The Early HOSPITAL Score to Predict 30-Day Readmission Soon After Hospitalization: a Prospective Multicenter Study

BACKGROUND

The simplified HOSPITAL score is an easy-to-use prediction model to identify patients at high risk of 30-day readmission before hospital discharge. An earlier stratification of this risk would allow more preparation time for transitional care interventions.

OBJECTIVE

To assess whether the simplified HOSPITAL score would perform similarly by using hemoglobin and sodium level at the time of admission instead of discharge.

DESIGN

Prospective national multicentric cohort study.

PARTICIPANTS

In total, 934 consecutively discharged medical inpatients from internal general services.

MAIN MEASURES

We measured the composite of the first unplanned readmission or death within 30 days after discharge of index admission and compared the performance of the simplified score with lab at discharge (simplified HOSPITAL score) and lab at admission (early HOSPITAL score) according to their discriminatory power (Area Under the Receiver Operating characteristic Curve (AUROC)) and the Net Reclassification Improvement (NRI).

KEY RESULTS

During the study period, a total of 3239 patients were screened and 934 included. In total, 122 (13.2%) of them had a 30-day unplanned readmission or death. The simplified and the early versions of the HOSPITAL score both showed very good accuracy (Brier score 0.11, 95%CI 0.10-0.13). Their AUROC were 0.66 (95%CI 0.60-0.71), and 0.66 (95%CI 0.61-0.71), respectively, without a statistical difference (p value 0.79). Compared with the model at discharge, the model with lab at admission showed improvement in classification based on the continuous NRI (0.28; 95%CI 0.08 to 0.48; p value 0.004).

CONCLUSION

The early HOSPITAL score performs, at least similarly, in identifying patients at high risk for 30-day unplanned readmission and allows a readmission risk stratification early during the hospital stay. Therefore, this new version offers a timely preparation of transition care interventions to the patients who may benefit the most.

Radiological Explorations of Patients with Upper or Febrile Urinary Tract Infection

Recent European Association of Urology (EAU) guidelines and a clinical prediction rule developed by Van Nieuwkoop et al. suggest simple criteria for performing radiological imaging for patients with a febrile urinary tract infection (UTI). We analysed the records of patients with a UTI from four hospitals in Switzerland. Of 107 UTI patients, 58% underwent imaging and 69% (95%CI: 59-77%) and 64% (95%CI: 54-73%) of them were adequately managed according to Van Nieuwkoop's clinical rule and EAU guidelines, respectively. However, only 47% (95%CI: 33-61%) and 57% (95%CI: 44-69%) of the imaging performed would have been recommended according to their respective rules. Clinically significant imaging findings were associated with a history of urolithiasis (OR = 11.8; 95%CI: 3.0-46.5), gross haematuria (OR = 5.9; 95%CI: 1.6-22.1) and known urogenital anomalies (OR = 5.7; 95%CI: 1.8-18.2). Moreover, six of 16 (38%) patients with a clinically relevant abnormality displayed none of the criteria requiring imaging according to Van Nieuwkoop's rule or EAU guidelines. Thus, adherence to imaging guidelines was suboptimal, especially when imaging was not recommended. However, additional factors associated with clinically significant findings suggest the need for a new, efficient clinical prediction rule.

Association of part-time clinical work with well-being and mental health in General Internal Medicine: A survey among Swiss hospitalists

INTRODUCTION

Burnout and low job satisfaction are increasing among the General Internal Medicine (GIM) workforce. Whether part-time compared to full-time clinical employment is associated with better wellbeing, job satisfaction and health among hospitalists remains unclear.

MATERIALS AND METHODS

We conducted an anonymized cross-sectional survey among board-certified general internists (i.e. hospitalists) from GIM departments in 14 Swiss hospitals. Part-time clinical work was defined as employment of <100% as a clinician. The primary outcome was well-being, as measured by the extended Physician Well-Being Index (ePWBI), an ePWBI ≥3 indicating poor wellbeing. Secondary outcomes included depressive symptoms, mental and physical health, and job satisfaction. We compared outcomes in part-time and full time workers using propensity score-adjusted multivariate regression models.

RESULTS

Of 199 hospitalists invited, 137 (69%) responded to the survey, and 124 were eligible for analysis (57 full-time and 67 part-time clinicians). Full-time clinicians were more likely to have poor wellbeing compared to part-time clinicians (ePWBI ≥3 54% vs. 31%, p = 0.012). Part-time compared to full-time clinical work was associated with a lower risk of poor well-being in adjusted analyses (odds ratio 0.20, 95% confidence interval 0.07-0.59, p = 0.004). Compared to full-time clinicians, there were fewer depressive symptoms (3% vs. 18%, p = 0.006), and mental health was better (mean SF-8 Mental Component Summary score 47.2 vs. 43.2, p = 0.028) in part-time clinicians, without significant differences in physical health and job satisfaction.

CONCLUSIONS

Full-time clinical hospitalists in GIM have a high risk of poor well-being. Part-time compared to full-time clinical work is associated with better well-being and mental health, and fewer depressive symptoms.

Factors associated with one-year mortality after hospital discharge: A multicenter prospective cohort study

OBJECTIVES

1) To identify predictors of one-year mortality in hospitalized medical patients using factors available during their hospital stay. 2) To evaluate whether healthcare system use within 30 days of hospital discharge is associated with one-year mortality.

