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RENAL INVOLVEMENT IN SARCOIDOSIS: REVIEW OF SIX CASES AT ONE CENTER
Abstract
Background and Aims
Sarcoidosis is an idiopathic multisystem granulomatous disease.Renal involvement in sarcoidosis is rare.It is usually due to abnormal calcium balance or parenchymal involvement.The aim of our study was to analyze the epidemiologic,clinical,paraclinical,therapeutic features and the outcome of sarcoidosis in patients with renal manifestations.
Methods
We carried a descriptive retrospective study including 6 patients with sarcoidosis,hospitalized in the nephrology department of Rabta Hospital of Tunis between 2012 and 2018.Renal biopsy was performed for all patients.
Results
Our series involved 5 women and one man with a mean age of 41.6 years.All patients presented with renal failure on admission.Laboratory tests showed normal calcium levels in five cases.One patient had hypercalcemia.Hypercalciuria was noted in one case.The angiotensin-converting enzyme was measured in 3 cases and it was normal.Extra-renal manifestations were:pulmonary interstitial syndrome(4 cases),anterior granulomatous uveitis(2 cases),cutaneous lesions(2 cases),cardiac sarcoidosis(one case),neurosarcoidosis(one case),hepatic sarcoidosis(one case),parotid gland sarcoidosis(one case)and polyarthritis(one case).Kidney biopsy showed granulomatous interstitial nephritis in five patients while the other patient had crystal nephropathy associated to interstitial nephritis without granuloma.All patients initially received oral prednisolone(1 mg/kg/day) with subsequent tapering.One patient was treated with inhaled corticosteroids for diffuse parenchymal lung involvement and two patients were put on immunosuppressive therapy (Azathioprine).No patient required dialysis.After a mean follow-up of 57 months,the outcome was marked by the improvement of serum creatinine in 4 patients,in whom one patient showed a new recurrence of renal sarcoidosis.Two patients reached end-stage renal disease.
Conclusions
Renal involvement is rare in sarcoidosis.Early diagnosis with appropriate treatment must be set early in order to prevent progression to chronic renal failure.
RISK FACTORS AND PROGNOSTIC PREDICTORS OF ACUTE KIDNEY INJURY IN ADULT LEPTOSPIROSIS
Abstract
Background and Aims
Leptospirosis is the most important zoonosis in the world. Acute kidney injury is a prominent feature of leptospirosis.There is a broad spectrum of renal pathological changes.This study aimed to investigate the risk factors and prognostic predictors of Acute Kidney Injury in Leptospirosis.
Methods
This was a retrospective study done in a tertiary care center in Southern India. The medical records of all patients who were admitted and treated for leptospirosis infection from January 2015 to Novemeber 2020 were analyzed. Demographic, clinical and laboratory data were compared between the groups and analyzed. Multiple Logistic regression was performed to analyze the possible risk factors and predictors of prognosis associated with AKI in Leptospirosis.
Results
Among the 258 adults, 163(63.2%) were males and 95 (36.8%) were females. 222 (84%) patients were below the age of 65 years while only 36 (14%) patients were above the age of 65 years. Among these patients, 69 (26.7%) patients developed. Association between Leptospirosis associated AKI and various risk factors were analyzed using Pearson chi square test which showed significant association with diabetes (P- 0.002, OR-3.081), Hypertension (P-0.0003, OR-5.075). Patients with AKI were older in which 38.9% patients were in the >65 years group. Predictors for AKI were leukocytosis (P = 0.009, OR 2.109), Hyperbilirubinemia (P = 0.05, OR = 2.481).
Conclusions
Identification of features like daibetes, hypertension, leukocytosis, hyperbilirubinemia should alert the clinician on risk of developing AKI in leptospirosis. Prompt antibiotic treatment, adequate hemodynamic resuscitation, and early renal support are the key success in the treatment of leptospirosis-associated AKI.
PHYSICIAN ASSESSMENT AND FEEDBACK DURING QUALITY CIRCLE TO REDUCE LOW-VALUE SERVICES IN OUTPATIENTS: A PRE-POST QUALITY IMPROVEMENT STUDY
Abstract
Background and Aims
The impact of the Choosing wisely (CW) campaign is debated as
recommendations alone may not modify physician behavior. The aim of this study was
to assess whether behavioral interventions with physician assessment and feedback
during quality circles (QCs) could reduce low-value services.
Methods
Pre-post quality improvement intervention with parallel comparison group involving outpatients
followed in a Swiss managed care network, including 700 general physicians (GP) and
150,000 adult patients. Interventions included performance feedback about low-value
activities and comparison with peers during QCs. We assessed individual physician
behavior and health care use from laboratory and insurance claims files between
August 1, 2016, through October 31, 2018. Main outcomes were the change in
prescription of three low value services six months before and six months after each
intervention: measurement of prostate specific antigen (PSA) and prescription rates of
proton pump inhibitor (PPI) and statins.
