Serum Levels of Adropin Improve the Predictability of MELD and Child-Pugh Score in Cirrhosis: Results of Proof-of-Concept Clinical Trial

Adropin is a peptide that was suggested to have a role in cirrhosis. The present study aimed to determine the ability to use serum adropin levels to improve their prediction accuracy as an adjunct to the current scores. In a single-center, proof-of-concept study, serum adropin levels were determined in thirty-three cirrhotic patients. The data were analyzed in correlation with Child-Pugh and MELD-Na scores, laboratory parameters, and mortality. Adropin levels were higher among cirrhotic patients that died within 180 days (1,325.7 ng/dL vs. 870.3 ng/dL, p = 0.024) and inversely correlated to the time until death (r ² = 0.74). The correlation of adropin serum levels with mortality was better than MELD or Child-Pough scores (r ² = 0.32 and 0.38, respectively). Higher adropin levels correlated with creatinine (r ² = 0.79. p < 0.01). Patients with diabetes mellitus and cardiovascular diseases had elevated adropin levels. Integrating adropin levels with the Child-Pugh and MELD scores improved their correlation with the time of death (correlation coefficient: 0.91 vs. 0.38 and 0.67 vs. 0.32). The data of this feasibility study suggest that combining serum adropin with the Child-Pugh score and MELD-Na score improves the prediction of mortality in cirrhosis and can serve as a measure for assessing kidney dysfunction in these patients.

Increased rates of idiopathic inflammatory myopathies during the COVID-19 pandemic: a single-centre experience

OBJECTIVES

Higher-level evidence is required to discern whether the incidence of idiopathic inflammatory myopathies (IIM) has increased during the COVID-19 pandemic and whether the disease pattern and course have changed. We aimed to analyse patients who were diagnosed with IIM at our tertiary care centre during the pandemic and compare them with IIM patients diagnosed before COVID-19.

METHODS

We retrospectively analysed the medical records of adult patients (>18 years) who were diagnosed with IIM during COVID-19 versus a control group of patients diagnosed before the outbreak. Included were patients whose diagnosis was made at the Department of Medicine and Rheumatology Unit of Hadassah Medical Center, Jerusalem, Israel. We also conducted a comprehensive review of the literature regarding SARS-CoV-2 infection and vaccine-induced IIM.

RESULTS

Our study yielded 18 and 16 diagnosed IIM patients over periods of 27 and 56 months in the COVID-19 and pre-pandemic cohorts, respectively. These constitute incidence rates of 0.66 and 0.28 patients/month, respectively, marking an increased rate in the COVID-19 group. Unique features were noted in IIM patients who were diagnosed during the pandemic. This includes male predominance (M:F ratio of 12:6), higher hospitalisation rate (0.77 vs. 0.43 admitted/total patients) and increased number of patients with CPK >10,000 U/L (3 vs. 1 patient). Despite the more severe presentation and course in the pandemic group, survival was comparable between the groups.

CONCLUSIONS

The incidence of IIM increased during the COVID-19 pandemic. These patients display unique features and a more severe presentation. Fortunately, the prognosis remains unchanged.

Disproportionately Low Albumin and High Neutrophil-to-Lymphocyte Ratio in Small Bowel Adenocarcinoma Patients With Long-Duration Crohn's Disease

INTRODUCTION

Although Crohn's disease (CD) is a known risk factor of small bowel adenocarcinoma (SBA), early diagnosis remains a significant clinical challenge. Identification of biomarkers for SBA may lead to early detection.

METHODS

This is a retrospective study comparing albumin levels and neutrophil-to-lymphocyte ratio (NLR) of patients with long-standing CD who underwent small bowel resection with and without malignancy.

RESULTS

Forty-two patients with CD were included in this study (11 with SBA). Median NLR before surgery was 8.5 (interquartile range 6.2-31.3) in patients with SBA and 3.8 (interquartile range 2.8-5.3) for patients without SBA ( P < 0.05). Mean albumin levels before surgery were significantly lower among patients with SBA compared with patients without SBA (2.6 ± 0.6 g/dL vs 3.5 ± 0.6 g/dL, respectively, P < 0.05), despite patients with SBA being under longer total parenteral nutrition treatment duration.

DISCUSSION

CD patients with SBA diagnosis have increased NLR and lower albumin before surgery compared with CD patients without detection of SBA.

Use of Colchicine for Pericardial Inflammation: Risks and Toxicities-A Cautionary Tale

Colchicine is commonly used as part of the treatment of acute and recurrent pericarditis. Neuromyopathy is a well-known, but probably underreported, side effect of colchicine. Here we present a unique case of a 56-year-old woman with recurrent episodes of colchicine-induced neuromyopathy over many years. (Level of Difficulty: Beginner.).

