Long-term effectiveness of zoledronic acid in patients with Paget's disease of bone - a retrospective cohort study.

PURPOSE: The aims of the current study were to describe clinical and biochemical features of patients with Paget disease of bone (PDB) followed at our medical center, and to examine the long-term effectiveness of zoledronate. METHODS: Retrospective cohort study included consecutive patients≥18 years with a diagnosis of PDB, followed in the Rabin Medical Center (RMC) Institute of Endocrinology from 1973 to 2023. The cohort comprised two groups: patients treated/not treated with zoledronic acid (ZOL/NZOL). The primary outcome was the percentage of patients who achieved a biochemical therapeutic response. RESULTS: Overall, 101 patients with PDB were included, 68 in the ZOL group and 33 in the NZOL group. The mean age was 65.2 ± 10.0 years, and 47% were female. Notably, 77% exhibited monostotic involvement, and only 3% had experienced fractures attributed to PDB. Mean ALP level at diagnosis was 160 ± 70.6 U/L. The median follow-up duration was 17 years since PDB diagnosis, comparable between the groups. Primary outcome was more prevalent in the ZOL compared to the NZOL group [42 patients (88%) VS 11 patients (52%) respectively, P = 0.004]. At the end of follow-up, mean ALP levels in the NZOL group were significantly higher than the levels in the ZOL group irrespective of the number of infusions received. CONCLUSION: The majority of patients with PDB experience a mild disease course, marked by monostotic involvement and a low prevalence of fractures. Zoledronic acid effectively manages PDB, providing sustained biochemical response. The necessity for multiple zoledronic acid injections remains questionable, often implemented due to osteoporosis.

Cabergoline treatment for surgery-naïve non-functioning pituitary macroadenomas.

PURPOSE: The treatment strategy of non-functioning pituitary adenomas (NFPAs) includes surgery, radiotherapy, medical therapy, or observation without intervention. Cabergoline, a dopaminergic agonist, was suggested for the treatment of NFPA remnants after trans-sphenoidal surgery. This study investigates the efficacy of cabergoline in surgery-naive patients with NFPA. METHODS: Retrospective cohort study including surgery-naive patients with NFPA ≥ 10 mm, treated with cabergoline at a dose of ≥ 1 mg/week for at least 24 months. Patients with chiasmal damage were excluded. Data collected included symptoms, in particular visual disturbances, hormonal levels, tumor characteristics and size evaluated by MRI. Tumor growth was defined as an increase in maximal diameter of ≥ 2 mm, and shrinkage as reduction of ≥ 2 mm. RESULTS: Our cohort included 25 patients treated with cabergoline as primary therapy. Mean age was 63.3 ± 17.3 years, 56% (14/25) were males. Mean tumor size at diagnosis was 18.6 ± 6.3 mm (median 17 mm, range 10-36), and the average follow-up period with cabergoline was 4.6 ± 3.4 years. Out of the 25 tumors, five tumors (20%) decreased in size (mean decrease of 5.0 ± 3.0 mm), 12 tumors (48%) remained stable, and eight (32%) increased in size (mean growth of 5.0 ± 3.3 mm) with cabergoline treatment. During the first two years of cabergoline treatment, the median tumor size exhibited a reduction of 0.5 mm. Patients with an increase in tumor size had larger adenomas at diagnosis and a longer follow-up. Two patients (8%) underwent surgery due to tumor enlargement. CONCLUSION: Primary treatment with cabergoline is a reasonable approach for selected patients with NFPAs without visual threat.

A Profound Vitamin B12 Deficiency in a Patient with Lofgren's Syndrome.

Lofgren's syndrome is a unique manifestation of sarcoidosis presenting with erythema nodosum, bilateral hilar lymphadenopathy and migratory polyarthritis. A concurrent vitamin B12 deficiency is not well described and may be related to a rare gastrointestinal manifestation of sarcoid and Lofgren's syndrome. We describe a case of a 57-year-old male presented with migratory polyarthritis, erythemic nodules, edema of his legs and fever. His laboratory tests showed anemia with a profound vitamin B12 deficiency. Imaging demonstrated bilateral hilar adenopathy. Pathology revealed non-necrotizing granulomas consistent with sarcoidosis. The patient was started on prednisone and vitamin B12 supplements with improvement of his complaints and vitamin B12 levels. Sarcoidosis can manifest in many extrapulmonary organs, including the gastrointestinal tract, resulting in nutritional deficiencies, such as vitamin B12 deficiency. Treatment of these nutritional deficiencies includes treatment with steroids, as well as vitamin supplementation. We suggest this case to be a rare manifestation of gastrointestinal involvement in Lofgren syndrome; however, a biopsy from the GI tract was not performed to confirm the diagnosis. An informed consent was obtained from the patient. An institutional approval was not required for the publication of this case.

