A missing coronary guidewire mimicking aortic dissection-a case report

Background

A retained coronary guidewire following coronary angiography is an extremely rare complication. We present a case of a retained coronary guidewire from a percutaneous coronary intervention done 2 years ago.

Case summary

An 80-year-old asymptomatic man with a history of ischemic heart disease and moderate aortic stenosis presented to the echocardiography lab for routine follow-up. Transthoracic echocardiography showed Moderate aortic stenosis and a suspected linear echogenic structure in the ascending aorta. trans-esophageal echocardiography was performed to reveal a mobile and linear echogenic structure originating from the sinuses of Valsalva/Sinotubular junction and extending to the ascending aorta. An electrocardiogram gated cardiac computed tomography was performed and showed A linear well-defined structure originating from the ostium of the left main coronary artery and extending to the ascending aorta-a coronary guidewire from an earlier procedure. A second look at the last invasive coronary angiography record demonstrated the same finding. A multidisciplinary heart team discussion was obtained and concluded that the risk of surgical or endovascular intervention outweighed the potential benefit. The patient was discharged home for a close clinical and echocardiographic follow-up.

Discussion

A retained coronary guidewire is a rare complication that operators should be aware of. Management should be case-specific depending on clinical presentation.

Cardiac Tamponade in Patients Treated with Direct Oral Anticoagulants

BACKGROUND

Direct oral anticoagulants (DOACs) are the treatment of choice for patients with non-valvular atrial fibrillation; however, bleeding risk remains significant. We reported a single-center experience with 11 patients who presented with hemorrhagic cardiac tamponade while treated with DOACs.

OBJECTIVES

To evaluate the characteristics and clinical outcomes of patients under DOACs with cardiac tamponade.

METHODS

We retrospectively identified 11 patients treated with DOACs admitted with pericardial tamponade in our cardiology unit during 2018-2021.

RESULTS

The mean age was 84 ± 4 years; 7 males. Atrial fibrillation was the indication for anticoagulation in all cases. DOACs included apixaban (8 patients), dabigatran (2 patients), and rivaroxaban (1 patient). Urgent pericardiocentesis via a subxiphoid approach under echocardiography guidance was successfully performed in 10 patients. One patient was treated with urgent surgical drainage with a pericardial window. Reversal of anticoagulation using prothrombin complex concentrate and idarucizumab was given before the procedure to 6 patients treated with apixaban and one patient treated with dabigatran. One patient, initially treated with urgent pericardiocentesis, underwent pericardial window surgery due to re-accumulation of blood in the pericardium. The pericardial fluid analysis demonstrated hemopericardium. Cytology tests were negative for malignant cells in all cases. Discharge diagnoses regarding the cause of hemopericardium included pericarditis (3 patients) and idiopathic (8 patients). Medical therapy included non-steroidal anti-inflammatory drugs (1 patient), colchicine (3 patients), and steroids (3 patients). No patient died during hospitalization.

CONCLUSIONS

Hemorrhagic cardiac tamponade is a rare complication of DOACs. We found good short-term prognosis following pericardiocentesis.

Transcatheter Left Atrial Appendage Occlusion: A Multi-Center Real Life Experience

(1) Background: left atrial appendage occlusion (LAAO) is considered an effective and relatively safe treatment for the prevention of thromboembolic events in patients with atrial fibrillation and a contra-indication for anticoagulation. We present a large multicenter real-world experience of transcatheter LAAO implementation in patients with atrial fibrillation who cannot be treated with chronic anti-coagulation; (2) Methods: included were atrial fibrillation patients who underwent transcatheter LAAO between 1 January 2016 and 30 June 2021. The study was conducted using the electronic health record database of Clalit Health Services (CHS). The primary outcomes included hemorrhagic and ischemic stroke following LAAO; (3) Results: included were 389 atrial fibrillation patients. During a median follow-up of 2.1 years, 13% patients had ischemic cerebrovascular accident (CVA), and 4.4% patients had hemorrhagic CVA. While the risk of ischemic stroke increased gradually over time, the risk of hemorrhagic CVA was highest during the first 3 months following the procedure. Moreover, previous ischemic stroke was the only significant predictor for both hemorrhagic and ischemic stroke following LAAO; (4) Conclusions: while the annual performance rate of transcatheter LAAO has increased significantly over the past years, post procedural long-term prognosis remains poor with a substantial risk of both thrombotic and bleeding events.

