Modesto Dos Santos J, Les Bujanda I, Etayo-Urtasun P
… +8 more, Sánchez Álvarez J, Izquierdo M, Sáez De Asteasu ML, Ruiz Castellano M, Llorente Diez B, Salinas Urra S, Pulido Fontes M, Lecumberri R
BACKGROUND: Venous thromboembolism (VTE) is a significant cause of preventable mortality in hospitalized patients. While risk assessment models such as Padua and IMPROVE-VTE scores have been validated in conventional hos...BACKGROUND: Venous thromboembolism (VTE) is a significant cause of preventable mortality in hospitalized patients. While risk assessment models such as Padua and IMPROVE-VTE scores have been validated in conventional hospitalization (CH), their applicability to hospital-at-home (HaH) remains uncertain. OBJECTIVES: To evaluate thrombotic risk stratification in HaH by comparing the 90-day VTE incidence and mortality between HaH and CH and developing an HaH-specific VTE predictive model. METHODS: This prospective observational cohort study comprised 2062 patients (1689 HaH; 373 CH) admitted for acute medical illnesses between 2022 and 2024. Thrombotic risk was assessed using Padua and IMPROVE-VTE scores. Primary outcomes were 90-day VTE incidence and mortality. Predictors of VTE in HaH were identified using multivariable logistic regression and incorporated into a novel model (TROMBODOM). RESULTS: HaH patients were older (mean, 71.7 vs. 64.5 years, respectively) and more often admitted for infections (90.1% vs. 63.0%, respectively) and cardiorespiratory failure (36.6% vs. 25.7%, respectively). A larger proportion of patients in HaH were classified as high-risk based on Padua (75.1% vs. 52.0%, respectively) and IMPROVE-VTE (46.3% vs. 27.1%, respectively). Ninety-day VTE incidence was lower in HaH (1.2% vs. 3.5%, respectively; OR, 0.33; 95%CI, 0.16-0.67), whereas mortality was higher (15.8% vs. 9.9%, respectively; OR: 1.70, 95%CI: 1.18-2.44). Padua and IMPROVE-VTE scores showed modest discriminatory capacity (AUC: 0.65 and 0.75, respectively) in HaH. TROMBODOM achieved superior predictive performance (AUC: 0.86). CONCLUSIONS: Padua and IMPROVE-VTE overestimated the thrombotic risk of HaH. The newly developed TROMBODOM model improved VTE risk stratification in HaH and requires external validation.
Primary biliary cholangitis (PBC) is a chronic cholestatic liver disease characterised by progressive immune-mediated destruction of the small intrahepatic bile ducts, leading to cholestasis, fibrosis, and ultimately cir...Primary biliary cholangitis (PBC) is a chronic cholestatic liver disease characterised by progressive immune-mediated destruction of the small intrahepatic bile ducts, leading to cholestasis, fibrosis, and ultimately cirrhosis. Despite therapeutic advances, up to 40% of patients fail to achieve an adequate biochemical response to first-line ursodeoxycholic acid (UDCA) and require second-line therapy. This narrative review traces the patient-physician journey from initial clinical suspicion through diagnosis, risk stratification, treatment selection, and long-term comorbidity management, with particular emphasis on the emerging role of peroxisome proliferator-activated receptor (PPAR) agonists. Fibrates are PPAR agonists that have been used for long time in PBC with evidence of their effect to improve biochemical response in PBC; however, their use remains off-label and they have undergone only limited safety and efficacy evaluation. Novel PPAR agonists-including seladelpar (PPARδ) and elafibranor (PPARα/δ)-have recently received conditional approval following phase 3 trials demonstrating significant reductions in alkaline phosphatase (ALP), alongside clinically meaningful improvements in pruritus and fatigue. These agents offer a favourable benefit-risk profile and represent an important therapeutic advance. In conclusion, effective management of PBC requires a holistic strategy integrating early diagnosis, individualised risk stratification, and timely escalation of targeted therapy. PPAR agonists mark a significant evolution in treatment by addressing biochemical disease activity, symptom burden, and quality of life simultaneously. Systematic identification and management of autoimmune and metabolic comorbidities remain essential throughout the patient journey.
