Interpretation of Heart and Lungs Sounds Acquired via Remote, Digital Auscultation Reached Fair-to-Substantial Levels of Consensus among Specialist Physicians.

BACKGROUND: Technological advancement may bridge gaps between long-practiced medical competencies and modern technologies. Such a domain is the application of digital stethoscopes used for physical examination in telemedicine. This study aimed to validate the level of consensus among physicians regarding the interpretation of remote, digital auscultation of heart and lung sounds. METHODS: Seven specialist physicians considered both the technical quality and clinical interpretation of auscultation findings of pre-recorded heart and lung sounds of patients hospitalized in their homes. TytoCareTM system was used as a remote, digital stethoscope. RESULTS: In total, 140 sounds (70 heart and 70 lungs) were presented to seven specialists. The level of agreement was measured using Fleiss' Kappa (FK) variable. Agreement relating to heart sounds reached low-to-moderate consensus: the overall technical quality (FK = 0.199), rhythm regularity (FK = 0.328), presence of murmurs (FK = 0.469), appreciation of sounds as remote (FK = 0.011), and an overall diagnosis as normal or pathologic (FK = 0.304). The interpretation of some of the lung sounds reached a higher consensus: the overall technical quality (FK = 0.169), crepitus (FK = 0.514), wheezing (FK = 0.704), bronchial sounds (FK = 0.034), and an overall diagnosis as normal or pathological (FK = 0.386). Most Fleiss' Kappa values were in the range of "fare consensus", while in the domains of diagnosing lung crepitus and wheezing, the values increased to the "substantial" level. CONCLUSIONS: Bio signals, as recorded auscultations of the heart and lung sounds serving the process of clinical assessment of remotely situated patients, do not achieve a high enough level of agreement between specialized physicians. These findings should serve as a catalyzer for improving the process of telemedicine-attained bio-signals and their clinical interpretation.

Automated processing of thermal imaging to detect COVID-19.

Rapid and sensitive screening tools for SARS-CoV-2 infection are essential to limit the spread of COVID-19 and to properly allocate national resources. Here, we developed a new point-of-care, non-contact thermal imaging tool to detect COVID-19, based on advanced image processing algorithms. We captured thermal images of the backs of individuals with and without COVID-19 using a portable thermal camera that connects directly to smartphones. Our novel image processing algorithms automatically extracted multiple texture and shape features of the thermal images and achieved an area under the curve (AUC) of 0.85 in COVID-19 detection with up to 92% sensitivity. Thermal imaging scores were inversely correlated with clinical variables associated with COVID-19 disease progression. In summary, we show, for the first time, that a hand-held thermal imaging device can be used to detect COVID-19. Non-invasive thermal imaging could be used to screen for COVID-19 in out-of-hospital settings, especially in low-income regions with limited imaging resources.

The liver in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.

BACKGROUND: The ongoing outbreak of COVID-19 is associated with higher levels of morbidity and mortality among patients with comorbidities, including the metabolic syndrome. Liver impairment has been reported in up to 54% of hospitalized patients with COVID-19. The impact of COVID-19 on a preexisting chronic liver disease is an actively studied area of research. The contribution of our study is towards determining the predictors of severity and the outcome of liver injury among hospitalized patients with COVID-19 infection, including patients with a preexisting liver disease and COVID-19. METHODS: This single center retrospective cohort study included all patients ≥18 years, admitted in Sheba Medical Center with confirmed COVID-19 infection. Demographic, clinical and laboratory data were obtained using the MDClone platform and rechecked after data decryption using electronic health records. RESULTS: Of 382 patients with COVID-19, 66.4% had increased liver biochemistry. Mild increase was observed in 76.7%. The higher level of fibrosis-4 (FIB-4) at admission was independently associated with higher mortality rate. Preexisting liver disease was detected in 15.4% patients. Most common etiology was nonalcoholic fatty liver disease (78.7%). The mortality of hospitalized patients with preexisting liver disease was 16.7% compared to 6.8% in patients without preexisting liver disease (RR = 2.792, P = 0.01). In multivariate analysis, liver disease adjusted to age and BMI was associated with mortality with high statistical significance. CONCLUSIONS: Patients with preexisting chronic liver disease were at a higher risk of mortality. The FIB-4 level at admission was associated with worse prognosis. These findings should be reevaluated in a larger cohort of patients.