Association between T wave morphology parameters and abnormal cardiac SPECT imaging

BACKGROUND

T-wave morphology dispersion (TMD) described the electrocardiographic T-wave heterogeneity during a single cardiac cycle. Total cosine R-to-T (TCRT) is the average of the cosines of the angles between the QRS and T vectors on the ECG. We examine the predictive value of TMD and TCRT calculation to assess abnormal myocardial perfusion.

METHODS

Retrospective single center cohort study including all patients referred for evaluation of ischemia by myocardial SPECT scanning with no known history of ischemic heart disease, from 1 January 2019 to 31 December 2019. Study endpoint was the correlation between the calculated TMD and TCRT values and detection of myocardial injury or ischemia by myocardial SPECT.

RESULTS

Among 606 patients, calculated TCRT was 0.401 ± 0.53 for the normal group and 0.283 ± 0.62 for the abnormal group (p = 0.007). Measured TMD was 22.9 ± 16.6 degrees (p < 0.001) in the normal group, compared to 31.5 ± 22.8 degrees (p < 0.001) for the abnormal group.

CONCLUSIONS

The results demonstrate a correlation between the decreased TCRT values and increase TMD and myocardial ischemia seen in SPECT results. The TCRT and TMD can be used as simple and non-invasive markers to predict abnormal SPECT results and ischemic heart disease in patients with no known cardiac history.

Impact of COVID-19 Pandemic on Cardiovascular Testing in Asia

Background

The coronavirus disease-2019 (COVID-19) pandemic significantly affected management of cardiovascular disease around the world. The effect of the pandemic on volume of cardiovascular diagnostic procedures is not known.

Objectives

This study sought to evaluate the effects of the early phase of the COVID-19 pandemic on cardiovascular diagnostic procedures and safety practices in Asia.

Methods

The International Atomic Energy Agency conducted a worldwide survey to assess changes in cardiovascular procedure volume and safety practices caused by COVID-19. Testing volumes were reported for March 2020 and April 2020 and were compared to those from March 2019. Data from 180 centers across 33 Asian countries were grouped into 4 subregions for comparison.

Results

Procedure volumes decreased by 47% from March 2019 to March 2020, showing recovery from March 2020 to April 2020 in Eastern Asia, particularly in China. The majority of centers cancelled outpatient activities and increased time per study. Practice changes included implementing physical distancing and restricting visitors. Although COVID testing was not commonly performed, it was conducted in one-third of facilities in Eastern Asia. The most severe reductions in procedure volumes were observed in lower-income countries, where volumes decreased 81% from March 2019 to April 2020.

Conclusions

The COVID-19 pandemic in Asia caused significant reductions in cardiovascular diagnostic procedures, particularly in low-income countries. Further studies on effects of COVID-19 on cardiovascular outcomes and changes in care delivery are warranted.

Cardiovascular and All-Cause Mortality Risk by Coronary Artery Calcium Scores and Percentiles Among Older Adult Males and Females

BACKGROUND

Coronary calcium is a marker of coronary atherosclerosis and established predictor of cardiovascular risk in general populations; however, there are limited studies examining its prognostic value among older adults (≥75 years) and even less regarding its utility in older males compared with females. Accordingly, we sought to examine the prognostic significance of both absolute and percentile coronary calcium scores among older adults.

METHODS

The multicenter Coronary Artery Calcium Consortium consists of 66,636 asymptomatic patients without cardiovascular disease. Participants ages ≥75 were included in this study and stratified by sex. Multivariable Cox regression models were constructed to assess cardiovascular and all-cause mortality risk by Agatston coronary calcium scores and percentiles.

RESULTS

Among 2,474 asymptomatic patients (mean age 79 years, 10.4-year follow-up), prevalence of coronary artery calcium was 92%. For both sexes, but in females more so than males, higher coronary calcium score and percentiles were associated with increased cardiovascular and all-cause mortality risk. Those at the lowest coronary calcium categories (0-9 and <25 percentile) had significantly lower risk of cardiovascular and all-cause mortality relative to the rest of the population. Multivariable analyses of traditional cardiovascular risk factors and coronary artery calcium variables revealed that age and coronary calcium were the strongest independent predictors for adverse outcomes.

CONCLUSIONS

Both coronary artery calcium scores and percentiles are strongly predictive of cardiovascular and all-cause mortality among older adults, with greater risk-stratification among females than males. Both low coronary artery calcium scores 0-9 and <25th percentile define relatively low risk older adults.