STUDY DESIGN AND SETTING

This prospective, observational study included adult patients from four mid-sized hospital general internal medicine units. During index hospitalization, we retrieved patient characteristics, including demographic and socioeconomic indicators, diagnoses, and early simplified HOSPITAL scores from electronic health records and patient interviews. Data on healthcare system use was collected using telephone interviews 30 days after discharge. Survival status at one year was collected by telephone and from health records. We used a univariable analysis including variables available from the hospitalization and 30-day post-discharge periods. We then performed multivariable analyses with one model using index hospitalization data and one using 30-day post-discharge data.

RESULTS

Of 934 patients, 123 (13.2%; 95% CI 11.0-15.4%) were readmitted or died within 30 days. Of 814 patients whose primary outcome was available, 108 died (13.3%) within one year. Using factors obtained during hospitalization, the early simplified HOSPITAL score (OR 1.50; 95% CI 1.31-1.71; P < 0.001) and not living at home (OR 4.0; 95% CI 1.8-8.3; P < 0.001) were predictors of one-year mortality. Using 30-day post-discharge predictors, hospital readmission was significantly associated with one-year mortality (OR 4.81; 95% CI 2.77-8.33; P < 0.001).

SIGNIFICANCE

Factors predicting one-year mortality were a high early simplified HOSPITAL score, not living at home, and a 30-day unplanned readmission.

Effects of a Multimodal Transitional Care Intervention in Patients at High Risk of Readmission: The TARGET-READ Randomized Clinical Trial

Importance

Hospital readmissions are frequent, costly, and sometimes preventable. Although these issues have been well publicized and incentives to reduce them introduced, the best interventions for reducing readmissions remain unclear.

Objectives

To evaluate the effects of a multimodal transitional care intervention targeting patients at high risk of hospital readmission on the composite outcome of 30-day unplanned readmission or death.

Design, Setting, and Participants

A single-blinded, multicenter randomized clinical trial was conducted from April 2018 to January 2020, with a 30-day follow-up in 4 medium-to-large-sized teaching hospitals in Switzerland. Participants were consecutive patients discharged from general internal medicine wards and at higher risk of unplanned readmission based on their simplified HOSPITAL score (≥4 points). Data were analyzed between April and September 2022.

Interventions

The intervention group underwent systematic medication reconciliation, a 15-minute patient education session with teach-back, a planned first follow-up visit with their primary care physician, and postdischarge follow-up telephone calls from the study team at 3 and 14 days. The control group received usual care from their hospitalist, plus a 1-page standard study information sheet.

Main Outcomes and Measures

Thirty-day postdischarge unplanned readmission or death.

Results

A total of 1386 patients were included with a mean (SD) age of 72 (14) years; 712 (51%) were male. The composite outcome of 30-day unplanned readmission or death was 21% (95% CI, 18% to 24%) in the intervention group and 19% (95% CI, 17% to 22%) in the control group. The intention-to-treat analysis risk difference was 1.7% (95% CI, -2.5% to 5.9%; P = .44). There was no evidence of any intervention effects on time to unplanned readmission or death, postdischarge health care use, patient satisfaction with the quality of their care transition, or readmission costs.

Conclusions and Relevance

In this randomized clinical trial, use of a standardized multimodal care transition intervention targeting higher-risk patients did not significantly decrease the risks of 30-day postdischarge unplanned readmission or death; it demonstrated the difficulties in preventing hospital readmissions, even when multimodal interventions specifically target higher-risk patients.

Trial Registration

ClinicalTrials.gov Identifier: NCT03496896.

[Number needed to treat: a useful toolto evaluate the effectiveness of a treatment?]

This article reviews the clinical implications and limitations of the number needed to treat (NNT). Clinicians can quickly use this rather intuitive statistical value to assess the expected effectiveness of a treatment and explain it to patients. However, careful attention must be paid to the outcomes used in defining an NNT, as well as, the rate of the specific event in the population and the duration of observation. Conflicts of interest may also affect this easily manipulated statistical tool. Some often prescribed treatments have an NNT well above 20, implying an uncertain benefit for the patient, which emphasizes the need to carefully weigh the risk-benefit balance (NNT vs. NNH: number needed to harm) when prescribing. This review shows particularly low NNTs for anti-infectious agents compared to other drugs frequently used in medical practice.

[Infectious diseases as you have never read them (second part…)]

The Covid-19 epidemic has turned our lives upside down; surprisingly certain aspects of this infection can also make you smile, as well as certain modes of transmission of infectious agents that we have grouped together in the form of an original "blooper" of infectious diseases.

Efficacy of Retreatment After Failed Direct-acting Antiviral Therapy in Patients With HCV Genotype 1-3 Infections

Hepatitis C virus infection is causing chronic liver disease, cirrhosis, and hepatocellular carcinoma. By combining direct-acting antivirals (DAAs), high sustained virologic response rates (SVRs) can be achieved. Resistance-associated substitutions (RASs) are commonly observed after DAA failure, and especially nonstructural protein 5A (NS5A) RASs may impact retreatment options.^1-3 Data on retreatment of DAA failure patients using first-generation DAAs are limited.^4-7 Recently, a second-generation protease- and NS5A-inhibitor plus sofosbuvir (voxilaprevir/velpatasvir/sofosbuvir [VOX/VEL/SOF]) was approved for retreatment after DAA failure.⁸ However, this and other second-generation regimens are not available in many resource-limited countries or are not reimbursed by regular insurance, and recommendations regarding the selection of retreatment regimens using first-generation DAAs are very important. This study aimed to analyze patients who were re-treated with first-generation DAAs after failure of a DAA combination therapy.