Atrial fibrillation (AF) is a common arrhythmia that a hospitalist may encounter. It is known to occur transiently or in response to specific triggers (trigger-induced AF), which presents a challenge to clinicians, espec...Atrial fibrillation (AF) is a common arrhythmia that a hospitalist may encounter. It is known to occur transiently or in response to specific triggers (trigger-induced AF), which presents a challenge to clinicians, especially when attempting to ascertain if it warrants assessment of recurrence risk and long-term management. The management of trigger-induced AF is an emerging area of study. In this review, we discuss questions that a hospitalist should consider and address in the management of trigger-induced AF. We discuss recommendations regarding anticoagulation along with rate and rhythm control strategies, in addition to the importance of long-term surveillance. We also examine the evidence base outlined by the most recent AF guidelines from the United States and Europe. Further investigation with randomized clinical trials is warranted to better understand the epidemiology and management of trigger-induced AF, as well as its long-term effects and care.
BACKGROUND: Chronic obstructive pulmonary disease (COPD) contributes substantially to morbidity, mortality, and healthcare costs. For patients with chronic respiratory failure, long-term home non-invasive ventilation (LT...BACKGROUND: Chronic obstructive pulmonary disease (COPD) contributes substantially to morbidity, mortality, and healthcare costs. For patients with chronic respiratory failure, long-term home non-invasive ventilation (LTHNIV) is an effective therapy, yet existing guidelines offer little direction on the most effective initiation and organization of care. We review current LTH-NIV implementation and management strategies and factors that facilitate or hinder successful treatment. METHODS: A systematic review of studies investigating the organization and implementation of LTHNIV for COPD patients was performed. Studies reporting primary clinical, economic, or organizational data on LTHNIV with home-based care were included, with a particular focus on interventions aiming to improve outcomes or care organization. The findings were synthesized narratively. PROSPERO: CRD42025648464. FINDINGS: From 870 records, 46 studies were included. The majority were from Europe, with fewer studies from Asia and North America. Differences in how LTHNIV is delivered to COPD patients were identified, with variation in initiation settings, stakeholder involvement, and follow-up strategies. Hospital-based initiation remained common, although outpatient and home-based models, often supported by remote titration or telemonitoring, were increasingly used. Follow-up was typically scheduled every 3-6 months across outpatient, inpatient, and home-based modalities. Successful care relied on patient education, technical support, and structured follow-up, supported by remote consultations. These new strategies promise improved patient comfort, adherence, communication, and collection of patient-centred outcomes. Telemonitoring emerged as a promising adjunct, enhancing individualized care, facilitating closer follow-up and early identification of technical or clinical issues. INTERPRETATION: The delivery of LTHNIV remains heterogeneous, even within countries. This variability in care organization and reporting mandates establishing harmonized, patient-centred pathways that integrate telemonitoring and coordinate collaboration among stakeholders, ensuring that patients and their caregivers remain central to the care process.
Aboubakr O, Mokhtari K, Nichelli L
… +9 more, Bielle F, Demeret S, Dubessy AL, Alamowitch S, Pineton De Chambrun M, Le Joncour A, Pourcher V, Idbaih A, Mathon B
BACKGROUND: The indications and timing of brain biopsy in adults with neurological diseases of unknown etiology remain controversial. We aimed to determine diagnostic yield, complications, outcomes, and survival after br...BACKGROUND: The indications and timing of brain biopsy in adults with neurological diseases of unknown etiology remain controversial. We aimed to determine diagnostic yield, complications, outcomes, and survival after brain biopsy and evaluate whether early biopsy improves prognosis. METHODS: We analyzed adults who underwent brain biopsy (2008-2024) after non-diagnostic workup at our institution. Primary outcomes were diagnostic yield, 6-month functional status using modified Rankin Scale (mRS), and overall survival (OS). Early biopsy was defined as ≤1 month after symptom onset. Multivariable logistic regression identified predictors of favorable outcomes (mRS≤2), and Cox models assessed OS. RESULTS: Among 3014 biopsies, 294 met inclusion criteria (mean age 50.6 ± 15.3 years; 47% immunocompromised). Biopsy provided a contributory diagnosis in 69% of patients and changed management in 71%. Symptomatic complications occurred in 3.4% of patients. Functional independence (mRS≤2) increased from 44.6% at biopsy to 54.1% at 6 months (p = 0.003), with 22% mortality. Baseline independence (OR 7.15, 95%CI 3.94-12.97) and early biopsy (OR 2.03, 95%CI 1.05-3.93) predicted favorable outcomes, whereas solid organ tumor history (OR 0.32) and altered consciousness (OR 0.53) predicted worse recovery. Early biopsy yielded a higher diagnostic success rate (82% vs. 65%, p = 0.005). During 37.9-month follow- up, 31% died (mean OS 9.3 months). Longer OS was associated with baseline independence and autoimmune/inflammatory diagnosis, whereas solid-organ tumors, altered consciousness, and coma predicted shorter OS. CONCLUSIONS: Brain biopsy is safe and diagnostically useful for cryptogenic neurological diseases. Early biopsy independently predicts better functional outcomes and higher diagnostic yield, supporting earlier tissue sampling after inconclusive noninvasive evaluation.