Relation of Intake of Saturated Fat to Atherosclerotic Risk Factors, Health Behaviors, Coronary Atherosclerosis, and All-Cause Mortality Among Patients Who Underwent Coronary Artery Calcium Scanning

Although very brief questionnaires are commonly used to assess physical activity, an analogous approach for assessing diet quality within clinical practice has not been developed. Thus, we undertook an exploratory study to evaluate the association between a single-item questionnaire regarding dietary quality and patient risk profiles, lifestyle habits, lipid values, coronary artery calcium (CAC) scores and mortality. We assessed 15,368 patients who underwent CAC scanning, followed for a median of 12.1 years for all-cause mortality. Diet quality was assessed according to a single-item question regarding self-reported adherence to a low saturated fat diet (0 = never, 10 = always), with patients categorized into 4 dietary groups based on their response, ranging from low to very high saturated fat intake. We observed a significant stepwise association between reported saturated fat intake and smoking, exercise activity, obesity, and serum cholesterol, low density lipoprotein, and triglyceride values. Following adjustment for age and risk factors, patients reporting very high saturated fat intake had an elevated hazard ratio for mortality versus low saturated fat intake: 1.22 (95% confidence interval 1.04 to 1.44). The hazard ratio was no longer significant after further adjustment for exercise activity. Upon division of patients according to baseline CAC, a stepwise relationship was noted between increasing saturated fat intake and mortality among patients with CAC scores ≥400 (p = 0.002). Thus, within our cohort, just a single-item exploratory questionnaire regarding very high saturated fat intake revealed stepwise associations with health behaviors and cardiac risk factors, suggesting the basis for further development of a practical dietary questionnaire for clinical purposes.

Associations Among Self-reported Physical Activity, Coronary Artery Calcium Scores, and Mortality Risk in Older Adults

Objective

To assess whether self-reported physical activity during daily life reduces the mortality risk associated with atherosclerotic burden, as measured by coronary artery calcium (CAC) scanning.

Methods

We assessed 2318 patients aged 65 to 84 years who underwent CAC scanning from August 31, 1998, through November 16, 2016, and had daily life physical activity assessed by a single-item question that was used to divide patients by low, moderate, and high physical activity levels. Patients were followed for a mean ± SD of 10.6±4.9 years for the occurrence of all-cause mortality.

Results

The results indicated a graded relationship between the magnitude of CAC abnormality and mortality and an inverse relationship between physical activity and mortality. Of patients with low CAC scores (0-99), those with low, moderate, and high physical activity levels had similarly low mortality rates. Of patients with high CAC scores (≥400), however, there was a stepwise increase in mortality with decreasing physical activity. Patients with CAC scores of 400 or greater but reporting high physical activity had a mortality rate that was similar vs that observed in patients with CAC scores of only 0 to 99 and low physical activity (19.9 vs 16.3 per 1000 person-years; P=.60).

Conclusion

Combining CAC score with self-reported physical activity level provides a synergistic means for predicting clinical risk in older patients, with high physical activity level substantially attenuating the mortality risk associated with elevated CAC scores. Moreover, the useful prognostic information afforded by just a single-item physical activity questionnaire supports current initiatives to make such assessments into a "fifth vital sign."

Simultaneous Tc-99m PYP/Tl-201 dual-isotope SPECT myocardial imaging in patients with suspected cardiac amyloidosis

INTRODUCTION

Assessment of myocardial uptake of Tc-99m-pyrophosphate (Tc-99m PYP) is pivotal in distinguishing transthyretin-associated cardiac amyloidosis (ATTR) from light chain amyloid (AL). It is often difficult to differentiate myocardial uptake from blood pool radioactivity with planar imaging or SPECT. We studied whether simultaneous dual-isotope Tc-99m PYP/Tl-201 SPECT improves assessment of Tc-99m PYP uptake compared to single-isotope SPECT.

METHODS

Simultaneous Tc-99m PYP/Tl-201 dual-isotope SPECT was acquired in 112 patients studied for possible cardiac amyloidosis. Visual interpretation was performed by two observers on single-isotope followed by dual-isotope SPECT. Heart-to-contralateral lung ratio (H/CL) of myocardial counts quantified by single-isotope and dual-isotope SPECT was compared between ATTR, AL, and no amyloidosis groups.

