Vasculopathy in patients with Fabry disease: current controversies and research directions

Fabry disease is an X-linked lysosomal storage disorder due to deficiency of the enzyme alpha-galactosidase A. The principal clinical manifestations of Fabry disease consist of cardiovascular complications including cerebrovascular, renal and cardiac disease but the pathophysiology of this specific vasculopathy is unclear. With the development of targeted treatment for Fabry disease, i.e. enzyme replacement therapy, it has become apparent that the removal of stored glycosphingolipid from the endothelial cells does not prevent progression of vascular disease in many patients. The aim of this study is to review the current available literature on vascular function tests, imaging and pathology studies and propose a hypothesis on the evolution of arterial complications in Fabry disease. Clearly, although premature atherosclerosis is suggested to occur, most studies describe absence of characteristic plaque formation. Smooth muscle cell hypertrophy, is probably the earliest feature of a complex vasculopathy, as in females and atypical cardiac variants, who have residual enzyme activity, no endothelial storage of significance is found. Subsequently, processes occur as observed in neo intima formation however with formation of more fibrotic structures. In the presence of a hyperdynamic circulation in combination with a less compliant vascular wall, it is hypothesized that upregulation of local renin angiotensine systems may occur. Angiotensin II is known to increase adhesion molecules, cytokines and chemokines and exerts a pro-inflammatory effect on leucocytes, endothelial cells and vascular smooth muscle cells. This enhances release of pro-thrombotic factors and opposes actions mediated through angiotensin 2 (AT2) receptor, including the release of nitric oxide (NO). A combination of reduced vascular compliance and activation of pro-thrombotic factors can lead to vascular complications in Fabry disease.

Exploring the preventable causes of unplanned readmissions using root cause analysis: Coordination of care is the weakest link

IMPORTANCE

Unplanned readmissions within 30days are a common phenomenon in everyday practice and lead to increasing costs. Although many studies aiming to analyze the probable causes leading to unplanned readmissions have been performed, an in depth-study analyzing the human (healthcare worker)-, organizational-, technical-, disease- and patient-related causes leading to readmission is still missing.

OBJECTIVE

The primary objective of this study was to identify human-, organizational-, technical-, disease- and patient-related causes which contribute to acute readmission within 30days after discharge using a Root-Cause Analysis Tool called PRISMA-medical. The secondary objective was to evaluate how many of these readmissions were deemed potentially preventable, and to assess which factors contributed to these preventable readmissions in comparison to non-preventable readmissions.

DESIGN

Cross-sectional retrospective record study.

SETTING

An academic medical center in Amsterdam, The Netherlands.

PARTICIPANTS

Fifty patients aged 18years and older discharged from an internal medicine department and acutely readmitted within 30days after discharge.

MAIN OUTCOME MEASURES

Root causes of preventable and unpreventable readmissions.

RESULTS

Most root causes for readmission were disease-related (46%), followed by human (healthcare worker)- (33%) and patient- (15%) related root causes. Half of the readmissions studied were considered to be potentially preventable. Preventable readmissions predominantly had human-related (coordination) failures.

CONCLUSION AND RELEVANCE

Our study suggests that improving human-related (coordinating) factors contributing to a readmission can potentially decrease the number of preventable readmissions.

The immune response in tubercular uveitis and its implications for treatment: From anti-tubercular treatment to host-directed therapies

Tubercular uveitis (TB-uveitis) remains a conundrum in the uveitis field, which is mainly related to the diverse clinical phenotypes of TB-uveitis. Moreover, it remains difficult to differentiate whether Mycobacterium tuberculosis (Mtb) is present in the ocular tissues, elicits a heightened immune response without Mtb invasion in ocular tissues, or even induces an anti-retinal autoimmune response. Gaps in the immuno-pathological knowledge of TB-uveitis likely delay timely diagnosis and appropriate management. In the last decade, the immunopathophysiology of TB-uveitis and its clinical management, including experts' consensus to treat or not to treat certain conditions with anti-tubercular treatment (ATT), have been extensively investigated. In the meantime, research on TB treatment, in general, is shifting more toward host-directed therapies (HDT). Given the complexities of the host-Mtb interaction, enhancement of the host immune response is expected to boost the effectiveness of ATT and help overcome the rising burden of drug-resistant Mtb strains in the population. This review will summarize the current knowledge on the immunopathophysiology of TB-uveitis and recent advances in treatment modalities and outcomes of TB-uveitis, capturing results gathered from high- and low-burden TB countries with ATT as the mainstay of treatment. Moreover, we outline the recent progress of HDT development in the pulmonary TB field and discuss the possibility of its applicability to TB-uveitis. The concept of HDT might help direct future development of efficacious therapy for TB-uveitis, although more in-depth research on the immunoregulation of this disease is still necessary.

Results on patient flow of implementing an Acute Medical Unit

BACKGROUND

There is an increased influx of patients needing admission. Introducing an acute medical unit (AMU) may increase the admission capacity without increasing the total number of beds.

METHODS

Data collected during the first four years after implementation of an AMU in an academic tertiary care center in Amsterdam were analyzed.

RESULTS

A 24 bed unit was realized. The total number of admissions increased in the first year with 977 (16%), with an additional 4.1% increase after 2 years with stabilization thereafter. The length of stay decreased, the absolute number of refusals declined, the number of readmissions remained unchanged.

CONCLUSION

Introduction of AMUs in overcrowded services could be beneficial in improving the strain on the acute healthcare systems.

The treatment outcomes in IgG4-related disease

INTRODUCTION

IgG4-related disease (IgG4-RD) is an emerging systemic inflammatory disease involving nearly all organs eventually leading to fibrosis. Prompt and adequate treatment to prevent irreversible organ damage is therefore pivotal. To evaluate the treatment outcomes, we studied a well-defined cohort of patients with IgG4-RD.

METHOD

32 patients with histologically confirmed IgG4-RD diagnosed between 1999 and April 2017 were included and reviewed for demographic and clinical characteristics. The response to treatment with glucocorticoids, disease modifying antirheumatic drugs, rituximab and other therapeutic interventions were evaluated.

RESULTS

Glucocorticoids as well as rituximab appeared successful therapeutic drugs leading to clinical remission (complete or partial remission) in all patients. Recurrences, however, were frequently seen (62% versus 100%, respectively). Diseases modifying antirheumatic drugs (DMARDs), including azathioprine, methotrexate and mycophenolate mofetil were effective in less than half of the cases. A minority of patients was treated with alternative treatments including hydroxychloroquine, thalidomide and infliximab which all appeared effective. Surgical intervention and radiotherapy in local disease seemed to induce clinical remission and were associated with low recurrence rates.

CONCLUSION

Glucocorticoids and rituximab induce substantial responses as well as primary surgical intervention and radiotherapy, while the efficacy of DMARDs is limited. Based on the few data available, hydroxychloroquine, infliximab and thalidomide may be promising treatment options for second or third line strategies.