Thyroid Disease and Systemic Lupus Erythematosus.

Background and Objectives: Thyroid disease has been associated with autoimmune disorders. As systemic lupus erythematosus (SLE) is a systemic autoimmune disease with diverse manifestations spanning across all organ systems, the relationship of SLE with thyroid disorders needs investigation. In particular, the relationship of SLE with autoimmune thyroid disease has attracted the interest of the research community. The aim was to evaluate the relationship of SLE with autoimmune thyroid disease. Materials and Methods: A cohort of 45 consecutive patients with a mean age of 47.97 years (range 21-79 years) and 45 age- and sex-matched controls were prospectively studied over a period of 12 months for the presence of thyroid disease and the prevalence of antithyroid antibodies. Results: Four patients (8.9%) were found to suffer from primary hypothyroidism, five (11.11%) from subclinical hypothyroidism and one (2.22%) from hyperthyroidism, whereas one (2.22%) of the controls had primary hypothyroidism and one (2.22%) had hyperthyroidism. Five patients (11.11%) had a thyroid hormone profile that was compatible with the presence of euthyroid sick syndrome. Thyroid peroxidase (TPOab) and thyroglobulin (Tgab) antibodies were detected in 20/45 and 15/45 of the SLE population and in 7/45 and 5/45 of the controls, respectively (p < 0.05, chi-square test). Conclusions: In conclusion, the incidence of clinical thyroid disease is greater amongst SLE patients than in a control population, and in a significant number of these patients, antithyroid antibodies are detectable. Thus, a subset of lupus patients appears to be predisposed to the development of thyroid disease, and this should be considered when evaluating patients with SLE.

The Prevalence of Gastrointestinal Bleeding in COVID-19 Patients: A Systematic Review and Meta-Analysis.

Introduction: Severe acute respiratory syndrome coronavirus 2 caused the coronavirus disease of 2019 (COVID-19), which rapidly became a pandemic, claiming millions of lives. Apart from the main manifestations of this infection concerning the respiratory tract, such as pneumonia, there are also many manifestations from the gastrointestinal tract. Of these, bleeding from the gastrointestinal tract is a significant complication quite dangerous for life. This bleeding is divided into upper and lower, and the primary pathophysiological mechanism is the entering of the virus into the host cells through the Angiotensin-converting enzyme 2 receptors. Also, other comorbidities and the medication of corticosteroids and anticoagulants are considered to favor the occurrence of gastrointestinal bleeding (GIB). Methods: This systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and the studies were searched in two different databases (Scopus and PubMed) from November 2019 until February 2023. All studies that reported GIB events among COVID-19 patients were included. Results: 33 studies were selected and reviewed to estimate the prevalence of GIB. A total of 134,905 patients with COVID-19 were included in these studies, and there were 1458 episodes of GIB. The prevalence of GIB, in these 33 studies, ranges from 0.47% to 19%. This range of prevalence is justified by the characteristics of the COVID-19 patients. These characteristics are the severity of COVID-19, anticoagulant and other drug treatments, the selection of only patients with gastrointestinal manifestations, etc. The pooled prevalence of gastrointestinal bleeding was estimated to be 3.05%, rising to 6.2% when only anticoagulant patients were included. Conclusions: GIB in COVID-19 patients is not a rare finding, and its appropriate and immediate treatment is necessary as it can be life-threatening. The most common clinical findings are melena and hematemesis, which characterize upper GIB. Treatment can be conservative; however, endoscopic management of bleeding with embolization is deemed necessary in some cases.

Post-COVID-19 and Irritable Bowel Syndrome: A Literature Review.