RESULTS

In 112 patients (39 ATTR and 26 AL patients, and 47 no amyloidosis), a lower proportion of no amyloidosis and AL patients were classified visually as equivocal with dual-isotope SPECT compared to single-isotope SPECT (2% vs 19%, P = 0.02 and 8% vs 35%, P = 0.04, respectively). H/CL measurements with single-isotope and dual-isotope were lower in AL and no amyloidosis patients vs ATTR patients (P < 0.05). Interobserver agreement of visual assessment was improved with dual-isotope SPECT (P = 0.03). AUCs for detection of ATTR by visual assessment and H/CL quantification were higher with dual-isotope (0.94 and 0.95, respectively) compared to single-isotope SPECT (0.84, P = 0.001 and 0.92, P = 0.02).

CONCLUSION

Tc-99m PYP/Tl-201 SPECT improves visual differentiation of ATTR and AL amyloidosis compared to single-isotope SPECT. Visual assessment and H/CL quantitation with dual-isotope SPECT provide similar discrimination between patients with ATTR and AL amyloidosis.

Risk of Stroke, Bleeding, and Death in Patients with Nonvalvular Atrial Fibrillation and Chronic Kidney Disease

INTRODUCTION

Atrial fibrillation (AF) and chronic kidney disease (CKD) are both associated with increased risk of stroke, and CKD carries a higher bleeding risk. Oral anticoagulation (OAC) treatment is used to reduce the risk of stroke in patients with nonvalvular AF (NVAF); however, the risk versus benefit of OAC for advanced CKD is continuously debated. We aim to assess the management and outcomes of NVAF patients with impaired renal function within a population-based cohort.

METHODS

We conducted a retrospective observational cohort study using ICD-9 healthcare coding. Patients with incident NVAF between 2004 and 2015 were identified stratified by CKD stage. We compared treatment strategies and estimated risks of stroke, death, or any major bleeding based on CKD stages and OAC treatment.

RESULTS

We identified 85,116 patients with incident NVAF. Patients with impaired renal function were older and had more comorbidities. OAC was most common among stage 2 CKD patients (49%) and least in stages 4-5 CKD patients (27.6%). Higher CKD stages were associated with worse outcomes. Stroke rates increased from 1.04 events per 100 person-years (PY) in stage 1 CKD to 3.72 in stages 4-5 CKD. Mortality increased from 3.42 to 32.95 events/100 PY, and bleeding rates increased from 0.89 to 4.91 events/100 PY. OAC was associated with reduced stroke and intracranial bleeding risk regardless of CKD stage, and with a reduced mortality risk in stages 1-3 CKD.

CONCLUSION

Among NVAF patients, advanced renal failure is associated with higher risk of stroke, death, and bleeding. OAC was associated with reduced stroke and intracranial bleeding risk, and with improved survival in stages 1-3 CKD.

Age- and gender-adjusted percentiles for number of calcified plaques in coronary artery calcium scanning

BACKGROUND

Age- and gender-adjusted percentiles of coronary artery calcium (CAC) score are commonly reported to compare a patient's coronary atherosclerosis burden to that of others of the same age and gender. The number of calcified plaques (numCP) detected on CAC scanning, a measure of plaque diffusivity, is associated with increased cardiovascular risk and, in the intermediate CAC range, adds to the CAC score in predicting mortality. This study aims to develop adjusted percentiles for numCP to provide a better context for understanding CAC scan findings.

METHODS AND RESULTS

Using nonparametric modeling techniques, the distribution of numCP was analyzed in 70,320 consecutive, asymptomatic patients without prior clinically-diagnosed cardiovascular disease who were part of the Coronary Artery Calcium Consortium and supplemented by additional patients referred for clinical CAC scanning in a single center between 1998 and 2016. Nomograms for age-adjusted numCP percentiles for each gender were generated using quantile regression. The prevalence and average number of calcified coronary plaque were found to be higher in men than women. Distribution of numCP in women was found to closely mirror that of men approximately a decade younger. NumCP increased consistently across age groups in both men and women for each quantile category.

CONCLUSIONS

A nomogram for age and gender-adjusted percentiles for the numCP on CAC scans has been developed in a large population of asymptomatic patients studied across multiple centers. This numCP nomogram may provide an additional tool for refining physician recommendations regarding treatment and expressing to patients how their CAC findings relate to others of similar age and gender. The numCP percentiles may also provide a meaningful way to evaluate and report the rate of progression of CAC on serial studies.

Improvement in LDL is associated with decrease in non-calcified plaque volume on coronary CTA as measured by automated quantitative software

BACKGROUND

Computed tomography coronary angiography (CTA) can be used for assessment of plaque characteristics; however, quantitative assessment of changes in plaque composition in response to LDL lowering has not been performed with CTA. We sought to assess the association between LDL reduction and changes in plaque composition with quantitative CTA.

