Social distancing and bacteraemia in the time of COVID-19.

BACKGROUND: Social distancing was the predominant strategy used to mitigate the spread of Coronavirus disease 2019 (COVID-19) at the start of the COVID-19 pandemic. AIMS: To study the impact of social distancing on the incidence of bacteraemia. The number of admitted patients with positive blood cultures in April-May 2020 in one tertiary medical centre was compared with the number during the same period in the previous 3 years (April-May 2017-2019). METHODS: Retrospective review of all positive blood cultures from January to July in the years 2017-2020. RESULTS: There were fewer cases of Streptococcus bacteraemia as well as coagulase-negative Staphylococcus bacteraemia and other possible contaminated blood cultures in April-May 2020. Compared with the previous 3 years, the incidence of Streptococcus pneumoniae bacteraemia among all bacteraemias was lower in April-May 2020 (5%) than in 2017-2019 (12.0%; 95% confidence interval 10.3-14.1%). In general, fewer cases of bacteraemia caused by oropharynx organisms were observed in April-May 2020; only 6 cases versus 31 (95% confidence interval 10-53) during the same period in 2017-2019. Only one case of S. pneumoniae bacteraemia was observed in April-May 2020 and its percentage among all bacteraemias was lower in April-May 2020 (0.4%) than during the same period in 2017-2019 (3.3%). CONCLUSION: The incidences of streptococcal bacteraemia and bacteraemia of organisms transmitted through respiratory secretions were lower when there were social distancing restrictions. Adopting measures of social distancing may decrease the morbidity from bacteraemia caused by oropharynx and respiratory bacteria.

Management Options for Linear Scleroderma ("En Coup de Sabre").

BACKGROUND: En coup de sabre (ECDS) is a form of linear-scleroderma, primarily affecting the face. Despite effectiveness of pharmacological interventions in the management of lesions, sequelae of cutaneous deformities are common. OBJECTIVE: Review the existing surgical tools for the correction of "en coup de sabre" ECDS lesions and facial deformities. MATERIALS AND METHODS: The authors conducted a literature search for reports on surgical interventions for ECDS deformations, in the electronic databases of PubMed, Scopus, and Cochrane Library Databases. RESULTS: Twenty-six publications reporting 39 patients were found in the literature. The average age of patients was 25 ± 4.7 years. Thirty-one of the patients were females. Six methods were found in the literature for surgical correction of ECDS. Fat grafting was performed in 41% of patients, surgical reconstruction in 18%, injectable fillers in 15%, implants in 10%, botulinum toxin injections in 8%, and bone/cartilage grafts in 8%. Imaging studies of the skull and face were performed in 36% of patients. Bony defects were found in 64.3% of them. CONCLUSION: Different surgical and minimally invasive options exist in the armamentarium of clinicians correcting ECDS deformities. Tailoring the method of correction to patient's needs and expectation is crucial in ensuring patient satisfaction.

Survival of patients with giant cell arteritis: a controversial issue.

OBJECTIVES: Epidemiologic studies differ regarding overall survival in giant cell arteritis (GCA). In this review we evaluated longevity and the impact of several disease parameters on survival of GCA patients. METHODS: Review of the medical literature during the period 1975-2018, using PubMed database. RESULTS: Epidemiologic studies addressing the issue of survival in GCA patients used variable methods of calculating mortality rates in relation to background population or in relation to selected controls. Several epidemiologic studies found that survival of GCA patients was similar to that of the general population. Others reported increased mortality in patients with GCA, or in subgroups of GCA patients. 5-Year and 10-year survival rates differed considerably among studies: 5-year survival rates ranged between 60-90% (except for 2 extremes of 35% and 97%), and 10-year survival rates ranged between 48-81%. Reasons for these discrepancies are unclear, and may be related to differences in populations, in the period of the study, and in study methods. Several studies found that mortality was increased in female GCA patients, and some reported increased mortality early in the course of the disease (mostly within the first 2 years after diagnosis). The deleterious effect of vision loss on survival was noted in a few studies, although most studies did not address the issue of mortality in this particular subgroup of GCA patients. CONCLUSIONS: Epidemiologic studies varied considerably in the reported outcomes of GCA patients: some found that the overall survival was similar to that of the general population while others reported increased mortality in GCA or in subgroups of GCA patients.