The well-being of Swiss general internal medicine residents

BACKGROUND

Physician well-being has an impact on productivity and quality of care. Residency training is a particularly stressful period.

OBJECTIVE

To assess the well-being of general internal medicine (GIM) residents and its association with personal and work-related factors.

METHODS

We conducted an anonymous electronic survey among GIM residents from 13 Swiss teaching hospitals. We explored the association between a reduced well-being (&ge;5 points based on the Physician Well-Being Index [PWBI]) and personal and work-related factors using multivariable mixed-effects logistic regression.

RESULTS

The response rate was 54% (472/880). Overall, 19% of residents had a reduced well-being, 60% felt burned out (emotional exhaustion), 47% were worried that their work was hardening them emotionally (depersonalisation), and 21% had career choice regret. Age (odds ratio [OR] 1.19, 95% confidence interval [CI] 1.05&ndash;1.34), working hours per week (OR 1.04 per hour, 95% CI 1.01&ndash;1.07) and &lt;2.5 rewarding work hours per day (OR 3.73, 95% CI 2.01&ndash;6.92) were associated with reduced well-being. Administrative workload and satisfaction with the electronic medical record were not. We found significant correlations between PWBI score and job satisfaction (rs = -0.54, p&lt;0.001), medical errors (rs = 0.18, p&lt;0.001), suicidal ideation (rs = 0.12, p = 0.009) and the intention to leave clinical practice (rs = 0.38, p &lt;0.001) CONCLUSIONS: Approximately 20% of Swiss GIM residents appear to have a reduced well-being and many show signs of distress or have career choice regret. Having few hours of rewarding work and a high number of working hours were the most important modifiable predictors of reduced well-being. Healthcare organisations have an ethical responsibility to implement interventions to improve physician well-being.

[Antiviral therapy for general practitioners]

Viral infections are extremely common and generally self-restricted, thus antiviral therapy is limited to precise indications. Apart from HIV (not reviewed in this article), the principal treatable viruses are HSV 1 and 2, VZV, CMV, Influenza A and B, and hepatitis B and C. Vaccination is another cornerstone of viral infections control. This article summarizes actual and available therapy. New treatments arrived recently on the market or are being developed : HCV can now be treated with a high success rate, baloxavir against the flu, a new zoster vaccine will probably soon be available in Switzerland and letermovir improves CMV prophylaxis in the case of hematopoietic stem cell transplant.

[Drug fever among Swiss' most sold drugs in primary care]

Drug fever is a little known side effect and should be considered as a differential diagnosis in the presence of fever. Its early recognition is important to avoid unnecessary investigations. Among the 70 most prescribed drugs in primary care in Switzerland, 8 have been linked to drug fever : amoxicillin, atorvastatin, rosuvastatin, esomeprazole, pantoprazole, rivaroxaban, salbutamol and trazodone. There are no specific criterias to distinguish a drug-induced fever. The diagnosis is confirmed with a positive rechallenge test. If a drug fever is suspected, it is recommended to stop the offending agent.

Frequency of use and acceptability of clinical prediction rules for pulmonary embolism among Swiss general internal medicine residents

INTRODUCTION

Whether clinical prediction rules for pulmonary embolism are accepted and used among general internal medicine residents remains uncertain. We therefore evaluated the frequency of use and acceptability of the Revised Geneva Score (RGS) and the Pulmonary Embolism Severity Index (PESI), and explored which factors were associated with rule use.

MATERIALS/METHODS

In an online survey among general internal medicine residents from 10 Swiss hospitals, we assessed rule acceptability using the Ottawa Acceptability of Decision Rules Instrument (OADRI) and explored the association between physician and training-related factors and rule use using mixed logistic regression models.

RESULTS

The response rate was 50.4% (433/859). Overall, 61% and 36% of the residents reported that they always or regularly use the RGS and the PESI, respectively. The mean overall OADRI score was 4.3 (scale 0-6) for the RGS and 4.1 for the PESI, indicating a good acceptability. Rule acceptability (odds ratio [OR] 6.19 per point, 95% confidence interval [CI] 3.64-10.51), prior training in emergency medicine (OR 5.14, CI 2.20-12.01), and availability of internal guidelines recommending RGS use (OR 4.25, CI 2.15-8.43) were associated with RGS use. Rule acceptability (OR 6.43 per point, CI 4.17-9.92) and rule taught at medical school (OR 2.06, CI 1.24-3.43) were associated with PESI use.

CONCLUSIONS

The RGS was more frequently used than the PESI. Both rules were considered acceptable. Rule acceptability, prior training in emergency medicine, availability of internal guidelines, and rule taught at medical school were associated with rule use and represent potential targets for quality improvement interventions.

[Infectious diseases as you have never read them]

Infectious diseases is known as a serious medical discipline. Nevertheless some experiences related by patients and unusual studies can bring a smile on your face. In this article, you will find a sample of rare and original studies in this field, extracted from a collection of comical published medical articles.