METHODS

Quantification of total, calcified, non-calcified and low-density non-calcified plaque volumes (TPV, CPV, NCPV and LD-NCPV) was performed using semi-automated software in 234 vessels from 116 consecutive patients (89 men, 60 ± 10 years) with baseline LDL>70 mg/dl. Significant reduction in LDL was defined as a decrease by >10% of baseline LDL. Changes (Δ) in plaque volumes between the second and baseline study were compared between patients with LDL reduction (n = 63) and those with no decrease in LDL (n = 53).

RESULTS

Median LDL at baseline was 98 mg/dl [interquartile range (IQR) 83-119 mg/dl] and median ΔLDL was -14 mg/dl (IQR -38 to 3 mg/dl). Mean interval between sequential CTA was 3.5 ± 1.6 years. TPV, NCPV, and LD-NCPV decreased in patients with a reduction in LDL compared to baseline; whereas, patients without reduction in LDL experienced an increase in TPV, NCPV and LD-NCPV. After adjusting for age, statin use, diabetes, baseline LDL and baseline TPV, reduction in LDL was associated with a decrease in TPV (P = 0.005), NCPV (P = 0.002) and LD-NCPV (P = 0.011) compared to patients without a reduction in LDL.

CONCLUSION

Reduction in LDL was associated with beneficial changes in the amount and composition of noncalcified plaque as measured using semi-automated quantitative software by CTA.

Comparison of the Coronary Artery Calcium Score and Number of Calcified Coronary Plaques for Predicting Patient Mortality Risk

Multiple coronary artery calcium (CAC) parameters have recently been proposed to improve risk prediction in patients with intermediate clinical risk based on CAC scoring, but outcome data that assess these variables are relatively sparse. We analyzed data from 11,633 consecutive asymptomatic patients undergoing CAC scanning that were followed for 8.8 ± 3.5 years for all-cause mortality (ACM). The patients who had coronary artery calcification were grouped by the number of calcified coronary plaques: 0, 1 to 5, 6 to 20, and >20 plaques. We examined the independent prognostic value of plaque number and its synergistic prognostic value when added to the CAC score. We observed a stepwise increase in ACM with increasing plaque number. In patients with a CAC score of 1 to 99, 6 plaques or more were associated with increased mortality. In patients with CAC scores of 100 to 399, there was a stepwise increase in ACM with increasing plaque number. For CAC >400, the risk of ACM was high regardless of plaque number. After risk adjustment, the number of plaques was a significant predictor of risk for ACM in the patients with an intermediate CAC score. In these patients, additional consideration of plaque number improved net reclassification improvement for predicting ACM by 29%. In conclusion, the number of calcified plaques adds to risk stratification beyond the CAC score in patients with intermediate CAC scores.

Impact of Exercise on the Relationship Between CAC Scores and All-Cause Mortality

OBJECTIVES

This study aims to assess the correlations among coronary artery calcium (CAC), self-reported exercise, and mortality in asymptomatic patients.

BACKGROUND

The interaction between reported exercise habits and CAC scores for predicting clinical risk is not yet well known.

METHODS

We followed 10,690 asymptomatic patients who underwent CAC scanning. Patients were divided into 4 groups based on a single-item self-reported exercise. Mean follow-up was 8.9 ± 3.5 years for the occurrence of all-cause mortality (ACM).

RESULTS

Annualized ACM progressively increased with increasing CAC score (p < 0.001) and decreasing exercise (p < 0.001). Among patients with CAC scores of 0, ACM was low regardless of the amount of exercise. Among patients with CAC scores from 1 to 399, there was a stepwise increase in ACM for each reported decrement in exercise, and this difference was markedly more pronounced among patients with CAC scores ≥400. Compared with highly active patients with a CAC score of 0, highly sedentary patients with CAC scores ≥400 had a 3.1-fold increase (95% confidence interval: 1.35 to 7.11) in adjusted ACM risk. Our single-item physical activity questionnaire was also predictive of risk factors and clinical and lipid profile measurements.

CONCLUSIONS

In asymptomatic patients, self-reported exercise is a significant predictor of long-term outcomes. Prognostic value of the reported exercise is additive to the increasing degree of underlying atherosclerosis. Among patients with high CAC scores, exercise may play a protective role, whereas reported minimal or no exercise substantially increases clinical risk. Our results suggest there is clinical utility for the use of a simple single-item exercise questionnaire for such assessments.

