The Canary in the Coal Mine

Case: The patient is a 32-year-old Asian male with PMH of ERSD secondary to minimal change disease (diagnosed at age 26) presented for acute onset shortness of breath, lower extremity edema, and abdominal distension. He underwent CTPE which showed large left pleural effusion, moderate pericardial effusion and as well as ascites. Transthoracic ECHO showed moderate to large pericardial effusion with evidence of tamponade physiology. The patient underwent emergent pericardiocentesis and placement of a pericardial drain. The pericardial fluid was bloody in appearance, fluid studies showed RBC 2047709, cytology negative malignancy and culture showing no growth. The patient also underwent left-sided thoracentesis with the removal of 1L bloody fluid with the placement of a left-sided pleural drain. Pleural fluid studies showed RBC 30803, cytology negative for malignancy and culture showing no growth. Furthermore, paracentesis was done with the removal of 800cc peritoneal fluid with bloody appearance. Fluid studies showed RBC 112577 and cytology negative for malignancy, negative cultures. Hemoglobin was around 8, platelets 102, CRP 18 and sed rate 53. ANA 1:640 speckled pattern, low C3 and C4, negative ANCA, RF, CCP, RNP, Smith ds DNA, SSA, SSB, C3 low and C4 normal (both initially low). He met 4/11 SLICC criteria for SLE including serositis, +ANA, anemia/thrombocytopenia and low complements, history of MCD. He was started on methylprednisolone resulting in the improvement of anemia/thrombocytopenia. Then transitioned to oral prednisone with a taper and was also started on plaquenil and imuran. Impact/Discussion: To date, the association of SLE with MCD has been described only in isolated case reports. Initially, the etiology of the patient’s MCD was unclear. He had no history of lupus nephritis and no known causes for secondary FSGS, but failed to recover renal function and ultimately progressed to ESRD. His dramatic presentation suggests that MCD was a harbinger of SLE—the metaphorical canary in the coal mine. In the context of his past medical history and his particular demographic, initial clinical suspicion for SLE was low. This case contributes to the body of literature supporting early consideration of SLE as a potential etiology for MCD and acute pericarditis. Conclusion: SLE is an autoimmune disorder with a wide spectrum of manifestations. Acute pericarditis is an important and potentially a life threatening complication of the disease. According to the most recent EULAR/ACR 2019 SLE criteria, acute pericarditis scores 6 points. A total of 10 points is required to diagnose SLE, thus recognizing SLE as a potential underlying cause in a newly diagnosed acute pericarditis or cardiac tamponade is crucial to initiate treatment and improve outcomes. A relevant association may exist between SLE and MCD.https://scholarlycommons.henryford.com/merf2020caserpt/1019/thumbnail.jp

Acute MI After First Sipuleucel-T Infusion for Prostate Cancer

Introduction: Advances in cancer therapy have improved patient survival statistics; however, treatment related adverse events can lead to significant morbidity and may be life threatening. Sipuleucel-T is the first FDA approved therapeutic cancer vaccine based on improved overall survival in patients with metastatic castration resistant prostate cancer. We describe a case of acute ST segment elevation myocardial infarction (STEMI) in a patient during the first sipuleucel-T infusion. Our aim is to increase physician awareness of this potential complication in order to avoid catastrophic outcome. Case presentation: A 59 year old gentleman with metastatic castration resistant prostate cancer, hypertension, diabetes and no prior cardiac disease (normal pharmacologic stress test and CT coronography within the last year) was undergoing his first sipuleucel-T infusion when he developed sudden chills. No signs or symptoms of anaphylaxis were reported. Patient’s presentation was attributed to infusion reaction. Diphenhydramine 50 mg was given with resolution of the symptoms. Within 20 minutes he developed substernal chest tightness with left arm radiation, along with dyspnea and diaphoresis. Vital signs were notable for BP 90/40, HR 94, and oxygen saturation 96% on room air. Physical exam revealed a diaphoretic male, with normal cardiac, chest, abdominal and extremity examination. EKG showed ST elevation in III, AVF with reciprocal depressions in anterolateral leads. Emergent left heart catheterization (LHC) revealed the culprit lesion at mid RCA (99% obstruction) and a Synergy drug-eluting stent (DES) was placed. In the recovery room, the patient had recurrent chest pain. Repeat emergent LHC revealed acute in-stent thrombus and likely plaque protrusion in the proximal end of previously placed stent with distal embolization. The lesion was ballooned requiring additional DES placement proximally overlying the initial stent and ultimate intraaortic balloon pump for coronary perfusion. He was discharged home in satisfactory condition with appropriate goal directed therapy. Discussion: Sipuleucel-T is an active cellular immunotherapy consisting of autologous peripheral-blood mononuclear cells that have been activated ex vivo with a recombinant fusion protein (PA2024). It has shown to improve survival in a phase III trial. Despite its approval over a decade ago, there remains a paucity of literature describing safety data in the post-marketing period. Summary of US reports submitted to FAERS (surveillance system designed to report AEs associated with drugs) revealed 38 cases of myocardial infarctions, all of which occurred after 2nd or 3rd doses. Most patients had cardiac risk factors. To our knowledge, this is the first case report describing STEMI in a patient during the first sipuleucel-T infusion. Increased awareness of this potential adverse event is important for involved physicians to avoid significant morbidity and mortality of affected patients.https://scholarlycommons.henryford.com/merf2020caserpt/1018/thumbnail.jp