[Shortening the antibiotherapy is in progress: get up to date!]

In a world where the emergence of resistant bacteria threatens the future use of many antibiotics, it is now critical to prescribe antibiotics carefully in order to minimize selective pressure. Limiting treatment duration would be one of the strategies to achieve this goal. Recent studies state that a reduction of the course of treatment is showing great benefit with no outcome difference.

Time to antibiotics administration and outcome in community-acquired pneumonia: Secondary analysis of a randomized controlled trial

BACKGROUND

The association between early antibiotic administration and outcomes remains controversial in patients hospitalized for community-acquired pneumonia.

METHODS

We performed a secondary analysis of a randomized controlled trial comparing two antibiotic treatment strategies for patients hospitalized for moderately severe CAP. The univariate and multivariate associations between time to antibiotic administration (TTA) and time to clinical stability were assessed using a Cox proportional hazard model. Secondary outcomes were death, intensive care unit admission and hospital readmission up to 90days.

RESULTS

371 patients (mean age 76years, CURB-65 score≥2 in 52%) were included. Mean TTA was 4.35h (SD 3.48), with 58.5% of patients receiving the first antibiotic dose within 4h. In multivariate analysis, number of symptoms and signs (HR 0.876, 95% CI 0.784-0.979, p=0.020), age (HR 0.986, 95% CI 0.975-0.996, p=0.007), initial heart rate (HR 0.992, 95% CI 0.986-0.999, p=0.023), and platelets count (HR 0.998, 95% CI 0.996-0.999, p=0.004) were associated with a reduced probability of reaching clinical stability. The association between TTA and time to clinical stability was not significant (HR 1.009, 95% CI 0.977-1.042, p=0.574). We found no association between TTA and the risk of intensive care unit admission, death or readmission up to 90days after the initial admission.

CONCLUSION

In patients hospitalized for moderately severe CAP, a shorter time to antibiotic administration was not associated with a favorable outcome. These findings support the current recommendations that do not assign a specific time frame for antibiotics administration.

[One year of infectious diseases : a review]

Several outbreaks have made the news in 2016 : Ebola has come at an end, Zika is booming and a resurgence of yellow fever takes place in Africa. In Switzerland, two hospital outbreaks have been reported, caused by Mycobacterium chimerae and Burkholderia cepacia. A major new article has consolidated the notion that prolonged antibiotic therapy is unnecessary in Lyme disease. As multiresistant bacteria are increasing in frequency, innovative therapeutic approaches are under development. For lung infections, sensitive and specific methods are in need to refine their etiological diagnosis. In pneumonia, therapy can be shortened without risk compared with usual practice. Finally, the epidemiology of bacterial meningitis has changed in the last 10 years, with a decrease of incidence.

Predictors and Implications of Early Clinical Stability in Patients Hospitalized for Moderately Severe Community-Acquired Pneumonia

Background

Assessment of early response to treatment is crucial for the management of community-acquired pneumonia (CAP).

Objective

To describe the predictors and the outcomes of early clinical stability

Methods

We did a secondary analysis of a multicentre randomized controlled trial on CAP treatment in which 580 patients hospitalized for moderately severe CAP were included. The association between demographic, clinical and biological variables available at inclusion and early clinical stability (stabilization of vital signs within 72 hours with predetermined cut-offs) was assessed by multivariate logistic regression. The association between early clinical stability and mortality, severe adverse events, and length of stay was also tested.

Results

Younger age (OR 0.98, 95% CI 0.96–0.99), lower platelet count (OR per 10 G/L increment 0.96, 95% CI 0.94–0.98), lower respiratory rate (OR 0.94, 95% CI 0.90–0.97), absence of hypoxemia (OR 0.58, 95% CI 0.40–0.85), lower numbers of co-morbid conditions (OR 0.82, 95% CI 0.69–0.98) and signs or symptoms (OR 0.78, 95% CI 0.68–0.90) were significantly associated with early clinical stability. Patients with early clinical stability had lower 90-days mortality (3.4% vs. 11.9%, p<0.001), fewer admissions to the intensive care unit (2.7% vs. 8.0%, p = 0.005) and a shorter length of stay (6.0 days, IQR 4.0–10.0 vs. 10.0 days, IQR 7.0–15.0, p<0.001).

Conclusions

Patients with younger age, less co-morbidity, fewer signs or symptoms, less respiratory compromise, and a lower platelet count are more likely to reach early clinical stability. Patients without early clinical stability have a worse prognosis and warrant close scrutiny.

[Acute pericarditis]

Acute pericarditis is an inflammation of the pericardium. Different etiologies are known, and can be classified in three groups: infectious, neoplastic and auto-immun. The diagnosis is based essentially on clinical signs and should be raised by position and respiratory dependent chest pain, especially when it follows a viral infection, and a pericardial friction rub on cardiac auscultation. An ECG and an echocardiography should be performed to assess the presence of a pericardial effusion. A diffuse and concave ST elevation permits the distinction with myocardial ischemia. The first line therapy is an association between NSAR and colchicine, the latter has shown to reduce the risk of recurrence.

