Non-coronary cardiac calcifications and outcomes in patients with heart failure.

BACKGROUND: Calcium deposits on heart valves are considered a local manifestation of atherosclerosis and are associated with poor cardiovascular outcomes. The clinical significance of cardiac calcifications among heart failure (HF) patients, as assessed by echocardiography, is unknown. This study evaluated associations of cardiac calcifications with mortality and hospital admissions in this specific population. METHODS: Medical records of all patients who initiated ambulatory surveillance at our HF clinic during 2011-2018 were reviewed. Calcifications in the aortic valve, aortic root, or the mitral valve were evaluated. Patients with moderate to severe regurgitation or stenosis of the aortic or mitral valves were excluded. The primary endpoint was the composite of long-term all-cause mortality and HF hospitalizations. Secondary endpoints were long-term all-cause mortality and more than one hospitalization due to HF. RESULTS: This retrospective study included 814 patients (mean age 70.9 ± 13 years, 63.2% male). Of the total cohort, 350 (43%) had no cardiac calcifications and 464 (57%) had at least 1 calcified site. Considering the patients with no calcification as the reference group yielded a higher adjusted odds ratios for the composite endpoint, all-cause death, and recurrent HF hospitalizations, among patients with any cardiac calcification (OR = 1.68, 95%CI = 1.1-2.5, p = 0.01, OR=1.61, 95%CI = 1.1-2.3, p < 0.01, and OR = 1.50, 95%CI = 1.1-2.2, p < 0.01, respectively). CONCLUSIONS: We found an independent association between cardiac calcifications and the risk of death and HF hospitalizations among ambulatory HF patients. Cardiac calcifications evaluated during routine echocardiography may contribute to the risk stratification of patients with HF.

Clinical outcomes of stroke in hemodialysis patients: a retrospective single-center study.

PURPOSE: The incidence of stroke in patients undergoing hemodialysis (HD) is eight-to-ten times greater than that of the general population. However, data on the outcome of stroke in these patients are limited. METHODS: In this retrospective observational cohort study, electronic medical records of all patients undergoing HD from 1.1.2014 to 31.12.2017 at Meir Medical Center, Israel, were reviewed. Stroke was defined as a focal neurological deficit of cerebrovascular origin, and confirmed as ischemic or hemorrhagic by computed tomography. Age- and sex-matched HD patients who did not experience a stroke (HD-NS) and hospitalized stroke patients with normal kidney function (NRF-S) served as the two control groups. Baseline demographic, clinical, and laboratory data were collected. Thrombolytic therapy, duration of hospital stay, and mortality were recorded. Functional status at discharge was assessed by the Modified Rankin Scale. RESULTS: In the cohort study group (HD-S), 52 strokes occurred during 248.3 patient years, an incidence rate of 8.13%, and a stroke rate of 0.19% patients/month. Most strokes in HD patients were ischemic, and only four patients were administered tissue plasminogen activator. HD-S had longer hospitalization than did NRF-S (10.6 ± 9.9 vs. 5.96 ± 5.3 days, p = 0.004) and lower functional status at discharge (Rankin score 3.75 ± 1.57 vs. 2.29 ± 1.89, p < 0.001). HD-S patients had a higher mortality than both HD-NS and NRF-S patients. CONCLUSIONS: Stroke outcome in these patients is dismal with prolonged hospital stay, poor functional status at discharge, very limited response to rehabilitation, and increased mortality.

ISPD guideline-driven retraining, exit site care and decreased peritonitis: a single-center experience in Israel.

PURPOSE: Evaluate the efficacy of retraining and catheter exit site care in reducing peritonitis rates. METHODS: This interventional study included all prevalent PD patients from 1/2009 to 12/2017 from a single center. Peritonitis rates and causative organisms were assessed and compared in three periods: (1) Before intervention (01/2009-12/2014), (2) after educational intervention: assessment of training process by infection control nurse and repeat training every 3 months, after each peritonitis episode and after hospitalizations > 2 weeks (01/2015-02/2016), and (3) in addition to the measures in period 2, an exit site care protocol including postoperative care, topical antibacterial therapy and nasal Staph aureus screening and eradication was implemented (03/2016-12/2017). RESULTS: The study included 201 patients (149 men, 52 women), mean age was 65.1 ± 12.6 years. After both interventions, including educational and exit site care strategies, peritonitis decreased significantly from 1.05 episodes per patient-year (n = 113) to 0.67 (n = 54); P = 0.017 between periods 1 and 3. The percentage of peritonitis-free patients increased from 27.4 to 52.4 and 55.6%, respectively (P = 0.001 between period 1 vs. 2 and period 1 vs. 3.). Coagulase-negative staph was the most common pathogen, causing 7.56 peritonitis episodes per year, followed by pseudomonas at 4.33 episodes annually and staph aureus at 3.44 episodes per year. CONCLUSIONS: Enforcement of an educational program and strict adherence to an exit site care protocol was associated with a significant decrease in peritonitis rates.

Fitz-Hugh-Curtis Syndrome Consequent to a Wound Infection Following Removal of a Peritoneal Dialysis Catheter.

Fitz-Hugh-Curtis syndrome (FHCS) is a condition characterized by inflammation of the liver capsule (perihepatitis) and adjacent peritoneal surfaces. We report a case of FHCS developing in a peritoneal dialysis (PD) patient in whom catheter removal due to recurrent peritonitis was complicated by post-operative wound infection. To the best of our knowledge, this is the first case description of FHCS in the context of PD.