Safety and efficacy of non-insulin therapy in non-critically ill hospitalized patients with type 2 diabetes mellitus.

INTRODUCTION: Clinical guidelines recommend insulin as the mainstay of therapy for hospitalized patients with diabetes mellitus. The aim of the current study is to evaluate safety and efficacy of non-insulin anti-hyperglycemic therapy in hospitalized patients. MATERIALS AND METHODS: Systematic review and meta-analysis of randomized controlled trials (RCTs) examining treatment of hospitalized patients with type 2 diabetes with insulin vs non-insulin therapy. We searched PubMed and the Cochrane Library for RCTs published from inception to November 30, 2022. Primary outcomes were 30-day mortality and hypoglycemic events during hospitalization. This meta-analysis includes two parts, the first is a comparison between insulin and non-insulin therapy and the second is a comparison between insulin only and a combination of insulin+non-insulin therapy. RESULTS: A total of 14 randomized control studies and 1570 patients were included. There was a lower incidence of 30-day mortality in the insulin+non-insulin group compared with the insulin group without statistical significance, RR 0.64 (95%CI 0.30-1.35). Hypoglycemic events were significantly lower with the non-insulin therapies compared to insulin therapy, RR 0.23 (95%CI 0.09-0.55). Mean daily glucose levels were significantly lower in the insulin+non-insulin group compared to the insulin group by 10.83 mg/dL (95%CI -14.78-(-6.87)). CONCLUSIONS: Non-insulin either with or without insulin, results in lower rates of hypoglycemia. Non-insulin+insulin is more effective than insulin alone in reducing blood glucose levels. Non-insulin-based therapy is safe and effective for control of hyperglycemia. Insulin combined with non-insulin drugs seems to be the preferred treatment option for the majority of hospitalized patients with type 2 DM in the non-critical care setting.

The prevalence of masked hypertension in patients with lone atrial fibrillation: a cross sectional analytical study.

Atrial fibrillation (AF) is prevalent in individuals with essential hypertension (HTN). Masked hypertension occurs in up to 15% of the general population and is associated with adverse clinical outcome. The aim of the current study was to evaluate the prevalence of masked hypertension in apparently normotensive individuals with lone AF. A cross sectional analytical study performed at the Rabin Medical Center included all patients > 18 years who visited the emergency department (ED) in the years 2018-2021 with idiopathic AF, had normal blood pressure (BP) values during their ED visit and did not have a history of hypertension or current use of anti-hypertensives. Ambulatory blood pressure monitoring (ABPM) was performed in all eligible patients within 30 days from ED visit. Data collected included information from the ED visit and data extracted from the monitoring device. A total of 1258 patients were screened for eligibility, of which 40 were included in the analysis. The average age was 53.4 ± 16 years, 28 patients (70%) were males. Overall, 18 individuals (46%) had abnormal BP values according to the 2017 ACC/AHA guidelines for the diagnosis of hypertension. Of these, 12 had abnormal 24-h BP average (≥ 125/75 mmHg), one had isolated daytime abnormal average (≥ 130/80 mmHg) and 11 had isolated night time abnormal average (≥ 110/65 mmHg). Masked hypertension is prevalent in patients with lone AF without a diagnosis of HTN and performing ABPM in such individuals should be strongly considered.

Natural history of nonfunctioning pituitary macroadenomas followed without intervention: A retrospective cohort study.

