Cardiovascular disease in diffuse idiopathic skeletal hyperostosis (DISH): from theory to reality-a 10-year follow-up study.

OBJECTIVE: To describe actual cardiovascular events over a decade in patients with diffuse idiopathic skeletal hyperostosis (DISH), without previously known CV diseases. METHODS: The medical records of patients with DISH and controls, beginning in 2006 (without known CV disease), were reviewed. Demographic, constitutional, and laboratory data were collected. Comparison of CV events following 2006 was performed according to the outcome definitions set by the Framingham score 2: coronary event demonstrated by a coronary imaging modality, acute myocardial infarction (MI), coronary death, congestive heart failure with a reduced ejection fraction, and angina pectoris. RESULTS: Data were available for 45 patients with DISH and 47 controls without DISH from the original cohort (91.8% and 97.9% respectively). By the Framingham score, 28.6% (± 20.33) of the DISH patients were expected to be affected with CVD at 10 years of follow-up. We observed that nearly 39% of them developed CVD during that period (95% CI 23.8-53.5%). The incidence of MI over the 10-year period was significantly higher in the DISH group (P = 0.005). The DISH group had higher morbidity with a higher composite outcome of 38.8% vs 25.5% in the control cohort, and the number of non-elective hospital admissions per patient, despite neither reaching statistical significance. CONCLUSION: Our study showed that the Framingham score underestimates the real risk for developing CVD in patients with DISH, specifically the risk for MI. We propose more scrutiny is warranted in evaluating CV risk in these patients, more demanding treatment target goals should be established, and earlier and more aggressive medical interventions should be undertaken, particularly primary prevention. Larger prospective studies are needed to corroborate these findings.

[COVID-19, THE KIDNEY AND HYPERTENSION].

INTRODUCTION: COVID-19, is a new corona virus of the Beta Coronavirus genus which originated in bats. The virus first emerged in China in December 2019 and has rapidly spread since to other areas worldwide. The World Health Organization (WHO) has therefore recently declared it as the source of a pandemic. The disease caused by the virus manifests in most cases as a lower respiratory tract infection leading to fever, cough and dyspnea, while more severe cases can led to respiratory failure and/or multi organ failure. COVID-19 enters the human cell using the ACE2, an enzyme abundant in renal tubular epithelial cells. Theoretically, this may be significant in several ways: acute kidney injury (AKI) as well as proteinuria and/or microhematuria could be associated with the penetration of COVID-19 into the cells. Moreover, medications based on RAAS inhibition, such and ACE inhibitors and ARBs, upregulate the enzyme ACE2 and could therefore hypothetically explain the high prevalence of hypertension and diabetes reported as previous diagnoses in severe cases. In the setting of chronic kidney disease, the risk of infection with COVID-19 is not clear at this time. However, hemodialysis patients represent a unique group of patients, mostly elderly and immunocompromised, for whom dialysis is a life-saving treatment which cannot be stopped. Hence, the COVID-19 pandemic has presented a complex medical and logistic challenge for the medical staff in hospital and community based dialysis units.

The Israeli Defense Forces Point of Injury Antimicrobial Treatment Protocol - A New Protocol and Review of the Literature.

INTRODUCTION: Combat wound infection is a common and serious complication, leading to significant morbidity and mortality. In 2005, a point of injury antimicrobial protocol was published by the Israel Defense Forces, in which Moxifloxacin was chosen. During 2016-2017, a revision of this protocol was performed and concluded with the publication of an updated protocol. The purpose of this report is to present this process and the revised protocol, together with a review of the literature. METHODS: We searched "Medline" and "Google Scholar" for studies dealing with antimicrobial prophylaxis in trauma, for militaries' point of injury antimicrobial protocol protocols and for established surgical antimicrobial prophylaxis protocols. RESULTS: Point of injury antimicrobial protocol is aimed at preventing early infection and its complications. The choice of Moxifloxacin for this purpose may not be optimal since Moxifloxacin spectrum might be overly broad, there is scant evidence supporting it for this indication, and the available preparation does not meet distinctive technical requirements. Contrarily, Ceftriaxone seemed to have suitable microbiological, pharmacological and technical features. CONCLUSION: Point of injury antimicrobial protocol should be used especially when evacuation and definitive surgical treatment are delayed. According to present scientific data and operational needs, Ceftriaxone was chosen for most penetrating injuries, with Metronidazole addition for penetrating abdominal and cranial trauma.

Portal Vein Thrombosis and Thrombocytopenia in Eosinophilic Granulomatosis with Polyangiitis: A Paradox?

A 36-year-old woman with eosinophilic granulomatosis with polyangiitis (EGPA) presented with necrotic skin lesions and pulmonary infiltrates. There was eosinophilic vasculitis on skin biopsy, and substantial tissue eosinophilia in her bone marrow. She had unexplained worsening thrombocytopenia, which prompted a thrombophilia work-up. However, abnormalities in liver enzymes led to the extraordinary finding of portal vein thrombosis. Thrombocytopenia resolved with treatment with low molecular weight heparin. This case highlights the risk of hypercoagulability in eosinophilia specifically, and in EGPA. We suggest that thrombosis should be ruled out in all cases of EGPA. LEARNING POINTS: Eosinophilia is a hypercoagulable state.Thrombocytopenia is not part of eosinophilic granulomatosis with polyangiitis (EGPA) and may herald thrombosis.Thromboembolism should be ruled out in the setting of EGPA with eosinophilia.Prompt diagnosis can prevent unnecessary procedures.

Neutropenia and eosinophilia among Ethiopian immigrants to Israel: Familial or environmental?

BACKGROUND: Due to trends of population movements, Israeli family physicians are treating increasing numbers of African immigrants from Ethiopia. These immigrants were found to have complete blood counts (CBC) that are different from other ethnic groups, with a higher prevalence of eosinophilia and neutropenia. OBJECTIVES: To evaluate haematological findings in an attempt to define whether they behave as familial (genetic) or environmental. METHODS: Retrospective chart review of 300 patients from a primary care clinic: 100 individuals of Ethiopian heritage born in Ethiopia (EE); 100 individuals of Ethiopian heritage born in Israel, whose parents were born in Ethiopia (EI), and a control group of 100 patients who were not of Ethiopian heritage (C). RESULTS: Absolute eosinophilia (greater than 500/dl) was found in 13% of the EE study group significantly higher than the two other groups (P < 0.05), with no difference between EI and C. neutropenia (defined as less than 1500/dl) was found in 32% of EE group, 20% of EI, and 1% of C (P < 0.01). CONCLUSION: On the one hand, findings point to a marked environmental influence on the eosinophilic response (most probably due to intestinal parasites present in immigrants from Ethiopia). On the other hand, a familial-genetic nature is probably the reason for the higher prevalence of neutropenia in this population, although some environmental influence may play a role. The knowledge of these findings may be useful for physicians treating people migrating from Africa.