Non-Interventional Weight Changes Are Associated with Alterations in Serum Uric Acid Levels

Background/Objectives: Serum uric acid is an established cardiovascular risk factor. Higher serum uric acid levels are associated with overweight and obesity. We assessed whether non-interventional weight changes affect serum uric acid levels. Methods: We performed a retrospective analysis of 19,193 participants referred to annual medical screening. Body mass index (BMI) and serum uric acid were measured annually. Subjects were divided into five groups according to changes in BMI between visits: large reduction (reduction of more than 5% in BMI), moderate reduction (reduction of more than 2.5% and 5% or less in BMI), unchanged (up to 2.5% change in BMI), moderate increase (increase of more than 2.5% and 5% or less in BMI), and large increase (increase of more than 5% in BMI). The primary outcome was serum uric acid level changes between visits. Results: A decrease in serum uric acid levels was evident as BMI decreased and an increase in serum uric acid levels was associated with an increase in BMI. The proportion of patients whose serum uric acid levels were increased by at least 10% between visits increased with the relative increase in BMI, while the proportion of patients whose serum uric acid levels were reduced by at least 10% decreased with the relative decrease in BMI. Conclusions: Non-interventional weight changes, even modest, are associated with significant alterations in serum uric acid levels. Our findings may aid in better risk stratification and the primary prevention of cardiovascular morbidity and mortality.

A 120-Minute Saline Infusion Test For The Confirmation Of Primary Aldosteronism: A Pilot Study

BACKGROUND

The saline infusion test (SIT) to confirm primary aldosteronism requires infusing two liters of normal saline over 240 minutes. Previous studies raised concerns regarding increased blood pressure and worsening hypokalemia during SIT. We aimed to evaluate the diagnostic applicability of a SIT that requires one liter of saline infusion over 120 minutes.

METHODS

A cross-sectional study, including all patients in a large medical center who underwent SIT from January 1st, 2015, to April 30th, 2023. Blood samples were drawn for baseline renin and aldosterone (t=0) after two hours (t=120 min) and after four hours (t=240 min) of saline infusion. We used ROC analysis to evaluate the sensitivity and specificity of various aldosterone cutoff values at t=120 to confirm primary aldosteronism.

RESULTS

The final analysis included 62 patients. A ROC analysis yielded 97% specificity and 90% sensitivity for a plasma aldosterone concentration of 397 pmol/L (14 ng/dL) at t=120 to confirm primary aldosteronism, and an area under the curve of 0.97 (95% CI [0.93, 1.00], P < 0.001). Almost half (44%) of the patients did not suppress PAC below 397 pmol/L (14 ng/dL) at t=120. Of them, only one (4%) patient suppressed PAC below 276 pmol/L (10 ng/dL) at t=240. Mean systolic blood pressure increased from 140.1±21.3 mm/Hg at t=0 to 147.6±14.5 mm/Hg at t=240 (p=0.011).

CONCLUSIONS

A PAC of 397 pmol/l (14 ng/dL) at t=120 has high sensitivity and specificity for primary aldosteronism confirmation.

Non-Interventional Weight Changes Are Associated with Alterations in Lipid Profiles and in the Triglyceride-to-HDL Cholesterol Ratio

BACKGROUND

Obesity is associated with dyslipidemia, and weight loss can improve obese patients' lipid profile. Here, we assessed whether non-interventional weight changes are associated with alterations in lipid profile, particularly the triglyceride (TG)-to-high-density lipoprotein cholesterol (HDL-C) ratio (TG/HDL-C).

METHODS

In this retrospective analysis of subjects referred to medical screening, body mass index (BMI), low-density lipoprotein cholesterol (LDL-C), TG, and HDL-C levels were measured annually. Patients were divided according to BMI changes between visits. The primary outcomes were the changes in LDL-C, TG, HDL-C, and the TG/HDL-C ratio between visits.

RESULTS

The final analysis included 18,828 subjects. During the year of follow-up, 9.3% of the study population lost more than 5% of their weight and 9.2% gained more than 5% of their weight. The effect of weight changes on TG and on the TG/HDL-C ratio was remarkable. Patients with greater BMI increases showed greater increases in their TG/HDL-C ratio, and conversely, a decreased BMI level had lower TG/HDL-C ratios. This is true even for moderate changes of more than 2.5% in BMI.

CONCLUSIONS

Non-interventional weight changes, even modest ones, are associated with significant alterations in the lipid profile. Understanding that modest, non-interventional weight changes are associated with alterations in the TG/HDL-C ratio may aid in better risk stratification and primary prevention of CV morbidity and mortality.

Elevated International Normalized Ratio and Mortality in Hospitalized Patients Treated with Direct Oral Anticoagulants

BACKGROUND

Direct oral anticoagulants (DOACs) are associated with a prolongation of the prothrombin time and an increased international normalized ratio (INR). The clinical significance of these changes is unclear. This study aimed to examine the association between an elevated INR on admission and in-hospital death and long-term survival in patients treated with DOACs.

METHODS

Data were retrospectively retrieved from records of hospitalized patients at the Sheba Medical Center between November 2008 and July 2023. Patients were selected based on DOAC treatment, coagulation profile, and INR test done within 48 hours of hospitalization. The outcomes were in-hospital mortality and mortality in the year following hospitalization.

RESULTS

The study included 11,399 hospitalized patients treated with DOACs. Patients with elevated INR had a 180% higher risk of in-hospital mortality (adjusted odds ratio 2.80; 95% confidence interval, 2.30-3.39) and a 57% increased risk of death during the following year (adjusted hazard ratio 1.57; 95% confidence interval, 1.44-1.71). Similar results were observed in subgroup analyses for each DOAC.

CONCLUSIONS

An elevated INR on admission is associated with a higher risk for in-hospital death and increased risk for mortality during the first year following hospitalization in hospitalized patients treated with DOACs. This highlights that elevated INR levels in patients on DOACs should not be dismissed as laboratory variations due to DOAC treatment, as they may serve as a prognostic marker.

Assessing Health-Related Quality of Life in Non-Directed Versus Directed Kidney Donors: Implications for the Promotion of Non-Directed Donation

Living kidney donation has increased significantly, but little is known about the post-donation health-related quality of life (HRQoL) of non-directed donors (NDs) vs. directed donors (DDs). We thus examined the outcomes of 112 living kidney donors (82 NDs, 30 DDs). For the primary outcomes-namely, the mean physical component summary (PCS) and mental component summary (MCS) scores of the 12-item Short Form Survey (SF-12) questionnaire-scores were significantly higher for the NDs vs. the DDs (PCS: +2.69, MCS: +4.43). For secondary outcomes, NDs had shorter hospital stays (3.4 vs. 4.4 days), returned to physical activity earlier (45 vs. 60 days), exercised more before and after donation, and continued physical activity post-donation. Regression analyses revealed that donor type and white blood cell count were predictive of the PCS-12 score, and donor type was predictive of the MCS-12 score. Non-directed donation was predictive of a shorter hospital stay (by 0.78 days, p < 0.001) and the odds of having PCS-12 and MCS-12 scores above 50 were almost 10 and 16 times higher for NDs, respectively (p < 0.05). These findings indicate the safety and potential benefits of promoting non-directed donation. However, careful selection processes must be maintained to prevent harm and exploitation.