Automatic Valve Plane Localization in Myocardial Perfusion SPECT/CT by Machine Learning: Anatomic and Clinical Validation

Precise definition of the mitral valve plane (VP) during segmentation of the left ventricle for SPECT myocardial perfusion imaging (MPI) quantification often requires manual adjustment, which affects the quantification of perfusion. We developed a machine learning approach using support vector machines (SVM) for automatic VP placement. Methods: A total of 392 consecutive patients undergoing ^99mTc-tetrofosmin stress (5 min; mean ± SD, 350 ± 54 MBq) and rest (5 min; 1,024 ± 153 MBq) fast SPECT MPI attenuation corrected (AC) by CT and same-day coronary CT angiography were studied; included in the 392 patients were 48 patients who underwent invasive coronary angiography and had no known coronary artery disease. The left ventricle was segmented with standard clinical software (quantitative perfusion SPECT) by 2 experts, adjusting the VP if needed. Two-class SVM models were computed from the expert placements with 10-fold cross validation to separate the patients used for training and those used for validation. SVM probability estimates were used to compute the best VP position. Automatic VP localizations on AC and non-AC images were compared with expert placement on coronary CT angiography. Stress and rest total perfusion deficits and detection of per-vessel obstructive stenosis by invasive coronary angiography were also compared. Results: Bland-Altman 95% confidence intervals (CIs) for VP localization by SVM and experts for AC stress images (bias, 1; 95% CI, -5 to 7 mm) and AC rest images (bias, 1; 95% CI, -7 to 10 mm) were narrower than interexpert 95% CIs for AC stress images (bias, 0; 95% CI, -8 to 8 mm) and AC rest images (bias, 0; 95% CI, -10 to 10 mm) (P < 0.01). Bland-Altman 95% CIs for VP localization by SVM and experts for non-AC stress images (bias, 1; 95% CI, -4 to 6 mm) and non-AC rest images (bias, 2; 95% CI, -7 to 10 mm) were similar to interexpert 95% CIs for non-AC stress images (bias, 0; 95% CI, -6 to 5 mm) and non-AC rest images (bias, -1; 95% CI, -9 to 7 mm) (P was not significant [NS]). For regional detection of obstructive stenosis, ischemic total perfusion deficit areas under the receiver operating characteristic curve for the 2 experts (AUC, 0.79 [95% CI, 0.7-0.87]; AUC, 0.81 [95% CI, 0.73-0.89]) and the SVM (0.82 [0.74-0.9]) for AC data were the same (P = NS) and were higher than those for the unadjusted VP (0.63 [0.53-0.73]) (P < 0.01). Similarly, for non-AC data, areas under the receiver operating characteristic curve for the experts (AUC, 0.77 [95% CI, 0.69-0.89]; AUC, 0.8 [95% CI, 0.72-0.88]) and the SVM (0.79 [0.71-0.87]) were the same (P = NS) and were higher than those for the unadjusted VP (0.65 [0.56-0.75]) (P < 0.01). Conclusion: Machine learning with SVM allows automatic and accurate VP localization, decreasing user dependence in SPECT MPI quantification.

Vitamin D inflammatory cytokines and coronary events: a comprehensive review

Myocardial infarction (MI) is the most common cause of cardiac injury in the Western world. Cardiac injury activates innate immune mechanisms initiating an inflammatory reaction. Inflammatory cytokines and vascular cell adhesion molecules (VCAM) promote adhesive interactions between leukocytes and endothelial cells, resulting in the transmigration of inflammatory cells into the site of injury. Low vitamin D levels are associated with higher prevalence of cardiovascular risk factors and a higher risk of MI. In this paper, we examine the effects of short-term vitamin D supplementation on inflammatory cytokine levels after an acute coronary syndrome. We recruited patients arriving to the hospital with an acute MI. All patients received optimal medical therapy and underwent a coronary catheterization. Half of the patients were randomly selected and treated with a daily supplement of vitamin D (4,000 IU) for 5 days. A short course of treatment with vitamin D effectively attenuated the increase in circulating levels of inflammatory cytokines after an acute coronary event. Control group patients had increased cytokine and cellular adhesion molecules serum concentrations after 5 days, while the vitamin D-treated group had an attenuated elevation or a reduction of these parameters. There were significant differences in VCAM-1 levels, C-reactive protein, and interleukin-6. There were trends toward significance in interleukin-8 levels. There were no significant differences in circulating levels of intercellular adhesion molecule 1, E-selectin, vascular endothelial growth factor, and tumor necrosis factor-α. These findings provide information on the anti-inflammatory effects of vitamin D on the vascular system and suggest mechanisms that mediate some of its cardioprotective properties. There is place for further studies involving prolonged vitamin D treatment in patients suffering from ischemic heart disease.