One year prognosis of young Middle Eastern patients undergoing percutaneous coronary interventions

Background: There is scarcity of data about the outcome in young Middle Eastern patients who undergo percutaneous coronary intervention (PCI). We sought to assess clinical and coronary angiographic features and one year outcome of young compared with older patients following PCI.Methods: Baseline clinical and coronary angiographic features and major cardiovascular events from hospital admission to one year were assessed in young patients (45 years of age).Results: Of 2426 patients; 308 (12.7%) were young. Young and older patients were predominantly males (76.3% vs. 79.8%; p=0.18) and had similar prevalence of hypertension, diabetes, dyslipidemia, and cigarette smoking. There were no differences between young and older patients in the rates of acute coronary syndrome as an indication for PCI (75.6% vs. 76.1%; p=0.90). The two groups had similar prevalence of one-vessel coronary artery disease (55.2% vs. 58.1%; p=0.37) and intervention for one vessel (74.0% vs. 72.1%; p=0.53). No significant differences were observed in the incidence of in-hospital adverse events in young compared with older patients. Incidence of adverse events in young patients at one year were not different from those in older patients, including cardiac death (3.63% vs. 2.11%), stent thrombosis (3.63% vs. 2.08%), major bleeding (1.30% vs. 1.18%), and coronary revascularization (3.65% vs. 3.24%); all p=NS.Conclusions: Among Middle Eastern patients undergoing coronary intervention; 13% were 45 years of age or younger. No favourable risk profile, coronary angiographic features or cardiovascular outcome were observed in young compared with older patients

The mental health impact of multiple deprivations under protracted conflict: a multilevel study in the occupied Palestinian territory

Building on the literatures examining the impacts of deprivation and war and conflict on mental health, this study investigates the impact of different forms of deprivation on mental health within a context of prolonged conflict in the occupied Palestinian territory(oPt). The study uses data from the Socio-Economic & Food Security Survey 2014 conducted by the Palestinian Central Bureau of Statistics, with an analytical sample of 7827 households in the West Bank(WB) and Gaza Strip(GS). The analysis is conducted for the combined sample, and for the WB and GS separately. The General Health Questionnaire-12 (GHQ12) score is our main outcome measure of poor mental health. The main predictor variables are various measures of deprivation (including subjective deprivation, material deprivation, food deprivation, and political deprivation), acute political, health, and economic shocks, and background socio-demographic characteristics. The results indicate significant variance at the locality level. We find significant positive associations between poor mental health and subjective, economic, political, and food deprivation; health, economic, and political stressors; age, and being a woman. Individuals who indicated that they felt somewhat or very deprived have significantly higher GHQ scores than individuals who indicated that they did not feel deprived (β=1·69 and 4·23 for those who felt deprived and who did not feel deprived, respectively, p<0·0001). Food consumption was inversely associated with GHQ score (β=−0·01, p<0·0001) and food insecurity was positively associated with GHQ score (β=0·19, p<0·0001). Health-related, political, and economic stressors were significantly positively associated with GHQ scores (β=1.36, 0·52, 0·23, and 0·19 respectively, p<0·0001). Age (β=0·089, p<0·0001) and being a woman were positively associated with GHQ score (β=0·25, p=<0.001), whereas education beyond secondary school level was inversely associated with GHQ score (β=−0·58, p<0·0001). The community effect suggests that spatial characteristics are influencing mental health, and warrant further investigation