The emergence of post-COVID-19 syndrome (PCS), a complex and multifactorial condition that follows the acute COVID-19 infection, has raised serious concerns within the global medical community. Concurrently, Irritable Bowel Syndrome (IBS), a widespread chronic gastrointestinal (GI) dysfunction, is considered to be one of the most common disorders of gut-brain interaction (DGBI) that significantly affects the quality of life and social functioning of patients. PCS presents a wide range of symptoms and GI manifestations, including IBS. This review aims to analyze the GI involvement and the prolonged symptoms of COVID-19 infection as part of PCS, in order to explore the potential development of post-infection IBS (PI-IBS) in COVID-19 patients. Irritating factors such as enteric infection, psychosocial conditions, food antigens, and antibiotics may lead to abnormalities in the physiological function of the GI system and could be involved in the development of PI-IBS. Through the presentation of the pathophysiological mechanisms and epidemiological studies that assessed the prevalence of IBS as part of PCS, we attempted to provide a better understanding of the long-term consequences of COVID-19 and the pathogenesis of PI-IBS. Even though PI-IBS is becoming a global challenge, there are only a few studies about it and therefore limited knowledge. Currently, the majority of the existing treatment options are referred to non-COVID-19-associated DGBIs. Forthcoming studies may shed light on the mechanisms of PI-IBS that could be targeted for treatment development.

Hyperhaemolytic transfusion reaction in two ß-thalassaemia major patients: The role of eculizumab.

WHAT IS KNOWN AND OBJECTIVE: Hyperhaemolytic transfusion reactions are rare life-threatening events predominantly affecting patients with haemoglobinopathies. We report two cases in ß-thalassaemia major patients on chronic transfusion therapy and highlight the role of eculizumab in its management. CASE SUMMARY: Patient 1 presented with intravascular haemolysis on day 7 (D7) post-transfusion and responded to treatment with corticosteroids and intravenous immunoglobulin. However, patient 2 presented with severe symptomatic anaemia (D4 post-transfusion) unresponsive to the aforementioned measures. Eculizumab administration led to resolution of the hyperhaemolysis. WHAT IS NEW AND CONCLUSION: We report the successful management of hyperhaemolysis with eculizumab in a ß-thalassemia major patient.

Acute leukemia presenting as acute lower limb ischemia.

Objectives: Acute lower limb ischemia (ALLI) is a common vascular emergency. However, ALLI presenting as the initial symptom of acute leukemia (AL) is scarce. Here we present a case of ALLI in the setting of acute myeloid leukemia (AML) while systematically reviewing the current literature to withdraw conclusions about the management, prognosis, and treatment for this atypical presentation of AL. Methods: We conducted a systematic electronic research according to Preferred Reporting Items for Systematic Review and Meta-Analysis protocol (PRISMA) for articles published from January 1981 up to January 2021 concerning ALLI in the setting of acute leukemia (AL). Patients' baseline characteristics were recorded and nine outcomes of interest were studied. Results: Twenty-six individuals, 16 males with a mean age of 46.3 years (±20) were included in this review. The diagnosis included 13 AML patients (50%), 11 acute promyelotic leukemia (APL) (42.3%) and two acute lymphoblastic leukemias (ALL) (7.7%). Treatment varied among nine different regimens. Four patients were treated with chemotherapy alone (15.4%), four with thrombectomy alone (15.4%), and 11 with a combination of chemotherapy and thrombectomy (42.3%). Eight major amputations were recorded (30. 8%). Thirty-day mortality was 35.7%. Forty-eight peripheral thrombotic events were recorded with 12 patients suffering recurrent thrombotic events. Conclusion: ALLI as the presenting symptom of AL is a rare condition that carries significant mortality and amputation rates. Timely diagnosis is crucial concerning short-term survival and limb salvage. APL, despite being the rarest form of AL, represented a significant proportion of the patient population in this review. The role of leukostasis in the disease's progression and the efficacy of leukapheresis as a treatment regimen should be further investigated through case-control studies.

Drug-Induced Liver Injury in Hospitalized Patients during SARS-CoV-2 Infection.