OBJECTIVE: The treatment strategy for nonfunctioning pituitary adenomas (NFPA) includes surgery, radiotherapy, medical treatment, or follow-up. Prior series of patients with NFPAs followed without intervention include small numbers of patients with macroadenomas. This study investigated the natural history of patients with macroadenomas followed without treatment. DESIGN AND PATIENTS: Retrospective cohort study included patients>18 years, with a diagnosis of NFPA ≥ 10 mm who were naïve to surgery or medical treatment and followed more than 12 months after diagnosis. Patients with chiasmal threat were excluded. Follow-up terminated if the patient underwent surgery, received cabergoline or was lost to follow-up. MEASUREMENTS: Data collected included evaluation of tumour characteristics and size by MRI, symptoms including visual disturbances, and hormonal levels. Tumour growth was defined as maximal diameter increase of ≥2 mm. RESULTS: The cohort included 49 patients (30 males, mean age 68.0 ± 12.0 years). At diagnosis, the average tumour size was 17.8 ± 5.9 mm. Mean follow-up time was 4.9 ± 4.9 years. Increase in tumour size occurred in 16 patients (33%), with an average growth of 5.1 ± 4.4 mm. Reduction in tumour size occurred in 10 patients (20%), with a mean decrease of 3.5 ± 1.3 mm. Twenty-three patients remained with stable tumours. Overall, 33 patients (67%) were observed without any intervention; 3 patients were operated and 13 were treated with cabergoline. None of the parameters including age, gender, baseline tumour size, invasiveness, visual disturbances, or hypopituitarism at diagnosis, predicted tumour growth. CONCLUSION: Observation of NFPAs without surgery or medical therapy is a reasonable approach in selected patients. In our study, no parameter predicted tumour growth.

Underrepresentation of women in randomized controlled trials: a systematic review and meta-analysis.

BACKGROUND: Although regulatory changes towards correcting the underrepresentation of women in randomized controlled trials (RCTs) occurred (National Institutes of Health 1994), concerns exist about whether an improvement is taking place. In this systematic review and meta-analysis, we aimed to assess the inclusion rates of women in recent RCTs and to explore the potential barriers for the enrollment of women. METHODS: RCTs published in 2017 examining any type of intervention in adults were searched in PubMed and Cochrane Library. The following predefined medical fields were included: cardiovascular diseases, neoplasms, endocrine system diseases, respiratory tract diseases, bacterial and fungal infections, viral diseases, digestive system diseases, and immune system diseases. Studies were screened independently by two reviewers, and an equal number of studies was randomly selected per calendric month. The primary outcome was the enrollment rate of women, calculated as the number of randomized women patients divided by the total number of randomized patients. Rates were weighted by their inverse variance; statistical significance was tested using general linear models (GLM). RESULTS: Out of 398 RCTs assessed for eligibility, 300 RCTs were included. The enrollment rate of women in all the examined fields was lower than 50%, except for immune system diseases [median enrollment rate of 68% (IQR 46 to 81)]. The overall median enrollment rate of women was 41% (IQR 27 to 54). The median enrollment rate of women decreased with older age of the trials' participants [mean age of trials' participants ≤ 45 years: 47% (IQR 30-64), 46-55 years: 46% (IQR 33-58), 56-62 years: 38% (IQR 27-50), ≥ 63 years: 33% (IQR 20-46), p < 0.001]. Methodological quality characteristics showed no significant association with the enrollment rates of women. Out of the 300 included RCTs, eleven did not report on the number of included women. There was no significant difference between these studies and the studies included in the analysis. CONCLUSIONS: Women are being inadequately represented, in the selected medical fields analyzed in our study, in recent RCTs. Older age is a potential barrier for the enrollment of women in clinical trials. Low inclusion rates of elderly women might create a lack of crucial knowledge in the adverse effects and the benefit/risk profile of any given treatment. Factors that might hinder the participation of women should be sought and addressed in the design of the study.

Re-Admission of COVID-19 Patients Hospitalized with Omicron Variant-A Retrospective Cohort Study.

In accordance with previous publications, re-admission rates following hospitalization of patients with COVID-19 is 10%. The aim of the current study was to describe the rates and risk factors of hospital re-admissions two months following discharge from hospitalization during the fifth wave due to the dominant Omicron variant. A retrospective cohort study was performed in Rabin Medical Center, Israel, from November 2021 to February 2022. The primary outcome was re-admissions with any diagnosis; the secondary outcome was mortality within two months of discharge. Overall, 660 patients were hospitalized with a diagnosis of COVID-19. Of the 528 patients discharged from a primary hospitalization, 150 (28%) were re-admitted. A total of 164 patients (25%) died throughout the follow-up period. A multi-variable analysis determined that elevated creatinine was associated with a higher risk of re-admissions. Rates of re-admissions after discharge during the Omicron wave were considerably higher compared to previous waves. A discharge plan for surveillance and treatment following hospitalization is of great importance in the management of pandemics.