[FUNCTIONAL INDEPENDENCE MEASURE SCALE SCORES IN SEVERELY DEPENDENT OLDER ADULTS UPON REHABILITATION COMPLETION FOLLOWING HIP FRACTURE].

INTRODUCTION: Functional Independence Measure (FIM) is a scale used to evaluate functional status during rehabilitation. The association between FIM scale scores upon hip fracture rehabilitation completion and functional status of older adults according to the Israeli Ministry of Health (MOH) guidelines has never been studied. AIMS: To study the association between FIM scale scores upon hip fracture rehabilitation completion and functional status of older adults. METHODS: A retrospective cross-sectional study was conducted at the Geriatric-Orthopedic unit at the Sheba Medical Center. The medical charts of older adults (age ≥65) admitted for rehabilitation following hip fracture during 2007-2012 were studied. Age, gender, total FIM score upon rehabilitation completion, functional status upon rehabilitation completion according to the Israeli MOH guidelines, and moving to a nursing-home were documented. RESULTS: The cohort included 453 older adults: 374 (82.6%) females; mean age 82.9±6.7 years. Most older adults were severely dependent upon rehabilitation completion (n=320, 70.6%) and 84 (26.3%) of whom moved to or returned to a nursing-home. Median total FIM scores upon rehabilitation completion was 100 (interquartile range (IQR): 92-111) in mildly dependent older adults, 72 (IQR: 53-87) in severely dependent community-dwelling older adults, and 39 (IQR: 29-58) in severely dependent nursing-home residents (p<0.001). Total FIM score of 85 (or less) had the highest sensitivity (78.4%) and specificity (91.0%) in representing severely dependent older adults. CONCLUSIONS: These findings may assist Israeli geriatricians to define the functional status of older adults upon hip fracture rehabilitation completion.

D-dimer and C-reactive Protein Blood Levels Over Time Used to Predict Pulmonary Embolism in Two COVID-19 Patients.

The diagnosis of pulmonary embolism is challenging in symptomatic COVID-19 patients since shortness of breath, chest pain, tachycardia, tachypnoea, fever, oxygen desaturation and high D-dimer blood levels might be features of both diseases. We present two COVID-19 patients in whom pulmonary embolism was suspected (and diagnosed) due to a discrepancy between an increase in D-dimer blood levels and a decrease in C-reactive protein blood levels over time. We believe that an opposite change in the blood levels of both biomarkers over time may be used as a novel method to predict pulmonary embolism in COVID-19 patients. LEARNING POINTS: The diagnosis of pulmonary embolism is challenging in COVID-19 patients since symptoms, signs and high D-dimer blood levels might be similar in both diseases.An increase in D-dimer blood levels and a decrease in C-reactive protein blood levels over time may be used as a novel method to predict pulmonary embolism in COVID-19 patients.

Prerehabilitation alanine aminotransferase blood levels and one-year mortality rates in older adults following hip fracture.