EHR Visual Overlay Promises to Improve Hypertension Guideline Implementation

Background: Primary care management of essential hypertension (HTN) has become increasingly challenging since recently published guidelines integrate atherosclerotic cardiovascular disease (ASCVD) risk stratification into decision making. Our objective was to measure whether overlay of visualdecision support (VDS) with standard electronic health record (EHR) platform improves guideline-based treatment, and reduces time burden associated with EHR use, in management of essential HTN. Methods: This was a quality improvement project. We interviewed primary care physicians and tasked each with two simulated patient encounters for HTN: (1) using standard EHR to guide treatment, and (2) using VDS to guide treatment. The VDS included graphical blood pressure (BP) trends, target BP with recommended interventions, ASCVD risk score, and information on the patient’s social determinants of health. We assessed whether treatment selection was congruent with guidelines and tracked time physicians consulted the EHR. Results: We evaluated 70 case simulations in total. Use of VDS compared to usual EHR was associated with: higher proportion of correct guideline prescribing (94% vs. 60%, p\u3c0.01), more ASCVD risk determination (100% vs. 23, p\u3c0.01), and more correct BP target identification (97% vs. 60%, p\u3c0.01). Time clinicians spent consulting the EHR fell an average of 121 seconds with use of VDS (p\u3c0.01). On a 10-point scale, clinicians rated the VDS 9.2 vs. 5.9 (p\u3c0.01) for ease of gathering necessary information to treat HTN. Conclusions: The integration video decision support tools to standard EHR can reduce physician time spent per patient encounter, while increasing adherence to guidelines and improving patient outcomes. Further testing in clinical practice is indicated.https://scholarlycommons.henryford.com/merf2019qi/1009/thumbnail.jp

Visual Analytics Dashboard Promises to Improve Hypertension Guideline Implementation

BACKGROUND: Primary care management of hypertension under new guidelines incorporates assessment of cardiovascular disease risk and commonly requires review of electronic health record (EHR) data. Visual analytics can streamline the review of complex data and may lessen the burden clinicians face using the EHR. This study sought to assess the utility of a visual analytics dashboard in addition to EHR in managing hypertension in a primary care setting. METHODS: Primary care physicians within an urban, academic internal medicine clinic were tasked with performing two simulated patient encounters for HTN management: the first using standard EHR, and the second using EHR paired with a visual dashboard. The dashboard included graphical blood pressure trends with guideline-directed targets, calculated ASCVD risk score, and relevant medications. Guideline-appropriate antihypertensive prescribing, correct target blood pressure goal, and total encounter time were assessed. RESULTS: We evaluated 70 case simulations. Use of the dashboard with the EHR compared to use of the EHR alone was associated with greater adherence to prescribing guidelines (95% vs. 62%, p\u3c0.001) and more correct identification of BP target (95% vs. 57%, p\u3c0.01). Total encounter time fell an average of 121 seconds (95% CI 69 - 157 seconds, p\u3c0.001) in encounters that used the dashboard combined with the EHR. CONCLUSIONS: The integration of a hypertension-specific visual analytics dashboard with EHR demonstrates the potential to reduce time and improve hypertension guideline implementation. Further widespread testing in clinical practice is warranted

Risk of severe SARS-CoV-2 infection in patients with autoimmune rheumatic diseases in Qatar: a cohort matched study