Outcome of Elderly Patients with Venous Thromboembolism Treated with Direct Oral Anticoagulants-A Retrospective Cohort Study.

INTRODUCTION: Randomized controlled trials that compared direct oral anticoagulants (DOACs) to vitamin K antagonists (VKA) for the treatment of venous thromboembolism (VTE), demonstrated both efficacy and safety of DOACs. The aim of the current study was to compare DOACs to VKA for the treatment of VTE in the elderly, in a real-life setting. METHODS: A retrospective cohort study was performed in Rabin Medical Center encompassing a 7-year period. Hospitalized patients >65 years, with a diagnosis of VTE discharged with DOACs or VKA were included. The primary outcome was a composite of all-cause mortality, major bleeding, recurrent VTEs and hospitalizations throughout the follow-up period of one year. RESULTS: A total of 603 patients were included in the final analysis. The mean age was 79.6 ± 8.5 years. The primary composite outcome occurred in 74.6% and 56.7% of the patients in the VKA group and DOACs group, respectively, hazard ratio 0.59, 95% confidence interval 0.46 to 0.76, in favor of the DOACs group. In a matched cohort analysis, the results were the same as the original analysis. CONCLUSION: In the elderly population, treatment of VTE with DOACs was associated with a lower rate of the composite outcome. DOACs are safe and effective for elderly patients with VTE.

Inadequate reporting of participants eligible for randomized controlled trials - A systematic review and meta-analysis.

OBJECTIVE: to characterize randomized controlled trials (RCTs) that did not report the overall number of participants assessed for eligibility and to identify factors associated with higher enrollment rates. STUDY DESIGN AND SETTING: Systematic review and meta-analysis of RCTs in several pre-defined fields in internal medicine. We randomly extracted 360 articles that were published in 2017. Trials that reported numbers of assessed for eligibility patients were compared with those who did not. Recruitment rates were calculated in order to investigate whether they were associated with trial characteristics. RESULTS: A total of 360 RCTs were included. Only 2-thirds of the trials (242/360) reported the number of patients assessed for eligibility. Trials reporting eligibility data had better methodology, reported on the tested hypothesis, included a placebo arm, evaluated soft outcomes, published their findings in higher impact journals and recruited a higher number of randomized patients than those who did not. Recruitment rates in 225 (62.5%) trials enabling their calculation, were significantly higher in trials sponsored by industry, conducted in multiple centers and countries, including inpatients, tested non-inferiority hypothesis, included a placebo arm, and evaluated surrogate outcomes. CONCLUSIONS: Reporting of participant eligibility continues to be scarce. Inadequate reporting was associated with poor methodological characteristics in trials.

A Randomized Clinical Trial of Linagliptin vs. Standard of Care in Patients Hospitalized With Diabetes and COVID-19.

Objective: To assess the effect of linagliptin vs. standard therapy in improving clinical outcomes in patients hospitalized with diabetes and coronavirus disease 2019 (COVID-19). Materials and Methods: We did an open-label, prospective, multicenter, randomized clinical trial in 3 Israeli hospitals between October 1, 2020, and April 4, 2021. Eligible patients were adults with type 2 diabetes mellitus and a diagnosis of COVID-19. A total of 64 patients, 32 in each group, were randomized to receive linagliptin 5 mg PO daily throughout the hospitalization or standard of care therapy. The primary outcome was time to clinical improvement within 28 days after randomization, defined as a 2-point reduction on an ordinal scale ranging from 0 (discharged without disease) to 8 (death). Results: The mean age was 67 ± 14 years, and most patients were male (59.4%). Median time to clinical improvement was 7 days (interquartile range (IQR) 3.5-15) in the linagliptin group compared with 8 days (IQR 3.5-28) in the standard of care group (hazard ratio, 1.22; 95% CI, 0.70-2.15; p = 0.49). In-hospital mortality was 5 (15.6%) and 8 (25.0%) in the linagliptin and standard of care groups, respectively (odds ratio, 0.56; 95% CI, 0.16-1.93). The trial was prematurely terminated due to the control of the COVID-19 outbreak in Israel. Conclusions: In this randomized clinical trial of hospitalized adult patients with diabetes and COVID-19 who received linagliptin, there was no difference in the time to clinical improvement compared with the standard of care. Clinical Trial Registration: ClinicalTrials.gov, identifier NCT04371978.