Predictors and Adverse Outcomes of Acute Kidney Injury in Hospitalized Renal Transplant Recipients

Data about in-hospital AKI in RTRs is lacking. We conducted a retrospective study of 292 RTRs, with 807 hospital admissions, to reveal predictors and outcomes of AKI during admission. In-hospital AKI developed in 149 patients (51%). AKI in a previous admission was associated with a more than twofold increased risk of AKI in subsequent admissions (OR 2.13, p &lt; 0.001). Other major significant predictors for in-hospital AKI included an infection as the major admission diagnosis (OR 2.93, p = 0.015), a medical history of hypertension (OR 1.91, p = 0.027), minimum systolic blood pressure (OR 0.98, p = 0.002), maximum tacrolimus trough level (OR 1.08, p = 0.005), hemoglobin level (OR 0.9, p = 0.016) and albumin level (OR 0.51, p = 0.025) during admission. Compared to admissions with no AKI, admissions with AKI were associated with longer length of stay (median time of 3.83 vs. 7.01 days, p &lt; 0.001). In-hospital AKI was associated with higher rates of mortality during admission, almost doubled odds for rehospitalization within 90 days from discharge and increased the risk of overall mortality in multivariable mixed effect models. In-hospital AKI is common and is associated with poor short- and long-term outcomes. Strategies to prevent AKI during admission in RTRs should be implemented to reduce re-admission rates and improve patient survival.

The Use of Brain Natriuretic Peptide as a Decision-supporting Tool in Hospitalized Patients

BACKGROUND

Most dyspneic patients in internal medicine departments have co-morbidities that interfere with the clinical diagnosis. The role of brain natriuretic peptide (BNP) levels is well-established in the acute setting but not in hospitalized patients.

OBJECTIVES

To evaluate the additive value of BNP tests in patients with dyspnea admitted to medical wards who did not respond to initial treatment.

METHODS

We searched the records of patients who were hospitalized in the department of internal medicine D at Sheba Medical Center during 2012 and were tested for BNP in the ward. Data collected included co-morbidity, medical treatments, diagnosis at presentation and discharge, lab results including BNP, re-hospitalization, and mortality at one year following hospitalization.

RESULTS

BNP results were found for 169 patients. BNP was taken 1.7 ± 2.7 days after hospitalization. According to BNP levels, dividing the patients into tertiles revealed three equally distributed groups with a distinctive character. The higher tertile was associated with higher rates of cardiac co-morbidities, including heart failure, but not chronic obstructive pulmonary disease. Higher BNP levels were related to one-year re-hospitalization and mortality. In addition, higher BNP levels were associated with higher rates of in-admission diagnosis change.

CONCLUSIONS

BNP levels during hospitalization in internal medicine wards are significantly related to cardiac illness, the existence of heart failure, and patient prognosis. Thus, BNP can be a useful tool in managing dyspneic patients in this setting.

The Multi-Ethnic Study of Atherosclerosis-Calcium Score Improves Statin Treatment Allocation in Asymptomatic Adults

Background

The current categorization of cardiovascular (CV) risk broadens the indications for statin therapy. Coronary artery calcium (CAC) identifies those who are most likely to benefit from primary prevention with statin therapy. The multi-ethnic study of atherosclerosis-calcium (MESA-C) includes CAC for CV risk stratification.

Objective

We aimed to establish whether the MESA-C score improves allocation to statin treatment in a cohort of asymptomatic adults. We also analyzed patient survival according to their risk score calculation.

Design

A retrospective analysis of asymptomatic adults.

Participants

A total of 632 consecutive subjects free of coronary artery disease (CAD) and/or stroke, mean age 56 ± 7 years, 84% male, underwent clinical evaluations and CAC measurements.

Main Measures

PCE and MESA-C risk scores were calculated for each subject. According to the 10-year risk for CV events, subjects were classified into moderate and high CV risk (≥7.5%) for whom a statin is clearly indicated, or borderline and low CV risk (<7.5%).

Key Results

During mean follow-up of 6.5 ± 3.3 years, 52 subjects experienced their first CV event. Those with a MESA-C risk score < 7.5% had favorable outcomes even when the PCE indicated a risk of ≥ 7.5%. The MESA-C score improved the discrimination of CV risk with the ROC curves C-statistics increasing from 0.653 for the PCE to 0.770 for the MESA-C. Of those, 84% (99/118) with borderline CV risk (5–7.5%) according to the PCE score, were reallocated by the MESA-C score into a higher (≥7.5%) or lower (<5%) CV risk category. Furthermore, subjects with low MESA-C scores had the highest survival rate regardless of the PCE risk, while those with high MESA-C risks had the lowest survival rate regardless of the PCE risk.

Conclusion

In asymptomatic subjects, the MESA-C score improves allocation to statin treatment and CV risk discrimination, while both scores are essential for more precise survival estimations.

Assessing the Usability of a Novel Wearable Remote Patient Monitoring Device for the Early Detection of In-Hospital Patient Deterioration: Observational Study

Background

Patients admitted to general wards are inherently at risk of deterioration. Thus, tools that can provide early detection of deterioration may be lifesaving. Frequent remote patient monitoring (RPM) has the potential to allow such early detection, leading to a timely intervention by health care providers.

Objective

This study aimed to assess the potential of a novel wearable RPM device to provide timely alerts in patients at high risk for deterioration.

Methods

This prospective observational study was conducted in two general wards of a large tertiary medical center. Patients determined to be at high risk to deteriorate upon admission and assigned to a telemetry bed were included. On top of the standard monitoring equipment, a wearable monitor was attached to each patient, and monitoring was conducted in parallel. The data gathered by the wearable monitors were analyzed retrospectively, with the medical staff being blinded to them in real time. Several early warning scores of the risk for deterioration were used, all calculated from frequent data collected by the wearable RPM device: these included (1) the National Early Warning Score (NEWS), (2) Airway, Breathing, Circulation, Neurology, and Other (ABCNO) score, and (3) deterioration criteria defined by the clinical team as a “wish list” score. In all three systems, the risk scores were calculated every 5 minutes using the data frequently collected by the wearable RPM device. Data generated by the early warning scores were compared with those obtained from the clinical records of actual deterioration among these patients.

Results

In total, 410 patients were recruited and 217 were included in the final analysis. The median age was 71 (IQR 62-78) years and 130 (59.9%) of them were male. Actual clinical deterioration occurred in 24 patients. The NEWS indicated high alert in 16 of these 24 (67%) patients, preceding actual clinical deterioration by 29 hours on average. The ABCNO score indicated high alert in 18 (75%) of these patients, preceding actual clinical deterioration by 38 hours on average. Early warning based on wish list scoring criteria was observed for all 24 patients 40 hours on average before clinical deterioration was detected by the medical staff. Importantly, early warning based on the wish list scoring criteria was also observed among all other patients who did not deteriorate.

Conclusions

Frequent remote patient monitoring has the potential for early detection of a high risk to deteriorate among hospitalized patients, using both grouped signal-based scores and algorithm-based prediction. In this study, we show the ability to formulate scores for early warning by using RPM. Nevertheless, early warning scores compiled on the basis of these data failed to deliver reasonable specificity. Further efforts should be directed at improving the specificity and sensitivity of such tools.