Segmental arterial mediolysis: a vasculitis mimicker. A single centre experience.

OBJECTIVES: Segmental arterial mediolysis (SAM) is a rare vasculopathy of unknown aetiology. It is non-atherosclerotic, non-inflammatory, non-hereditary, non-infectious, large to medium-sized arteriopathy. SAM is a condition which in some circumstances behaves as a vasculitis mimicker and should be recognised in order to provide appropriate treatment and avoid unnecessary immune-suppressive therapy. METHODS: We report a single-centre experience of 6 consecutive SAM cases (3 males and 3 females). A literature search of cases reported with SAM was performed and data summarised. RESULTS: Abdominal or flank pain was the presenting symptom in 5 of the 6 patients. CT angiography (CTA) was the method of diagnosis in all 6 patients. 3 patients underwent therapeutic angiography; 2 with angiographic embolisation because of bleeding, and one patient needed a stent insertion because of left renal infarction. 2 patients underwent FDG-PET to rule out vasculitis. Serological tests were negative in all case, but C-reactive protein was elevated in 4 of them. 2 patients were treated with angiographic embolisation due to bleeding, 2 treated with anti-platelet therapy, one with stent insertion, and one with antihypertensive treatment. A medical literature review of 160 additional cases shows that abdominal or flank pain was the chief complaint in the vast majority of the cases. Renal and abdominal medium-sized arteries were the most commonly involved. CTA was the preferred method of diagnosis. CONCLUSIONS: SAM should be suspected in cases presenting with abdominal or flank pain. Angiographic features should be carefully studied by experienced radiologists to rule out vasculitis.

Predicting post-vaccination autoimmunity: who might be at risk?

Vaccinations have been used as an essential tool in the fight against infectious diseases, and succeeded in improving public health. However, adverse effects, including autoimmune conditions may occur following vaccinations (autoimmune/inflammatory syndrome induced by adjuvants--ASIA syndrome). It has been postulated that autoimmunity could be triggered or enhanced by the vaccine immunogen contents, as well as by adjuvants, which are used to increase the immune reaction to the immunogen. Fortunately, vaccination-related ASIA is uncommon. Yet, by defining individuals at risk we may further limit the number of individuals developing post-vaccination ASIA. In this perspective we defined four groups of individuals who might be susceptible to develop vaccination-induced ASIA: patients with prior post-vaccination autoimmune phenomena, patients with a medical history of autoimmunity, patients with a history of allergic reactions, and individuals who are prone to develop autoimmunity (having a family history of autoimmune diseases; asymptomatic carriers of autoantibodies; carrying certain genetic profiles, etc.).

The diagnosis and classification of giant cell arteritis.

Giant-cell arteritis (GCA) involves the major branches of the aorta with predilection for the extracranial branches of the carotid artery. It occurs in individuals older than 50 years and the incidence increases with age. The signs and symptoms of giant cell arteritis can be classified into four subsets: cranial arteritis, extracranial arteritis, systemic symptoms and polymyalgia rheumatica. Patients may develop any combination of these manifestations, associated with laboratory evidence of an acute-phase reaction. The only test that confirms GCA diagnosis is a temporal artery biopsy, showing vasculitis with mononuclear cell inflammatory infiltrates, often with giant cells. Due to the focal and segmental nature of the infiltrates, areas of inflammation may be missed by the biopsy and the histological examination is normal in about 15% of the cases. Some imaging modalities may aid in the diagnosis of GCA. Among those, color duplex ultrasonography of the temporal arteries is more commonly used. There are no independent validating criteria to determine whether giant cell arteritis is present when a temporal artery biopsy is negative. The American College of Rheumatology criteria for the classification of giant cell arteritis may assist in the diagnosis. However, meeting classification criteria is not equivalent to making the diagnosis in individual patients, and the final diagnosis should be based on all clinical, laboratory, imaging and histological findings. Glucocorticoids are the treatment of choice for GCA. The initial dose is 40-60 mg/day for most uncomplicated cases. Addition of low-dose aspirin (100 mg/d) has been shown to significantly decrease the rate of vision loss and stroke during the course of the disease.