Pregnancy outcome following bacteriuria in pregnancy and the significance of nitrites in urinalysis - a retrospective cohort study.

Background The association between bacteriuria and adverse pregnancy outcomes has been extensively described. The current practice of screening all pregnant women for bacteriuria is challenged by recent studies. We aimed to evaluate pregnancy outcomes among women with a positive urine culture, to assess the significance of positive urinary nitrites in this setting. Methods This was a retrospective cohort study at the emergency department (ED) of the Helen Schneider Hospital for Women, Israel, during 2014-2018. This included all gravida women >18 years old within the 20th week of pregnancy or above, admitted to the ED with diverse complains, who had urinalysis collected and subsequently had a positive urine culture. Clinical and obstetric characteristics were stratified by positive vs. negative nitrites in urinalysis. The primary outcome was premature delivery, and the secondary outcomes were a composite outcome of all recorded pregnancy complications and the significance of urinalysis in predicting urinary tract infection (UTI). Results Overall, 874 pregnant women with a positive urine culture were included. Of them, 721 (79%) patients had a negative nitrite in their urine exam (NNU-group) and 153 (21%) had a positive nitrite in their urine exam (PNU-group). Escherichia coli was the most common pathogen, with significantly higher rates of growth in the PNU-group vs. NNU-group [129 (84.3%) vs. 227 (38.4%), P < 0.001]. Premature delivery was recorded with no association of symptomaticity or nitrite status. Among symptomatic women with classic symptoms of UTI, PNU was significantly associated with decreased risk for major peripartum complications [odds ratio (OR) with 95% confidence interval (CI) of 0.22 (0.05-0.94)]. Conclusion Our findings support that PNU among symptomatic pregnant women with UTI-related symptoms was associated with lower risk of developing major adverse obstetrical outcomes.

Comparison of sublingual vs. intramuscular administration of vitamin B12 for the treatment of patients with vitamin B12 deficiency.

There are several methods to treat vitamin B12 deficiency (VB12d): intramuscular (IM), oral, sublingual (SL), and intranasal vitamin B12 (VB12) preparations. Large studies comparing the efficacy of SL vs. IM supplements are lacking. The aim of the present study was to compare the efficacy of SL versus the standard IM administration of VB12 in restoring B12 levels. This was a retrospective analysis of data from the computerized pharmacy records of Maccabi Health Service (MHS). Data were recorded for all patients older than 18 years of age who were prescribed VB12 during January 2014-December 2017. The main outcome was the change in levels of serum vitamin B12 (sVB12) after treatment. Overall, there were 4281 patients treated with VB12 supplements. Of them, 830 (19.3%) patients were treated with VB12 IM injections and 3451 (80.7%) with SL tablets. The mean ± SD difference between sVB12 levels before and after administration of VB12 supplements was significantly higher in the SL group vs. IM injection group (252 ± 223 vs. 218 ± 184 ng/L, p < 0.001). SL VB12 significantly increased the odds ratio (OR) for an increase of sVB12 levels, compared to the IM group, OR 1.85, CI 95% 1.5-2.3, p < 0.001. This is the largest study that documents therapy with SL preparations of VB12 sufficient and even superior to the IM route. The SL overcomes the challenges of IM injections and should be the first line option for patients with VB12d.

Association between anemia at three different time points and new-onset diabetes after kidney transplantation--a retrospective cohort study.

