Refractory nonfunctioning pituitary adenomas

Non-functioning pituitary adenomas (NFPAs) comprise silent tumors of different pituitary lineages that tend to escape early detection and present as invasive macroadenomas with symptoms of mass effect. Incomplete surgical resection is common and may be followed by significant rates of subsequent remnant progression. Pituitary tumors are defined as refractory when resistance to optimal standard therapies including surgery, radiotherapy, and medical treatment is documented. In the absence of approved medications for the treatment of NFPAs, the last criterion to classify these tumors as refractory is ill defined. Silent corticotroph and null cell adenomas have been reported, albeit not in all studies, to be larger and recur more often compared with silent gonadotroph tumors. Nevertheless, it is currently unknown if certain NFPA subtypes are more often refractory using well defined criteria. The response rate to temozolomide is lower in NFPA compared to that seen in functioning tumors. Refractory NFPAs present a significant diagnostic and therapeutic challenge and are associated with increased morbidity and mortality rates.

Disaster Medicine Education for Israeli Medical Response Teams to the Ukrainian Refugee Crisis

INTRODUCTION

Disaster Medicine (DM) requires skills, knowledge, and prior experience that are rarely put to test by health care providers. Pediatric DM presents unique challenges in terms of both knowledge and practice.

METHODS

An anonymous survey consisting of demographic and five-point Likert scale questions was administered to physicians, nurses, and other medical personnel from Israel's major medical emergency teams who were deployed to respond to the refugee crisis in Ukraine. This included teams from the Hadassah and Tel Aviv Sourasky Medical Centers and the Israel Ministry of Health.

RESULTS

Of the 171 members of the medical teams deployed on the Ukraine border, a total of 105 responses were obtained (61.4%) from 61 physicians, 50 nurses, and 12 other health care providers. The teams were composed of pediatricians (31.6%), internal medicine physicians (21.6%), Emergency Medicine and intensive care physicians (18.0%), and 31.0% other specialties.For 60% of the participants, this was their first deployment, and 78% had received no training in DM. Members rated the need for DM training at 4/5 (IQR 3-5). Forty-nine (49) members (46.6%) were not briefed on situational awareness and 97 members (89.5%) were not trained in the recognition of acute stress reactions. The responders also rated their concerns about providing medical aid to children at 2/5 (IQR 1-3). A medical clown was part of the teams 42.8% of the time; the presence of clowns was rated at a median of 4/5 (IQR 4-5). The team members underscored the need for more targeted training in DM at 5/5 (IQR 3-5).

CONCLUSION

The findings highlight the need for the formulation of a disaster education model that includes pediatric DM.

Outcomes of ICU patients treated with intravenous immunoglobulin for sepsis or autoimmune diseases

OBJECTIVES

To evaluate the outcomes of hospitalized patients in two intensive care units (ICU) treated with intravenous immunoglobulin (IVIg) added to standard-of-care therapy. The indications for IVIg therapy were sepsis or autoimmune disease.

METHODS

We conducted a retrospective study involving adult patients with sepsis and autoimmune diseases, who received IVIg in the ICU at Wolfson and Sheba Medical Centers. A predefined chart was compiled on Excel to include a complete demographic collection, patient comorbidities, chronic medication use, disease severity scores (Charlson Comorbidity Index; SOFA and APACHE II index scores), indication and dosage of IVIg administration, duration of hospitalization and mortality rates.

RESULTS

Patients (n - 111) were divided into 2 groups: patients with sepsis only (n-67) and patients with autoimmune disease only (n-44). Septic patients had a shorter ICU stay, received IVIg early, and had reduced mortality if treated with high dose IVIg. Patients with autoimmune diseases did not have a favorable outcome despite IVIg treatment. In this group, IVIg was administered later than in the sepsis group.

CONCLUSIONS

IVIg therapy improved the outcomes for ICU patients with sepsis.

[DIFFERENT ANESTHESIA APPROACHES IN THE TRANSCATHETER AORTIC VALVE IMPLANTATION (TAVI) PROCEDURE AND THEIR POSSIBLE EFFECT ON MORBIDITY AND MORTALITY]

BACKGROUND

Transcatheter aortic valve implantation (TAVI) is used in patients with severe aortic stenosis (AS) who are at high surgical risk. Pre- and post-operative management is challenging as these patients are older, have significant comorbidities and a very high expected mortality rate in conventional surgery. There is no consensus in the literature about the preferred form of anesthesia, however, currently most centers perform the procedure using local anesthesia with sedation (LA-S).

OBJECTIVES

To compare general anesthesia (GA) and LA-S in patients undergoing TAVI.

METHODS

A retrospective review of the first 100 patients who underwent TAVI (11/2008-6/2011) at the Rabin Medical Center, due to severe and symptomatic AS and a counter-indication for conventional valve replacement surgery.