In the last few years, the world has had to face the SARS-CoV-2 infection and its multiple effects. Even though COVID-19 was first considered to be a respiratory disease, it has an extended clinical spectrum with symptoms occurring in many tissues, and it is now identified as a systematic disease. Therefore, various drugs are used during the therapy of hospitalized COVID-19 patients. Studies have shown that many of these drugs could have adverse side-effects, including drug-induced liver injury-also known as DILI-which is the focus of our review. Despite the consistent findings, the pathophysiological mechanism behind DILI in COVID-19 disease is still complex, and there are a few risk factors related to it. However, when it comes to the diagnosis, there are specific algorithms (including the RUCAM algorithm) and biomarkers that can assist in identifying DILI and which we will analyze in our review. As indicated by the title, a variety of drugs are associated with this COVID-19-related complication, including systemic corticosteroids, drugs used for the therapy of uncontrolled cytokine storm, as well as antiviral, anti-inflammatory, and anticoagulant drugs. Bearing in mind that hepatotoxicity is very likely to occur during COVID-19, especially in patients treated with multiple medications, we will also refer to the use of other drugs used for DILI therapy in an effort to control and prevent a severe and long-term outcome.

Is HbA1c an ideal biomarker of well-controlled diabetes?

HbA1c is a biomarker with a central role in the diagnosis and follow-up of patients with diabetes, although not a perfect one. Common comorbidities encountered in patients with diabetes mellitus, such as renal insufficiency, high output states (iron deficiency anaemia, haemolytic anaemia, haemoglobinopathies and pregnancy) and intake of specific drugs could compromise the sensitivity and specificity of the biomarker. COVID-19 pandemic poses a pressing challenge for the diabetic population, since maintaining optimal blood glucose control is key to reduce morbidity and mortality rates. Alternative methods for diabetes management, such as fructosamine, glycosylated albumin and device-based continuous glucose monitoring, are discussed.

Diagnosing a Patient with Erdheim-Chester Disease during the COVID-19 Pandemic.

Background: Erdheim-Chester disease (ECD) is a rare hematopoietic neoplasm of histiocytic origin characterized by an insidious course. The coronavirus disease 2019 (COVID-19) pandemic has put an enormous strain on healthcare systems worldwide both directly and indirectly, resulting in the disruption of healthcare services to prevent, diagnose and manage non-COVID-19 disease. Case Presentation: We describe the case of a 58-year-old male patient with sporadic episodes of self-resolving mild fever and anemia of chronic disease with onset two years before the current presentation. Positron emission/computed tomography scan revealed the presence of moderately hypermetabolic perirenal tissue masses. In order to achieve diagnosis, repeated perirenal tissue biopsies were performed, and the diagnostic evaluation was complicated by the strain put on the healthcare system by the COVID-19 pandemic. The patient contracted SARS-CoV-2 and required hospitalization, but recovered fully. No further ECD target organ involvement was documented. Treatment options were presented, but the patient chose to defer treatment for ECD. Conclusion: A high index of suspicion and multidisciplinary team collaboration is paramount to achieve diagnosis in rare conditions such as ECD. Disruptions in healthcare services in the pandemic milieu may disproportionately affect people with rare diseases and further study and effort is required to better meet their needs in the pandemic setting.

Circadian Pattern of Acute Myocardial Infarction and Atrial Fibrillation in a Mediterranean Country: A study in Diabetic Patients.

Background and objectives: The circadian pattern seems to play a crucial role in cardiovascular events and arrhythmias. Diabetes mellitus is a complex metabolic disorder associated with autonomic nervous system alterations and increased risk of microvascular and macrovascular disease. We sought to determine whether acute myocardial infarction (AMI) and atrial fibrillation (AF) follow a circadian pattern in diabetic patients in a Mediterranean country. Materials and Methods: This retrospective study included 178 diabetic patients (mean age: 67.7) with AMI or AF who were admitted to the coronary care unit. The circadian pattern of AMI and AF was identified in the 24-h period (divided in 3-h and 1-h intervals). Patients were also divided in 3 groups according to age; 40-65 years, 66-79 years and patients older than 80 years. A chi-square goodness-of-fit test was used for the statistical analysis. Results: AMI seems to occur more often in the midnight hours (21:00-23:59) (p < 0.001). Regarding age distribution, patients between 40 and 65 years were more likely to experience an AMI compared to other age groups (p < 0.001). Autonomic alterations, working habits, and social reasons might contribute to this phenomenon. AF in diabetic patients occurs more frequently at noon (12:00-14:59) (p = 0.019). Conclusions: Diabetic patients with AMI and AF seem to follow a specific circadian pattern in a Mediterranean country, with AMI occurring most often at midnight hours and AF mostly at noon. Autonomic dysfunction, glycemic fluctuations, intense anti-diabetic treatment before lunch, and patterns of insulin secretion and resistance may explain this pattern. More studies are needed to elucidate the circadian pattern of AMI and AF in diabetic patients to contribute to the development of new therapeutic approaches in this setting.