A Unique Case of Myositis

Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a rare systemic small-vessel disease, with heterogeneous clinical manifestations. While arthralgia and myalgia are common in the disease course, frank myositis is exceedingly rare. Immune-mediated necrotizing myopathy (IMNM) is a subtype of idiopathic inflammatory myopathies (IIMs), characterized by severe myositis. We report herein a case of prominent diffuse myositis with shared features of AAV and IMNM.

Codivir suppresses SARS-Cov-2 viral replication and stabilizes clinical outcome: In vitro and Phase I clinical trial results

BACKGROUND

Treatment of severe acute respiratory distress syndrome coronavirus 2 (SARS-CoV-2) remains a significant challenge in the face of increased worldwide morbidity and mortality. The acute illness caused by SARS-CoV-2 is initiated by a viral phase, followed by an inflammatory phase. Numerous anti-inflammatory and anti-viral therapies, with a relatively minor clinical effect, have been applied. Developing a safe and efficient direct anti-viral treatment is essential as it can block disease progression before significant complications ensue and potentially prevent transmission.

AIM

The present phase 1 study aimed to determine the safety of Codivir, a newly developed anti-viral agent, and to preliminarily assess its anti-viral activity in patients infected by COVID-19.

METHODS

In vitro studies were conducted to determine the direct anti-viral effect of Codivir using an immunofluorescence-based assay and to assess its cytotoxic effect by tetrazolium assay (MTT). In a phase I clinical trial, Codivir was administered for ten days in 12 patients who were followed for its safety. Patients were followed for clinical manifestations during administration. Sequential nasal viral PCR titers (Cycle Threshold, CT) were determined preceding and during treatment.

RESULTS

In vitro, Codivir showed activity against SARS-CoV-2 with 90% viral replication suppression and minimal cytotoxicity. The anti-viral activity was demonstrated at the early stages of infection, post-entry of the virus in the cell. Codivir was safe in all 12 patients in phase I clinical trial and significantly suppressed viral replication in 5/7 fully assessed patients, with an anti-viral effect noted as early as three days.

SUMMARY

The present study's data support the safety of Codivir administration in humans and suggest its significant anti-COVID-19 effect. These results support the testing of the drug in more extensive controlled trials in patients with SARS-CoV-2.

Characteristics of endovascular pneumococcal infections; a decade of nationwide surveillance study

In order to characterize pneumococcal endovascular infection in the post-vaccination era, a retrospective nationwide study based on the Israeli Adult IPD database was conducted. Between 2010 and 2019, 0.6% (23 cases) of IPD cases were of endovascular type, occurring mainly in males (72.3%) with underlying medical conditions (78.2%). Additional pneumococcal source (10 patients) and concomitant infections were not uncommon. Penicillin and ceftriaxone susceptibility rates were 65.2% and 91.3%, respectively; 60.9% of the isolates were not covered by the pneumococcal conjugate vaccine. 21.7% of patients died during hospitalization. In conclusion, pneumococcal endovascular infections still carry significant morbidity and mortality.

Improving Diuretic Response in Heart Failure by Implementing a Patient-Tailored Variability and Chronotherapy-Guided Algorithm

Heart failure is a major public health problem, which is associated with significant mortality, morbidity, and healthcare expenditures. A substantial amount of the morbidity is attributed to volume overload, for which loop diuretics are a mandatory treatment. However, the variability in response to diuretics and development of diuretic resistance adversely affect the clinical outcomes. Morevoer, there exists a marked intra- and inter-patient variability in response to diuretics that affects the clinical course and related adverse outcomes. In the present article, we review the mechanisms underlying the development of diuretic resistance. The role of the autonomic nervous system and chronobiology in the pathogenesis of congestive heart failure and response to therapy are also discussed. Establishing a novel model for overcoming diuretic resistance is presented based on a patient-tailored variability and chronotherapy-guided machine learning algorithm that comprises clinical, laboratory, and sensor-derived inputs, including inputs from pulmonary artery measurements. Inter- and intra-patient signatures of variabilities, alterations of biological clock, and autonomic nervous system responses are embedded into the algorithm; thus, it may enable a tailored dose regimen in a continuous manner that accommodates the highly dynamic complex system.

