The rate of ward to intensive care transfer and its predictors among hospitalized COPD patients, a retrospective study in a local tertiary center in Saudi Arabia

OBJECTIVE

To investigate the prevalence of intensive care unit (ICU) admission and its predictors among hospitalized chronic obstructive pulmonary disease (COPD) patients.

METHODS

An observational retrospective study was conducted. All patients with a confirmed diagnosis of COPD according to the GOLD guidelines between 28 and 2020 and 1 March 2023 at Al-Noor Specialist Hospital were included in this study. Patients were excluded if a preemptive diagnosis of COPD was made clinically without spirometry evidence of fixed airflow limitation. Descriptive results were presented as frequency (percentage) for categorical variables and mean (SD) for continuous variables and to estimate prevalence of ICU admission. Predictors of ICU admission among hospitalized COPD patients were determined using logistic regression analysis. A SPSS (Statistical Package for the Social Sciences) version 25 was used to perform all statistical analysis.

RESULTS

A total of 705 patients with COPD were included in this study. The mean age was 65.4 (25.3) years. Around 12.4% of the hospitalized patients were admitted to the ICD. Logistic regression analysis identified that older age (OR; 1.92, (1.41-2.62)), smoking (OR; 1.60 (1.17-2.19)), and having specific comorbidities (Hypertension (OR; 1.98 (1.45-2.71)), Diabetes mellitus (OR; 1.42 (1.04-1.93)), GERD (OR; 2.81 (1.99-3.96)), Ischemic heart disease (OR; 3.22 (2.19-4.75)), Obstructive sleep apnea syndrome (OR; 2.14 (1.38-3.33)), stroke (OR; 4.51 (2.20-9.26))) were predictors of ICU admissions among patients with COPD.

CONCLUSIONS

Our study found that a step-up approach to inpatient COPD management requires admission to the ICU in 12.4%, for which age, smoking status, cardiovascular, and stroke were important predictors. Further clinical research is needed to provide a validated model that can be incorporated into clinical practice to monitor this patient population during their admission and identify at-risk individuals for early transfer to higher acuity settings and intensive care units.

Expert Opinion Guidance on the Detection of Early Connective Tissue Diseases in Interstitial Lung Disease

There is a significant variation in symptoms and clinical presentation of connective tissue disorders (CTD) associated with interstitial lung disease (ILD) (CTD-ILD). This presents difficulties in the diagnosis and treatment of CTD-ILD. Early detection and treatment of CTD-ILD using a multidisciplinary approach have been shown to enhance patient outcomes. This exercise aims to explore clinical components to develop a screening tool for pulmonologists for early detection of CTD in ILD and to provide a framework for a multidisciplinary approach in managing CTD-ILD. This in turn will lead to early treatment of CTD-ILD in collaboration with rheumatologists. A panel of 12 leading rheumatologists from the Middle East and North Africa (MENA) region met virtually to select the most relevant clinical findings to aid in identifying CTD-ILD. Twelve panellists opted to investigate seven of the most common inflammatory autoimmune disorders. The panel discussed how to improve the early detection of CTD-ILD. Clinical characteristics were categorized, and a nine-item questionnaire was created. A biphasic algorithm was developed to guide early referral to a rheumatologist based on the presence of one of nine clinical features of CTD (Phase 1) or the presence of CTD-specific antibodies (Phase 2). A brief questionnaire has been developed to serve as a simple and practical screening tool for CTD-ILD detection. Additional research is needed to validate and evaluate the tool in longitudinal cohorts.

Splenic Infarction Induced by Dengue Hemorrhagic Fever: A Rare Presentation

Haematological and vascular features of dengue virus infection are common and vary from tiny skin haemorrhages to significant bleeding such as epistaxis, gastrointestinal bleeding and hematuria. Spontaneous splenic rupture has also been reported as an atypical manifestation in dengue fever. We report a case of splenic infarction in a 35-year-old man who presented with fever, vomiting, diffuse abdominal pain and distention, diarrhoea, hematuria, headache, back pain, hypotension, pleural effusion and ascites. Laboratory evaluation confirmed the diagnosis of dengue hemorrhagic fever, and abdominal imaging revealed splenic infarction. He required intensive care, responded well to inotropic support and remarkably improved.

