Characteristics of Pericardial Biopsy: 100 Cases in a Single Center

BACKGROUND

Pericardial biopsies are rarely performed during the diagnosis and management of pericardial diseases. The circumstances and clinical profile of patients undergoing pericardial biopsies are largely uncharacterized.

OBJECTIVES

To examine the circumstances in which pericardial biopsies are obtained and to evaluate their diagnostic yield.

METHODS

We studied a total of 100 cases (71% males, mean age 60.8 years, range 8.1-84.5 years) of surgically resected pericardium specimens obtained from 2000 to 2015 at Sheba Medical Center, the largest medical center in Israel. Patients were classified into groups according to four major histological etiologies: idiopathic pericarditis, constrictive pericarditis, malignant pericarditis, and post-cardiac injury syndrome (PCIS). The clinical history and course, laboratory, echocardiography, and histological results were reviewed retrospectively.

RESULTS

Causes of pericarditis according to histological definitions included idiopathic pericarditis (29%), constrictive pericarditis (29%), PCIS (9%), and malignant pericarditis (26%). Overall sensitivity of the pericardial biopsy in patients with malignancy was 57.7%. During the study period, we found a trend toward an increased number of biopsies due to constrictive pericarditis and PCIS, along with a decrease in the number of biopsies performed in patients with malignant or idiopathic pericarditis. The diagnosis following biopsy did not change for any of the patients.

CONCLUSIONS

Our findings suggest a low diagnostic yield from pericardial biopsies, especially in malignant pericarditis. This conclusion, along with novel therapies, resulted in the infrequent use of pericardial biopsy in recent years.

Sarcopenia is associated with a greater incidence of delayed gastric emptying following pancreaticoduodenectomy

BACKGROUND AND AIMS

Sarcopenia is the degenerative loss of skeletal muscle and has been associated with a variety of post-operative complications. We propose sarcopenia is associated with delayed gastric emptying (DGE) following elective pancreaticoduodenectomy (PD).

METHODS

A retrospective analysis of a computerised database maintained in real time of all patients undergoing PD within our hepatobiliary unit was performed. The cross-sectional area of the psoas muscle at the upper border of L3 was calculated and corrected for patient height. The lowest quartile of gender specific groups was considered to be sarcopenic.

RESULTS

61 patients were included, 32 male and 29 female of whom 8 from each group were sarcopenic (26.2%). Although the sarcopenic and non-sarcopenia groups were found to be comparable, significantly more sarcopenic patients were older (75 vs 64 years, p = 0.003), had a lower body mass index (21.9 vs 25.0 kg/m², p = 0.003) and suffered from DGE (7/16 vs 8/45, p = 0.045). On multivariate analysis, these variables maintained their significance with DGE having an OR of 6.042 (p = 0.036).

CONCLUSION

Sarcopenia is significantly associated with DGE, older age and lower BMI in this specific cohort of patients. Further research into the reversibility of this phenomenon is warranted.

The 'SILENT Alarm': When History Taking Reveals a Potentially Fatal Toxicity

Introduction

The combination of acute/sub-acute neurological and metabolic derangements should always raise the suspicion of toxicity, either endogenous or exogenous. The adverse effects of psychiatric medications are especially difficult to determine since the psychiatric background of patients is often inaccessible.

Clinical Presentation

A 66-year-old man presented to the emergency department with dysarthria and uncontrolled tremor, rapidly deteriorating into a complex of severe neurological and metabolic derangements. Only after repeated attempts to take a thorough history was lithium toxicity identified.

Conclusion

Thorough, comprehensive history taking, including chronic medications and their substitutes, is essential and lifesaving when potentially lethal medications are involved.

LEARNING POINTS

Sodium phosphate enemas do not worsen renal function among hospitalized patients with mild to moderate renal failure: a matched, case-control study

BACKGROUND

Sodium phosphate enemas (SPEs) are widely used among hospitalized patients despite their potential to worsen renal failure.