Trial Registration

ClinicalTrials.gov NCT04220359; https://clinicaltrials.gov/ct2/show/NCT04220359

The association between adrenal adenoma size, autonomous cortisol secretion and metabolic derangements

OBJECTIVE

Autonomous cortisol secretion (ACS) is common in patients with adrenal incidentalomas (AI). ACS is associated with increased cardiovascular morbidity and mortality. Data regarding the association between radiological characteristics of adrenal adenomas, their hormonal functionality and metabolic outcomes, are scarce and inconclusive. In this study, we aim to delineate the association between radiological characteristics of AI, ACS and metabolic status.

METHODS

A cross-sectional study of 77 patients with AI who underwent a comprehensive hormonal evaluation. Radiological assessments were performed by an independent radiologist blinded to the clinical and hormonal phenotype of each case. Linear regression models were used to evaluate the association between post dexamethasone suppression test (DST) cortisol levels, metabolic indices and radiological measurements.

RESULTS

Mean maximal adenoma diameter was greater in patients with versus without ACS (20.35 ± 6 vs. 27.09 ± 9.3 mm, respectively, p < .01). Maximal adenoma diameter was found to be positively and linearly correlated with post-DST morning cortisol levels across their entire range (R = .474, p < .01). Linear correlations between maximal adenoma diameter and indices of glycemic control showed a correlation coefficient (R) of .481 and .463 for fasting plasma glucose (FPG) and haemoglobin A1c (HbA1c), respectively, p < .01. When analysis included only patients with ACS, an R = .584 and R = .565 was observed for FPG and HbA1c, respectively (p < .01 for both). The association between maximal adenoma diameter and both FPG and post-DST morning cortisol intensified in patients with metabolic syndrome.

CONCLUSION

There is a quantitative positive mild correlation between AI size and both cortisol autonomy and metabolic parameters.

The urologist's learning curve of "in-bore" magnetic resonance-guided prostate biopsy

Background

The combination of multi-parametric MRI to locate and define suspected lesions together with their being targeted by an MRI-guided prostate biopsy has succeeded in increasing the detection rate of clinically significant disease and lowering the detection rate of non-significant prostate cancer. In this work we investigate the urologist’s learning curve of in-bore MRI-guided prostate biopsy which is considered to be a superior biopsy technique.

Materials and methods

Following Helsinki approval by The Chaim Sheba Medical Center ethics committee in accordance with The Sheba Medical Center institutional guidelines (5366-28-SMC) we retrospectively reviewed 110 IB-MRGpBs performed from 6/2016 to 1/2019 in a single tertiary center. All patients had a prostate multi-parametric MRI finding of at least 1 target lesion (prostate imaging reporting and data system [PI-RADS] score ≥ 3). We analyzed biopsy duration and clinically significant prostate cancer detection of targeted sampling in 2 groups of 55 patients each, once by a urologist highly trained in IB-MRGpBs and again by a urologist untrained in IB-MRGpBs. These two parameters were compared according to operating urologist and chronologic order.

Results

The patients’ median age was 68 years (interquartile range 62–72). The mean prostate-specific antigen level and prostate size were 8.6 ± 9.1 ng/d and 53 ± 27 cc, respectively. The mean number of target lesions was 1.47 ± 0.6. Baseline parameters did not differ significantly between the 2 urologists’ cohorts. Overall detection rates of clinically significant prostate cancer were 19%, 55%, and 69% for PI-RADS 3, 4 and 5, respectively. Clinically significant cancer detection rates did not differ significantly along the timeline or between the 2 urologists. The average duration of IB-MRGpB targeted sampling was 28 ± 15.8 min, correlating with the number of target lesions (p < 0.0001), and independent of the urologist’s expertise. Eighteen cases defined the cutoff for the procedure duration learning curve (p < 0.05).

Conclusions

Our data suggest a very short learning curve for IB-MRGpB-targeted sampling duration, and that clinically significant cancer detection rates are not influenced by the learning curve of this technique.

Adrenal ganglioneuroma resected for suspicious malignancy: multicenter review of 25 cases and review of the literature

Purpose

We reviewed the experience with adrenal ganglioneuroma (AGN) pathologically confirmed following adrenalectomy in medium- to high-volume medical centers.

Methods

The medical records of all adrenalectomy cases in 4 medical centers between 2006 and 2020 were retrospectively reviewed for demographics, clinical, radiological and laboratory findings, surgical treatment, pathology results, and outcomes.

Results

Twenty-five out of 875 adrenalectomy cases (2.9%) were pathologically confirmed as AGN. Those patients' average age was 40.5 years (range, 4-76 years), 13 (52.0%) were males, and 18 lesions (72.0%) were right-sided. One patient had a family history of neurofibromatosis, and another had a succinate dehydrogenase gene mutation. Abdominal/back pain attributed to mass effect was the most common symptom. All 25 patients underwent abdominal computerized tomography scanning in which the average maximal tumor diameter was 6.61 cm. The mean pre- and postcontrast Hounsfield units (HU) values were 35.2 and 59, respectively; and the mean late-phase HU value was 71.1. Twenty-two patients (88.0%) underwent minimally invasive surgery. The average tumor diameter recorded in the final pathology report was 7 cm. Isolated AGN was diagnosed in 21 cases (84.0%), and the additional components reported for the remaining 4 cases included pheochromocytoma (2), ganglioneuroblastoma (1), and neurofibroma (1). The average follow-up length was 16.8 months (range, 1-136 months), during which there was no recurrence or death.

Conclusion

AGN is a rare, slow-growing, large benign tumor with radiological characteristics similar to those seen in malignant tumor. Final diagnosis is established by pathology after surgical resection, preferably minimally invasive, with an overall excellent prognosis.

Distinct Prognostic Factors in Sporadic and Multiple Endocrine Neoplasia Type 1-Related Pancreatic Neuroendocrine Tumors

Pancreatic neuroendocrine tumors (PNET) may develop sporadically or in the context of hereditary syndromes. In patients with multiple endocrine neoplasia type 1 (MEN1), PNET is the leading cause of death. Our aim was to compare the mortality risk in sporadic and MEN1-related PNETs and identify high-risk populations. A retrospective Surveillance, Epidemiology, and End Results database analysis of patients with PNET was used. Patients with MEN1 were defined by syn/metachronous pituitary adenoma. Clinical data were retrieved, and all-cause mortality (ACM) risk was compared in univariate and multivariable analyses. The cohort included 569 patients (46.6% males) with sporadic (n=542) and MEN1-related (n=27) PNETs. Age at diagnosis of MEN1-related PNET was significantly younger than with sporadic PNETs (mean age 49.2±16.7 vs. 61.6±12.7 years, respectively; p < 0.001). Survival analysis showed a trend for a better outcome in patients with MEN1-related vs. sporadic PNET (Log-rank, p=0.09) and in subgroup analysis for patients with advanced disease (p=0.08). Furthermore, among patients followed expectantly, those with MEN1-related PNET had lower ACM risk than their sporadic counterparts (p=0.08). Multivariable analysis demonstrated lower ACM risk in patients diagnosed with MEN1 (hazard ratio 0.35, 95% confidence interval 0.11-1.2, p=0.09), further supporting the trend detected in the univariate analysis. In conclusion, our study demonstrates the distinct clinical profile of patients with MEN1-related PNET compared to sporadic disease and emphasizes the expertise required to accurately manage patients with PNET in this rare context. The cautious decision-making required before embarking on surgical intervention is further emphasized in this robust analysis of a large cancer database.