Incidence and course of COVID-19 hospitalizations among patients with familial Mediterranean fever

Objectives

To evaluate the incidence of hospitalization for COVID-19 in patients with familial Mediterranean fever (FMF), as compared with the general population, and to compare the disease course between FMF inpatients, and age, sex, ethnicity, and comorbidity-matched non-FMF COVID-19 inpatients.

Methods

We used electronic medical records (EMR) to obtain data about the total number of the insured population and the number of FMF patients in the two largest health management organizations (HMOs) in Jerusalem, Clalit and Meuhedet. The total number of COVID-19 inpatients at the Hadassah Medical Center, including those with FMF, for the period between the 1 February 2020, and the 10 March 2021 was retrieved from the EMR of Hadassah. COVID-19 course was compared between the FMF inpatient group and age, sex, ethnicity, and comorbidity-matched non-FMF COVID-19 inpatients. Each FMF inpatient was matched with 2 non-FMF controls.

Results

We found no statistically significant difference in the odds of hospitalization for COVID-19 between FMF patients and the non-FMF population (0.46% vs 0.41%; p= 0.73). Furthermore, we found similar disease severity and therapeutic approach in FMF COVID-19 inpatients and matched non-FMF COVID-19 inpatients.

Conclusions

Neither FMF, nor baseline colchicine therapy appear to affect the incidence of hospitalization for COVID-19 or the disease course, in terms of severity and therapeutic approach.

Autoimmune phenomena following SARS-CoV-2 vaccination

Vaccines represent an attractive possible solution to the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pandemic. Widespread vaccine distribution has yet to occur in most countries, partially due to public concerns regarding possible side effects. While studies indicate the vaccine is exceptionally safe, rare systemic side effects remain possible. In Israel, where a large percentage of the population has been rapidly vaccinated, such adverse events may be more apparent. We report a series of patients presenting with de-novo or flares of existing autoimmune conditions associated with the Pfizer BNT162b2 mRNA SARS-CoV-2 vaccine. All patients were assessed in our tertiary care center in Israel and had no history of previous SARS-COV-2 infection. We observed that while immune phenomena may occur following vaccination, they usually follow a mild course and require modest therapy. We briefly expound on the theoretical background of vaccine related autoimmunity and explore future research prospects.

Introducing variability in targeting the microtubules: Review of current mechanisms and future directions in colchicine therapy

Microtubules (MTs) are highly dynamic polymers that constitute the cellular cytoskeleton and play a role in multiple cellular functions. Variability characterizes biological systems and is considered a part of the normal function of cells and organs. Variability contributes to cell plasticity and is a mechanism for overcoming errors in cellular level assembly and function, and potentially the whole organ level. Dynamic instability is a feature of biological variability that characterizes the function of MTs. The dynamic behavior of MTs constitutes the basis for multiple biological processes that contribute to cellular plasticity and the timing of cell signaling. Colchicine is a MT‐modifying drug that exerts anti‐inflammatory and anti‐cancer effects. This review discusses some of the functions of colchicine and presents a platform for introducing variability while targeting MTs in intestinal cells, the microbiome, the gut, and the systemic immune system. This platform can be used for implementing novel therapies, improving response to chronic MT‐based therapies, overcoming drug resistance, exerting gut‐based systemic immune responses, and generating patient‐tailored dynamic therapeutic regimens.

Treatment of B-cell depleted COVID-19 patients with convalescent plasma and plasma-based products

Severe acute respiratory syndrome coronavirus 2 infected patients, receiving background anti-CD20 therapy, were treated with convalescent plasma or plasma-based products. Eight patients were included in the study, presenting with prolonged disease course and delayed viral clearance. CP/plasma-based products were offered as an add-on therapy to standard medical treatment. All patients showed remarkable clinical and laboratory improvement. In addition, polymerase chain reaction from nasopharyngeal swabs rapidly converted to negative following plasma administration. This study emphasizes the therapeutic efficacy of convalescent plasma and plasma-based products in a subgroup of immunocompromised patients with iatrogenic B-cell depletion.

Blood cultures of adult patients discharged from the emergency department-is the safety net reliable?