AIM

We decided to assess the extent to which this side effect is clinically relevant.

DESIGN

We conducted a matched case-control, retrospective study in a cohort of hospitalized patients.

METHODS

Patients treated and untreated with SPEs were matched for age, gender, baseline creatinine, usage of certain medications and several background diagnoses. Three groups of matched patients (whole study cohort, patients with baseline creatinine > 1.5 mg/dl and those with baseline creatinine > 2 mg/dl) were compared with regards to their creatinine and blood electrolyte concentrations during 3 consecutive hospitalization days after SPE application.

RESULTS

Four hundred and twelve patients were included in this study of which 206 were treated by single SPEs. Exact matching was done for the whole study cohort, for 108 patients with baseline creatinine > 1.5 mg/dl and for 58 patients with baseline creatinine > 2 mg/dl. During 3 consecutive days after SPEs, the maximal blood concentrations of creatinine, phosphor and potassium did not differ significantly between treated patients and matched controls, in all three patients' groups.

CONCLUSION

Application of SPEs neither seem to worsen mild to moderate renal failure, nor are associated with hyperphosphatemia or hyperkalemia in patients hospitalized in internal medicine departments.

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.

The interaction between anti-Ro/SSA and anti-La/SSB autoantibodies and anti-infectious antibodies in a wide spectrum of auto-immune diseases: another angle of the autoimmune mosaic

OBJECTIVES

The presence of anti-Ro/SSA and anti-La/SSB antibodies has been linked with autoimmunity in general and with several autoimmune diseases (AID) in particular. In the current study we evaluated these antibodies in a wide spectrum of AID as well as the links between them and anti-infectious antibodies.

METHODS

We examined 2082 sera from patients with 16 different AID compared to 524 sera from geographically-matched healthy controls, for the presence and titres of anti-Ro/SSA and anti-La/SSB. All samples were also tested for a variety of anti-infectious agents' antibodies using the BioPlex 2200-immunoassay (Bio-Rad, USA).

RESULTS

Anti-Ro/SSA was more prevalent, with significantly higher titre in 5 autoimmune diseases namely Sjögren's syndrome (SS), systemic lupus erythematosus (SLE), antiphospholipid syndrome (APS) both primary and APS linked to SLE, systemic sclerosis (SSc) and primary biliary cirrhosis (PBC). Anti-La/SSB was more prevalent with higher titers in SS, SLE, APS linked to SLE and PBC. Prevalence, but not titers, of both antibodies were higher also in polymyositis (PM). Additionally, we found a correlation between anti-Ro/SSA antibodies and antibodies of the IgM and IgG subtypes directed at cytomegalovirus as well as IgG-antibodies directed at Epstein-Barr virus (EBV) and toxoplasma (p<0.001). Anti-La/SSB antibodies correlated with the presence of IgG antibodies against EBV early antigen (p<0.001).

CONCLUSIONS

In a large cohort of patients with autoimmune diseases we found an association between anti-Ro/SSA and anti-La/SSB antibodies and 6 autoimmune diseases, amongst which primary APS and PM. Additionally, we observed linkages between these autoantibodies and anti-infectious antibodies directed at Epstein-Barr virus, toxoplasma and cytomegalovirus. Our findings support the concept of interplay between infectious agents and autoimmunity, such as the plausibility of an infectious agent that trigger the immune system to produce specific antibodies which will later result in a unique group of AID.

[THE INPUT OF MEASURING INFLIXIMAB LEVELS AND LEVELS OF ANTIBODIES TO INFLIXIMAB IN THE MANAGEMENT OF PATIENTS WITH RHEUMATIC DISEASES]

BACKGROUND

High levels of infliximab (IFX) directed antibodies (IFX-Ab) may result in significant reduction in IFX concentration and loss of drug efficacy.

OBJECTIVES

To assess the input of measuring serum IFX levels and levels of IFX-Ab in the management of rheumatic diseases.