Non-interventional weight changes affect systolic blood pressure in normotensive individuals

The association between obesity and hypertension is well established. Weight loss has been shown to reduce blood pressure (BP) among hypertensive patients. Nevertheless, the effect of weight changes on BP in normotensive individuals is less clear. The author explored the association between non‐interventional weight alterations and BP changes in a large cohort of normotensive adults. This is a retrospective analysis of normotensive individuals, between 2010 and 2018. All weight changes were non‐interventional. Body mass index (BMI) and BP were measured annually. Patients were divided according to the change in BMI between visits: reduction of more than 5% ("large reduction"), between 2.5% and 5% ("moderate reduction"), reduction of <2.5% or elevation of <2.5% ("unchanged"), elevation between 2.5% and 5% ("moderate increase"), and elevation of more than 5% ("large increase"). The primary outcome was the change in systolic BP (SBP) between the visits. The final analysis included 8723 individuals. 20% of the patients reduced their BMI by at least 2.5% and 24.5% increased their BMI by more than 2.5%. "High reduction" inferred an absolute decrease of 3.6 mmHg in SBP, while "large increase" resulted in an absolute increase of 1.9 mmHg in SBP. The proportion of individuals with at least 10 mmHg decrease in SBP progressively declined according to the relative decrease in BMI, and the proportion of patients with at least 10 mmHg increase in SBP progressively increased. This effect was more pronounced in individuals with higher baseline SBP. Among normotensive adults, modest non‐interventional weight changes may have significant effects on SBP.

The Quantitative Relationship Between Autonomous Cortisol Secretion, Dysglycemia and the Metabolic Syndrome

OBJECTIVE

Autonomous cortisol secretion (ACS) is the most common endocrine abnormality in the evaluation of adrenal incidentalomas. The categorization of ACS is derived from a 1 mg dexamethasone suppression test (DST). Impaired DST is associated with several metabolic derangements. In this study we analyzed the association between post-DST cortisol level, analyzed as a continuous parameter, and indices of glycemic metabolism.

METHODS

We prospectively collected data of 1,976 patients evaluated for adrenal incidentalomas in a large tertiary medical center between December 1, 2017, and August 31, 2019. Seventy-three patients completed the evaluation process. Post-DST cortisol levels were analyzed for correlation with various metabolic parameters, including fasting plasma glucose (FPG) and hemoglobin A1c (HbA1c) among the general cohort and for subgroups stratified by the number of metabolic syndrome (MS) criteria.

RESULTS

Post-DST cortisol demonstrated a linear association with FPG and HbA1c across its entire cortisol range (R = 0.51 and 0.41, respectively; P≤.01). The association between post-DST cortisol and FPG was strengthened with an increased number of metabolic syndrome criteria. Patients with 4 MS criteria show a stronger association (R = 0.92) compared to patients with only a single criterion (R = 0.509). Furthermore, mean post-DST cortisol levels increased as the number of MS criteria accumulated.

CONCLUSION

Post-DST cortisol should be viewed as a continuous parameter in risk stratification algorithms for the development of MS and particularly dysglycemia.

The association between systolic blood pressure reduction during clonidine suppression testing and the decrease in plasma catecholamines and metanephrines

Borderline isolated norepinephrine (NE) and normetanephrine (NMT) elevation is common among patients with suspected pheochromocytoma and paraganglioma (PPGL). The clonidine suppression test (CST) may help establish the etiology in these cases. Prolonged laboratory processing and/or paucity of reliable biochemical assays may limit the utility of CST. The aim of this study was to evaluate whether blood pressure (BP) reduction during CST is associated with alterations in plasma NMT/NE, thereby potentially providing an immediate indication of CST results. In this cross-sectional study, the authors included all consecutive patients with suspected PPGL who underwent CST from January 1, 2014, to December 31, 2019. Linear regression models were conducted to evaluate the association between BP reduction and decrease in plasma NMT/NE. The final analysis included 36 patients (17 males). The decrease in systolic BP (SBP) 90 minutes postclonidine was associated with a decrease in plasma NMT (R = 0.668, P = .025) and NE (R = 0.562, P = .005). A 40% decrease in NMT and NE correlated with a 9.74% and 7.16% decrease in SBP, respectively. Subgroup analyses demonstrated that the association between SBP reduction and the decrease in plasma NMT (R = 0.764, P = .046) and NE (R = 0.714, P = .003) strengthens among patients with hypertension and among those with diabetes mellitus (R = 0.974, P = .026 for NMT). In conclusion, SBP reduction during CST is associated with plasma NMT and NE decrease. Therefore, the decrease in SBP 90 minutes postclonidine may serve as an immediate complementary clinical tool for PPGL diagnosis.

SUN-131 The Roles of Two Insulin Receptor Isoforms in Triple Negative Breast Cancer Growth

Systemic hyperinsulinemia is believed to be an important factor in the progression of a number of cancers, including breast cancer by activating the insulin receptor (IR) signaling cascade in the tumor cells. The IR is expressed in two isoforms, IR-A and IR-B. IR-B is the full-length isoform, while IR-A is lacking 12 amino acids in the α-subunit due to exon 11 alternative splicing. IR-A is predominantly expressed in cancer tissues, while IR-B is mostly expressed in metabolic tissues. The IR and closely related insulin-like growth factor 1 receptor (IGF-1R) are expressed in different ratios in cancer cells. Compared with estrogen receptor positive breast cancers, triple negative breast cancers (TNBC) frequently have higher ratios of IR to IGF-1R. Hyperinsulinemia is associated with increased prevalence of TNBC in pre-menopausal women. Although new targeted therapies are emerging, among breast cancer subtypes TNBC continues to carry the worst prognosis and therefore developing a greater understanding of the links between IR signaling and TNBC progression is critical. The aim of this study is to understand the role of IR-A and IR-B on proliferation, metastasis and metabolism in breast cancer cells. We stably overexpressed human IR-A (IR-A OE) and IR-B (IR-B OE) in TNBC MDA-MB-231 (231) and murine c-myc/vegf overexpressing Mvt1 cells with lentiviral transduction using pLVX-IRES-puro HIV-1-based expression vectors with cDNA encoding the human IR-A,IR-B and control cDNA sequences. Native murine IR was silenced using lentiviral transduction of shRNA in the Mvt1 cells. Overexpression of IR was confirmed at a protein level by western blot, and RNA isoform expression was confirmed using real time PCR. Cell proliferation assays were performed in DMEM/10% FBS and revealed that MDA-MB-231 cells with IR-A OE cells had 15% higher proliferation rates than 231 IR-B OE cells. We then examined the IR signaling pathways by western blot in DMEM/10% FBS. No differences in phosphorylated or total ERK1/2 were observed between control, 231 IR-A OE and 231 IR-B OE cells. 231 IR-A OE cells were found to have 15-fold greater Akt phosphorylation (Ser473) than 231 control cells (p=0.0008) and 4 fold higher pAkt(Ser473) compared with 231 IR-B OE cells (p=0.0016). Further, we found that 231 IR-A OE cells had approximately 2 fold greater expression of c-myc protein compared with both 231 control (p=0.047) and 231 IR-B OE cells (p=0.026). No differences in c-myc expression were observed between 231 IRB OE and 231 control cells. In our previous studies we found that insulin stimulates c-myc expression and silencing the IR reduces c-myc expression in cancer cells. Our current studies show that IR-A, rather than IR-B is the insulin receptor isoform that regulates c-myc expression in human TNBC. Reference: (1) Belfiore et al., Endocr Relat Cancer. 2011; 18(4):R125-R147. (2) Ferguson et al., Breast Cancer Res. 2012; 14(1): R8.

