The challenge of prognostic markers in acute pancreatitis: internist's point of view.

Acute pancreatitis, the most frequent hospitalization reason in internal medicine ward among gastrointestinal diseases, is burdened by high mortality rate. The disease manifests mainly in a mild form, but about 20-30% patients have a severe progress that requires intensive care. Patients presenting with acute pancreatitis should be clinically evaluated for organ failure signs and symptoms. Stratifying patients in the first days from symptoms onset is essential to determine therapy and care setting. The aim of our study is to evaluate prognostic factors for acute pancreatitis patients, hospitalized in internal medicine wards, and moreover, understanding the role of various prognostic scores validated in intensive care setting in predicting in-hospital mortality and/or admission to intensive care unit. We conducted a retrospective study enrolling all patients with diagnosis of acute pancreatitis admitted took an internal medicine ward between January 2013 and May 2019. Adverse outcome was considered in-hospital mortality and/or admission to intensive care unit. In total, 146 patients (137 with positive outcome and 9 with adverse outcome) were enrolled. The median age was (67.89 ± 16.44), with a slight prevalence of male (55.1%) compared to female (44.9%). C protein reactive (p = 0.02), creatinine (p = 0.01), sodium (p = 0.05), and troponin I (p = 0.013) after 48 h were significantly increased in patients with adverse outcome. In our study, progression in SOFA score independently increases the probability of adverse outcome in patients hospitalized with acute pancreatitis. SOFA score > 5 is highly predictive of in-hospital mortality (O.R. 32.00; C.I. 6.73-152.5; p = 0.001) compared to other scores. The use of an easy tool, validated in intensive care setting such as SOFA score, might help to better stratify the risk of in-hospital mortality and/or clinical worsening in patients hospitalized with acute pancreatitis in internal medicine ward.

Incidence of deep vein thrombosis through an ultrasound surveillance protocol in patients with COVID-19 pneumonia in non-ICU setting: A multicenter prospective study.

OBJECTIVE: The aim of this study was to assess the incidence of deep vein thrombosis (DVT) of the lower limbs, using serial compression ultrasound (CUS) surveillance, in acutely ill patients with COVID-19 pneumonia admitted to a non-ICU setting. METHODS: Multicenter, prospective study of patients with COVID-19 pneumonia admitted to Internal Medicine units. All patients were screened for DVT of the lower limbs with serial CUS. Anticoagulation was defined as: low dose (enoxaparin 20-40 mg/day or fondaparinux 1.5-2.5 mg/day); intermediate dose (enoxaparin 60-80 mg/day); high dose (enoxaparin 120-160 mg or fondaparinux 5-10 mg/day or oral anticoagulation). The primary end-point of the study was the diagnosis of DVT by CUS. RESULTS: Over a two-month period, 227 consecutive patients with moderate-severe COVID-19 pneumonia were enrolled. The incidence of DVT was 13.7% (6.2% proximal, 7.5% distal), mostly asymptomatic. All patients received anticoagulation (enoxaparin 95.6%) at the following doses: low 57.3%, intermediate 22.9%, high 19.8%. Patients with and without DVT had similar characteristics, and no difference in anticoagulant regimen was observed. DVT patients were older (mean 77±9.6 vs 71±13.1 years; p = 0.042) and had higher peak D-dimer levels (5403 vs 1723 ng/mL; p = 0.004). At ROC analysis peak D-dimer level >2000 ng/mL (AUC 0.703; 95% CI 0.572-0.834; p = 0.004) was the most accurate cut-off value able to predict DVT (RR 3.74; 95%CI 1.27-10, p = 0.016). CONCLUSIONS: The incidence of DVT in acutely ill patients with COVID-19 pneumonia is relevant. A surveillance protocol by serial CUS of the lower limbs is useful to timely identify DVT that would go otherwise largely undetected.

Role of masked coronary heart disease in patients with recent-onset atrial fibrillation and troponin elevations.

BACKGROUND: Patients with recent-onset atrial fibrillation (AF) and cardiac troponin I (cTnI) elevations show poor outcomes. Coronary heart disease might be a cause, consequence, or an innocent bystander. OBJECTIVE: The aim of this study was to recognize and treat coronary heart disease to avoid adverse events. METHODS: Patients with recent-onset AF participated in the study. The exclusion criteria were acute coronary syndrome and severe comorbidities. Patients managed with standard care (group 1, n=1086, years 2010-2011) were compared with patients managed with tailored care inclusive of echocardiography and stress testing when required (group 2, n=1055, years 2012-2013). ENDPOINT: The endpoint was a composite of ischemic vascular events including stroke, acute coronary syndrome, revascularization and cardiovascular death at 6 months of follow-up. RESULTS: Of 4008 patients considered, 2141 were enrolled; 183 showed cTnI elevations, 92 in group 1 and 91 in group 2. cTnI elevations, known ischemic heart disease and age were predictors of the endpoint on multivariate analysis. Overall, two versus seven patients (P=0.033) in groups 1 and 2, respectively, underwent revascularization. Eventually, 16 patients in group 1 versus five patients in group 2 reached the endpoint (P=0.019). Patients of group 2 were managed as follow: 35 were admitted, 15 with positive stress testing and 20 with high cTnI values (mean values: 0.64±1.01 ng/ml). Fifty-six patients were discharged with negative stress testing results (n=13) or very low cTnI values (n=43, mean values 0.29±0.30 ng/ml). CONCLUSION: In patients with AF and cTnI elevations, tailored care inclusive of echocardiography and stress testing succeeded in recognizing and treating masked 'critical' coronary heart disease, avoiding adverse events.