PURPOSE: Anemia has been reported to be associated with diabetes, but the association between new-onset diabetes after transplantation (NODAT) and anemia has not been reported. METHODS: Patients who underwent kidney transplantation and did not have diabetes prior to transplantation were included in this study. Hemoglobin levels and the prevalence of anemia (hemoglobin <12 g/dL in females and <13 g/dL in males) were evaluated at three time points (prior to transplantation, 6 months following transplantation or 1 month before the development of NODAT, 2 years following transplantation, or following the development of NODAT) and were compared between those who developed NODAT and those who did not. Variables associated with the development of anemia were compared between the two groups. RESULTS: A total of 266 kidney transplant recipients were included, of which 71 (27%) developed NODAT during the time of the follow-up. Hemoglobin and hematocrit levels and the prevalence of anemia were similar in those with and without NODAT at all three time points evaluated. Ferritin levels, prior to transplantation and mean corpuscular volume (MCV) posttransplantation post-NODAT development, were slightly but significantly lower in those with NODAT, although both were within the normal range. CONCLUSIONS: Pretransplantation ferritin levels and posttransplantation post-NODAT development MCV are inversely associated with the development of NODAT in kidney transplants.

Elevated blood pressure during emergency departments visit is associated with increased rate of hospitalization for heart failure: A retrospective cohort study.

There is a limited literature discussing the long-term outcome of patients admitted to the emergency department with elevated blood pressure. The aim of the present study was to evaluate outcomes of patients with hypertension who attended an emergency department. All patients with hypertension who attended an emergency department without target organ damage were evaluated. A composite end point at 18 months, which included all-cause mortality, acute coronary syndrome, cerebrovascular accident, or hospitalization for heart failure, were compared between patients with hypertension and those with normotension. Overall, 410 patients were included in the study. Baseline characteristics were similar between patients with hypertension and those with normotension, except chronic renal failure being more prevalent in patients with hypertension. The composite primary end point occurred similarly in both groups; however, hospitalization for heart failure was significantly more common in patients with hypertension. Elevated blood pressure during an emergency department visit is associated with an increased risk for hospitalization for heart failure during an 18-month follow-up period compared with normotension.

Comparison between two-point and three-point compression ultrasound for the diagnosis of deep vein thrombosis.

Lower extremity deep vein thrombosis (DVT) is a frequent cause of admission to the emergency departments (ED). Although the gold standard for diagnosis is the Duplex ultrasound examination, the current study used for diagnosis of DVT in the ED by emergency physicians is the point-of-care compression ultrasound (POCUS). To compare the sensitivity and specificity of the two-point and three-point compression ultrasound (2PCUS and 3PCUS respectively) for diagnosis of lower extremity DVT in an ED management. We prospectively recruited outpatients who were admitted to the ED with suspected lower extremity DVT. Each patient underwent 2PCUS and 3PCUS performed by a trained ED physician. The ED physician recorded the results and then referred the patient to the vascular clinic for the Duplex ultrasound examination. 195 patients recruited to this study between July 2015 and June 2016 in the ED of Rabin Medical Center-Beillinson Hospital, Israel. DVT was diagnosed by Duplex examination in 48 of 195 patients (24.6%). There were significant correlations among the findings regarding the deep veins on both the 2PCUS and 3PCUS tests and on the Duplex examination (p < 0.001). DVT at any vein was correctly diagnosed with the 2PCUS in 38 of48 patients with positive findings on Duplex examination and incorrectly diagnosed (false positive) in 2 of 133 patients without DVT (sensitivity 82.76%, specificity 98.52%). DVT was correctly diagnosed with the 3PCUS in 43 of 48 DVT and incorrectly diagnosed (false positive) in 2 of133 patients without DVT (sensitivity 90.57%, specificity 98.52%). The sensitivity of the 3PCUS was significantly higher than the 2PCUS (p < 0.001), while the specificity was similar. A short training is satisfactory for achieving a good clinical capability to identify DVT by ED physicians. The 3PCUS examination preformed in the ED, is a noninvasive, accurate and quick diagnostic test for evaluation of patients presenting with signs and symptoms suggestive of a DVT. By Using 3PCUS, the ED physicians may decrease time to diagnosis, definitive care and length of stay in the ED.

Posttransplantation anemia in kidney transplant recipients: A retrospective cohort study.