Results
QC intervention with physician feedback and peer comparison resulted in lower rates of PPI prescription (pre-post mean prescriptions per GP 25.5 ± 23.7 vs 22.9 ± 21.4 , p-value<0.01; PSA measurement (6.5 ± 8.7 vs 5.3 ± 6.9 tests per GP, p<0.01; and statins (6.1 ± 6.8 vs 5.6 ± 5.4 prescriptions per GP, p<0.01). Changes in prescription of low-value services among GP who did not attend QCs were
not statistically significant over this time period.
Conclusions
Our results demonstrate a modest but statistically significant effect of QCs with educative feedback
in reducing low-value services in outpatients with low impact on coefficient of variation.
ANALYSIS THROUGH QUALITY CRITERIA IN PALLIATIVE SEDATION: COMPARISON BETWEEN MEDICAL SPECIALTIES
Abstract
Background and Aims
Describing all the aspects that palliative sedation encompasses is essential for a correct approach to this process. Our objective is to analyze possible differences regarding quality criteria in palliative sedation between different units.
Methods
Data were collected from all deaths from the Palliative Care, Internal Medicine and Oncology units of our hospital during the second semester of 2019. The variables analyzed through the medical history were: age, gender, referring physician, sedation, initiation of sedation by referring or on-call doctor, symptom, patient capacity, survival after sedation, consent and drug. Chi square was performed between qualitative variables and Kruskal Wallis between qualitative/quantitative variables. SPSS 20.0 was used.
Results
More than 60% of the patients were over 75 years old; fifty-one percent were women. Sedation was indicated in 52%, with a significant difference between services, less frequently in Palliative (26%) compared to Internal Medicine (56%). There was no significant difference in survival time after sedation (p = 0.079). There was a significant difference in terms of the description of the refractory symptom, always reflected by Palliatives (100%) versus Oncology (30%) and Internal Medicine (25%). The same happened with the capacity, consent and drug used. There was no significant difference in the frequency of sedation by the doctor on call (p = 0.355).
Conclusions
The differences described point to the benefit of reinforcing training in all medical specialties that can initiate palliative sedation.
BLOOD PRESSURE IN A POPULATION OF A RURAL AREA OF RWANDA: PRELIMINARY DATA
Abstract
Background and Aims
Arterial hypertension likely affects millions of people in Africa and is the most important cause of heart disease and stroke. In Sub-Saharan Africa, the burden of hypertension is a rapid growing health threat. The aim of our study was to perform a screening of the local population living in the rural area of the District of Nyaruguru (Rwanda) to determine the prevalence of high BP.
Methods
Between February and July 2020, instructed health care providers collected some anthropometric data (such as height and weight) and measured BP three times in a sitting position with a validated oscillometric device (OMRON HEM-7322U).
Results
A total of 7336 subjects participated to the screening, with median age of 32 (IQR 21, 47) years; 4053 (55%) were female, age 35 (23, 49) years; 3283 (45%) were male, age 30 (20, 44) years (p<0.001). BMI was 20.7 (19.0, 22.3) in males and 21.8 (20.0, 23.8) in females (p<0.001). The mean of the last two BP measurements was 119.5±15.2mmHg. Males had a higher SBP 120.1±14.0mmHg compared to females 118.6±16.1mmHg (p<0.001.). SBP ≥140mmHg in 642 subjects (8.8%), without differences between males (8.4%) und females (9.0%); p=0.36.
Conclusions
Surprisingly, in a very rural peripheral region where the average age of the inhabitants is relatively low, about 9% of the subjects examined have abnormal blood pressure values. These data confirm the need to implement also in rural areas of Rwanda an adequate strategy for the prevention, diagnosis and treatment of hypertension.
CONTINUOUS WIRELESS MONITORING IN INTERNAL MEDICINE UNIT GOES FROM HOSPITAL TO THE FIELD TO IMPROVE MANAGEMENT OF COMPLEX PATIENTS: GREEN LINE H-T STUDY PRELIMINARY RESULTS
Abstract
Background and Aims
In Internal Medicine Unit (IMU) are increasing patients with serious illness, under acute exacerbation of previous diseases needing high intensity care and evaluation of clinical deterioration risk. Literature reported different results (3.5-15.1% ) about major complications (MC) in patients discharged at home, and there are no Telemedicine randomized trials.