Background: It remains unclear whether patients with autoimmune rheumatic diseases (ARDs) are at a higher risk of poor outcomes from a SARS-CoV-2 infection. We evaluated whether patients with an ARDs infected with SARS-CoV-2 were at a higher risk of a poorer outcome than those without an ARDs. Methods: Patients with an ARDs infected with SARSCoV-2 were matched to control patients without a known ARDs. Matching was performed according to age (6 years) and sex at a case-to-control ratio of 1:3. Demographic and clinical data were extracted from the databases and were compared between the two groups. Severe SARS-CoV-2 infection was the primary outcome and was defined as the requirement for oxygen therapy support, the need for invasive or noninvasive mechanical ventilation, or the use of glucocorticoids. Results: A total of 141 patients with an ARDs were matched to 398 patients who formed the control group. The mean ages (SD) of the ARDs and nonARDs groups were 44.4 years (11.4) and 43.4 years (12.2). Women accounted for 58.8% of the ARDs group and 56.3% of the control group (p = 0.59). Demographics and comorbidities were balanced between the groups. ARDs included connective tissue disease in 43 (30.3%) patients, inflammatory arthritis in 92 (65.2%), and other ARDs in 8 (5.7%). ARDs medications included biological/targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs) in 28 (15.6%) patients, conventional synthetic DMARDs in 95 (67.4%), and immunosuppressive antimetabolites in 13 (9.2%). The ARDs group had more respiratory and gastrointestinal symptoms related to SARS-CoV-2 infection than the control group (24.8% and 20.6% vs. 10% and 5.3%, respectively; p, 0.001 for both). Severe SARS-CoV2 infection was more common in the ARDs group than in the control group (14.9% vs. 5.8%; p, 0.001). Conclusions: In this single-center matched cohort study, patients with an ARDs experienced more respiratory and gastrointestinal symptoms related to SARS-CoV-2 infection and had more severe infection than those from the control group. Therefore, patients with an ARDs require close observation during the coronavirus disease 2019 pandemic

An Unfortunate Case of Nonuremic Calciphylaxis

Learning Objective #1: Recognize and distinguish calciphylaxis from other forms of ulcerating vasculitides in nonuremic patients. CASE: A 74-year-old female smoker with a history of diabetes and peripheral artery disease (PAD) presents with painful persistent ulcers on her left arm and bilateral legs. She had a similar presentation one year ago and was diagnosed with thromboangiitis obliterans (Buerger\u27s disease) after a biopsy of the leg ulcer showed inflammatory intraluminal thrombus. At that time, the patient was treated with antibiotics and counseled on smoking cessation. She successfully quit smoking, however skin ulcers continued to progress, which is unusual in Buerger\u27s disease. She returned one year later with painful necrotic skin lesions involving the proximal legs, feet, and arms. Extensive rheumatological, hematological, endocrinological, vascular and genetic testing were all negative. A repeat punch biopsy was performed and revealed calcification and thrombosis of arterioles in the dermis and subcutaneous adipose tissue. Given extensive necrosis, she required bilateral transmetacarpal amputations. IMPACT/DISCUSSION: We present a rare case of extensive non-uremic calciphylaxis in a patient with normal renal function. Calciphylaxis is an ischemic skin disorder recognized in patients with end-stage renal disease (ESRD). Our patient\u27s history of heavy smoking, diabetes, and PAD gave suspicion to Buerger\u27s disease, diabetic foot ulcerations, or ischemic ulcerations. It is essential to make the proper diagnosis, as treatment varies. The ulcers in Buerger\u27s disease normally involve the distal legs and feet, whereas those in calciphylaxis involve the proximal extremities. Histologically, Buerger\u27s disease has an intraluminal thrombus with relative sparing of the vessel wall and internal elastic lamina. This contrasts with calciphylaxis, which has thrombotic occlusion with dermal arteriolar calcification and subintimal fibrosis. Although rare, a systematic review revealed 36 reported cases of nonuremic calciphylaxis. The exact incidence of the disease is unknown. The only available treatment for calciphylaxis is sodium thiosulfate, but this is ineffective in patients with normal kidney function because it gets cleared by the kidneys too quickly to have any effect. Conclusion: Calciphylaxis is a potentially lethal disorder that carries high morbidity and mortality if not recognized early. Although it is most commonly seen in patients with ESRD, clinical suspicion in non-uremic patients with the appropriate lesion distribution and histological findings is essential to early treatment. Further clinical research is needed to better understand non-renal etiologies and treatment

One year prognosis of young Middle Eastern patients undergoing percutaneous coronary interventions