Does the COVID-19 Pandemic Affect Morbidity and Mortality Rates of Emergency General Surgery? A Retrospective Study from a Single-Center Tertiary Greek Hospital.

Background and Objectives: The outbreak of the COVID-19 pandemic had a major impact on all aspects of health care. Few up-to-date studies have actually assessed the impact of COVID-19 on emergency surgeries. The aim of this study was to provide an overview of the impact of the pandemic relating to the emergency surgery performed, as well as morbidity and mortality rates during the first year of the pandemic (March 2020-February 2021) and during the control period. In this period, the first propaedeutic surgery department and the third surgery department of the University General Hospital of Thessaloniki "AHEPA" in Greece provided continuous emergency general surgery services. Material and Methods: The study is in a retrospective cohort and included patients who were admitted to the Emergency Department and underwent emergency general surgery during the control period (n = 456), March 2019-February 2020 and during the first year of the pandemic (n = 223), March 2020-February 2021. Gender, age, type of surgical operation (morbidity), ICU need, the patient's outcome, and days of hospitalization were compared. Results: A total of 679 emergency surgeries were included. Statistically significant differences emerged between the two time periods in the total number of emergency surgeries performed (p < 0.001). The most common type of surgery in the control period was associated with soft tissue infection while, during the pandemic period, the most common type of surgery was associated with the hepatobiliary system. In addition, the mortality rates nearly doubled during the pandemic period (2.2% vs. 4%). Finally, the mean age of our sample was 50.6 ± 17.5 and the majority of the participants in both time periods were males. Conclusions: The COVID-19 pandemic changed significantly the total number of emergency general surgeries performed. Mortality rates doubled and morbidity rates were affected between the control and pandemic periods. Finally, age, gender, length of hospitalization, intensive care unit hospitalization, and laparoscopy use in patients undergoing emergency surgery during the pandemic were stable.

Bacteremia due to a toxin A-negative, B-positive Clostridioides difficile ribotype 017 strain.

Clostridioides difficile is the leading cause of healthcare-associated diarrhea. Although the incidence of C. difficile-associated diarrhea is increasing worldwide, bacteremia due to C. difficile is relatively rare and represents the least frequent extra-colonic manifestation of C. difficile infection. To date, only 60 C. difficile bacteremia cases with detailed clinical patient characteristics have been reported in the literature, and another 77 cases have been identified in epidemiological reports. We report a rare and fatal case of bacteremia due to C. difficile from a Greek hospital.

A large observational study of patients with primary immune thrombocytopenia receiving romiplostim in European clinical practice.

OBJECTIVE: Romiplostim has maintained long-term platelet counts in patients with immune thrombocytopenia (ITP) for up to 5 yr in clinical studies. This prospective observational study aimed to describe romiplostim utilisation and outcomes in European clinical practice. METHODS: Adults with primary ITP who received romiplostim in routine care were eligible. RESULTS: Three-hundred and forty patients were eligible for analysis, of whom 299 (88%) completed the 2-yr observation period. The median age was 62 yr, with 43% of patients aged ≥65 yr, and two-thirds of patients initiated romiplostim before splenectomy. The median average weekly dose of romiplostim was 2.8 µg/kg. The median baseline platelet count was 20 × 109 /L, which increased after 2 wk of romiplostim treatment and remained >50 × 109 /L thereafter. After romiplostim initiation, there was a decrease in rates of grade ≥3 bleeding events (from 12 to 2 per 100 patient-years) and ITP-related hospitalisations (from 87 to 33 per 100 patient-years). The rate of thrombotic events was 2 per 100 patient-years, and bone marrow fibrosis occurred in two patients. CONCLUSIONS: Romiplostim dosing, effectiveness and safety in an unselected real-world ITP population seemed comparable with that observed in clinical studies.

