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.

Effectiveness of Influenza Vaccine in Hemodialyzed Patients: A Retrospective Study.

Infection is one of the leading causes of mortality in dialysis patients, second only to cardiovascular disease. This retrospective study assessed the efficacy and clinical outcomes of influenza vaccination among hemodialysis (HD) patients. In the 2014-2015 season, 104 of 164 (63.6%) HD patients were vaccinated for influenza by the outpatient community health system facilities. Significantly more patients, 159 of 170 (93.8%), were vaccinated in 2015-2016 by the hospital dialysis unit staff during an inpatient HD session (P <0.001). A trend toward fewer complications from influenza infection was observed in vaccinated patients. Among HD patients with diabetes (who comprised 56% of the study population), the incidence of influenza was 17% among nonvaccinated patients vs. 6.3% among those who were vaccinated (P =0.026). The inpatient vaccination policy resulted in a greater rate of vaccination. HD patients with diabetes benefit from influenza vaccination, with a significantly lower incidence of influenza infection.

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.

Kruppel-like factors in an endothelial and vascular smooth muscle cell coculture model: impact of a diabetic environment and vitamin D.

Endothelial cells (EC) and vascular smooth muscle cells (VSMC) are involved in the development of local and diffuse vasculopathies by participating in inflammatory processes that can lead to uncontrolled vascular complications. Our aim was to study the possible interactions of EC and VSMC in an in vitro coculture model exposed to diabetic-like conditions and the effect of vitamin D on cellular pathways that might lead to an inflammatory response. EC and VSMC were isolated from different umbilical cords and stimulated in an in vitro coculture model in a diabetic-like environment and calcitriol for 24 h. Total RNA and protein were extracted from cells and analyzed for the expression of selected inflammatory-related markers. The EC-VSMC coculture in a diabetic-like environment induced the expression of inflammatory markers such as Kruppel-like factors, thioredoxin-interacting protein (TXNIP), IL-6, and IL-8. Addition of vitamin D to the EC-VSMC coculture induced selective changes in the inflammatory response. This model could lead to a better understanding of the interactions between EC and VSMC in the inflammatory processes involved in diabetes and emphasizes the role of vitamin D in the inflammatory response. The use of different donors strengthens the significance of our findings showing that genetic variations do not affect the impact of vitamin D on the expression of inflammatory-related proteins in our model.

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.

[Laparoscopic management of peritoneal dialysis catheters].

INTRODUCTION: Peritoneal dialysis (PD) is one of the established methods for the management of patients with end-stage renal failure. Laparoscopy has been used to assist in the insertion of new catheters as well as for the salvage of malfunctioning peritoneal dialysis catheters (PDC). OBJECTIVES: The purpose of this retrospective study was to review our experience in the utilization of laparoscopy for the management of PDC. METHODS: We reviewed the charts of all consecutive patients who had undergone either a ap-assisted insertion of a PDC utilizing a modified peritoneoscopic Y-TEC [Medigroup, Inc, Oswego, Ill) technique (YT) under direct laparoscopic vision or laparoscopic-assisted procedures for the salvage of a malfunctioning PD catheter. RESULTS: Twenty nine patients had undergone 43 procedures that included the insertion of a new PD catheter using the modified YT technique, YT with simultaneous adhesiolysis and omentectomy; YT with repair of an epigastric hernia, omentectomy, adhesiolysis and repositioning of PDC; and ravage and repositioning of the obstructed PD catheter in all patients who needed repositioning of the catheter, the PDC was fixed with an intraperitoneal suture to the lower anterior abdominal wall. Postoperatively, malfunction of the catheter was found in one patient due to reclotting of PDC caused by oozing as a result of extensive adhesiolysis. One patient needed emergent laparotomy due to small bowel perforation that was missed during a difficult laparoscopic adhesiolysis. CONCLUSIONS: Laparoscopic surgery may be helpfuL for the diagnosis and the management of a malfunctioning PDC. A modified YT technique is safe and may be one of the alternative methods for the placement of a PDC.

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.