Ethnic Variability Among Jews is Associated With Hypertension: Results of a Nationwide Study of 1.44 Million Adolescents

BACKGROUND

Adolescent hypertension is a major cardiovascular risk factor that may be related to ethnic variability. Contemporary Jews can be divided into three distinct ethnic groups: Ashkenazi, Oriental, and Sephardi origins. The aim of our study was to investigate the association of ethnicity and hypertension among Israeli adolescents.

METHODS

We conducted a population retrospective cohort study of males and females, aged 16-19, eligible for mandatory military service in the Israeli Defense Forces (IDF) between 1994 and 2013. Medical and sociodemographic data, including body mass index (BMI), age, years of education, residential socioeconomic status, and parents' country of birth, were retrieved. Ethnicity of the parents was based upon their country of birth. The examinees were assigned to a certain ethnicity only if both parents had the same ethnicity. Logistic regression models were applied to compute the odds ratio (OR) and 95% confidence intervals (95% CI) for hypertension among the different Jewish ethnicities.

RESULTS

The final cohort included 1,445,176 adolescents, of whom 716,289 were born to parents of the same Jewish ethnicity. Ashkenazi ethnicity was associated with an increased risk of hypertension compared to Sephardi and Oriental ethnicities (adjusted OR of 2.93 (95% CI, 2.52-3.41) and 1.56 (1.38-1.77), respectively). Oriental ethnicity was associated with an increased risk of hypertension compared with the Sephardi ethnicity (OR of 1.91 (1.60-2.27)). Similar results were observed in a sub-analysis, which included only Israeli-born examinees.

CONCLUSIONS

Our results indicate that ethnicity is significantly associated with hypertension among Jewish adolescents. Ashkenazi Jews had the highest risk of hypertension.

Normal-range emergency department serum phosphorus levels and all-cause mortality

PURPOSE OF THE STUDY

Hypophosphataemia and hyperphosphataemia are frequently encountered in hospitalised patients and are associated with significant clinical consequences. However, the prognostic value of normal-range phosphorus levels on all-cause mortality and hospitalisations is not well established. Therefore, we examined the association between normal-range phosphorus levels, all-cause mortality and hospitalisations in patients presenting to the emergency department of a tertiary medical centre in Israel.

STUDY DESIGN

A retrospective analysis of patients presenting to the Chaim Sheba Medical Center emergency department between 2012 and 2018. The cohort was divided into quartiles based on emergency department phosphorus levels: 'very-low-normal' (p ≥ 2 mg/dL and p ≤ 2.49 mg/dL), 'low-normal' (p ≥ 2.5 mg/dL and p ≤ 2.99 mg/dL), 'high-normal' (p≥  3 mg/dL and p≤3.49 mg/dL) and 'very-high-normal' (p ≥  3.5 mg/dL and p ≤ 4 mg/dL). We analysed the association between emergency department phosphorus levels, hospitalisation rate and 30-day and 90-day all-cause mortality.

RESULTS

Our final analysis included 223 854 patients with normal-range phosphorus levels. Patients with 'very-low-normal' phosphorus levels had the highest mortality rate. Compared with patients with 'high-normal' phosphorus levels, patients with 'very-low-normal' levels had increased 30-day all-cause mortality (OR 1.3, 95% CI 1.1 to 1.4, p<0.001), and increased 90-day all-cause mortality (OR 1.2, 95% CI 1.1 to 1.3, p<0.001). Lower serum phosphorus levels were also associated with a higher hospitalisation rate, both for the internal medicine and general surgery wards (p<0.001).

CONCLUSIONS

Lower phosphorus levels, within the normal range, are associated with higher 30-day and 90-day all-cause mortality and hospitalisation rate.

Isolated autoimmune adrenocorticotropic hormone deficiency: From a rare disease to the dominant cause of adrenal insufficiency related to check point inhibitors

OBJECTIVE

Immune checkpoint inhibitors have introduced a new and heterogeneous class of immune-related adverse effects, with the endocrine system being a predominant target for autoimmunity. Autoimmune hypothalamic-pituitary-adrenal axis (HPA) diseases induced by checkpoint inhibitors are being increasingly recognized. We aimed to characterize the spectrum of checkpoint associated hypothalamic-pituitary-adrenal axis endocrinopathies.

DESIGN

A retrospective cohort study of a tertiary cancer center.

METHODS

Patients were characterized for HPA axis abnormalities based on clinical and pituitary axes evaluation. The risk for developing HPA endocrinopathies was compared by log- rank test, by the time since checkpoint inhibitors initiation. Additionally, the risk for developing HPA endocrinopathies after adjusting for covariates was assessed using multivariable logistic regression analysis.

RESULTS

Among 1615 patients, fourteen (0.87%) patients developed isolated adrecocorticotrophic hormone deficiency (IAD), six (0.37%) - hypophysitis and no case of adrenalitis was identified. IAD presented with mild and non-specific symptoms, mainly asthenia. In multivariable analysis, exposure to both PD-1/PD-L1 and Ipilimumab and female gender were associated with an increased odds ratio (OR) for developing IAD (6.98 [95% CI 2.38-20.47, p < .001] and 3.67 [95% CI 1.13-11.84, p = .03]), respectively.

CONCLUSIONS

IAD, a rare disease before the immunotherapy era, has become a predominant checkpoint related HPA axis autoimmune injury. Despite its life threatening potential, IAD may be missed due to its subtle presentation. Patients exposed to Ipilimumab and PD-1/PD-L1 in combination or sequentially and women have an increased risk for developing IAD.

Renal glucosuria is associated with lower body weight and lower rates of elevated systolic blood pressure: results of a nationwide cross-sectional study of 2.5 million adolescents

Background

Gene coding mutations found in sodium glucose co-transporters (SGLTs) are known to cause renal glucosuria. SGLT2 inhibitors have recently been shown to be effective hypoglycemic agents as well as possessing cardiovascular and renal protective properties. These beneficial effects have to some extent, been attributed to weight loss and reduced blood pressure. The aim of the current study was to evaluate the prevalence of renal glucosuria amongst a large cohort of Israeli adolescents and to investigate whether renal glucosuria is associated with lower body weight and lower blood pressure values.

Methods

Medical and socio-demographic data were collected from the Israeli Defense Force’s conscription center’s database. A cross-sectional study to evaluate the association between conscripts diagnosed as overweight [BMI percentiles of ≥ 85 and < 95 and obesity (≥ 95 BMI percentile)] and afflicted with renal glucosuria was conducted. In addition, we assessed the association of renal glucosuria with elevated diastolic and systolic blood pressure. Multinomial regression models were used.

Results

The final study cohort comprised 2,506,830 conscripts of whom 1108 (0.044%) were diagnosed with renal glucosuria, unrelated to diabetes mellitus, with males twice as affected compared to females. The adjusted odds ratio for overweight and obesity was 0.66 (95% CI 0.50–0.87) and 0.62 (95% CI 0.43–0.88), respectively. Adolescents afflicted with renal glucosuria were also less likely to have an elevated systolic blood pressure of 130–139 mmHg with an adjusted odds ratio of 0.74 (95% CI 0.60–0.90).

Conclusions

Renal glucosuria is associated with lower body weight and obesity as well as with lower rates of elevated systolic blood pressure.

