Cardiovascular Risk Factors and the Risk of Discontinuation of Advanced Therapies Due to Treatment Failure in Rheumatoid Arthritis: Results From the Ontario Best Practices Research Initiative.

OBJECTIVES: Our goal was to investigate whether cardiovascular disease (CVD) risk factors are associated with the retention of biologic disease-modifying antirheumatic drugs (bDMARDs) or targeted-synthetic DMARDs (tsDMARDs) in patients with rheumatoid arthritis (RA). METHODS: We included participants in the Ontario Best Practices Initiative RA registry who initiated their first bDMARD or tsDMARD. Participants were grouped by the number of baseline CVD risk factors (0, 1, or ≥2). The primary outcome was time-to-discontinuation of therapy for any reason. Secondary outcomes included discontinuation for primary failure, secondary failure, or due to adverse events. Competing risks hazards model, adjusted for clinically important confounders, estimated the association between CVD risk factors and treatment retention. RESULTS: The sample included 872 patients, of which 58% (n = 508) discontinued their b/tsDMARD after a median of 13 months from the time of initiation. The most common causes for treatment discontinuation were primary failure (n = 72), secondary failure (n = 126), or adverse events (n = 133). Patients with no CVD risk factors experienced significantly longer treatment survival compared to patients with 1 or ≥2 CVD risk factors. In multivariable-adjusted analysis, there was no association between all-cause discontinuation and CVD risk factors. However, there was a significant association between the presence of >1 CVD risk factor and treatment discontinuation, notably due to secondary treatment failure, but not due to adverse events. CONCLUSION: Multiple CVD risk factors increase the risk of treatment failure in RA, particularly for secondary treatment failure. To improve patient outcomes, future research should focus on developing strategies to identify early treatment nonresponse and investigate the potential modifiability of this association.

A Case of Metastatic CNS Melanoma of Unknown Primary Presenting with Seizures.

Seizures are a common occurrence. The goal of evaluating a seizure is to identify the etiology and to determine the likelihood of recurrence as well as guide management. We present a unique presentation of a 47-year-old female that presented with late onset seizures admitted due to status epilepticus. Brain magnetic resonance indicated diffuse supratentorial hemorrhagic lesions. Neurological workup including brain vessel imaging, CT chest, abdomen, and pelvis as well as CSF and serological workup for vasculitis failed to demonstrate the cause of her brain lesions. Ultimately, a brain biopsy showed metastatic melanoma of unknown primary origin.

Immunoglobulin G4 (IgG4)-Related Sialadenitis and Dacryoadenitis With Chronic Rhinosinusitis.

Immunoglobulin G4-related disease (IgG4-RD) is a new disease entity of rare and complex immune-mediated fibroinflammatory conditions that can affect any organ. The concomitance of IgG4 sclerosing sialadenitis and dacryoadenitis with rhinosinusitis is extremely rare. We report a case of IgG4 sclerosing sialadenitis and dacryoadenitis (Mikulicz's disease) diagnosed in a middle-aged African American man with a long-standing history of chronic rhinosinusitis who presented with progressively worsening bilateral salivary and lacrimal glands swelling. Imaging revealed pansinusitis, symmetric enlargement of the lacrimal glands, parotid glands, and submandibular glands. Serological IgG4 level was significantly elevated and the diagnosis of IgG4 sclerosing sialadenitis was confirmed by histopathology. A robust clinical response in the facial swelling and nasal manifestations was noted after the initiation of immunotherapy with corticosteroids.

Cardiac Troponin-I and COVID-19: A Prognostic Tool for In-Hospital Mortality.

BACKGROUND: The number of fatalities due to coronavirus disease 2019 (COVID-19) is escalating with more than 800,000 deaths globally. The scientific community remains in urgent need of prognostic tools to determine the probability of survival in patients with COVID-19 and to determine the need for hospitalization. METHODS: This is a retrospective cohort study of patients with a diagnosis of COVID-19 admitted to a tertiary center between March 2020 and July 2020. Patients age 18 years and older were stratified into two groups based on their troponin-I level in the first 24 h of admission (groups: elevated vs. normal). The aim of the study is to explore the utility of cardiac troponin-I level for early prognostication of patients with COVID-19. RESULTS: This cohort of 257 patients included 122/257 (47%) women with a mean age of 63 ± 17 years. Patients with an elevated troponin-I level were more likely to be older (77 ± 13 vs. 58 ± 16 years, P < 0.0001), have a history of hypertension (P < 0.0001), diabetes mellitus (P = 0.0019), atrial fibrillation or flutter (P = 0.0009), coronary artery disease (P < 0.0001), and chronic heart failure (P = 0.0011). Patients with an elevated troponin-I level in the first 24 h of admission were more likely to have higher in-hospital mortality (52% vs. 10%, P < 0.0001). Troponin-I level in the first 24 h of admission had a negative predictive value of 89.7% and a positive predictive value of 51.9% for all-cause in-hospital mortality. CONCLUSIONS: Troponin-I elevation is commonly seen in patients with COVID-19 and is significantly associated with fatal outcomes. However, a normal troponin-I level in the first 24 h of admission had a high negative predictive value for all-cause in-hospital mortality, thereby predicting favorable survival at the time of discharge.

The Effect of Hydroxychloroquine on In-Hospital Mortality in COVID-19.

Background: Hydroxychloroquine (HCQ) is an antimalarial medication that has been tested against various viral illnesses. The available evidence regarding the role of HCQ in the coronavirus disease 2019 (COVID-19) remains controversial. Methods: This is a comparative retrospective cohort study that aims to evaluate the efficacy and safety of HCQ in hospitalized patients with COVID-19. The primary outcome was all-cause in-hospital mortality. Secondary outcomes included ICU admission rate, mechanical ventilation, prolonged length of stay (LOS), QTc prolongation and cardiac arrest. Results: A cohort of 175 hospitalized patients with COVID-19 were included with a median (interquartile range [IQR]) age of 66 [48-79] years. Of whom, 82 (47%) patients received HCQ. The overall mortality rate was 34.1%; 95% CI [23.7-44.6] and 16.1%; 95% CI [8.5-23.7] in the HCQ group vs. the control group, respectively (p = 0.67). A Cox regression analysis was performed adjusting for age, gender, BMI, SpO2/FiO2 ratio and CXR findings, and demonstrated that the association between HCQ use and the all-cause in-hospital mortality was not statistically significant (HR = 1.15; 95% CI [0.54-2.48]; p-value = 0.72). Patients who received HCQ were more likely to be admitted to the intensive care unit, require mechanical ventilation and have a prolonged LOS compared to those who did not receive the medication. No statistically significant difference was found in the likelihood of QTc prolongation or cardiac arrest. Conclusions: The use of HCQ in patients hospitalized with COVID-19 confers no benefit in patient morbidity or mortality.