BACKGROUND: Chronic pancreatitis is associated with high mortality, but evidence on the causes of death is limited. We investigated cause-specific mortality, including cancer-related deaths, over a 20-year period followi...BACKGROUND: Chronic pancreatitis is associated with high mortality, but evidence on the causes of death is limited. We investigated cause-specific mortality, including cancer-related deaths, over a 20-year period following chronic pancreatitis diagnosis. METHODS: Using Danish national health registries, we conducted a nationwide cohort study of incident adult (>18 years) chronic pancreatitis cases from 2002 to 2022. Patients were followed from diagnosis until death or the end of follow-up. Cause-specific mortality was estimated using cumulative incidence functions accounting for competing risks. FINDINGS: Among 14,565 patients (mean age 59 years; 64% male) followed for a median of 10.2 years, 7001 (48%) died. In the first 5 years after chronic pancreatitis diagnosis, the leading causes of death were pancreatitis-related, pancreatic cancer, and liver disease, with corresponding 5-year cumulative incidences of 4.5%, 3.4%, and 4.4%, respectively. Beyond 5 years, deaths from extra-pancreatic cancers, respiratory, and cardiovascular disease became more common with corresponding 20-year cumulative risk incidences of 13.4%, 6.1% and 7.0%, respectively. Among cancer deaths, pancreatic cancer predominated early, whereas lung cancer became the leading cause of cancer-related deaths after 5 years. In sensitivity analyses with a 2-year lag between chronic pancreatitis and pancreatic cancer diagnosis, the 5-year cumulative pancreatic cancer incidence decreased from 3.4% to 0.5%, indicating misclassification of early pancreatic cancers. INTERPRETATION: Cause-specific mortality in chronic pancreatitis changes over time. Early deaths are driven by pancreatitis-related deaths and liver disease, whereas extra-pancreatic cancers, respiratory, and cardiovascular deaths become more prominent later. FUNDING: This study was not funded.
Erectile dysfunction often coexists with arterial hypertension. They both share a common vascular pathophysiology, while antihypertensive treatment may also affect sexual function. Although some of the older antihyperten...Erectile dysfunction often coexists with arterial hypertension. They both share a common vascular pathophysiology, while antihypertensive treatment may also affect sexual function. Although some of the older antihypertensive drugs had a significant impact on erectile function, new antihypertensive drugs may exert a neutral or even beneficial effect. After scrutinized review, recent evidence paints a more nuanced picture. This article critically reviews the relationship between various classes of antihypertensive drugs and ED, discusses underlying mechanisms, and provides evidence-based recommendations tailored to clinical practice.
"Unpatients" are health-conscious individuals -carrying a genetic susceptibility whose impact is unclear with respect to the risk of a clinical event- who may shape their lives around periodic check-ups and preventive me..."Unpatients" are health-conscious individuals -carrying a genetic susceptibility whose impact is unclear with respect to the risk of a clinical event- who may shape their lives around periodic check-ups and preventive measures. Here, information from likely pathogenic single nucleotide polymorphisms (SNPs) and variants of uncertain significance in haemostasis are used to highlight current issues and directions for "unpatients". Despite their individually low relative risks (RR ≤ 2.0) for a first episode of venous thromboembolism (VTE), weak SNPs and variants of uncertain significance collectively confer RRs that are quantitatively comparable to those of established VTE risk factors. However, a high polygenic risk score (PRS) does not represent a definitive disease risk, and a low PRS does not imply a zero chance of clinical events. Advanced techniques to explore molecular variants may help to refine management and medical decision-making for "unpatients." Artificial intelligence (AI)-based tools are needed to expand disease-specific insights and prevent inappropriate conclusions when handling advanced analyses and large datasets. Yet AI-driven approaches involve the management of sensitive personal health data by non-medical experts and the use of computational methods that may be opaque even to specialists, raising ethical and legal concerns. While new strategies are being explored to generate clinically relevant genomic prediction tools, targeted education for physicians, patients, and families is essential. In domains affecting diagnostic and therapeutic progress, protection against discrimination -and attention to the evolving dimensions of the patient-physician relationship-should be ensured for carriers of genetic susceptibility and members of "genetically bound tribes."