The association between fasting plasma glucose and glycated hemoglobin in the prediabetes range and future development of hypertension

Background

Prediabetes is a well-established risk factor for progression to overt diabetes mellitus (DM), which is in turn associated with development of hypertension (HTN) and vice versa. However, the role of prediabetes and HbA1c in particular as an independent risk factor for the development of hypertension is unclear.

Aim

In this current study, we aimed to evaluate the association between both fasting plasma glucose (FPG) and hemoglobin A1c (HbA1c) levels in the prediabetes range and development of HTN among a large cohort of normotensive subjects.

Design and methods

We investigated 5016 normotensive participants without DM and other cardiovascular risk factors who were annually screened in a tertiary medical center. Subjects were divided into normoglycemic and prediabetic groups. Normoglycemia was defined as HbA1c < 5.7% and FPG < 100 mg/dl. Prediabetes was defined according to the ADA criteria, i.e., 6.5% > HbA1c ≥ 5.7% or impaired fasting glucose (IFG):126 mg/dl > FPG ≥ 100 mg/dl. Subgroup analysis was made by dividing participants into four groups according to FPG and HbA1C levels, i.e., normoglycemia, impaired HbA1c only, IFG only, and both parameters impaired.

Results

During a follow-up of 3.7 ± 2.9 years, 318 (6.3%) subjects developed HTN. A cumulative hazard function for the development of hypertension showed a 2.89-fold ([95% CI 2.19–3.83], p < .0001) increased risk for HTN in the prediabetic population. In a multivariable Cox proportional hazard regression model adjusted to common confounding risk factors for HTN, prediabetes was found to be independently associated with a 1.95-fold ([95%, CI 1.43–2.52] p < .0001) increased risk for hypertension. Impaired HbA1C only was not found to be independently associated with HTN, while IFG only showed a 2.13-fold (95%, [CI 1.46–3.11] p < .0001) increased risk for HTN compared to normoglycemic, and a 2.55-fold ([95% CI 1.85–3.51] p < .0001) increased risk for HTN when both parameters impaired.

Conclusion

Our study demonstrates that FPG in the prediabetes range, albeit not glycated hemoglobin, is independently and significantly associated with future development of HTN. Therefore, our findings further highlight the pivotal predictive role of IFG for HTN development as opposed to the limited independent role of abnormal HbA1c levels.

Electronic supplementary material

The online version of this article (10.1186/s12933-019-0859-4) contains supplementary material, which is available to authorized users.

Interleukin-1α deficiency reduces adiposity, glucose intolerance and hepatic de-novo lipogenesis in diet-induced obese mice

OBJECTIVE

While extensive research revealed that interleukin (IL)-1β contributes to insulin resistance (IR) development, the role of IL-1α in obesity and IR was scarcely studied. Using control, whole body IL-1α knockout (KO) or myeloid-cell-specific IL-1α-deficient mice, we tested the hypothesis that IL-1α deficiency would protect against high-fat diet (HFD)-induced obesity and its metabolic consequences.

RESEARCH DESIGN AND METHODS

To induce obesity and IR, control and IL-1α KO mice were given either chow or HFD for 16 weeks. Glucose tolerance test was performed at 10 and 15 weeks, representing early and progressive stages of glucose intolerance, respectively. Liver and epididymal white adipose tissue (eWAT) samples were analyzed for general morphology and adipocyte size. Plasma levels of adiponectin, insulin, total cholesterol and triglyceride (TG), lipoprotein profile as well as hepatic lipids were analyzed. Expression of lipid and inflammation-related genes in liver and eWAT was analyzed. Primary mouse hepatocytes isolated from control mice were treated either with dimethyl sulfoxide (DMSO) (control) or 20 ng/mL recombinant IL-1α for 24 hours and subjected to gene expression analysis.

RESULTS

Although total body weight gain was similar, IL-1α KO mice showed reduced adiposity and were completely protected from HFD-induced glucose intolerance. In addition, plasma total cholesterol and TG levels were lower and HFD-induced accumulation of liver TGs was completely inhibited in IL-1α KO compared with control mice. Expression of stearoyl-CoA desaturase1 (SCD1), fatty acid synthase (FASN), elongation of long-chain fatty acids family member 6 (ELOVL6), acetyl-CoA carboxylase (ACC), key enzymes that promote de-novo lipogenesis, was lower in livers of IL-1α KO mice. Treatment with recombinant IL-1α elevated the expression of ELOVL6 and FASN in mouse primary hepatocytes. Finally, mice with myeloid-cell-specific deletion of IL-1α did not show reduced adiposity and improved glucose tolerance.

CONCLUSIONS

We demonstrate a novel role of IL-1α in promoting adiposity, obesity-induced glucose intolerance and liver TG accumulation and suggest that IL-1α blockade could be used for treatment of obesity and its metabolic consequences.

OP449 inhibits breast cancer growth without adverse metabolic effects

Hyperinsulinemia is associated with a decrease in breast cancer recurrence-free survival and overall survival. Inhibition of insulin receptor signaling is associated with glycemic dysregulation. SET is a direct modulator of PP2A, which negatively regulates the PI3K/AKT/mTOR pathway. OP449, a SET inhibitor, decreases AKT/mTOR activation. The effects of OP449 treatment on breast cancer growth in the setting of pre-diabetes, and its metabolic implications are currently unknown. We found that the volumes and weights of human MDA-MB-231 breast cancer xenografts were greater in hyperinsulinemic mice compared with controls (P < 0.05), and IR phosphorylation was 4.5-fold higher in these mice (P < 0.05). Human and murine breast cancer tumors treated with OP449 were 47% and 39% smaller than controls (P < 0.05, for both, respectively). AKT and S6RP phosphorylation were 82% and 34% lower in OP449-treated tumors compared with controls (P < 0.05, P = 0.06, respectively). AKT and S6RP phosphorylation in response to insulin was 30% and 12% lower in cells, pre-treated with OP449, compared with control cells (P < 0.01, P < 0.05, respectively). However, even with decreased AKT/mTOR activation, body weights and composition, blood glucose and plasma insulin, glucose tolerance, serum triglyceride and cholesterol levels were similar between OP449-treated mice and controls. Xenografts and liver tissue from OP449-treated mice showed a 64% and 70% reduction in STAT5 activation, compared with controls (P < 0.01 and P = 0.06, respectively). Our data support an anti-neoplastic effect of OP449 on human breast cancer cells in vitro and in xenografts in the setting of hyperinsulinemia. OP449 led to the inhibition of AKT/mTOR signaling, albeit, not leading to metabolic derangements.

Type 2 Diabetes Mellitus and Cancer: The Role of Pharmacotherapy

Purpose Type 2 diabetes mellitus (T2DM) is becoming increasingly prevalent worldwide. Epidemiologic data suggest that T2DM is associated with an increased incidence and mortality from many cancers. The purpose of this review is to discuss the links between diabetes and cancer, the effects of various antidiabetic medications on cancer incidence and mortality, and the effects of anticancer therapies on diabetes. Design This study is a review of preclinical and clinical data regarding the effects of antidiabetic medications on cancer incidence and mortality and the effects of anticancer therapies on glucose homeostasis. Results T2DM is associated with an increased risk and greater mortality from many cancer types. Metformin use has been associated with a decrease in cancer incidence and mortality, and there are many ongoing randomized trials investigating the effects of metformin on cancer-related outcomes. However, data regarding the association of other antidiabetes medications with cancer incidence and mortality are conflicting. Glucocorticoids, hormone-based therapies, inhibitors that target the phosphatidylinositol 3-kinase-Akt-mammalian target of rapamycin pathway, and insulin-like growth factor 1 receptor-targeted therapy have been associated with high rates of hyperglycemia. These agents mediate their deleterious metabolic effects by reducing insulin secretion and increasing insulin resistance in peripheral tissues. Conclusion Studies must be performed to optimize cancer screening strategies in individuals with T2DM. A greater understanding of the mechanisms that link diabetes and cancer are needed to identify targets for therapy in individuals with diabetes who develop cancer. Data from clinical studies are needed to further elucidate the effects of antidiabetic medications on cancer incidence and progression. As several anticancer therapies alter glucose homeostasis, physicians need to be aware of these potential effects. Careful patient screening and monitoring during treatment with these agents is necessary.