[Advice for those that want to specialize in infectious diseases in Switzerland]

In Switzerland the specialty of Infectious Diseases attracts many young physicians. In this article we describe the place of infec- tious diseases in Switzerland. We review its usefulness for patients, the requirements to obtain a title of specialist, its different subs- pecialists and the potential job openings of this training.

Tobacco Stained Fingers and Its Association with Death and Hospital Admission: A Retrospective Cohort Study

BACKGROUND

Among smokers, the presence of tobacco stains on fingers has recently been associated with a high prevalence of tobacco related conditions and alcohol abuse.

OBJECTIVE

we aimed to explore tobacco stains as a marker of death and hospital readmission.

METHOD

Seventy-three smokers presenting tobacco-tar staining on their fingers and 70 control smokers were followed during a median of 5.5 years in a retrospective cohort study. We used the Kaplan-Meier survival analysis and the log-rank test to compare mortality and hospital readmission rates among smokers with and smokers without tobacco stains. Multivariable Cox models were used to adjust for confounding factors: age, gender, pack-year unit smoked, cancer, harmful alcohol use and diabetes. The number of hospital admissions was compared through a negative binomial regression and adjusted for the follow-up time, diabetes, and alcohol use.

RESULTS

Forty-three patients with tobacco-stained fingers died compared to 26 control smokers (HR 1.6; 95%CI: 1.0 to 2.7; p 0.048). The association was not statistically significant after adjustment. Patients with tobacco-stained fingers needed a readmission earlier than smokers without stains (HR 2.1; 95%CI: 1.4 to 3.1; p<0.001), and more often (incidence rate ratio (IRR) 1.6; 95%CI: 1.1 to 2.1). Associations between stains and the first hospital readmission (HR 1.6; 95%CI: 1.0 to 2.5), and number of readmissions (IRR 1.5; 95%CI: 1.1 to 2.1) persisted after adjustment for confounding factors.

CONCLUSIONS

Compared to other smokers, those presenting tobacco-stained fingers have a high unadjusted mortality rate and need early and frequent hospital readmission even when controlling for confounders.

β-Lactam monotherapy vs β-lactam-macrolide combination treatment in moderately severe community-acquired pneumonia: a randomized noninferiority trial

IMPORTANCE

The clinical benefit of adding a macrolide to a β-lactam for empirical treatment of moderately severe community-acquired pneumonia remains controversial.

OBJECTIVE

To test noninferiority of a β-lactam alone compared with a β-lactam and macrolide combination in moderately severe community-acquired pneumonia.

DESIGN, SETTING, AND PARTICIPANTS

Open-label, multicenter, noninferiority, randomized trial conducted from January 13, 2009, through January 31, 2013, in 580 immunocompetent adult patients hospitalized in 6 acute care hospitals in Switzerland for moderately severe community-acquired pneumonia. Follow-up extended to 90 days. Outcome assessors were masked to treatment allocation.

INTERVENTIONS

Patients were treated with a β-lactam and a macrolide (combination arm) or with a β-lactam alone (monotherapy arm). Legionella pneumophila infection was systematically searched and treated by addition of a macrolide to the monotherapy arm.

MAIN OUTCOMES AND MEASURES

Proportion of patients not reaching clinical stability (heart rate <100/min, systolic blood pressure >90 mm Hg, temperature <38.0°C, respiratory rate <24/min, and oxygen saturation >90% on room air) at day 7.

RESULTS

After 7 days of treatment, 120 of 291 patients (41.2%) in the monotherapy arm vs 97 of 289 (33.6%) in the combination arm had not reached clinical stability (7.6% difference, P = .07). The upper limit of the 1-sided 90% CI was 13.0%, exceeding the predefined noninferiority boundary of 8%. Patients infected with atypical pathogens (hazard ratio [HR], 0.33; 95% CI, 0.13-0.85) or with Pneumonia Severity Index (PSI) category IV pneumonia (HR, 0.81; 95% CI, 0.59-1.10) were less likely to reach clinical stability with monotherapy, whereas patients not infected with atypical pathogens (HR, 0.99; 95% CI, 0.80-1.22) or with PSI category I to III pneumonia (HR, 1.06; 95% CI, 0.82-1.36) had equivalent outcomes in the 2 arms. There were more 30-day readmissions in the monotherapy arm (7.9% vs 3.1%, P = .01). Mortality, intensive care unit admission, complications, length of stay, and recurrence of pneumonia within 90 days did not differ between the 2 arms.

CONCLUSIONS AND RELEVANCE

We did not find noninferiority of β-lactam monotherapy in patients hospitalized for moderately severe community-acquired pneumonia. Patients infected with atypical pathogens or with PSI category IV pneumonia had delayed clinical stability with monotherapy.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00818610.

Tobacco-stained fingers: a clue for smoking-related disease or harmful alcohol use? A case-control study

OBJECTIVE

Tobacco stain on fingers is frequent. However, there is scarce description of this clinical sign. We aimed to explore tobacco stain on fingers as a marker of tobacco-related disease independent of cumulative tobacco exposure, and to find behavioural and environmental characteristics associated with those stains.

DESIGN

Case-control study.

SETTING

A Swiss community hospital of 180 beds.

PARTICIPANTS

49 adults presenting tobacco-tars staining on fingers were matched to 49 control smokers by age, gender, height and pack-year (PY).