Polymyalgia rheumatica--diagnosis and classification.

Polymyalgia rheumatica is the most common inflammatory rheumatic disease of the elderly, and shares many pathogenetic and epidemiological features with giant cell arteritis. The typical symptoms are bilateral aching of the shoulder girdle, associated with morning stiffness. The neck and hip girdle may also be involved. The diagnosis of polymyalgia rheumatica is made primarily on clinical grounds. There is no single diagnostic test, but sets of diagnostic or classification criteria have been suggested by several groups of investigators, based on the typical clinical presentation and laboratory evidence of acute-phase reaction. Other conditions that may mimic polymyalgia rheumatic, such as elderly-onset rheumatoid arthritis, must be excluded by appropriate testing and close monitoring of the disease course. Glucocorticoids at low doses (15-20 mg prednisone per day initially) are the mainstay of treatment.

Autoimmune aspects of giant cell arteritis.

Giant cell arteritis (GCA) is considered to be a T cell-dependent disease. Autoantibodies have not consistently been found in GCA. The exception is antiphospholipid antibodies (APLA), which were found in 30-80% of GCA cases. Recently, efforts have been made to seek autoantibodies in GCA using newer methods of detection: serological identification of antigens by recombinant cDNA expression cloning, and a proteomic approach. In these studies, lamin C (a nuclear envelope antigen) was recognized by antibodies in 32% of GCA sera and none of the controls. Other autoantigenic proteins were also identified: lamin A, vinculin (a cytoskeleton antigen), and annexin 5 (an endothelial protein). In a recent study, 92% of 36 patients with GCA and/or polymyalgia rheumatica (PMR) had autoantibodies to a human ferritin peptide (the heavy chain N-terminal); 89% had antibodies to bacterial ferritin peptide of Staphylococcus epidermidis. The significance of these findings needs to be studied further. GCA may be a part of the newly described ASIA syndrome (autoimmune syndrome induced by adjuvants). A recent study from Italy reported 10 cases of GCA/PMR within 3 months of influenza vaccination. These comprised 50% of all cases of GCA/PMR diagnosed during the 6 year period of the study. Another 11 cases of GCA following influenza vaccinations were reported. GCA pathogenesis involves all branches of the immune system, including antigen-presenting cells, T cells and B cells, and autoantibody formation is not uncommon. GCA etiology remains unknown, but may be associated with exposure to bacterial or viral antigens.

[Giant cell arteritis--old questions, current answers].

Giant cell arteritis (GCA) is the most common systemic vasculitis in the elderly. Over several decades there has been an increase in its incidence, although this trend has changed in North America, northern Europe and in Israel. The signs and symptoms of GCA can be classified into four general subsets: manifestations of cranial arteritis, extra-cranial arteritis, systemic symptoms and polymyalgia rheumatica (PMR). The diagnosis is based on clinical characteristics and established by the presence of inflammatory markers. However, the only specific diagnostic test is a temporal artery biopsy. The optimal length of the biopsy appears to be between 10- 20 mm. Bilateral biopsies may increase the diagnostic yield. Patients with "biopsy negative giant cell arteritis" are characterized by older age, more headaches at presentation and thrombocytosis. Some imaging modalities may aid in the diagnosis of GCA. The most commonly used is color duplex ultrasound of the temporal arteries, showing the "dark halo sign" in characteristic cases. This modality has high specificity (around 90%), and is useful for ruling out a diagnosis in low risk patients. Glucocorticoids are the treatment of choice in GCA. The addition of anti-platelet drugs (such as low-dose aspirin (100 mg/d)) has been shown to decrease the ischemic complication rate significantly during the course of the disease. Nevertheless, there are no effective steroid sparing drugs for GCA. Methotrexate may be considered in a subgroup of high risk patients.