The association between normal-range admission potassium levels in Israeli patients with acute coronary syndrome and early and late outcomes

Abnormal serum potassium levels are associated with an increased risk of ventricular arrhythmias and mortality in patients with acute myocardial infarction (AMI). The aim of the present study was to evaluate whether different levels of serum potassium, within the normal range, are associated with worse outcomes. The present study comprised 1277 patients with AMI and normal-range admission potassium levels (3.5-5.2 mEq/L), who were enrolled and prospectively followed up in the Acute Coronary Syndrome Israeli Survey between 2010 and 2013. Patients were divided into 4 quartiles based on admission potassium levels; "normal-low" (K ≥ 3.5 and K ≤ 3.9), "normal-moderate" (K > 3.9 and K ≤ 4.18), "normal-high" (K > 4.18 and K ≤ 4.45), and "normal-very high" (K > 4.45 and K ≤ 5.2). We analyzed the association between admission serum potassium levels and 7 days in-hospital complication rates, and 30-day and 1-year all-cause mortality rates. Patients with "normal-very high" potassium displayed increased frequency of baseline clinical risk factors and experienced a higher rate of acute kidney injury during hospitalization compared with the "normal-low" group (7.7% vs 2.4%; P = 0.002). However, the rate of in-hospital ventricular arrhythmias was similar across the range of admission potassium levels (overall P = 0.26), Multivariate analysis showed that compared with "low-normal" potassium values, patients with "normal-very high" potassium levels experienced increased risk for 30-days (adjusted hazard ratio 2.88, 95% confidence interval 1.05-7.87, P = 0.039) and 1-year all-cause mortality (adjusted hazard ratio 1.98, 95% confidence interval 1.05-3.75, P = 0.034). In patients admitted with AMI, admission serum potassium levels of 4.45 to 5.2 mEq/L are not associated with in-hospital ventricular arrhythmias, but are associated with increased short and long-term mortality.

The association between admission systolic blood pressure of heart failure patients with preserved systolic function and mortality outcomes

INTRODUCTION

Heart failure is a major cause of death and disability and poses a significant public health concern. Approximately half of the patients admitted with heart failure, have preserved left ventricular ejection fraction. The association between systolic blood pressure (SBP) and long-term outcome in this group has not been well established.

AIM

The aim of our study is to evaluate the association between admission SBP and short term and long-term mortality outcomes in patients with heart failure and preserved systolic function.

METHODS

1230 consecutive patients presenting with preserved left ventricular (LV) systolic function (defined as an LV ejection fraction ≥40%) were included in this survey. Patients were divided into quartiles according to admission SBP: low admission SBP (<127mmHg), intermediate admission SBP (128-145mmHg), high admission SBP (146-170mmHg) and very-high admission SBP (>170mmHg). Primary outcome included in hospital, one and four year mortality rates.

RESULTS

Elevated admission SBP was found to be associated with improved short and long-term mortality (HR=0.25 95% CI - 0.09-0.7, p=0.007 and HR=0.7 95% CI - 0.56-0.88, p=0.002 for the highest versus low SBP group, respectively). This finding was most notable in patients with acute heart failure and patients with ejection fraction≥50%.

CONCLUSION

Elevated admission SBP is associated with a favorable short and long-term outcome in patients with heart failure and preserved systolic function.

KEY MESSAGE

Low admission SBP is an independent predictor for short and long-term mortality in patients with HF and PSF.

Interleukin-1α deficiency attenuates endoplasmic reticulum stress-induced liver damage and CHOP expression in mice

BACKGROUND & AIMS

ER stress promotes liver fat accumulation and induction of inflammatory cytokines, which contribute to the development of steatohepatitis. Unresolved ER stress upregulates the pro-apoptotic CHOP. IL-1α is localized to the nucleus in apoptotic cells, but is released when these cells become necrotic and induce sterile inflammation. We investigated whether IL-1α is involved in ER stress-induced apoptosis and steatohepatitis.

METHODS

We employed WT and IL-1α-deficient mice to study the role of IL-1α in ER stress-induced steatohepatitis.

RESULTS

Liver CHOP mRNA was induced in a time dependent fashion in the atherogenic diet-induced steatohepatitis model, and was twofold lower in IL-1α deficient compared to WT mice. In the ER stress-driven steatohepatitis model, IL-1α deficiency decreased the elevation in serum ALT levels, the number of apoptotic cells (measured as caspase-3-positive hepatocytes), and the expression of IL-1β, IL-6, TNFα, and CHOP, with no effect on the degree of fatty liver formation. IL-1α was upregulated in ER-stressed-macrophages and the protein was localized to the nucleus. IL-1β mRNA and CHOP mRNA and protein levels were lower in ER-stressed-macrophages from IL-1α deficient compared to WT mice. ER stress induced the expression of IL-1α and IL-1β also in mouse primary hepatocytes. Recombinant IL-1α treatment in hepatocytes did not affect CHOP expression but upregulated both IL-1α and IL-1β mRNA levels.

CONCLUSION

We show that IL-1α is upregulated in response to ER stress and IL-1α deficiency reduces ER stress-induced CHOP expression, apoptosis and steatohepatitis. As a dual function cytokine, IL-1α may contribute to the induction of CHOP intracellularly, while IL-1α released from necrotic cells accelerates steatohepatitis via induction of inflammatory cytokines by neighboring cells.

High-risk type-2 diabetes mellitus patients, without prior ischemic events, have normal blood platelet functionality profiles: a cross-sectional study

Background

Patients with type 2 diabetes mellitus (DM) display a predisposition for vascular disease. Platelets taken from vasculopathic diabetic patients, show enhanced stimuli-induced activation and aggregation responses. Aspirin remains the cornerstone antiplatelet agent for secondary prevention of vascular complications among diabetic patients, yet evidence of its efficacy and safety in primary prevention are conflicting. Our aim was to assess whether high risk diabetic patients, without previous ischemic events, have abnormal platelet functionality profiles.

Methods

The study included 82 diabetic patients and 86 matched non-diabetic patients without prior ischemic events nor treatment with anti-platelet medications. Blood samples were analyzed for platelet markers of activation, turnover and leukocyte-platelet interactions.

Results

Our final analysis included 122 males (74 %), with a mean age of 61 years. Mean platelet volume (MPV) was similar between the diabetic patients and controls (9.2 fL for both). Following activation, PAC-1 binding and P-selectin expression were found comparable between the diabetic patients and controls (83 % versus 81 % and 76 % versus 74 %, respectively). Leukocyte-platelet aggregates (LPAs) were similar between the diabetic patients and controls (18 % versus 17 %, respectively). Neutrophil-platelet aggregates (NPAs) and monocyte-platelet aggregates (MPAs) were also found similar in the diabetic patients and controls. Elevated fasting plasma glucose was associated with increased LPAs rates.

