Predicting outcome of patients with severe urinary tract infections admitted via the emergency department.

OBJECTIVE: To evaluate clinical prediction tools for making decisions in patients with severe urinary tract infections (UTIs). METHODS: This was a retrospective study conducted at 2 hospitals (combined emergency department (ED) census 190,000). Study patients were admitted via the ED with acute pyelonephritis or severe sepsis-septic shock related UTI. Area under the receiver operating characteristic curve (AUROC) augmented by decision curve analysis and sensitivity of each rule for predicting mortality and ICU admission were compared. RESULTS: The AUROC of PRACTICE was greater than that of BOMBARD (0.15 difference, 95% confidence interval [CI] = 0.09-0.22), SIRS (0.21 difference, 95% CI = 0.14-0.28) and qSOFA (0.06 difference, 95% CI = 0-0.11) for predicting mortality. PRACTICE had a greater net benefit compared to BOMBARD and SIRS at all thresholds and a greater net benefit compared to qSOFA between a 1% and 10% threshold probability level for predicting mortality. PRACTICE had a greater net benefit compared to all other scores for predicting ICU admission across all threshold probabilities. A PRACTICE score >75 was more sensitive than a qSOFA score >1 (90% versus 54.3%, 35.7 difference, 95% CI = 24.5-46.9), SIRS criteria >1 (18.6 difference, 95% CI = 9.5-27.7), and a BOMBARD score >2 (12.9 difference, 95% CI = 5-12.9) for predicting mortality. CONCLUSION: PRACTICE was more accurate than BOMBARD, SIRS, and qSOFA for predicting mortality. PRACTICE had a superior net benefit at most thresholds compared to other scores for predicting mortality and ICU admissions.

Acute Hepatitis E: A Rare Cause of Acute Liver Failure in a Patient With Acute Myeloid Leukemia.

Immunocompromised patients are particularly at risk to develop hepatitis E virus (HEV) infection and its related complications. We present a rare case of HEV infection in a 35-year-old Hispanic female with concomitant acute myeloid leukemia (AML). The patient presented with acute liver failure within a few weeks after receiving a blood transfusion. Our case likely represented an acute de novo HEV infection after chemotherapy in a patient with concurrent AML, evidenced by the presence of anti-HEV IgM antibodies as well as histological findings, and with a previous history of recent transfusions being one of the strongest risk factors for transmission. Liver failure from an acute de novo hepatitis E infection with concurrent AML can be catastrophic in the immunosuppressed patient. Our case is particularly unique due to the uncommon presentation of acute hepatitis E in a non-pregnant reproductive aged Hispanic female with recently diagnosed AML. Clinicians should maintain a low threshold to test serum HEV-RNA if a patient presents with signs and symptoms suggestive of acute hepatitis.

Plummer-Vinson Syndrome and Heart Failure: An Unusual Association in an African American Woman.

BACKGROUND Plummer-Vinson syndrome (PVS) is a rare disorder composed of the triad of dysphagia, iron-deficiency anemia (IDA), and esophageal webs. It is most prevalent in middle-aged white women, and the dysphagia often improves when the anemia is treated. It is well established that chronic hypertension can lead to congestive heart failure (CHF). While IDA is frequently found concomitantly with CHF, there have been no reported cases of new-onset CHF with anemia presenting as PVS. CASE REPORT We present the case of a 48-year-old African American woman with symptomatic anemia and new-onset congestive heart failure secondary to hypertension, who presented with the classic symptoms of PVS. CONCLUSIONS CHF with accompanying IDA may be an independent risk factor for the development of PVS. At the very least, there is an association between CHF-induced IDA and PVS. Patients presenting with CHF with symptoms of dysphagia should be considered at risk for the syndrome, and endoscopy may be warranted. Treatment for PVS includes iron replacement, and in some cases requires mechanical dilation.

ßArrestin2 Mediates Renal Cell Carcinoma Tumor Growth.

Renal Cell Carcinoma (RCC) is one of the most lethal urological cancers worldwide. The disease does not present early clinical symptoms and is commonly diagnosed at an advanced stage. Limited molecular drivers have been identified for RCC, resulting in the lack of effective treatment for patients with progressive disease. Ubiquitous ßArrestin2 (ßArr2) is well established for its function in the desensitization and trafficking of G protein-coupled receptors. More recently, ßArr2 has been implicated in the regulation of fundamental cellular functions, including proliferation and invasion. We used bioinformatic and genetic approaches to determine role of ßArr2 in RCC tumor growth. Analysis of published human datasets shows that ARRB2 (gene encoding ßArr2) expression is increased in RCC tumor compared to normal tissue and that high levels of ARRB2 correlate with worse patient survival. Experimentally, we show that knockout of ARRB2 decreases rate of RCC cell proliferation and migration in vitro and xenograft tumor growth in animals. Mechanistically, ßArr2 regulates c-Src activity, Cyclin A expression and cell cycle progression that are involved in tumor growth. These results show that ßArr2 is a critical regulator of RCC tumor growth and suggest its utility as a potential marker and drug target to treat advanced disease.