamase (ESBL)-producing enterobacteriaceae among patients at hospital admission and of subsequent colonization with ESBL-producing enterobacteriaceae among patients during hospitalization.

OBJECTIVE: To determine the rates of and risk factors for carriage and acquisition of extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae during hospitalization. DESIGN: Cohort study. SETTING: Shaare Zedek Medical Center, a 550-bed teaching hospital. METHODS: During a 5-month period (February 1-June 30, 2004), 167 (8%) of 1,985 newly admitted general medical patients were enrolled in our study. Nasal, oropharyngeal, and rectal swab specimens were obtained at admission and every 2-3 days until hospital discharge or death. Enterobacteriaceae isolates were tested for ESBL, and Staphylococcus aureus isolates were tested for methicillin resistance. RESULTS: Of the 167 patients enrolled in our study, 15 (9%) were identified as nasal carriers of methicillin-resistant S. aureus (MRSA) at admission, and 13 (8%) were rectal carriers of ESBL-producing Enterobacteriaceae at admission. Univariate risk factors for rectal carriage of ESBL-producing Enterobacteriaceae included female sex (odds ratio [OR], 11 [95% confidence interval {CI}, 1.4-238]; P < .05), nursing home residence (OR, 6.9 [95% CI, 1.8-27]; P < .01), recent antibiotic treatment (OR, 9.8 [95% CI, 1.7-74]; P < .05), and concomitant nasal carriage of MRSA and/or ESBL-producing Enterobacteriaceae (OR, 5.8 [95% CI, 1.2-26]; P < .01). Multivariate risk factors were female sex and recent antibiotic treatment. During hospitalization, 35 (21%) of 167 patients had acquired rectal carriage of ESBL-producing Enterobacteriaceae (P = .002, for trend analysis). Of the 12 patients who were still in the hospital 2 weeks after admission, 4 (33%) were carriers of ESBL-producing Enterobacteriaceae. Univariate risk factors for acquisition included an age of older than 65 years (P < .005), nursing home residence (OR 2.6, [95% CI, 0.98-2.6]), impaired cognition (OR, 4.8 [95% CI, 1.9-12]), recent antibiotic treatment (OR, 2.7 [95% CI, 0.9-8.3]), respiratory assistance (OR, 4.2 [95% CI, 1.2-14]), and prolonged hospitalization. Multivariate risk factors were an age of older than 65 years and broad-spectrum antibiotic therapy. CONCLUSIONS: Rectal carriage of ESBL-producing Enterobacteriaceae occurred in 13 (8%) of 167 patients at admission to the medical departments of our hospital and in 4 (33%) of 12 patients still remaining in our hospital after 2 weeks.

Misplacement of percutaneously inserted gastrostomy tube into the colon: report of 6 cases and review of the literature.

BACKGROUND: With the increasing use of percutaneous endoscopic gastrostomy (PEG), rare complications are seen; one of them is misplacement of the tube into the colon. We describe the various clinical pictures and treatment approaches. METHODS: Case series from our hospital and case reports from the literature are presented. Symptoms, time interval from symptoms to diagnosis, time elapsed from initial PEG insertion to replacement or to regression, regression of gastrostomy tube to the colon vs colonic placement of reinserted tube, and treatment approaches are evaluated. RESULTS: We identified and studied 6 patients in our hospital who had misplacement of a PEG into the colon. A review of the English literature revealed another 22 adult cases with this complication. Of the total 28 cases, 8 had previous abdominal pathology. Seventeen patients developed symptoms after tube replacement, whereas in 11 the tube had not been changed. Fourteen had diarrhea, 11 presented with fecal discharge in or around the tube, and 3 were asymptomatic. Thirteen showed colocutaneous fistula without residual connection to the stomach. Ten patients were treated surgically and 14 conservatively by removal of the tube. One patient had colonoscopic clipping of the fistula. CONCLUSIONS: Gastroenterologists should adhere strictly to cautionary measures to prevent misplacement of PEG into the colon. In patients with PEG feeding, the clinician should suspect misplacement of the tube into the colon when there is recurrent severe diarrhea of undigested food or fecal content in the tube, particularly after tube replacement. Treatment may be conservative in most cases.

Urinary retention: a cause of hyponatremia?

BACKGROUND: Syndrome of inappropriate antidiuretic hormone secretion (SIADH) is the most common cause of hyponatremia in elderly hospitalized patients; however in many patients the etiology remains unclear even after routine investigations. OBJECTIVE: To report our experience of the association of hyponatremia and urinary retention in elderly hospitalized patients. PATIENTS: Six patients with hyponatremia and urinary retention who were admitted to the geriatric department in our hospital during a four-year period (2001-2004). RESULTS: The mean age of the patients was 85 years. The mean serum sodium level was 120 mEq/l, average volume of retained urine was 933 ml (range 500-1,500 ml). All patients underwent a comprehensive work-up seeking a possible cause for the hyponatremia. The diagnostic work-up was negative. In 5 of the patients the laboratory findings fulfilled the criteria for SIADH. In all patients hyponatremia resolved following urinary catheterization and fluid restriction. All patients made a complete recovery. CONCLUSIONS: Potentially, urinary retention by itself may cause hyponatremia. The possible mechanism for this is SIADH, triggered by bladder distention or pain due to bladder distention. Urinary catheterization may be the key to treatment in these cases of hyponatremia.

Antimicrobial susceptibilities of urinary pathogens in a multidisciplinary long-term care facility.

UNLABELLED: In order to determine bacterial distribution and antimicrobial susceptibility of urinary pathogens in a long-term-care-facility (LTCF), urine cultures were examined when clinically indicated. The LTCF consists of 286 beds, housing 931 residents during 32 months, in various wings; independent and frail residents (wing-A), nursing and demented patients (wing-B), and skilled-nursing patients (wing-C). A total of 1,401 positive urine cultures were obtained: E. coli was isolated significantly less often in wing-C than in wing-A (p = 0.02) and wing-B (p = 0.009). There was no significant difference in frequency of other organisms. Susceptibility of organisms decreased significantly from wing-C to wing-B (p < 0.05-0.001), and from wing-B to wing-A (p < 0.05-0.001). Susceptibility rates' decreased significantly over time in wing-B, less in wing-C and not at all in wing-A. IN CONCLUSION: When selecting empiric antibiotic therapy for serious urinary tract infection in a long-term-care resident, one should take into account the microbial environment of the individual patient's department.