Vitamin D deficiency is associated with poor outcomes and increased mortality in severely ill patients

BACKGROUND

Vitamin D plays a seminal role in many homeostatic mechanisms. In this study, we assessed the correlation between circulating vitamin D levels and mortality rates in critically ill patients.

METHODS

All patients admitted to the intensive care units (ICUs) and internal medicine wards in a university-based hospital that required mechanical ventilation were admitted. Data collected included the underlying disease, basic hematological and biochemical blood test results, APACHE II scores and serum 25-hydroxyvitamin D [25(OH)D] levels. The primary end point was defined as all-cause mortality within 60 days from admission or from acute deterioration.

RESULTS

Between December 2008 and June 2009, 130 patients were enrolled. Average vitamin D concentration was 14.04 ± 6.9 ng/ml; 107 patients were vitamin D deficient (< 20 ng/ml). Total mortality rate after 60 days was 44.3%. Vitamin D levels were correlated with white blood cell (WBC) count, but with no other measured variable. Among the deceased patients, survival curves indicated that survival of patients with vitamin D deficiency was significantly shorter than those whose vitamin D concentration was >20 ng/ml (P < 0.05); the average survival time was 15.3 ± 12.4 days for vitamin D deficient patients compared with 24.2 ± 16.5 days among those with normal vitamin D levels.

CONCLUSION

This study demonstrated that low vitamin D levels are common among patients admitted to ICU. We observed longer survival times among vitamin D sufficient patients. Our results indicate that vitamin D concentration may be either a biomarker of survival or a co-factor. We recommend assessing the effects of vitamin D supplementation in critically ill patients.

Low serum vitamin D concentrations in patients with schizophrenia

BACKGROUND

Vitamin D is increasingly associated with the pathology of cognition and mental illness. Vitamin D receptors have been detected on neurons that regulate behavior.

OBJECTIVE

To assess vitamin D serum concentrations in patients with major depression and schizophrenia as compared to healthy controls and to determine if a correlation exists between serum levels of vitamin D and disease activity.

METHODS

We recruited 50 patients with schizophrenia and compared them to 33 patients with major depression and 50 controls with no major psychopathology. The Positive and Negative Syndrome Scale (PANSS) for schizophrenia and the Hamilton Depression scale for depression were administered on the same day the blood samples were drawn. We used LIAISON 25-OH vitamin D (DiaSorin) immunoassay to measure serum concentrations of 25-OH vitamin D.

RESULTS

Lower serum vitamin D concentrations were detected among patients with schizophrenia (15.0 +/- 7.3 ng/ml) compared to patients with depression (19.6 +/- 8.3 ng/ml) and to controls (20.2 +/- 7.8 ng/ml, P < 0.05). We found no correlation between disease activity, measured by the PANSS score, and vitamin D levels.

CONCLUSIONS

Serum vitamin D levels were lower in patients with schizophrenia as compared to patients with depression and to healthy controls. No correlation was found between serum concentration and disease activity. Additional studies are needed to elucidate the role of vitamin D in the autoimmune mechanism and in the pathogenesis of schizophrenia.

Screening for common neurologic diseases among Israeli adolescents

Neurologic disorders are the common causes of morbidity among adolescents. The estimated prevalence of common neurologic disorders relies on relatively small samples. We aimed to identify the prevalence of common neurologic disorders among Israeli adolescents. In Israel, all 17-year-old Israeli nationals are required to undergo a health-screening examination at the Israel Defense Forces recruiting office. Neurology specialists evaluate and classify suspected neurologic disorders. The findings included a high prevalence of neurologic morbidity among the 94 805 adolescents (61.5% males and 39.5% females) examined in 2001. The most prevalent diagnoses were headaches and learning disorders. The frequency of chronic headache in this study was relatively low. A significant difference in morbidity patterns between male and female adolescents was noted. Overall, we found that the prevalence of chronic, frequent headaches among adolescents is much lower than that reported previously. Headache, learning disability, epilepsy, and infectious or traumatic head injury were the most common diagnoses.