We investigated the clinical implications of the practice in our emergency department (ED) of discharging patients with pending blood cultures. We reviewed the medical records of adults discharged with positive blood cultures from the ED of a 330-bed university hospital during a five-year period. Clinical characteristics, laboratory data, and antibiotic treatment prescribed in the ED and at discharge were accessed. Antimicrobial susceptibility profiles were used to determine whether antibiotic treatment was adequate. The outcomes assessed for 90 days following discharge were return to the ED, hospitalization, modified diagnosis, and death. Of 220,681 visits to the ED, 1362 showed positive blood cultures; of these, 307 (22.5%) were from discharged patients. More than half the isolates (56.3%) were considered contaminants. Of 124 visits with true bacteremia, Enterobacteriaceae were the most common pathogens (67.0%). This is concordant with urinary tract infection (UTI) being the most common diagnosis (52.4%). With antibiotic treatment, 69.4% had been discharged with antibiotic treatment, which was adequate in two-thirds of them. Among the 77 who returned to the ED, 27.5% had persistent bacteremia. The diagnosis was changed in 44.2% of them, mostly with brucellosis or bone and joint infections, and 84.4% were subsequently hospitalized. Within three months, 5.6% of bacteremic patients died, all after hospitalization. Bacteremia in discharged patients occurred mainly in association with UTI. Outcomes were generally favorable, although only about half received appropriate antibiotic treatment. Diagnoses were changed in a relatively high proportion of patients following culture results.

A Personalized Signature and Chronotherapy-Based Platform for Improving the Efficacy of Sepsis Treatment

Sepsis remains a major therapeutic challenge and is associated with a high rate of morbidity and mortality. It is a dynamic condition in which multiple parameters change over time, rendering it difficult to overcome the various injurious responses, which worsen the prognosis in these patients. The prognosis of sepsis is associated with a disbalance of compensatory responses to infectious triggers, part of which can be deleterious. Marked inter- and intra-patient variability characterizes the mechanisms that underlie sepsis progression and determine the response to therapy. In this paper, we review some of the data on the use of chronopharmacological approaches for the treatment of patients with sepsis and discuss the role of the autonomic nervous system in the mechanisms associated with immune response and chronotherapy in these patients. We describe the implementation of an individualized platform that is based on the personalized autonomic nervous system, immune, and chronobiology-derived parameters for generating a patient-tailored therapeutic regimen. The notion of overcoming the deleterious compensatory response in a highly dynamic system in sepsis is presented to ensure an improved response to current therapies.

Hospital-onset adult invasive pneumococcal disease in Israel: Sicker patients, different pathogens

OBJECTIVES

Invasive pneumococcal disease (IPD) usually has its onset in the community (CO-IPD), but it can commence following hospitalization (HO-IPD). This study compared HO-IPD and CO-IPD cases during the implementation of the pneumococcal conjugate vaccine (PCV) program for children in Israel.

METHODS

This was a nationwide retrospective cohort study of adult (age >18 years) IPD patients covering the period from the implementation of the PCV7/13 program in 2009/2010 through 2015. HO-IPD and CO-IPD were defined as IPD with onset ≥4 and ≤2 days from admission, respectively. Patient characteristics, outcome measures, serotypes, and antimicrobial susceptibility were compared for the entire cohort, followed by a matched case-control analysis.

RESULTS

The study included 114 patients with HO-IPD and 2180 with CO-IPD. After matching HO-IPD to CO-IPD patients by age, sex, and comorbidities, the mortality rate and discharge to long-term care facility rate were significantly higher for HO-IPD patients than for CO-IPD patients (44.6% vs. 26.3% and 26.5% vs. 8.2%, respectively). HO-IPD isolates were less often covered by PCV13 (39.6% vs. 49.0%) and pneumococcal polysaccharide vaccine PPSV23 (56.6% vs. 71.3%) and more often resistant to penicillin (9.3% vs. 3.6%), ceftriaxone (3.8% vs. 0.75%), and levofloxacin (9.3% vs. 0.8%).

CONCLUSIONS

HO-IPD was associated with higher morbidity and mortality than CO-IPD and was more often caused by non-vaccine serotypes (primarily non-PCV13 types) and antibiotic-resistant strains.

Phosphorylation of Ribosomal Protein S6 Mediates Mammalian Target of Rapamycin Complex 1-Induced Parathyroid Cell Proliferation in Secondary Hyperparathyroidism

Secondary hyperparathyroidism is characterized by increased serum parathyroid hormone (PTH) level and parathyroid cell proliferation. However, the molecular pathways mediating the increased parathyroid cell proliferation remain undefined. Here, we found that the mTOR pathway was activated in the parathyroid of rats with secondary hyperparathyroidism induced by either chronic hypocalcemia or uremia, which was measured by increased phosphorylation of ribosomal protein S6 (rpS6), a downstream target of the mTOR pathway. This activation correlated with increased parathyroid cell proliferation. Inhibition of mTOR complex 1 by rapamycin decreased or prevented parathyroid cell proliferation in secondary hyperparathyroidism rats and in vitro in uremic rat parathyroid glands in organ culture. Knockin rpS6(p-/-) mice, in which rpS6 cannot be phosphorylated because of substitution of all five phosphorylatable serines with alanines, had impaired PTH secretion after experimental uremia- or folic acid-induced AKI. Uremic rpS6(p-/-) mice had no increase in parathyroid cell proliferation compared with a marked increase in uremic wild-type mice. These results underscore the importance of mTOR activation and rpS6 phosphorylation for the pathogenesis of secondary hyperparathyroidism and indicate that mTORC1 is a significant regulator of parathyroid cell proliferation through rpS6.