RESULTS

A total of 46 patients underwent the procedure with GA and 54 with LA-S. In 63 patients, the transfemoral approach was used, transapical in 23, and transaxillary in 11. There were no significant differences in short- and long-term mortality, but average hospitalization was longer in the GA group. A larger proportion of patients needed norepinephrine and blood transfusions during the procedure in the GA group. In the LA-S group, more conduction, vascular complications and postoperative fever were observed. In comparisons between anesthesia methods with the transfemoral approach, most of the differences lost their significance. Therefore, these differences are most likely attributed to the surgical approach and not to the anesthesia method.

CONCLUSIONS

There is no clear preference for GA in TAVI. LA-S appears to be an effective and safe option for eligible patients.

Hemoptysis and a cardiac murmur: is it primary or secondary antiphospholipid syndrome?

Endocarditis is most frequently infective in origin, and thus, when a patient presents with a clinical picture suggestive of endocarditis, an extensive work up aimed at finding the infectious agent is warranted. Among systemic lupus erythematosus (SLE) patients, cardiovascular disease is prevalent in more than 50% of patients including valvular disease and non-infective endocarditis, known as Libman-Sacks (LS) endocarditis. The prevalence of LS syndrome among SLE patients with secondary antiphospholipid syndrome (APS) is higher than in SLE without APS. Here, we present a case of a patient diagnosed with primary APS who presented with hemoptysis and a cardiac murmur. The diagnosis of SLE was established following the findings of non-infective verrucous vegetations together with diffuse alveolar hemorrhage (DAH). Treatment with high-dose corticosteroids and intravenous immunoglobulins yielded substantial resolution of the vegetations and regression of the DAH. Hence, aortic valve replacement was successfully performed as an elective procedure and without any postoperative complications. The patient is in remission after a 6-month follow-up. The clinical findings of DAH and double valve non-infectious endocarditis prompted the diagnosis of SLE with secondary APS.

Rituximab induction without maintenance for granulomatosis with polyangiitis and dialysis - Case report and literature review

ANCA-associated vasculitis (AAV) may lead to irreversible organ damage, particularly end-stage renal disease (ESRD) requiring dialysis. The chances of renal recovery diminish with prolonged dialysis. We describe a case of a 32-year-old woman admitted for pulmonary infiltrates and acute renal failure. Autoimmune workup revealed an elevated titer of proteinase 3-antineutrophil cytoplasmic antibody (PR3-ANCA). The diagnosis of granulomatosis with polyangiitis (GPA) was confirmed by renal biopsy. The patient received induction therapy with IV rituximab (375 mg/m² per week for 4 weeks) along with systemic high-dose IV corticosteroids and one pulse of IV cyclophosphamide (1000 mg). Rapid deterioration of her kidney function led to pulmonary edema requiring intensive care (ICU) hospitalization. Dialysis and plasmapheresis were initiated. Significant clinical improvement ensued, but the patient remained dialysis dependent. No immunosuppressive maintenance therapy other than prednisone was given. Chronic dialysis was discontinued successfully after eight months. At a follow-up of 30 months since her hospitalization, the patient is in complete remission without relapses. We suggest that rituximab induction without maintenance therapy for GPA ESRD may be adequate.

Cardiac Manifestations of Antiphospholipid Syndrome With Focus on Its Primary Form

Antiphospholipid syndrome (APS) is a multisystem autoimmune disease most commonly associated with recurrent arterial and venous thromboembolism and recurrent fetal loss. Other possible antiphospholipid antibody (aPL)-related clinical manifestations include cardiac involvement. The heart can be involved through immune mediated and /or thrombotic mechanisms. Mortality due to cardiovascular problems is elevated in APS. However, the cardiovascular risk in patients with primary APS (PAPS) compared with lupus-related APS is yet to be established. Cardiac symptoms of APS include valve abnormalities (thickening and vegetations), coronary artery disease (CAD), myocardial dysfunction, pulmonary hypertension, and intracardiac thrombi. Heart valve lesions are the most common cardiac manifestation, observed in approximately one third of PAPS patients and usually do not cause hemodynamic significance. Deposits of immunoglobulins including anticardiolipin (aCL), and of complement components, are commonly observed in affected heart valves from these patients. This suggests that an inflammatory process is initiated by aPL deposition, eventually resulting in the formation of valvular lesion. aPL may have a direct role in the atherosclerotic process via induction of endothelial activation. Multiple traditional and autoimmune-inflammatory risk factors are involved in triggering an expedited atherosclerotic arterial disease evident in APS. It is imperative to increase the efforts in early diagnosis, control of risk factors and close follow-up, in the attempt to minimize cardiovascular risk in APS. Clinicians should bear in mind that a multidisciplinary therapeutic approach is of paramount importance in these patients. This article reviews the cardiac detriments of APS, including treatment recommendations for each cardiac complication.