Low alanine aminotransferase (ALT) blood levels prior to rehabilitation are associated with poor function in older adults following hip fracture. We hypothesized that low ALT blood levels prior to rehabilitation were also associated with one-year mortality in this population. Included were 456 older adults (age ≥ 60 years, 82.5% women) admitted for rehabilitation following hip fracture. ALT blood levels were documented between one and six months prior to rehabilitation. Excluded were patients with ALT blood levels over 40 IU/L possibly consistent with liver injury. The main outcome was all-cause mortality one year following rehabilitation admission. The study group included 142 (31.1%) patients with low (≤10 IU/L) ALT blood levels and the control group included 314 (68.9%) patients with high-normal (11-40 IU/L) ALT blood levels. Overall, 52 (11.4%) patients died within one year following rehabilitation admission. Compared with the control group, patients with low ALT blood levels had significantly higher 1-year mortality rates [17.6 vs. 8.6%, odds ratio 2.27, 95% confidence interval (CI) 1.27-4.08]. Cox regression analysis showed that low ALT blood levels prior to rehabilitation were associated with one-year mortality (hazard ratio 1.88, 95% CI 1.08-3.28) together with age (hazard ratio 1.06, 95% CI 1.02-1.11), independent of gender. However, this association was no longer significant following adjustment also for peripheral vascular disease, admission and discharge functional independence measure scores, albumin serum levels, and length of rehabilitation. In conclusion, low ALT blood levels prior to rehabilitation are associated with one-year mortality in older adults following hip fracture. They may be used when only age and gender are known.

Personalized diabetes management recommendations at hospital discharge based on a computerized, pre-hospitalization clinical profile analysis: A prospective, electronic health records-based study.

BACKGROUND: While glycemic control of hospitalized diabetic patients is straightforward, personalization of management at discharge is challenging. Treatment guidelines base recommendations on the clinical profile of patients. We checked the feasibility of implementing discharge recommendations, based on the clinical profile in the patients' electronic health records (EHR). METHODS: A decision-making algorithm was devised according to current guidelines. It was incorporated into the EHR. A prospective follow-up of eligible diabetes patients was done. RESULTS: During 15 months, 835 patients (HbA1c was 6.9% [6.2%-7.8%]) met our inclusion criteria. The rate of HbA1c acquisition increased from 55% during Q1 to 85%, 86%, 88%, and 87% thereafter. Also, the rate of incorporating personalized management recommendations to discharge letters increased: from 14.9% during Q1 to 42.9%, 43.0%, 47.2%, and 53.4% thereafter. Fifty-eight (17.3%) of patients who got personalized recommendations upon discharge were found to have HbA1c values that were over 1% deviating from suggested target HbA1c. They got the most stringent recommendations. Twenty-nine (50%) of them had available follow-up HbA1c values showing a significant drop in HbA1c: from 9.1% (8.4%-10.2%) to 8.5% (7.4%-9.5%), P = .03. CONCLUSIONS: Personalized, EHR algorithm-based, management recommendations for diabetes upon discharge from hospitalization are feasible and beneficial.

Structured, Protocol-Based Pulse-Oximetry Measurement Improves the Evaluation of Hypoxemic Patients at Hospital Admission.

BACKGROUND: Accurate pulse oximetry reading at hospital admission is of utmost importance, mainly for patients presenting with hypoxemia. Nevertheless, there is no accepted or evidence-based protocol for such structured measuring. OBJECTIVES: To devise and assess a structured protocol intended to increase the accuracy of pulse oximetry measurement at hospital admission. METHODS: The authors performed a prospective comparison of protocol-based pulse-oximetry measurement with non-protocol based readings in consecutive patients at hospital admission. They also calculated the relative percentage of improvement for each patient (before and after protocol implementation) as a fraction of the change in peripheral capillary oxygen saturation (SpO2) from 100%. RESULTS: A total of 460 patients were recruited during a 6 month period. Implementation of a structured measurement protocol significantly changed saturation values. The SpO2 values of 24.7% of all study participants increased after protocol implementation (ranging from 1% to 21% increase in SpO2 values). Among hypoxemic patients (initial SpO2 < 90%), protocol implementation had a greater impact on final SpO2 measurements, increasing their median SpO2 readings by 4% (3-8% interquartile range; P < 0.05). Among this study population, 50% of the cohort improved by 17% of their overall potential and 25% improved by 50% of their overall improvement potential. As for patients presenting with hypoxemia, the median improvement was 31% of their overall SpO2 potential. CONCLUSIONS: Structured, protocol based pulse-oximetry may improve measurement accuracy and reliability. The authors suggest that implementation of such protocols may improve the management of hypoxemic patients.