OUTCOME MEASURES

Documented smoking-related carcinoma, ischaemic heart disease, peripheral arterial disease, stroke and chronic obstructive pulmonary disease (COPD), also determined by lung function, were compared between groups. Association between harmful alcohol use, mental disorders or unemployment and tar-staining was adjusted for smoking behaviour through conditional logistic regression.

RESULTS

Overall cigarette-related disease was high in the case group (84%), and symptomatic peripheral arterial disease was more frequent compared to controls (OR 3.5, CI 95% 1.1 to 14.6). Smoking-related carcinoma, ischaemic heart disease, stroke and COPD were not statistically different for control smokers. Harmful alcohol use was strongly associated with stains and this association persists after adjustment for smoking unfiltered cigarettes, smoking more than one pack of cigarettes in a day and age at smoking onset (adjusted OR 4.6, CI 95% 1.2 to 17.2). Mental disorders and unemployment were not statistically significant.

CONCLUSIONS

Patients with tobacco-tar-stained fingers frequently have cigarette-related disease, however statistically not more than control smokers matched for PY, except for symptomatic peripheral arterial disease. This study suggests a link between stained fingers and addictive behaviour or concomitant high alcohol consumption.

[Unprotected fellatio: what are the risks?]

Unprotected fellatio, which has been practiced by all civilizations since mists of time, is now becoming a cause of concern due to the AIDS epidemic. Most of the sexually transmitted infectious diseases are concerned by fellatio and only few medical studies deal with this topic. This paper is therefore a non exhaustive review of risks brought upon by unprotected fellatio. It is almost impossible to assess the exact risk for a given infection because of the complexity of sexual intercourse, which is rarely exclusively oro-genital.

[Cellulitis: clinical manifestations and management]

Cellulitis is an acute bacterial non-necrotizing dermal-hypodermal infection predominantly affecting the lower limbs. It is characterised by a circumscribed erythema with a raised border and fever. The predisposing factors are skin wounds, edema from any cause and systemic factors (diabetes, immunosuppression). The diagnosis is clinical and the most common complication is recurrence. Other complications include local abscess, fasciitis and bacteremia. The germ is rarely identified. The majority of infections (85%) is due to group A beta-hemolytic streptococcus. The treatment of cellulitis consists of an association of an antibiotic with rest of the concerned area.

[Norovirus gastroenteritis: frequent, often epidemic, with potentially severe complications]

Norovirus are the most frequent causes of epidemic gastroenteritis. Infections generally resolve spontaneously, but may lead to severe complications including death, or become chronic in immunocompromised hosts. Complications preferentially occur in immunocompromised hosts and their consequences are sometimes severe in vulnerable individuals living in confined spaces, such as healthcare settings. Norovirus have a high capacity to mutate. This and their capacity to persist in the water and on everyday objects of our surroundings favor the occurrence of epidemics. As a vaccination protective against most relevant strains is currently not available and in view of their high contagiousness, the prevention and control of the norovirus gastroenteritis remains a major clinical challenge.

[Adult severe community-acquired pneumonia: from diagnosis to intensive care]

Severe community-acquired pneumonia is defined as a pneumonia acquired in an extra-hospital setting requiring intensive care. Clinical scores such as the ATS modified rule can help the clinician to recognize quickly the patients needing ICU. Evidence based interventions decreasing mortality consist of rapid administration of antibiotics, by probably privileging an association containing a macrolide, as well as fast and specialized care of shock and respiratory failure. Severe community-acquired pneumonia is burdened by a short and long-term important mortality.

Hepatitis delta in Switzerland: a silent epidemic

OBJECTIVES

The sero-prevalence of co-infection with the hepatitis B virus (HBV) and the hepatitis D virus (HDV) is well known in many European countries, starting from 6.8% in Germany to more than 27% in some Turkish areas. To gain a better description of this infection in Switzerland, and to characterise those affected, a questionnaire was sent to all Swiss gastroenterologists, hepatologists and infectologists.

METHODS

A questionnaire was received by 349 physicians which asked them to report on all HBV- and HDV-infected patients seen at their units/offices.

RESULTS

A total of 101 HDV-positive patients seen by 78 specialists were analysed. The physicians were in charge of 1'699 patients with chronic hepatitis B, giving a 5.9% prevalence of HDV infection in HBV-positive patients. A predominance of males (75%) from Switzerland (39%), and of African origin (21%) was recorded. Most had been contaminated by intravenous drug use (62%), followed by vertical transmission (15%), sexual contact (13%) or transfusion with blood or blood products (2%). The majority (74%) had a very low (<103 UI/ml) HBV viral load and 75% were HBeAg-negative. A total of 76% percent of those who had a liver biopsy had significant fibrosis (≥F2), and only 21% had received standard therapy (interferon or pegylated interferon-α). Overall, 10% recovered spontaneously (anti-HBs-positive).

CONCLUSION

With a prevalence of 5.9% of hepatitis D in HBsAg-positive patients, Switzerland seems less affected than most other European countries, however, it is possible that this infection is under-diagnosed. Intravenous drug use was the main risk factor. Associated advanced liver disease was also very common.