We sought to assess the frequency and predictors of early and late posttransplantation anemia (PTA). In addition, we aimed to assess the outcomes of patients with anemia and to assess the impact of anemia on mortality, graft function, and graft failure.Patients who underwent kidney transplantation in a single center during a 4-year period were included. Predictors associated with the development of anemia at 6 months (early PTA) or 2 years (late PTA) were evaluated in a univariate and multivariate analyses. The effects of anemia and other variables on mortality and graft function were assessed.A total of 266 kidney transplant recipients were included. The prevalence of PTA at 6 months (early PTA) was 51.3% and at 2 years (late PTA) was 36.6%. Female sex was significantly associated with early PTA. Patients with early PTA proceeded to late PTA. Patients with both early and late PTA had a higher mortality rate at 4 years compared to patients without anemia. On multivariable analysis, lower Hb at 2 years posttransplantation (hazard ratio [HR] 0.716, 95% confidence intervals [CI] 0.541-0.948, for every increment of 1 g/dL) was significantly associated with mortality. Patients with late PTA suffered a decline in eGFR compared to patients without anemia (P = .026). Furthermore, a lower Hb at 2 years posttransplantation was also associated with graft failure (HR 0.775, 95% CI 0.619-0.969, for every increment of 1 g/dL).Post-transplantation anemia is significantly associated with late mortality, with a decline in graft function and with an increased incidence of graft failure.

Pregnancy in women with nonclassic congenital adrenal hyperplasia: Time to conceive and outcome.

OBJECTIVE: Nonclassic congenital adrenal hyperplasia (NCAH) is common among Ashkenazi Jews (1:400). It is associated with various degrees of postnatal virilization, irregular menses and infertility. Therapy of symptomatic subjects consists of physiologic doses of glucocorticoids. The objective of this study was to evaluate the effect of glucocorticoid treatment on fertility and on pregnancy outcome in women with NCAH. DESIGN, SETTING AND PATIENTS: This retrospective study included 75 women diagnosed with NCAH who were followed in our clinic and sought fertility between 2008 and 2015. RESULTS: Seventy-two women succeeded in conceiving (187 pregnancies). Time to conception was 4.0 ± 7 months without and 3.3 ± 3 months with glucocorticoid therapy (P = .43). Seventeen pregnancies were achieved by glucocorticoid therapy after failure to conceive spontaneously. Time to conception before therapy initiation was 10.2 ± 11.4 months compared to 3.3 ± 3.4 months after therapy initiation (P = .02). Of 187 pregnancies, 135 (72%) resulted in live births, 38 (20.3%) ended in spontaneous miscarriages during the first trimester, seven (3.7%) were electively terminated, three (1.6%) were ectopic and four (2.1%) were ongoing during the study with similar rate in glucocorticoid treated and untreated pregnancies. CONCLUSIONS: The 96% pregnancy rate among our cohort of NCAH females was similar to the 95% rate reported for the normal population. Glucocorticoid therapy may shorten the time to conceive in a subgroup of women with NCAH. Glucocorticoid therapy did not affect the rate of first trimester miscarriage. Our 77% live birth rate was similar to the 72% live birth rate in the current healthy US population.

Can Diastolic Blood Pressure Decrease in Emergency Department Setting be Anticipated?

INTRODUCTION: There are no obvious guidelines for therapy of elevated blood pressure (BP) in the emergency department (ED). Diastolic BP is probably more difficult to control compared with systolic BP. AIM: To characterize patients who respond with a significant decrease in diastolic BP in the ED, whether treated or not. METHODS: In this retrospective cohort study, all patients attending a tertiary care ED with elevated BP were evaluated. Clinical characteristics of patients in whom diastolic BP decreased ≥20% were compared with those in whom diastolic BP decreased <20%. RESULTS: Overall, 391 patients were included in the final analysis (64% females), of which diastolic BP of 106 (27%) patients decreased ≥20%. Patients in whom diastolic BP decreased ≥20% were older (70.1 ± 13 years vs. 65.9 ± 16.7 years, P = 0.011) and had a history of ischemic heart disease (IHD) and cerebrovascular disease (CVA) prior to the ED visit [30 patients (28.3%) vs. 45 patients (15.8%) for a history of IHD, P = 0.005 and 16 patients (15.1%) vs. 21 patients (7.4%) for CVA, P = 0.02]. CONCLUSIONS: A history of IHD is associated with a higher decrease in diastolic BP irrespective of the use of medical treatment during the ED visit whereas a history of TIA/CVA was associated with a higher decrease in diastolic BP only in patients who were treated in the ED.