Early Diagnosis Of Inflammatory Arthritis By Primary Care Physicians Following Training By A Rheumatologist

Background

Early diagnosis and therapeutic management of inflammatory arthritis (IA) is crucial for minimizing disease progression and improving outcomes. We recently developed the New Early Arthritis Referral Criteria to help improve the detection of suspected early IA via musculoskeletal (MSK) examination. The present study aimed to evaluate the agreement between rheumatologists and primary care physicians (PCPs) trained by rheumatologists in detecting IA when applying the standardized MSK examination techniques used to develop this criteria in a real-world setting in Jeddah, Saudi Arabia.

Methods

This quasi-experimental study was conducted in 4 primary health centers and involved 30 PCPs and 3 rheumatologists. All PCPs were trained by rheumatologists to apply the standardized MSK examination techniques used to develop the New Early Arthritis Referral Criteria. Patients were eligible if they were >18 years of age and presented with small-joint pain that persisted for >6 weeks. Patients were excluded if they had prior diagnosis of osteoarthritis, hand fractures, or rheumatic disease associated with IA. All patients were examined separately by a PCP and a rheumatologist, with the findings compared via kappa statistics and the rheumatologist’s findings considered the “gold standard”.

Results

Data from 202 of the 203 enrolled patients were analyzed. There was fair-to-moderate agreement between PCPs and rheumatologists when assessing swelling of the small joints and wrist of the right side (range of kappa: 0.14–0.41) and low-to-moderate agreement in similar examinations of the left side (range of kappa: 0.04–0.42). Assessments of joint tenderness showed fair-to-moderate agreement for both the right side (range of kappa: 0.22–0.47) and left side (range of kappa: 0.24–0.45). P-values were significant for virtually all comparisons.

Conclusion

MSK examinations by PCPs showed a promising extent of agreement in detecting IA with those by rheumatologists following training. Refinement of the standardized training process could further improve accuracy and help PCPs to confidently identify cases of early IA, thus allowing earlier intervention than is typical in this setting.

Fatigue severity in anti-nuclear antibody-positive individuals does not correlate with pro-inflammatory cytokine levels or predict imminent progression to symptomatic disease

Background

Fatigue is a common symptom of systemic autoimmune rheumatic disease (SARD). Patients with SARD have a protracted pre-clinical phase during which progressive immunologic derangements occur culminating in disease. In this study, we sought to determine when fatigue develops and whether its presence correlates with inflammatory factors or predicts disease progression.

Methods

Anti-nuclear antibody (ANA)-negative healthy controls (HCs) and ANA-positive participants with no criteria, at least one clinical criteria (undifferentiated connective tissue disease, UCTD), or meeting SARD classification criteria were recruited. Fatigue was assessed using a modified version of the FACIT-F questionnaire and the presence of fibromyalgia determined using a questionnaire based on the modified 2010 ACR criteria. Peripheral blood expression of five IFN-induced genes was quantified by NanoString and the levels of IL-1β, IL-6, or TNF-α by ELISA.

Results

Fatigue was as prevalent and severe in individuals lacking SARD criteria as it was in UCTD and SARD. Overall, ~ 1/3 of ANA⁺ subjects met fibromyalgia criteria, with no differences between sub-groups. Although fatigue was more severe in these individuals, those lacking fibromyalgia remained significantly more fatigued than ANA⁻ HC. However, even in these subjects, fatigue correlated with the widespread pain index and symptom severity scores on the fibromyalgia questionnaire. Fatigue was not associated with elevated cytokine levels in any of the ANA⁺ sub-groups and did not predict imminent disease progression.

Conclusions

Fatigue is common in ANA⁺ individuals lacking sufficient criteria for a SARD diagnosis, correlates with fibromyalgia-related symptoms, and is not associated with inflammation or predictive of disease progression.