Is there a role for low-dose eltrombopag as maintenance therapy in the treatment of immune thrombocytopenia?

BACKGROUND/AIM: Thrombopoietin receptor agonists (romiplostim and eltrombopag) have recently been licensed for the treatment of thrombocytopenia in patients with chronic immune thrombocytopenia (ITP) with an insufficient response to corticosteroids, immunoglobulins or splenectomy. In the present case series, we present 4 nonresponding patients with chronic ITP who achieved maintenance of complete response (CR) for a period of at least 6 months on eltrombopag treatment administered in a modified regimen of 25 mg for 2, 3 or 5 days a week. METHODS: The present study is a retrospective, nonconsecutive case series of 4 eltrombopag-treated patients with chronic ITP. Secondary ITP had been excluded in each patient, first-line therapy had failed and splenectomy had been refused. Furthermore, each patient was treated with eltrombopag, which resulted in a CR for a mean of 2 months. Consequently, decreased eltrombopag dosages have been able to maintain long-term CR. RESULTS/CONCLUSION: Despite the low quality of evidence, our study results support the use of reduced-dose eltrombopag as a maintenance therapy after achieving CR. It seems a very promising strategy for the effective maintenance of response, improving health-related quality of life, lowering costs and possibly improving the safety in the treatment of ITP.

Initially lymphocytic Sweet's syndrome in male patients with myelodysplasia: a distinguished clinicopathological entity? Case report and systematic review of the literature.

BACKGROUND: Sweet's syndrome (SS) is an acute febrile neutrophilic dermatosis. It can occur as an idiopathic, drug-induced or malignancy-associated entity. SS is also seen in patients with myelodysplastic syndrome (MDS) where it may present atypically, both clinically and histologically. In a few rare cases of MDS, lymphocytic infiltrates are the presenting feature of SS. METHODS: MEDLINE and Scopus were the data sources for our review. RESULTS: A clinicopathological subsetemerged of 12 male SS patients with MDS and a mean age of 67.3 years in which the initial SS lesions were lymphocytic infiltrates. However, from 0.5 to 8 years later, sequential biopsies revealed neutrophilic dermal infiltration typical of SS. CONCLUSION: Initially lymphocytic infiltrates in this subset could be attributed either to an early timing of the biopsy concerning the age of the lesion or to the dysgranulopoiesis syndrome. A possible relationship between the dysfunction of the receptor of the granulocyte-macrophage colony stimulating factor, the gene of which is located on the pseudoautosomal X-Y region, may exist in MDS patients with initially lymphocytic SS. This could explain the male gender of this subset and might establish initially lymphocytic SS as a distinguished clinicopathological entity for predicting the occurrence and even the prognosis of MDS.

Hyperglycemic Patterns in Acute Stroke Patients.

Background and objective Hyperglycemia following a stroke can independently aggravate the ischemic area. Ensuring adequate glucose management can help avoid complications and minimize mortality and disability in these patients. This study aimed to investigate hyperglycemic patterns in acute stroke patients. Materials and methods We conducted a non-interventional prospective observational study involving acute stroke patients by employing continuous glucose monitoring (CGM) for 72 hours after the onset of stroke symptoms. Admission glucose, patients' total mean glucose (TMG), and time in range (TIR) (70-140 mg/dl) were correlated with the hyperglycemic patterns elicited by the CGM system software. Data were analyzed using SPSS Statistics 26.0 (IBM Corp., Armonk, NY) with descriptive statistics, the Kruskal-Wallis test, and χ2 test. Results Our cohort comprised 105 diabetic and non-diabetic stroke patients. The hyperglycaemic patterns that we observed were as follows: (i) hyperglycemia from 23:00 to 10:00, (ii) 06.00 to 10.00, (iii) at night and after meals, iv) no pattern, v) unspecified patterns. Patients with nocturnal and morning hyperglycemia had admission glucose of 183 mg/dl, mean 72-hour glucose of 156 mg/dl, and TIR of 37%. Patients who did not develop a hyperglycemic pattern either had admission glucose of 131 mg/dl and TIR of 89% or had high admission glucose (197 mg/dl) and a short TIR (14%). Conventional pre-meal capillary glucose tests do not appear to detect these patients' hyperglycemic tendencies. Conclusions These results may indicate the necessity for more intensive measurements during the night or dawn in this patient population. Admission glucose could be considered a predictor of hyperglycemic patterns and contribute to the patient's care plan.