Tropheryma whipplei tricuspid endocarditis: a case report and review of the literature

INTRODUCTION

The main clinical manifestations of Whipple's disease are weight loss, arthropathy, diarrhea and abdominal pain. Cardiac involvement is frequently described. However, endocarditis is rare and is not usually the initial presentation of the disease. To the best of our knowledge, this is the first reported case of a patient with Tropheryma whipplei tricuspid endocarditis without any other valve involved and not presenting signs of arthralgia and abdominal involvement.

CASE PRESENTATION

We report a case of a 50-year-old Caucasian man with tricuspid endocarditis caused by Tropheryma whipplei, showing signs of severe shock and an absence of other more classic clinical signs of Whipple's disease, such as arthralgia, abdominal pain and diarrhea. Tropheryma whipplei was documented by polymerase chain reaction of the blood and pleural fluid. The infection was treated with a combined treatment of doxycycline, hydroxychloroquine and sulfamethoxazole-trimethoprim for one year.

CONCLUSION

Tropheryma whipplei infectious endocarditis should always be considered when facing a blood-culture negative endocarditis particularly in right-sided valves. Although not standardized yet, treatment of Tropheryma whipplei endocarditis should probably include a bactericidal antibiotic (such as doxycycline) and should be given over a prolonged period of time (a minimum of one year).

Treatment of hepatitis C in HCV mono-infected and in HIV-HCV co-infected patients: an open-labelled comparison study

BACKGROUND/AIMS

Treatment of chronic HCV infection has become a priority in HIV+ patients, given the faster progression to end-stage liver disease. The primary endpoint of this study was to evaluate and compare antiviral efficacy of Peginterferon alpha 2a plus ribavirin in HIV-HCV co-infected and HCV mono-infected patients, and to examine whether 6 months of therapy would have the same efficacy in HIV patients with favourable genotypes 2 and 3 as in mono-infected patients, to minimise HCV-therapy-related toxicities. Secondary endpoints were to evaluate predictors of sustained virological response (SVR) and frequency of side-effects.

METHODS

Patients with genotypes 1 and 4 were treated for 48 weeks with Pegasys 180 microg/week plus Copegus 1000-1200 mg/day according to body weight; patients with genotypes 2 and 3 for 24 weeks with Pegasys 180 microg/week plus Copegus 800 mg/day.

RESULTS

132 patients were enrolled in the study: 85 HCV mono-infected (38: genotypes 1 and 4; 47: genotypes 2 and 3), 47 HIV-HCV co-infected patients (23: genotypes 1 and 4; 24: genotypes 2 and 3). In an intention-to-treat analysis, SVR for genotypes 1 and 4 was observed in 58% of HCV mono-infected and in 13% of HIV-HCV co-infected patients (P = 0.001). For genotypes 2 and 3, SVR was observed in 70% of HCV mono-infected and in 67% of HIV-HCV co-infected patients (P = 0.973). Undetectable HCV-RNA at week 4 had a positive predictive value for SVR for mono-infected patients with genotypes 1 and 4 of 0.78 (95% CI: 0.54-0.93) and of 0.81 (95% CI: 0.64-0.92) for genotypes 2 and 3. For co-infected patients with genotypes 2 and 3, the positive predictive value of SVR of undetectable HCV-RNA at week 4 was 0.76 (95%CI, 0.50-0.93). Study not completed by 22 patients (36%): genotypes 1 and 4 and by 12 patients (17%): genotypes 2 and 3.

CONCLUSION

Genotypes 2 or 3 predict the likelihood of SVR in HCV mono-infected and in HIV-HCV co-infected patients. A 6-month treatment with Peginterferon alpha 2a plus ribavirin has the same efficacy in HIV-HCV co-infected patients with genotypes 2 and 3 as in mono-infected patients. HCV-RNA negativity at 4 weeks has a positive predictive value for SVR. Aggressive treatment of adverse effects to avoid dose reduction, consent withdrawal or drop-out is crucial to increase the rate of SVR, especially when duration of treatment is 48 weeks. Sixty-one percent of HIV-HCV co-infected patients with genotypes 1 and 4 did not complete the study against 4% with genotypes 2 and 3.

[Acute community-acquired bacterial meningitis in adults]

Bacterial meningitis in adults is fatal in 20% of patients and leads to sequels in 30%. The clinical presentation includes two of the following four symptoms and signs: fever, headache, stiff neck, altered mental status. The essential ancillary test is the analysis of the cerebrospinal fluid. Sometimes, the lumbar puncture is not feasible or deferred (brain computer tomography), requiring antibiotics and corticosteroids early. 80% of bacterial meningitis are secondary to pneumococcus or meningococcus. Empirical antibiotics must be given as soon as possible and provide coverage for these both bacteria. Corticosteroids are also recommended for some meningitis. A score can predict the evolution. Preventive measure must be taken for close contacts of a patient with a meningococcal meningitis.

[Antibiotics: drug and food interactions]

Antibiotics are widely prescribed in medical practice. Many of them induce or are subject to interactions that may diminish their anti-infectious efficiency or elicit toxic effects. Food intake can influence the effectiveness of an antibiotic. Certain antibiotics can lower the effectiveness of oral contraception. Oral anticoagulation can be influenced to a great extent by antibiotics and controls are necessary. Interactions are also possible via enzymatic induction or inhibition of cytochromes. The use of an interaction list with substrates of cytochromes enables to anticipate. Every new prescription should consider a possible drug or food interaction.

