Arterial Thromboembolism in Patients With Atrial Fibrillation and CHA2DS2-VASc Score 0 to 2 With and Without Cancer

Background

It is unclear whether newly diagnosed cancer adds to the risk of arterial thromboembolism (ATE) in patients with atrial fibrillation/flutter (AF). This is especially relevant for AF patients with low to intermediate CHA₂DS₂-VASc scores in whom the risk-benefit ratios between ATE and bleeding are delicately balanced.

Objectives

The objectives were to evaluate the ATE risk in AF patients with a CHA₂DS₂-VASc score of 0 to 2 with and without cancer.

Methods

A population-based retrospective cohort study was performed. Patients with a CHA₂DS₂-VASc score of 0 to 2 not receiving anticoagulation at cancer diagnosis (or the matched index date) were included. Patients with embolic ATE or cancer before study index were excluded. AF patients were categorized into AF and cancer and AF and no cancer cohorts. Cohorts were matched for multinomial distribution of age, sex, index year, AF duration, CHA₂DS₂-VASc score, and low/high/undefined ATE risk cancer. Patients were followed from study index until the primary outcome or death. The primary outcome was acute ATE (ischemic stroke, transient ischemic attack, or systemic ATE) at 12 months using International Classification of Diseases-Ninth Revision codes from hospitalization. The Fine-Gray competing risk model was used to estimate the HR for ATE with death as a competing risk.

Results

The 12-month cumulative incidence of ATE was 2.13% (95% CI: 1.47-2.99) in 1,411 AF patients with cancer and 0.8% (95% CI: 0.56-1.10) in 4,233 AF patients without cancer (HR: 2.70; 95% CI: 1.65-4.41). The risk was highest in men with CHA₂DS₂-VASc = 1 and women with CHA₂DS₂-VASc = 2 (HR: 6.07; 95% CI: 2.45-15.01).

Conclusions

In AF patients with CHA₂DS₂-VASc scores of 0 to 2, newly diagnosed cancer is associated with an increased incidence of stroke, transient ischemic attack, or systemic ATE compared with matched controls without cancer.

A RETROPERITONEAL SEMINOMA WITH ENTRAPPED NERVE GANGLION MASQUERADING AS A PARAGANGLIOMA

Objective

The differential diagnosis of retroperito-neal tumors includes lymphoid, germ cell, and neurogenic tumors such as paraganglioma. Paragangliomas are rare neuroendocrine tumors of the autonomic nervous system, which may secrete catecholamines and their metabolites. Clinical features include sustained or paroxysmal hypertension, headaches, sweating, and palpitations. Here we present an unusual case of a retroperitoneal tumor entrapping a sympathetic nerve ganglion and mimicking paraganglioma.

Methods

A 57-year-old man with a history of controlled hypertension presented with paroxysms of tachycardia, flushing, high blood pressure, and headache. Ambulatory blood pressure monitoring showed uncontrolled labile hypertension with a normal nocturnal dip. Abdominal computed tomography (CT) demonstrated a 6.1 cm mass in the right retroperitoneum with adjacent lymphadenopathy. Paraganglioma was suspected and 24-hour urine demonstrated elevated normetanephrines (575 mcg/24 hours; normal, 5 to 290 mcg/24 hours) and vanillylmandelic acid (8.3 mg/24 hours; normal, 0.5 to 6.6 mg/24 hours). 68-Gallium DOTATATE positron emission tomography/CT showed weak uptake in the retroperitoneal mass and no other mass lesions.

Results

Following preparation with alpha-adrenergic blockers, surgical excision was performed with diagnostic and curative intent. Postoperatively, hypertension and paroxysmal symptoms resolved completely. The histopathology report described seminoma with an entrapped large ganglion within the tumor.

Conclusion

We describe a retroperitoneal seminoma with an entrapped ganglion causing hypertension and paroxysmal symptoms, with laboratory and imaging features compatible with paraganglioma. Awareness of the rare possibility of mechanical pressure on a ganglion, within the differential diagnosis of retroperitoneal mass and sympathetic symptoms may aid in clinical decision making in atypical cases.

Lifestyle Medicine Around the World: Lifestyle Medicine in Israel

In 2015, the Centers for Disease Control in the United States declared that 7 of 10 deaths per year are caused by chronic diseases; in Israel, the situation is consistent with this assessment. Healthy Israel 2020, an Israeli Ministry of Health initiative, places physicians at the forefront of health promotion and preventive medicine. In 2012, the Israeli Society of Lifestyle Medicine (ISLM) was established under the auspices of the Israel Association for Family Physicians. This decision was taken because we, the authors, wanted to promote change in the primary care services through the recruitment of key leaders for implementation of lifestyle medicine (LM), including improved attitudes, knowledge, motivation, and skills of primary care physicians and health providers. Today, the ISLM is an active member of the Israeli Medical Association, promoting educational activities, physician's health, and well-being initiatives; developing tools for health-promoting clinics; and more. Our future plans are to incorporate LM as an integral part of daily practice in all sectors of the medical profession in Israel. This is challenging, but we see this as the only way to effectively combat the noncommunicable disease epidemic.

New-onset diabetes in elderly subjects: association between HbA1c levels, mortality, and coronary revascularization

OBJECTIVE

New-onset diabetes mellitus (DM) in elderly patients is associated with increased risk of diabetes complications and mortality. It is unknown whether glycemic control in this population influences the mortality risk.

RESEARCH DESIGN AND METHODS

The current study was conducted using the computerized database of the Sharon-Shomron District of Clalit Health Services in Israel. Included in the study were subjects 65 years of age and above with new-onset DM. The primary outcome measures were all-cause mortality and coronary revascularization procedures with either percutaneous coronary intervention or coronary artery bypass grafting.

RESULTS

Participants (n = 2,994) were stratified into four groups according to their mean HbA1c levels during the follow-up period (<6.5% [48 mmol/mol], 6.5-6.99% [48-52 mmol/mol], 7-7.49% [53-57 mmol/mol], and ≥7.5% [58 mmol/mol]). During a mean follow-up of 5.54 ± 2.1 years, 1,173 (39.17%) participants died and 285 (9.51%) underwent coronary revascularization. An HbA1c level >7.5% (58 mmol/mol) was associated with a significantly increased all-cause mortality rate (hazard ratio [HR] 1.74 [95% CI 1.2-1.8], P < 0.0001). This difference remained statistically significant after a multivariate model adjusted for the conventional cardiovascular risk factors and for the use of hypoglycemic agents and statins. Kaplan-Meier survival plots revealed lower survival rates in this group of patients. Coronary revascularization rates were highest among subjects with HbA1c 6.5-6.99% (48-52 mmol/mol) (HR 1.6 [1.01-2.4], P < 0.05) and lowest in patients with HbA1c ≥7.5% (58 mmol/mol).

CONCLUSIONS

An HbA1c level >7.5% (58 mmol/mol) is associated with increased risk for all-cause mortality and with a lower revascularization rate in elderly patients with new-onset DM.