Methods
Prospective, randomized, controlled, open-label, multi-center study for the evaluation of critically ill patients admitted in IMU and sent to subacute managed care unit or to earlier home discharge to evaluate the effectiveness of wireless monitoring of clinical conditions vs. traditional clinical monitoring on outcomes. Continuous wireless vital parameters and blood glucose monitoring are assured by WIN@Hospital and Dexcom G6 devices. Overall planned sample size is 300 patients.
Results
Since September 2019 70 patients were enrolled (M 30/F 40), mean age 76.8 (50% >80 years), Comorbidity: Cumulative Illness Rating Scale CIRS-CI: 4, CIRS SI: 1.8. About 30% scored BRASS (Blaylock Risk Assessment Screening Score) ≥20, Barthel mean value 63,2; Exton-Smith scale 15,7, Charlson Index 3,8, indicating need for step-down care. Fadoi Complimed score results are being processed. Overall major complications were 15% at 5 and 30 days of follow-up. The main complications highlighted by continuous home monitoring were cardiac arrhythmias, glycemic decompensation and drug interactions. A trend towards reduction of MC in experimental group appears to be seen.
Conclusions
Integrating hospital and field is a new challenge of Telemedicine allowing to improve patients’ management, both during hospital stay and after discharge, reducing the risk of early re-hospitalization and inappropriate access to the emergency room.
EFFICACY OF BETA-BLOCKERS IN PREVENTING TRASTUZUMAB-INDUCED CARDIOTOXICITY AMONG ADULT BREAST CANCER PATIENTS
Abstract
Background and Aims
Cardiac dysfunction is a significant toxicity associated with HER2-directed therapy - the risk for which can be increased by concomitant or antecedent exposure to other cardiotoxic agents particularly anthracyclines. This study sought to assess the efficacy of beta-blockers in preventing trastuzumab-induced cardiotoxicity.
Methods
A systematic search using MEDLINE, SCOPUS, CENTRAL, and Europe PMC databases was conducted until October 11, 2020. Included were randomized controlled trials of adult breast cancer patients on trastuzumab therapy and given beta-blockers (versus placebo). The primary outcome was a change in left ventricular ejection fraction (LVEF) from baseline to end of study. Secondary outcomes measured were changes in cardiac biomarkers (e.g. BNP), and safety. Validity of included studies was assessed using the Cochrane Risk-of-Bias tool. Pooled estimates for each outcome were reported as weighted mean differences.
Results
We identified 3 published trials (N=396). Beta-blocker therapy was associated with significantly higher LVEF on follow-up versus placebo (Mean Difference 1.84; 95% CI: 0.36-3.32; P=0.01; I²=63%). There was a trend toward benefit in the prevention of marked increases in BNP among those treated with beta-blockers versus placebo (Mean Difference 2.40; 95% CI: -1.70-5.87; P=0.18; I²=47%). A narrative description of adverse cardiac events and other cardiac imaging parameters was reported as well.
Conclusions
Beta-blockers appear to be well-tolerated and effective in preventing trastuzumab-induced cardiotoxicity, as well as in potentially attenuating elevations in serum BNP levels among adult breast cancer patients.
SEVERE ANEMIA: IS THE VALUE OR TIME THAT MATTERS?
Abstract
Background and Aims
Severe anemia is a common problem at the emergency department. Aim was to assess the severity of anemia according to its level and duration, in terms of development of ischemic electrocardiographic (ECG) changes and hemodynamic instability.
Methods
In 115 patients (58.3% women), mean age 77.7±11.4 (Μ±1SD) with hematocrit value≤24% or hemoglobin value ≤8 g/dl, hematocrit and hemoglobin levels, ECG abnormalities compatible with anemia, medical history, medications, and reason of admission were recorded. Chi-square and Man-Whitney U tests were used to compare categorical and continuous data respectively.
Results
75 patients (65.2%) had hemoglobin value≤6.5 g/dl and 19 patients (16.5%) suffered from acute anemia. When we compared the patients according to the level of anemia, we found no statistically significant differences between the two groups in terms of the presence of ECG changes or hemodynamic instability. When we compared the patients according to the anemia duration, we found that patients with acute anemia were more likely to have lowest systolic (U=548.5, p=0,006), diastolic (U=546.5, p=0,009) and mean pressure (U=541, p=0,005) and T wave abnormalities (χ2=5086, p=0,024), while ST segment depression has a marginal trend toward significance (χ2=3.558, p=0,059). Concerning heart rate, patients with acute anemia had higher mean heart rate (87.8/min vs 83.8/min), but this difference didn’t reach statistical significance. This result was not statistically significant even when we excluded from the analysis those receiving medication with bradycardic effect.
Conclusions
Although the value of the anemia looks more impressive, its duration (acute or chronic) is what determines the severity.