Conclusions

High risk type-2 diabetes mellitus patients, without prior ischemic events, have normal blood platelet functionality profiles.

Severe ASIA syndrome associated with lymph node, thoracic, and pulmonary silicone infiltration following breast implant rupture: experience with four cases

Silicone has been considered biologically inert; thus it has been employed in many medical devices and nowadays is commonly used in plastic surgery for mammary prosthesis. It is well tolerated in most cases. However, autoimmune disorders and siliconomas with granulomatous reactions after silicone implant rupture have been described. We report cases of four women who developed systemic disorders following rupture of silicone breast implants resulting in lymph node and thoracic silicone infiltration. The symptoms in these cases, including arthralgia, myalgia, generalized weakness, severe fatigue, sleeping disturbances, cognitive impairment, memory loss, irritable bowel syndrome, and weight loss, clearly match the criteria of the recently defined autoimmune/inflammatory syndrome induced by adjuvants (ASIA).

Treating hypertension in type 2 diabetes

INTRODUCTION

The co-existence of hypertension and diabetes mellitus is very common. Hypertension remarkably increases the cardiovascular risk in diabetic patients. Lowering blood pressure (BP) in these patients is particularly beneficial.

AREAS COVERED

This paper will discuss what the target BP is for diabetic patients and how that target can be reached.

EXPERT OPINION

Previous guidelines recommended lowering BP < 130/80 mmHg in diabetic patients. However, recent studies did not support this target and accordingly most recent guidelines recommend lowering BP to < 140/90 mmHg in diabetic patients. Non-pharmacological approaches are recommended in all patients. If BP levels are above the target despite non-pharmacological treatment, drug therapy should be initiated. Despite the lack of clear evidence, blockers of the renin-angiotensin-aldosterone system (RAAS) represent the cornerstone of the antihypertensive arsenal; however, in most patients combination therapy is required. Combination of RAAS blocker and a calcium antagonist is the preferred one. In many patients three or four drugs are needed. Treatment should be individualized according to concomitant risk factors and diseases and according hemodynamic and laboratory parameters as well as age. In order to maximally reduce cardiorenal risk, lipid and glycemic control should also be achieved.

Serum potassium levels predict blood pressure response to aldosterone antagonists in resistant hypertension

The objective of this study was to identify factors associated with the blood pressure (BP) response to spironolactone--aldosterone receptor antagonist as an add-on therapy in patients with resistant hypertension (HTN). We retrospectively reviewed the data of subjects with resistant HTN who were treated with add-on spironolactone in a large HTN clinic. A paired Student's t-test was used to assess the differences between the BP values before and during spironolactone administration, and multivariate analysis was used to assess the predictors of a satisfactory BP response (a decrease in systolic BP >10%). We analyzed the data of 48 hypertensive participants. The add-on spironolactone therapy had a significant BP-lowering effect in both systolic and diastolic BP values (P < 0.01 for both). Baseline serum potassium levels of <4.5 mEq l(-1) were associated with a satisfactory BP response (P < 0.01). Furthermore, every decrement of 1 mEq l(-1) of serum potassium was independently associated with a fivefold higher rate of achieving a satisfactory BP response to spironolactone therapy (P = 0.024). Additional factors independently associated with an improved systolic BP response were old age (P = 0.033), body mass index (P = 0.033) and high baseline systolic BP (P=0.004). Our results support the use of add-on spironolactone therapy in patients with resistant HTN who are elderly and obese and have high systolic BP and serum potassium levels <4.5 mEq l(-1).

[Dyspnea, hypoxia and a confusional state--a post-recovery diagnosis]

We present a case of a 48 year old female, with a medical history significant for paraplegia due to a cervical cord injury and a history of transitional cell carcinoma, which necessitated a urinary bladder ileal reconstruction. The patient was hospitalized due to an acute confusional state, severe respiratory distress and hemolytic anemia. One day prior to hospitalization, she was involved in a minor motor vehicle accident, yet she and her family denied any injuries due to the accident and the patient did not complain of pain. During the course of her hospitalization the patient was febrile, yet we did not find any evidence of an infectious cause for her symptoms. Notably, lumbar puncture and MRI scan were relatively contraindicated, hence a CNS infection was not completely ruled out. We also thoroughly investigated her respiratory symptoms, but could not reach a conclusive diagnosis. Nevertheless, after approximately 14 days of diagnostic efforts, empirical antibiotic treatment and supportive care, all clinical and laboratory abnormalities had resolved. The patient was discharged with a presumed diagnosis of a poorly understood infectious process. However, not long after, she returned to the emergency department complaining of a red, painful, swollen right knee. Imaging studies demonstrated a right supracondylar as well as a tibial plateau fracture. Consequently, a post-recovery diagnosis of fat emboli syndrome was made.

Temporal trends in management of hypertension among Israeli adults, 2002-2010: lesson from the Acute Coronary Syndromes Israeli Survey (ACSIS)

Our aim was to evaluate trends in blood pressure (BP) management and BP levels among patients admitted with acute coronary syndromes (ACS) over the past decade. The study population comprised 7658 ACS patients enrolled in the Acute Coronary Syndromes Israeli Survey (ACSIS) between 2002 and 2010. We compared patients' characteristics, admission systolic BP levels, and antihypertensive therapy between those hospitalized during the early (years: 2002-2004) and late (years: 2008-2010) periods. Among 7658 study participants, 4421 (58%) were hypertensive. Hypertensive patients presenting from 2008 to 2010 tended to exhibit lower BP levels (P < .001). The use of angiotensin converting enzyme inhibitors (ACEi)/angiotensin receptor blockers (ARB) and beta-blockers has increased over the years (P < .001 for both), whereas the use of diuretics and calcium antagonists has remained stable (P = .77 for both). The use of diuretics tended to increase in hypertensive subjects without prior cardiovascular disease (P = .05). In addition, the late period was characterized by a significant increase in the use of two or more antihypertensive agents (combination therapy) compared with the early period (57% vs 50%; P < .001). BP levels decreased among Israeli hypertensive patients presenting with ACS between 2002 and 2010, possibly due to increased use of ACEi/ARB, and combination therapies during this time period.

Should we change the target blood pressure in diabetic patients?

Hypertension is a major modifiable risk factor for cardiovascular morbidity and mortality in diabetic patients. Guidelines recommend lowering blood pressure (BP) to less than 130/80 mmHg in diabetic patients. These recommendations are based on several studies in diabetic patients that showed the benefit of intensive BP control. However in all the studies the achieved BP was higher than 130/80 mmHg. Re-evaluation of earlier studies, as well as more recently accumulated data suggest that intensive BP control is associated with a significant reduction in all-cause mortality and stroke rate, but with no benefit for other microvascular or macrovascular (cardiac, renal and retinal) outcomes. Intensive BP control is associated with an increased risk of serious adverse effects, particularly for systolic BPs levels lower than 130 mmHg. When determining the target BP in diabetic patients one should balance the potential cerebrovascular protection against the increased risk of serious side effects, and the absence of benefit for other circulatory system. It seems therefore, that lowering BP to levels close to 130/80 mmHg should be the main goal of treatment in diabetic patients.