[Shaare Zedek Medical Center's model of an integrated division of internal medicine].

BACKGROUND: The specialty and practice of internal medicine have been subject to serious challenges in the last two decades. METHODS: We describe the integrative model of internal medicine as developed in our hospital, providing solutions to some major challenges. RESULTS: Major components include: (1) Senior physicians and residents are employed by the Division rather than individual Departments of Medicine, allowing for balanced distribution of professional capabilities. (2) Two medical departments specialize in geriatric medicine, while the other departments take care of younger, more intellectually challenging patients. Senior and junior staff members rotate through these departments, allowing for exposure to different patient populations and professional expertise. (3) The backbone of senior physicians is rewarded by a set of incentives, including dedicated time for research. (4) Senior staff from the subspecialties contributes annually 1-2 months as senior physicians in the departments and receive academic and other compensation for their efforts. (5) In cases where medical departments elsewhere are flooded with corridor admissions (a source of frustration and burnout), a short admission unit in the emergency department relieves internal medicine pressures and shortens evaluation and therapy for many patients. CONCLUSION: Our integrative model of internal medicine allows for improved patient and staff distribution, greater satisfaction among patients and family members, greater professional satisfaction among physicians, while resident vacancies are filled with competent residents.

Association between histological features in temporal artery biopsies and clinical features of patients with giant cell arteritis.

BACKGROUND: In most cases of giant cell arteritis (GCA) the diagnosis is confirmed by temporal artery biopsy. Aside from the diagnostic purpose, histological parameters may serve as prognostic markers. OBJECTIVES: To review positive temporal artery biopsies ofGCA in an attempt to correlate various histological parameters with clinical features, disease complications and outcome. METHODS: Positive biopsies from 65 GCA patients were randomly selected for review by a single pathologist. In each biopsy the following parameters were scored: intensity and location of the inflammatory infiltrate, presence of giant cells and other cell types, fragmentation and calcification of the internal elastic lamina, intimal thickening, and presence of luminal thrombus. Clinical data were obtained from the patients' charts. Intensity of the initial systemic inflammatory reaction (ISIR) at the time of diagnosis was scored by the presence of five parameters: fever, anemia, thrombocytosis, leukocytosis, and sedimentation rate >100 mm/hr. RESULTS: In cases with bilateral positive biopsy (n=27), there was good correlation between the two sides regarding intensity of inflammation (r= 0.65, P< 0.001), location of the infiltrate (r= 0.7, P< 0.001), degree of intimal thickening (r= 0.54, P 0.001), and presence of giant cells (r= 0.83, P< 0.001). The rate of corticosteroid discontinuation tended to be quicker in patients with inflammatory infiltrates confined mainly to the adventitia, but other histological parameters did not affect this rate. CONCLUSIONS: Inflammatory infiltrates confined to the adventitia were associated with more neuro-ophthalmic ischemic manifestations, weak/moderate ISIR at the time of diagnosis, and faster rate of corticosteroid discontinuation. No association was found between other temporal artery biopsy histological parameters and clinical features of GCA patients.

A simplified scoring tool for prediction of readmission in elderly patients hospitalized in internal medicine departments.