Real-time ultrasound-guided renal biopsy with a biopsy gun in children: safety and efficacy

Real-time ultrasound-guided renal biopsy (RB) with a biopsy gun has become a standard procedure in the treatment of children. The purpose of the study was to establish the complication rate after real-time ultrasound-guided RB with a biopsy gun, the adequacy of renal tissue samples for pathohistological tests, the rate of concurrence between clinical and pathohistological diagnoses, and the benefits of the procedure. From January 1994 to October 1999, 88 renal biopsies were performed on 82 children, 81 of whom (35M, 46F, aged 3-20 y) were included in this retrospective study. The nephrotic syndrome (in infants, older children, those with evidence of nephritis or failing corticosteroid therapy) was the most frequent indication of RB. Other indications were non-nephrotic proteinuria, nephritic syndrome, glomerular haematuria, renal allograft dysfunction, unexplained acute or chronic renal failure, and kidney disease progression monitoring. No serious complications were noted. The adequacy rate of renal tissue samples ranged from 93.1 to 96.6%, depending on which definition of the adequacy of renal tissue samples was used. Clinical and pathohistological diagnoses matched in 81.4% of the cases. Data obtained by RB were very beneficial to patients in terms of establishing, confirming or altering the diagnosis and, consequently, the treatment.

CONCLUSION

The results confirm that real-time ultrasound-guided RB with a biopsy gun is a safe procedure and provides information that is very beneficial to patients.

Cyclic voiding urosonography for detecting vesicoureteric reflux in renal transplant recipients

BACKGROUND

The clinical significance of vesicoureteric reflux (VUR) in renal transplant recipients remains controversial. Voiding urosonography (VUS), a new modality for detecting VUR, can be used in these patients. The sensitivity of X-ray and radionuclide cystography for detecting VUR may be improved with cyclic procedures. The aim of our study was to evaluate whether cyclic VUS is superior to the single-cycle procedure.

METHODS

Cyclic VUS was performed in 27 renal transplant recipients. Eight were children or adolescents and the remaining 19 recipients were adults. VUS was performed according to accepted guidelines. After the first micturition, the catheter was left in place and the entire procedure was repeated under the same conditions.

RESULTS

Both initial cycle and cyclic VUS detected 17 out of 27 (63%) VURs in the same patients. The sensitivity was not improved by cyclic VUS. However, there were differences between the initial cycle and cyclic VUS (P=0.028) when comparing the number of negative results and the grades of VURs detected. This difference was even more pronounced when analysing only positive results. In the initial cycle, five out of 17 (29%) VURs were grade III, compared with 10 out of 17 (59%) grade III VURs in the same patients using the cyclic procedure (P=0.008).

CONCLUSIONS

Cyclic VUS did not improve the detection sensitivity for VUR in our study. However, given that VUR grade may be important for the management of renal transplant recipients, the use of cyclic VUS may provide a useful diagnostic tool for these patients.

Echo-enhanced ultrasound voiding cystography in children: a new approach

The development of echo-enhancing agents has significantly improved the detection of the movement of fluid within the urinary tract by ultrasonography (US). The purpose of our study was to compare ultrasound voiding cystography (USVC) for the detection of vesicoureteric reflux (VUR) in children with direct radionuclide voiding cystography (DRVC). Ninety-nine children, aged 1.1-12.3 years, with 198 potentially refluxing units, were investigated simultaneously by DRVC and USVC. The indications for cystography were urinary tract infection, follow-up of a previously detected VUR, and screening of siblings of children with VUR. During the investigation an echo-enhancing agent (Levovist) was administered intravesically through a catheter already in place for the DRVC. The movement of both agents, radiotracer and Levovist, was registered simultaneously by a computerized gamma camera and US, respectively. The results were analyzed with DRVC representing the reference diagnostic test. The overall sensitivity and specificity of USVC for the detection of VUR were 79% and 92%, respectively. USVC may represent a reliable diagnostic tool for the detection and follow-up of VUR in children.