Alanine aminotransferase blood levels and rehabilitation outcome in older adults following hip fracture surgery.

Low alanine aminotransferase (ALT) blood levels are associated with frailty and poor outcome in older adults. Therefore, we studied the association between ALT blood levels before rehabilitation and rehabilitation outcome in older adults following hip fracture surgery. A total of 490 older adults (age>60 years, mean age: 82.9±6.7 years, 82.0% women) admitted to rehabilitation following hip fracture surgery were included. The rehabilitation outcome was assessed by Functional Independence Measure (FIM) scores. ALT blood levels were documented between 1 and 6 months before rehabilitation. Patients with ALT blood levels over 40 IU/l possibly consistent with liver injury were excluded. The cohort was divided into two groups: patients with ALT more than 10 IU/l and patients with ALT less than or equal to 10 IU/l. Upon rehabilitation discharge, the FIM outcome measures (motor, cognitive, gain, efficiency) were significantly higher in patients with ALT more than 10 IU/l relative to patients with ALT less than or equal to 10 IU/l (P<0.05). A logistic regression analysis adjusted for age and sex showed that patients with ALT more than 10 IU/l were more likely to have higher (second to fourth upper quartiles) total FIM scores (>50), cognitive FIM scores (>16), and FIM efficiency (>0.228) upon rehabilitation discharge (odds ratio=1.56-1.78). However, this association was no longer significant following adjustment also for admission total FIM score, cognitive impairment, cancer, and albumin serum levels. High-normal ALT blood levels before rehabilitation are associated with a better rehabilitation outcome in older adults following hip fracture surgery. It may be used when data on admission FIM score, cognitive impairment, cancer, and albumin serum levels are not available.

Risk of falling among hospitalized patients with high modified Morse scores could be further Stratified.

BACKGROUND: Falls during hospitalization harbor both clinical and financial outcomes. The modified Morse fall scale [MMFS] is widely used for an in-hospital risk-of-fall assessment. Nevertheless, the majority of patients at risk of falling, i.e. with high MMFS, do not fall. The aim of this study was to ascertain our study hypothesis that certain patients' characteristics (e.g. serum electrolytes, usage of a walking device etc.) could further stratify the risk of falls among hospitalized patients with MMFS. METHODS: This was a retrospective cohort analysis of adult patients hospitalized in Internal Medicine departments. RESULTS: The final cohort included 428 patients aged 76.8±14.0 years. All patients had high (9 or more) MMFS upon admission, and their mean MMFS was 16.2±6.1. A group of 139 (32.5%) patients who fell during their hospitalization was compared with a control group of 289 (67.5%) patients who did not fall. The fallers had higher MMFS, a higher prevalence of mild dependence, and a greater use of a cane or no walking device. Regression analysis showed the following patients' characteristics to be independently associated with an increased risk of falling: mild dependence (OR=3.99, 95% CI 1.97-8.08; p<0.0001), treatment by anti-epileptics (OR=3.9, 95% CI 1.36-11.18; p=0.011), treatment by hypoglycemic agents (OR=2.64, 95% CI 1.08-6.45; p= 0.033), and hypothyroidism (OR=3.66, 05%CI 1.62-8.30; p=0.002). In contrast to their role in the MMFS, the use of a walker or a wheelchair was found to decrease the risk of falling (OR=0.3, 95% CI 0.13-0.69; p=0.005 and OR=0.25, 95% CI 0.11-0.59; p= 0.002). CONCLUSIONS: Further risk stratification of hospitalized patients, already known to have a high MMFS, which would take into account the characteristics pointed out in this study, should be attained.

Asymptomatic urinary retention in elderly women upon admission to the Internal Medicine department: A prospective study.