METHODS

Serum levels of IFX and anti-IFX-Ab were measured by ELISA (IFX-Abs were also identified by anti-human lambda chain Ab) and correlated to patients (responders and nonresponders) disease activity scores.

RESULTS

A total of 144 tests for IFX were performed in 91 patients (mean age 50.2 years and disease duration 9.9 years). Among responders (57 patients) levels (mean, median) of IFX were significantly higher than in non-responders (34 patients) (4.2 mcg/ml (2.3) versus 1.1 mcg/ml (0.45)); levels of IFX-Ab in responders were significantly lower than in non-responders (4.59 mcg/ml (1.0) versus 13.1 (6.1)). High IFX-Ab levels predicted IFX discontinuation in 8.8% of responders and 55.9% among non-responders. In non-responders with low IFX levels and low IFX-Ab, the shortening of re-treatment intervals lead to significant improvement. In about 28% of patients, results of blood tests influenced treatment decisions.

CONCLUSIONS

Assessment of immunogenicity of anti-TNF monoclonal antibodies proved useful information for guiding the therapy in rheumatic diseases with suboptimal clinical response. Patients with low IFX levels and low levels of IFXAb may benefit from increasing the drug dose or decreasing of re-treatment intervals. In patients with negligible serum levels of IFX and high levels of IFX-Ab, the therapy should be switched to another biological agent, probably with a different mechanism of action.

The Association Between Giant Cell Arteritis and Ischemic Heart Disease: A Population Based Cross-Sectional Study

BACKGROUND

Patients with giant cell arteritis (GCA) suffer from inflammatory diseases often treated by large amounts of corticosteroids. Whether this inflammatory burden also carries an increased risk for cardiovascular morbidity, and especially ischemic heart disease, is not clearly established.

OBJECTIVES

To clarify the linkage between GCA and ischemic heart disease.

METHODS

In a cross-sectional study, we assessed the association between GCA and ischemic heart disease, adjusting for cardiovascular risk factors, among GCA patients and matched controls using the database of the largest healthcare provider in Israel.

RESULTS

The study group was comprised of 5659 GCA patients and 28,261 age and gender matched controls. The proportion of ischemic heart disease was higher in the GCA group (27.5% vs. 12.5% among controls, odds ratio 2.65). Diabetes mellitus, hypertension, hyperlipidemia and smoking were also found to have higher concurrency in GCA. After stratifying for those cardiovascular co-morbidities using logistic regression, GCA remained independently associated with ischemic heart disease with an odds ratio of 1.247 (1.146-1.357 P < 0.001).

CONCLUSIONS

GCA is associated with both cardiovascular risk factors and ischemic heart disease. Healthcare professionals should not overlook this aspect of the disease when managing GCA patients.

Low alanine transaminase is not associated with increased rate of mortality in patients with advanced lung cancer

Background: Low alanine transaminase (ALT) has been shown to serve as a marker for sarcopenia and frailty in both healthy populations and in patients with chronic illness. Its yield in cancer patients in general and in particular in lung-cancer patients was not assessed. Methods: Lung cancer patients presenting to an outpatient thoracic oncology clinic in a tertiary hospital were included. ALT plasma levels as well as other potential prognostic factors were collected retrospectively. Associations of those factors with survival were examined by univariate and multivariate analyses. Results: 203 patients were eligible for analysis, of which 149 (73.4%) were diagnosed to have advanced disease. During median follow-up period of 15.4 months, 79 (38.9%) died. The mean ALT level of activity was 17.53±7.8 IU/L. The following parameters were found to be associated with increased risk of mortality: histologic type, male gender, advanced disease and low performance status upon diagnosis. Low ALT levels were not found to be associated with increased risk of mortality. Conclusion: Low ALT activity levels, associated with sarcopenia, frailty and shortened survival in other patients' populations might not be predictive for shortened survival in lung cancer patients.  