Polyfunctional HCV-specific T-cell responses are associated with effective control of HCV replication

HCV infection has a severe course of disease in HIV/HCV co-infection and in liver transplant recipients. However, the mechanisms involved remain unclear. Here, we evaluated functional profiles of HCV-specific T-cell responses in 86 HCV mono-infected patients, 48 HIV/HCV co-infected patients and 42 liver transplant recipients. IFN-gamma and IL-2 production and ability of CD4 and CD8 T cells to proliferate were assessed after stimulation with HCV-derived peptides. We observed that HCV-specific T-cell responses were polyfunctional in HCV mono-infected patients, with presence of proliferating single IL-2-, dual IL-2/IFN-gamma and single IFN-gamma-producing CD4+ and dual IL-2/IFN-gamma and single IFN-gamma-producing CD8+ cells. In contrast, HCV-specific T-cell responses had an effector profile in HIV/HCV co-infected individuals and liver transplant recipients with absence of single IL-2-producing HCV-specific CD4+ and dual IL-2/IFN-gamma-producing CD8+ T cells. In addition, HCV-specific proliferation of CD4+ and CD8+ T cells was severely impaired in HIV/HCV co-infected patients and liver transplant recipients. Importantly, "only effector" T-cell responses were associated with significantly higher HCV viral load and more severe liver fibrosis scores. Therefore, the present results suggest that immune-based mechanisms may contribute to explain the accelerated course of HCV infection in conditions of HIV-1 co-infection and liver transplantation.

Prospective study on procalcitonin and other systemic infection markers in patients with leukocytosis

OBJECTIVE

To better assess the diagnosis of an infection in patients presenting at an emergency department with peripheral blood leukocytosis (>10 x 10(9) cells/l) on laboratory testing.

METHODS

We prospectively evaluated serum procalcitonin concentration (PCT), C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR). Patients were divided into two groups according to their final diagnosis: patients with infection and those without infection. PCT, CRP, and ESR were compared between these groups. Sensitivity, specificity, positive predictive values, negative predictive values, receiver operating characteristic curves, and areas under the curves were calculated for each biological measurement.

RESULTS

Out of 173 patients, 99 (57%) had a final diagnosis of systemic infection. If a cutoff point of 0.5 ng/ml is considered, procalcitonin concentration had a sensitivity of 0.57, a specificity of 0.85, a negative predictive value of 0.59, and a positive predictive value of 0.84 for the diagnosis of a systemic infection. Adding CRP or ESR to PCT gave no more information (p=0.84).

CONCLUSIONS

Only about half of the patients attending the emergency department with leukocytosis were suffering from an infection. Determination of the procalcitonin level may be useful for these patients, particularly in the case of a value higher than 0.5 ng/ml.

Ictal bradycardia and asystole: an uncommon cause of syncope

We report on two patients with recurrent syncope secondary to ictal bradyarrhythmias, triggered by partial epileptic seizures with atypical, stereotyped auras. Ictal bradyarrhythmias are potentially lethal, and likely originate from the involvement of limbic autonomic regions. The appropriate treatment is double-headed, including an antiepileptic drug and the implantation of a pacemaker.

[Bad bats?]

For many centuries, man is fascinated by bats, the only flying mammals. Probably because of their particular immune system, bats can be considered an important reservoir for new emerging viral diseases like SARS-Coronavirus, Marburg fever, Ebola fever and Nipah virus encephalitis. During closer contact, they can transmit rabies and probably other nonviral infectious diseases. Bats get closer to man due to ecological modifications like deforestation, so that transmission of new infectious agents might provoke dramatic epidemics.

CD4-guided scheduled treatment interruptions compared with continuous therapy for patients infected with HIV-1: results of the Staccato randomised trial

BACKGROUND

Stopping antiretroviral therapy in patients with HIV-1 infection can reduce costs and side-effects, but carries the risk of increased immune suppression and emergence of resistance.

METHODS

430 patients with CD4-positive T-lymphocyte (CD4) counts greater than 350 cells per muL, and viral load less than 50 copies per mL were randomised to continued therapy (n=146) or scheduled treatment interruptions (n=284). Median time on randomised treatment was 21.9 months (range 16.4-25.3). Primary endpoints were proportion of patients with viral load less than 50 copies per mL at the end of the trial, and amount of drugs used. Analysis was intention-to-treat. This study is registered at ClinicalTrials.gov with the identifier NCT00113126.

FINDINGS

Drug savings in the scheduled treatment interruption group, compared with continuous treatment, amounted to 61.5%. 257 of 284 (90.5%) patients in the scheduled treatment interruption group reached a viral load less than 50 copies per mL, compared with 134 of 146 (91.8%) in the continued treatment group (difference 1.3%, 95% CI-4.3 to 6.9, p=0.90). No AIDS-defining events occurred. Diarrhoea and neuropathy were more frequent with continuous treatment; candidiasis was more frequent with scheduled treatment interruption. Ten patients (2.3%) had resistance mutations, with no significant differences between groups.

INTERPRETATION

Drug savings with scheduled treatment interruption were substantial, and no evidence of increased treatment resistance emerged. Treatment-related adverse events were more frequent with continuous treatment, but low CD4 counts and minor manifestations of HIV infection were more frequent with scheduled treatment interruption.