Upper Respiratory Tract Infection among Dialysis Patients.

BACKGROUND: Upper respiratory tract infection (URTI) occurs frequently in the general population and is considered a benign self-limited disease. Dialysis patients constitute a high risk population whose morbidity and mortality rate as a result of URTI is unknown. OBJECTIVES: To assess the local incidence, morbidity and mortality of URTI in dialysis patients compared to the general population. METHODS: In this retrospective cohort study we reviewed the charts of all chronic dialysis patients diagnosed with URTI at Meir Medical Center, Kfar Saba, Israel during the 2014-2015 winter season. RESULTS: Among 185 dialysis patients, 40 were found to be eligible for the study. The average age was 66.1 ± 15.7 years, and the co-morbidity index was high. Influenza A was the most common pathogen found, followed by rhinovirus, respiratory syncytial virus and para-influenza. Of the 40 patients 21 (52.5%) developed complications: pneumonia in 20%, hospitalization in 47.5%, and respiratory failure requiring mechanical ventilation in 12.5%. Overall mortality was 10%. General population data during the same seasonal period showed a peak pneumonia incidence of 4.4% compared to 20% in the study population (P < 0.0001). CONCLUSIONS: The study findings show that compared to the general population, URTI in dialysis patients is a much more severe disease and has a higher complication rate. Influenza A, the most common pathogen, is associated with a worse prognosis.

Henoch-Schonlein purpura antecedent to Crohn's disease.

We report a 13-year-old youth who initially presented with the typical rash of Henoch-Schonlein purpura followed a month later by a nephrotic syndrome and hematuria. Renal biopsy revealed crescentic IgA nephropathy. The patient was aggressively treated with steroids leading to a remission of his nephrotic syndrome. Three years after his initial presentation, he developed bloody diarrhea and Crohn's disease was diagnosed.

Multiple aetiologies of secondary hypertension in one patient.

Apart from seeking target organ damage, the investigation of hypertension is primarily aimed at finding a treatable cause of the hypertension. The finding of one such cause is usually construed as being the sole culprit responsible for the patient's elevated blood pressure. The existence of multiple aetiologies of secondary hypertension in one patient is infrequent. In this report, we describe such a patient in whom secondary hypertension due to Cushing's disease, renovascular and finally baroreflex failure was successively documented.

Worsening of hyperglycemia due to atorvastatin in a renal transplant patient.

New-onset diabetes mellitus post-renal transplantation [post-transplantation diabetes mellitus (PTDM)] and impaired glucose tolerance are among the most serious adverse metabolic disturbances of kidney transplants. We report a renal transplant patient whose mild post-transplant hyperglycaemia considerably worsened upon substituting atorvastatin for pravastatin. The patient was a 58-years-old Caucasian man who underwent living, non-related kidney transplantation. The mean blood sugar level (BSL) following transplantation was 113.8 mg/dl. In an attempt to reduce LDL cholesterol, atorvastatin 40 mg/day was substituted for pravastatin. Soon after commencement of atorvastatin, polydipsia and polyuria appeared. Both fasting and 2-h post-prandial BSL values increased, while there was no change in the patient's medications, dietary habits and renal function. Upon reverting back to pravastatin, BSL promptly declined to the previously mentioned baseline values. Since PTDM is a strong independent factor of graft failure, cardiovascular events and mortality, physicians should be made aware of this possible adverse effect of atorvastatin on glucose tolerance.

Blood-pressure categories in adolescence predict development of hypertension in accordance with the European guidelines.

BACKGROUND: It is estimated that by 2025, >1.5 billion adults worldwide will be hypertensive. Early identification of the population at risk would lead to improved utilization of preventive measures. We aimed to evaluate whether baseline body mass index (BMI) and blood-pressure (BP) values during adolescence (categorized according to the guidelines of the European Society of Hypertension-European Society of Cardiology) are of use in predicting the development of hypertension in young adulthood. METHODS: The study population consisted of 18,513 male regular army personnel who were initially recruited at 16.5 and 19 years of age between 1976 and 1996. The main outcome was the percentage of subjects who developed hypertension (> or =140 systolic and > or =90 diastolic) at ages 26 to 45 years. RESULTS: At baseline, BP categories were: optimal, 5961 (32.2%); normal, 7998 (43.2%); and high normal, 4554 (24.6%). Moreover, 1377 (7.4%) were overweight (BMI 25-30 kg/m(2)), and 199 (1.1%) were obese (BMI >30 kg/m(2)). At follow-up, 2277 (12.3%) subjects developed hypertension. The percentages progressing to hypertension were 9.46%, 11.99%, and 16.56% for optimal, normal, and high-normal categories, respectively (P < .01). Odds ratios (OR) for the development of hypertension in the normal and high-normal categories versus optimal were 1.30 (95% confidence interval [CI], 1.22-1.39) and 1.79 (95% CI, 1.67-1.93), respectively, adjusted for age and BMI. The ORs for hypertension in overweight and obese versus normal BMI were 1.75 (95% CI, 1.66-1.86) and 3.75 (95% CI, 3.45-4.07), adjusted for age and BP. Of 9762 remaining at ideal BMI at follow-up, the percentages progressing to hypertension were 5.3%, 6.4%, and 9.5% for optimal, normal, and high normal (at baseline) (P < .01). CONCLUSIONS: The risk of developing hypertension in young adulthood may be predicted by BP categories and BMI at adolescence.