Coexistent malignant conditions in rheumatoid arthritis - A population-based cross-sectional study

OBJECTIVES

The aim of this study was to evaluate if association exist between rheumatoid arthritis and malignant diseases.

METHODS

A cross-sectional study was conducted comparing rheumatoid arthritis patients with age and gender matched controls regarding the proportion of patients with comorbid malignant conditions. Chi-square tests and t-tests were used for univariate analysis. A logistic regression model was used for multivariate analysis. The study was performed utilising the medical database of Clalit Health Services.

RESULTS

The study group included 11 782 rheumatoid arthritis patients and 57 973 controls. The total proportion of malignancies was significantly higher in the study group than in the control group (21.4% vs 11.2%; P<.001). The disease for which there was the strongest association among patients with rheumatoid arthritis was non-Hodgkin's lymphoma (1.1% vs 0.6%; P<.01). After multivariate analysis, lung cancer was not found to be significantly associated with rheumatoid arthritis.

CONCLUSION

Rheumatoid arthritis is associated with several malignant disorders, in particular non-Hodgkin's lymphoma. Appropriate measures for non-Hodgkin's lymphoma screening in this patient population should be considered.

Iatrogenic superior mesenteric vein injury: the perils of high ligation

PURPOSE

The purpose of this review is to highlight the perils and pitfalls associated with high vascular ligation during right colectomies for adenocarcinoma and to identify the various mechanisms of injury to the superior mesenteric vein (SMV) and its tributaries.

METHODS

This is a retrospective chart review of 304 right colectomies (159 open and 145 laparoscopic) performed over a period of 10 years (1 June 2006-31 May 2016) for right-sided colonic adenocarcinoma in an academic medical center.

RESULTS

During a 10-year study period, we encountered five cases in which significant damage to the SMV and its tributaries occurred. This accounts for a total of 1.6 % of all right colectomies performed for colonic adenocarcinoma.

CONCLUSIONS

Iatrogenic superior mesenteric vein injury is a rare, severe, and underreported complication of both open and laparoscopic right colectomy for colonic adenocarcinoma. We identified several mechanisms of injury such as anatomic misperception, excessive traction and pulling on the venous system, extensive tumor involvement of the mesentery, and uncontrolled suturing attempts at hemostasis. We believe that increased awareness of this complication with profound understanding of vascular anatomy and the different mechanisms of injury will allow surgeons to avoid this often devastating complication.

Disability Progression in Multiple Sclerosis Is Affected by the Emergence of Comorbid Arterial Hypertension

BACKGROUND AND PURPOSE

We assessed the prevalence and potential association of hypertension with multiple sclerosis (MS)-related disability progression.

METHODS

This was a retrospective study of 2,813 patients who were followed for 20 years. We modeled the associations of several risk factors with the pattern of disability progression. The primary end point was the rate of disability progression.

RESULTS

In total, 2,396 patients were available for analysis, of which 1,074 (44.8%) scored 4 (EDSS4) on the Expanded Disability Status Scale (EDSS), 717 (29.9%) scored 6 (EDSS6), and 261 (10.9%) scored 8 (EDSS8). The mean times to reach scores of 4, 6, and 8 were 123.5, 163.1, and 218.9 months, respectively. Hypertension was present in 207 (8.6%) patients during follow-up. Hypertension was associated with a higher probability of reaching each EDSS score compared to non-hypertensive patients: 62% vs. 43% for EDSS4 (p<0.01), 51% vs. 28% for EDSS6 (p<0.01), and 17% vs. 10% for EDSS8 (p<0.01). Nevertheless, hypertensive MS patients experienced longer intervals to reach each EDSS score: longer by 51.6, 38.9, and 62.7 months to EDSS4, EDSS6, and EDSS8, respectively (p<0.01) when compared to non-hypertensive MS patients reaching the same EDSS scores.