Glucose Fluctuations in Acute Ischemic Stroke.

INTRODUCTION: The Oxfordshire Community Stroke Project denotes four subtypes of ischemic stroke (total and partial anterior infarct, posterior, and lacunar). Hyperglycemia has been associated with a larger infarct size and poor prognosis. AIM: The purpose of the study was to investigate the correlation of glucose fluctuations with the Oxford sub-categories and patient outcomes using a blinded continuous glucose monitoring system. METHODS: This is a non-interventional prospective observational study. Stroke patients with symptoms onset in the last 24h, participated in the study. A glucose sensor was placed for 72 hours. Disability was assessed using the modified Rankin Scale. Stroke subtypes were compared with total mean glucose and time in range using ANOVA analysis. Multiple ordinal logistic regression was employed to analyze outcomes and survival. RESULTS: The sample consisted of 105 diabetic and non-diabetic patients. The overall mean glucose was 127.06 mg/dL and the time in range (70-140 mg/dL) was 70.98%. There was no significant difference between the stroke sub-categories and the total mean glucose. For every one-point increase in the time in range, we expect a 1.5% reduction in the odds of having a worse outcome. Patients with total anterior infarct are 2.31 times more likely to have a worse outcome than lacunar patients. CONCLUSION: The utilization of the Oxford classification may not be necessary for managing acute ischemic stroke glucose levels. Achieving glucose regulation and an increase in time in range can be attained through meticulous control, potentially extending life expectancy. Continuous glucose monitors may aid in achieving this objective.

Hodgkin Lymphoma Presenting as Cardiac Tamponade in a Young Female.

Hodgkin lymphoma (HL) is an uncommon malignancy that is characterized by Hodgkin or Reed-Sternberg cells. Cardiac implications of HL remain one of the least investigated subjects. There are few case reports in the literature of cardiac tamponade in HL patients. We describe a case of a 21-year-old female patient who presented with cardiac tamponade as an initial presentation of HL. Any pericardial effusion significant for tamponade requires immediate drainage and fluid analysis for thorough investigation. Prompt identification and timely intervention are crucial in effectively addressing these complex situations. Therefore, clinicians should maintain heightened awareness in such cases.

Diabetes Mellitus Type 1 During COVID-19: Psychological Symptoms and Eating Attitudes.

BACKGROUND: Diabetes Mellitus Type 1 is a chronic metabolic disorder, the treatment of which extremely burdens the patient. The lockdown, as a measure to prevent the spreading of the 2019 coronavirus disease, was a major challenge for the general public. People with chronic diseases, such as T1D patients, have complex emotional and psychological needs and are at increased risk for both depressive symptoms and anxiety. OBJECTIVE: The aim of this study was to evaluate the impact of body mass index of T1D patients on the psychological symptoms and eating habits, as well as the prognostic factors of the psychological symptoms during the lockdown period. METHODS: Diabetes mellitus patients were invited to complete this survey from the outpatient Diabetes clinic of the General Hospital of Chania and the "AHEPA" General University Hospital of Thessaloniki in Greece. Psychological symptoms were assessed using the DASS-42 questionnaire, and eating habits were assessed using the EAT-26 questionnaire. RESULTS: Overall, 112 T1D patients were analyzed (response rate: 28.8%). Obese T1D patients appear to be at greater risk of developing psychological symptoms, such as depression, anxiety, and stress. Furthermore, disordered eating behaviors and bulimia and food preoccupation subscale are associated with psychological symptoms. CONCLUSION: The findings suggest that obese T1D patients are at greater risk of developing psychological symptoms. Moreover, when an eating disorder is triggered, negative psychological symptoms such as depression and anxiety are reduced. The results of this study may guide targeted interventions among T1D patients.