AIM: To assess the incidence and associated risk factors of asymptomatic urinary retention in elderly women upon admission to the Internal Medicine department. METHODS: Two hundred and two consecutive elderly women (mean age 84.4 ± 5.7 years) who were admitted to four Internal Medicine departments at a tertiary medical center were prospectively enrolled. All patients underwent post-void residual urine (PVR) measurements on the morning following the admission day. The measurements were undertaken by using a portable ultrasound bladder scan. Asymptomatic urinary retention was defined as PVR ≥ 200 ml without lower urinary tract symptoms, or abdominal pain, in two consecutive measurements. RESULTS: Asymptomatic urinary retention was diagnosed in 29 (14.4%) women (mean PVR: 353.1 ± 155.2 ml; range: 200-712 ml). The mean age, prevalence of chronic diseases, and the use of opioid and antimuscarinic drugs were similar in women with versus without asymptomatic urinary retention. A binary logistic regression analysis showed that asymptomatic urinary retention was significantly and independently associated with low mobility, measured by the functional independence measure (FIM) scale (odds ratio = 0.7, 95% confidence interval 0.6-0.9, P = 0.026), and hypothyroidism (odds ratio = 2.4, 95% confidence interval 1.0-5.8, P = 0.049). Among 174 (86.1%) patients in whom thyroid-stimulating hormone (TSH) serum levels were measured, a statistically significant correlation was demonstrated between TSH values and PVR measurements. CONCLUSIONS: Asymptomatic urinary retention in elderly women upon admission to the Internal Medicine department is not infrequent and is independently associated with hypothyroidism and low mobility. PVR measurements should, therefore, be considered in all women with a low level of mobility and/or hypothyroidism upon admission to the Internal Medicine department. Neurourol. Urodynam. 36:794-797, 2017. © 2016 Wiley Periodicals, Inc.

Vomiting and Hyponatremia Are Risk Factors for Worse Clinical Outcomes Among Patients Hospitalized Due to Nonsurgical Abdominal Pain: A Retrospective Cohort Study.

After initial evaluation in the Emergency Department (ED), many patients complaining of abdominal pain are classified as suffering from nonsurgical abdominal pain (NSAP). Clinical characteristics and risk factors for worse prognosis were not published elsewhere.Characterizing the clinical profile of patients hospitalized due to NSAP and identifying predictor variables for worse clinical outcomes.We made a retrospective cohort analysis of patients hospitalized due to NSAP compared to matched control patients (for age, gender, and Charlson comorbidity index) hospitalized due to other, nonsurgical reasons in a ratio of 1 to 10. We further performed in-group analysis of patients admitted due to NSAP in order to appreciate variables (clinical and laboratory parameters) potentially associated with worse clinical outcomes.Overall 23,584 patients were included, of which 2144 were admitted due to NSAP and 21,440 were matched controls. Patients admitted due to NSAP had overall better clinical outcomes: they had lower rates of in-hospital and 30-days mortality (2.8% vs 5.5% and 7.9% vs 10.4% respectively, P < 0.001 for both comparisons). They also had a significantly shorter length of hospital stay (3.9 vs 6.2 days, P < 0.001). Rates of re-hospitalization within 30-days were not significantly different between study groups. Among patients hospitalized due to NSAP, we found that vomiting or hyponatremia at presentation or during hospital stay were associated with worse clinical outcomes.Compared to patients hospitalized due to other, nonsurgical reasons, the overall prognosis of patients admitted due to NSAP is favorable. The combination of NSAP with vomiting and hyponatremia is associated with worse clinical outcomes.

Marked Improvement in Refractory TTP Directly after H. pylori Eradication Therapy.

Thrombotic thrombocytopenic purpura (TTP) is a life-threatening disorder involving thrombotic microangiopathy and is characterized by increased platelet aggregation throughout the body. Acquired TTP can be triggered by a variety of conditions including infections. We hereby describe a case report of an 81-year-old female presenting to the internal medicine department with TTP and active chronic gastritis, positive for Helicobacter pylori (H. pylori) on biopsy. The TTP was highly resistant to medical therapy; however the patient underwent complete resolution of her TTP following H. pylori eradication. We conclude that acquired TTP may be triggered by H. pylori infection and that treating the underlying infection may play a role in improving TTP's outcome in some patients, especially when disease is refractory to medical therapy.