CONCLUSIONS

Disability progression is more prevalent amongst hypertensive MS patients. However, they experience longer time intervals between the stages of disability progression.

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.

Sarcoidosis and Autoimmunity: From Genetic Background to Environmental Factors

Sarcoidosis is a chronic multisystem disease with variable course resulting from the interaction between environmental factors and the immune system of individuals genetically predisposed. The evidence linking sarcoidosis with environmental triggers such as metals is increasing. We describe the case of a 44 year old female with a history. of smoking since age 30 and previous mercury dental filling who presented at physical examination with numerous subcutaneous nodules. Laboratory data showed accelerated erythrocyte sedimentation rate and high titer of anti-U1 ribonucleoprotein antibodies (U1 RNP). Skin biopsy and chest X-ray suggested the diagnosis of sarcoidosis. In this report we illustrate the different causes involved in the onset of sarcoidosis.

[SGLT2 inhibitors: a new therapeutic class for the treatment of type 2 diabetes mellitus]

SGLT2 (Sodium Glucose co-Transporter 2 Inhibitors) inhibitors are a new group of oral medications for the treatment of type 2 diabetes mellitus patients. These medications interfere with the process of glucose reabsorption in the proximal convoluted tubules in the kidneys, therefore increasing both glucose and water diuresis. SGLT2 inhibitors were found to be effective in lowering HbA1c levels in double-blinded studies, both as monotherapy and in combination with other oral hypoglycemic medications of various other mechanisms of action. SGLT2 Inhibitors are not a risk factor for hypoglycemia and are suitable for combination with insulin therapy. Their unique mode of action, relying on glomerular filtration, make these medication unsuitable for usage as treatment for type 2 diabetes patients who are also suffering from moderate to severe renal failure. Their main adverse effects are increased risk for urinary and genital tract infections. The following review describes the relevant pathophysiology addressed by these novel medications, evidence for efficacy and the safety profile of SGLT2 Inhibitors.

Long-term follow-up of patients with scleroderma interstitial lung disease treated with intravenous cyclophosphamide pulse therapy: a single-center experience

BACKGROUND

Scleroderma lung disease (ILD-SSc) is treated mainly with cyclophosphamide (CYC). The effectiveness of CYC was judged after 12-24 months in most reports.

OBJECTIVES

To analyze the effect of monthly intravenous CYC on pulmonary function tests including forced vital capacity (FVC) and diffusing lung capacity (DLCO), as well as Rodnan skin score (mRSS), during long-term follow-up.

METHODS

We retrospectively collected the data on 26 ILD-SSc patients who began CYC treatments before 2007. Changes in FVC, DLCO and mRSS before treatment, and at 1,4 and 7 years after completion of at least six monthly intravenous CYC treatments for ILD-SSc were analyzed.

RESULTS

Mean cumulative CYC dose was 8.91 ± 3.25 G. More than 30% reduction in FVC (0%, 8%, and 31% of patients), DLCO (15%, 23%, 31%), and mRSS (31%, 54%, 62%) at years 1, 4 and 7 was registered. During the years 0-4 and 4-7, annual changes in FVC, DLCO and mRSS were 3.2 vs. 0.42% (P < 0.040), 4.6 vs. 0.89% (P < 0.001), and 1.8 vs. 0.2 (P = 0.002). The greatest annual FVC and DLCO reduction over the first 4 years correlated with mortality (P = 0.022). There were no differences in the main variables regarding doses of CYC (< 6 G and > 6 G).

CONCLUSIONS

In patients with ILD-SSc, CYC stabilized the reduction of FVC during treatment, but this effect was not persistent. The vascular characteristic of ILD-SSc (DLCO) was not affected by CYC treatment. CYC rapidly improved the mRSS. This effect could be achieved with at least 6 G of CYC. Higher rates of annual reduction in FVC and DLCO in the first 4 years indicate the narrow window of opportunity and raise the question regarding ongoing immunosuppression following CYC infusions.