Increased Risk for Cancer in Young Patients with Severe Obstructive Sleep Apnea

BACKGROUND

Several studies in animal models and human with obstructive sleep apnea syndrome (OSAS) demonstrated an increase in cancer aggressiveness and mortality. However, there is a need for further clinical evidence supporting a correlation between OSAS and cancer incidence.

OBJECTIVES

To reveal whether OSAS presence and severity is correlated with cancer incidence in a large homogenous patients' cohort.

METHODS

We analyzed a cohort of over 5,000 concurrently enrolled patients, age > 18, with suspected OSAS, from a tertiary medical academic center. Patients underwent whole night polysomnography, the gold standard diagnostic tool for OSAS, and were classified for severity according to the Apnea Hypopnea Index (AHI). Data on cancer incidence were obtained from the Israel National Cancer Registry. A multivariate Cox proportional-hazards analysis, adjusted for age, gender, and BMI, was performed to estimate the hazard-ratio of new cancer incidence.

RESULTS

Among 5,243 subjects with a median follow-up of 5.9 years, 265 were diagnosed with cancer. The most prevalent cancers were prostate (14.7%), hematological (12.8%), urothelial (9.4%), colorectal (9%), and breast (8.3%). In subjects who were diagnosed at age below 45 years (n = 1,533), a high AHI (> 57/h) was significantly associated with cancer (HR 3.7, CI 1.12-12.45, p = 0.008).

CONCLUSIONS

Patients younger than 45 with severe OSAS have a significantly higher all-type cancer incidence than the general population. These results should encourage clinicians to detect and diagnose young patients with suspected OSAS and to recommend cancer screening methods in this high-risk population.

Long-term Metabolic Effects of Laparoscopic Sleeve Gastrectomy

IMPORTANCE

The prevalence of laparoscopic sleeve gastrectomy (LSG) is increasing, but data on its long-term effect on obesity-related comorbidities are scarce. Because the population of bariatric patients is young, long-term results of those comorbidities are highly relevant.

OBJECTIVE

To investigate the long-term effects of LSG on weight loss, diabetes mellitus, hypertension, dyslipidemia, and hyperuricemia.

DESIGN, SETTING, AND PARTICIPANTS

Cohort study using a retrospective analysis of a prospective cohort at a university hospital. Data were collected from all patients undergoing LSGs performed by the same team between April 1, 2006, and February 28, 2013, including demographic details, weight follow-up, blood test results, and information on medications and comorbidities.

MAIN OUTCOMES AND MEASURES

Excess weight loss, obesity-related comorbidities, and partial and complete remission at 1, 3, and 5 years of follow-up.

RESULTS

A total of 443 LSGs were performed. Complete data were available for 241 of the 443 patients (54.4%) at the 1-year follow-up, for 128 of 259 patients (49.4%) at the 3-year follow-up, and for 39 of 56 patients (69.6%) at the 5-year follow-up. The percentage of excess weight loss was 76.8%, 69.7%, and 56.1%, respectively. Complete remission of diabetes was maintained in 50.7%, 38.2%, and 20.0%, respectively, and remission of hypertension was maintained in 46.3%, 48.0%, and 45.5%, respectively. Changes in high-density lipoprotein cholesterol level (mean [SD] level preoperatively and at 1, 3, and 5 years, 46.7 [15.8], 52.8 [13.6], 56.8 [16.0], and 52.4 [13.8] mg/dL, respectively) and triglyceride level (mean [SD] level preoperatively and at 1, 3, and 5 years, 155.2 [86.1], 106.3 [45.3], 107.2 [53.4], and 126.4 [59.7] mg/dL, respectively) were significant compared with preoperative and postoperative measurements (P < .001). The decrease of low-density lipoprotein cholesterol level was significant only at 1 year (P = .04) and 3 years (P = .04) (mean [SD] level preoperatively and at 1, 3, and 5 years, 115.8 [33.2], 110.8 [32.0], 105.7 [25.9], and 110.6 [28.3] mg/dL, respectively). The changes in total cholesterol level did not reach statistical significance (mean [SD] level preoperatively and at 1, 3, and 5 years, 189.5 [38.2], 184.0 [35.4], 183.4 [31.2], and 188.1 [35.7] mg/dL, respectively). No changes in comorbidity status correlated with preoperative excess weight. Hypertriglyceridemia was the only comorbidity whose remission rates at 1 year of follow-up (partial/complete, 80.6%; complete, 72.2%) correlated with percentage of excess weight loss (76.8%) (P = .005).

CONCLUSIONS AND RELEVANCE

Undergoing LSG induced efficient weight loss and a major improvement in obesity-related comorbidities, with mostly no correlation to percentage of excess weight loss. There was a significant weight regain and a decrease in remission rates of diabetes and, to a lesser extent, other comorbidities over time.