BACKGROUND: Frequent readmissions significantly contribute to health care costs as well as work load in internal medicine wards. OBJECTIVE: To develop a simple scoring method that includes basic demographic and medical characteristics of elderly patients in internal medicine wards that would allow prediction of readmission within 3 months of discharge. METHODS: We conducted a retrospective observational study of 496 hospitalized patients using data collected from discharge letters in the computerized archives. Univariate and multivariate logistic regression analyses were performed and factors that were significantly associated with readmission were selected to construct a scoring tool. Validity was assessed in a cohort of 200 patients. RESULTS: During a 2 year follow-up 292 patients were readmitted at least once within 3 months of discharge. Age 80 or older, any degree of impaired cognition, nursing home residence, congestive heart failure, and creatinine level > 1.5 mg/dl were found to be strong predictors of readmission. The presence of each variable was scored as 1. A score of 3 or higher in the derivation and validation cohorts corresponded with a positive predictive value of 80% and 67%, respectively, when evaluating the risk of rehospitalization. CONCLUSIONS: We propose a practical, readily available five-item scoring tool that allows prediction of most unplanned readmissions within 3 months. The strength of this scoring tool, as compared with previously published scores, is its simplicity and straightforwardness.

Ophthalmic adverse events following facial injections of botulinum toxin A: A systemic literature review.

BACKGROUND: Over the years, botulinum toxin has found its place as a neuromuscular blocking agent in numerous medical fields. Since the approval of botulinum toxin by the FDA for cosmetic indications in 2002, it had become the most commonly performed esthetic procedure worldwide, with ever-growing demand. The characteristics of the toxin, along with the facial areas it is injected to, could possibly account for a wide array of complication. METHODS: The authors conducted a literature search for reported cases of ophthalmic adverse events following Botulinum toxin facial injections in the electronic databases of PubMed and Cochrane Library databases. RESULTS: The authors found 25 publications, reporting 49 cases of ophthalmic adverse events following botulinum toxin injections. Injections for cosmetic indications accounted for 51% of all injections, treatment of blepharospasms for 22% of cases, protective ptosis for 11% of cases, and treatment of hemifacial spams for 8% of cases. The average quantity of botulinum toxin injected to a single patient ranged between 1.25 and 75 units, with a median of 13.75 units.Majority of injections for cosmetic indications were performed to the lateral canthal area (56%), followed by the glabella (28%) and the forehead (20%).Adverse events following injections included diplopia (64%), ptosis (14%), and decrease in visual acuity or vision loss (8%). CONCLUSIONS: Botulinum toxin is gaining extreme popularity in the management of a wide area of diseases and for cosmetic indications. Proper knowledge of potential adverse events is crucial for the clinician in attempt to decrease complications.

Clinical implications of ANCA positivity in a hospital setting: a tertiary center experience.

ANCA testing plays an established critical role in the diagnosis of ANCA Associated vasculitis (AAV). The spectrum of diseases associated with positive ANCA has recently broadened, thus calling into question the diagnostic implications of ANCA positivity in a hospital setting. We retrospectively studied all adult patients who had a positive ANCA test (by Indirect Immunofluorescence (IIF), ELISA or both) performed over the span of 19 years. Subjects were then divided into discordant (positive on one assay) and concordant ANCA (positive on both assays) groups based on their ANCA positivity status. The two groups were then compared with regards to their demographic, clinical and laboratory characteristics, the indication for ANCA testing in both groups and their final diagnoses. Of the 9189 ANCA tests ordered during the 19-year span of the study, 389 (4.2%) were positive. Two hundred and forty subjects met the exclusion criteria (patients aged less than 18 years or the lack of clinical and laboratory data in the medical file) thus resulting in a final cohort of 149 subjects. Of them, 122 subjects had discrepant ANCA results and 27 had matching ANCA results. Most cases in the discrepancy group were IIF positive and ELISA negative (86.8%). The diagnosis of AAV was highly unlikely in cases with discrepant IIF and ELISA serologies compared to cases with matching IIF and ELISA serologies (4.1% versus 44.4%, p value < 0.001). The diagnosis of AAV in unlikely in subjects with discrepancies between IIF and ELISA, particularly with only positive IIF.