Background: There is scarcity of data about the outcome in young Middle Eastern patients who undergo percutaneous coronary intervention (PCI). We sought to assess clinical and coronary angiographic features and one year outcome of young compared with older patients following PCI.Methods: Baseline clinical and coronary angiographic features and major cardiovascular events from hospital admission to one year were assessed in young patients (&lt;45 years of age) compared with older patients (&gt;45 years of age).Results: Of 2426 patients; 308 (12.7%) were young. Young and older patients were predominantly males (76.3% vs. 79.8%; p=0.18) and had similar prevalence of hypertension, diabetes, dyslipidemia, and cigarette smoking. There were no differences between young and older patients in the rates of acute coronary syndrome as an indication for PCI (75.6% vs. 76.1%; p=0.90). The two groups had similar prevalence of one-vessel coronary artery disease (55.2% vs. 58.1%; p=0.37) and intervention for one vessel (74.0% vs. 72.1%; p=0.53). No significant differences were observed in the incidence of in-hospital adverse events in young compared with older patients. Incidence of adverse events in young patients at one year were not different from those in older patients, including cardiac death (3.63% vs. 2.11%), stent thrombosis (3.63% vs. 2.08%), major bleeding (1.30% vs. 1.18%), and coronary revascularization (3.65% vs. 3.24%); all p=NS.Conclusions: Among Middle Eastern patients undergoing coronary intervention; 13% were 45 years of age or younger. No favourable risk profile, coronary angiographic features or cardiovascular outcome were observed in young compared with older patients

Predictors of Iatrogenic Hypoglycemia in Treatment of Hyperkalemia

Background: Hypoglycemia is a potential adverse outcome that could complicate the treatment of hyperkalemia with insulin administration. Treatment needs to be individualized for patients\u27 specific characteristics to avoid iatrogenic hypoglycemia. Our study aimed to identify characteristics that could increase the risk of hypoglycemia. Methods: A retrospective study at a large tertiary institution was conducted from December 2016 to November 2017. A chart review was performed on adult patients who received subcutaneous insulin and intravenous glucose for treatment of hyperkalemia (potassium \u3e 5 mmol/L) while present in the emergency department or inpatient setting. Patients who received insulin for the treatment of hyperglycemia were excluded. Data including demographics, insulin dose, and laboratory values were collected. The cohort was divided into two groups; patients who developed hypoglycemic events (defined as serum glucose \u3c 70 mg/dL) and those who did not. Univariate and multivariate analysis was performed. The primary outcome was incidence of hypoglycemia. The secondary outcome was identifying predictors of hypoglycemia. Results: 1156 consecutive patients with hyperkalemia who were treated with insulin were analyzed. Mean age was 61 years, 59% were males, and 61% were African American. 69% had chronic kidney disease, and of those 32.7% were on hemodialysis. The mean dose of insulin administered was 0.105 +0.05 units/kg for a median pre-treatment potassium level of 5.9 mmol/L. 17.8% of patients developed hypoglycemia (N=206). The median pre-treatment glucose level was 126 mg/dL, and mean hypoglycemia level was 53 mg/dL. On multivariate analysis age (p=0.0328), pre-treatment glucose level (p\u3c 0.0001), and insulin dosing (p=0.0032) were significant predictors of hypoglycemia. For every 10-year increase in age, the risk of hypoglycemia increased by an odds ratio (OR) of 1.128. For every 10 mg/dL increase in the pre-treatment glucose level, the odds of developing hypoglycemia were reduced by an OR of 0.929. For every 0.025 units/kg increase of insulin dosing above the 0.1 units/kg usually administered, the OR for hypoglycemia was increased by 1.006. There was a significant difference in the rates of hypoglycemic events between the emergency department (24.2%) compared to the general practice units (18.4%) and intensive care units (12.8%) (p\u3c 0.001). There was no relationship between insulin dose and pre-treatment glucose (R2= 0.0006). Conclusions: Patients with older age, lower pre-treatment glucose and higher insulin doses were at increased risk of developing hypoglycemia following treatment of hyperkalemia with insulin. Clinicians should more regularly evaluate baseline glucose levels when treating hyperkalemia with insulin to prevent iatrogenic hypoglycemia