Effects of tobacco smoke on immunity, inflammation and autoimmunity

Smoking is a central factor in many pathological conditions. Its role in neoplasm, lung and cardiovascular diseases has been well established for years. However it is less acknowledged the cigarette smoking affects both the innate and adoptive immune arms. Cigarette smoke was shown to augment the production of numerous pro-inflammatory cytokines such as TNF-alpha, IL-1, IL-6, IL-8 GM-CSF and to decrease the levels of anti-inflammatory cytokines such as IL-10. Tobacco smoke via multiple mechanisms leads to elevated IgE concentrations and to the subsequent development of atopic diseases and asthma. Cigarette smoke has also been shown activate in many ways macrophage and dendritic cell activity. While it is better evident how cigarette smoke evokes airway diseases more mechanisms are being revealed linking this social hazard to autoimmune disorders, for instance via the production of antibodies recognizing citrullinated proteins in rheumatoid arthritis or by the elevation of anti-dsDNA titers in systemic lupus erythematosus. The current review underlines the importance of smoking prevention and eradication not only in respiratory disorders but also in autoimmune conditions as well.

Arrhythmias and conduction defects in rheumatological diseases--a comprehensive review

OBJECTIVES

To review the clinical aspects of cardiac arrhythmias and conduction disturbances in several common and less encountered adult rheumatic diseases and to underline the importance of prompt diagnosis and management in these patients.

METHODS

The PubMed database was searched for articles published between the years 1960 and 2008 for keywords referring to autoimmune diseases. All relevant English-written articles were reviewed. Most were uncontrolled series and case reports, due to the lack of prospective studies and randomized trials.

RESULTS

Rheumatologic conditions may affect the cardiovascular system and increase morbidity and mortality. Rhythm and conduction defects are usually mild but may be life-threatening; in certain diseases, such as in systemic lupus erythematosus they may resolve following therapy with corticosteroids. Conduction defects occur frequently in patients with spondyloarthropathies and in those with various forms of vasculitis. Enhanced variation of the QT interval may be a sensitive marker of a higher arrythmogenic tendency in patients with autoimmune conditions.

CONCLUSIONS

It is important to identify patients at high risk for cardiac arrhythmias. Treating such patients with arrhythmias should not differ fundamentally from other patients. Nevertheless, appropriate clinical attention and judgment should be applied to exclude the possibility that arrhythmias reflect uncontrolled myocardial inflammation.

The role of infections in the immunopathogensis of systemic sclerosis--evidence from serological studies

Infections are believed to often play a role in the immunopathogenesis of autoimmune disorders; such is the case in systemic sclerosis (SSc). In order to evaluate the potential role infections may have on the pathogenesis of SSc, we assessed serological reactivity against various infectious agents in patients with SSc and compared them with healthy controls. Serological samples obtained from 80 patients with SSc were compared with 296 compatible healthy controls. Both groups were of European origin. All samples were tested for the presence of antibodies directed against hepatitis B virus, hepatitis C virus, toxoplasmosis, rubella, CMV, EBV, and Treponema pallidum. We applied Bio-Rad commercial and experimental kits to assess most antigens and ELISA assays to complete the panel. Patients with SSc had elevated IgM and IgG against Toxoplasma gondii and against CMV. Higher titers were also detected against the hepatitis B virus core protein (recombinant HBc antigen) using MONOLISA anti-HBc Plus commercial kit (Bio-Rad). A significantly higher rate of IgM antibodies against the capsid antigen of the EBV was detected in SSc patients compared with healthy controls, as well. These data demonstrate that antibodies against CMV, HBV, and toxoplasmosis were detected more often in patients with SSc. This association implies that infectious agents may have a role in disease pathogenesis and expression.

Hepatotoxicity rates do not differ in patients with rheumatoid arthritis and psoriasis treated with methotrexate

OBJECTIVE

MTX hepatotoxicity is considered to occur more frequently in patients with psoriasis than in patients with RA. However, toxicity guidelines are based on reports from studies with small sample sizes and limited follow-up periods. The current study's objective was to examine the long-term risk of MTX hepatotoxicity based on a database review of patients with RA or psoriasis, and to examine whether the two populations differed.

METHODS

We conducted a retrospective cohort review among members of a large health maintenance organization (HMO) in Israel who were diagnosed with either RA (n = 119) or psoriasis (n = 690) and who had purchased at least one dose of MTX. Liver function analyses were performed serially in these patients during the follow-up. All abnormal assays were recorded in the computerized database of the HMO.

RESULTS

Both groups had hepatic enzyme elevation; the pre-disposing factors predictive of liver damage were female gender and a higher cumulative dose of MTX (hazard ratios, 1.46 and 1.07, respectively, P < 0.001). Age, concurrent diseases and type of disease had no influence on susceptibility to liver damage. No statistically significant difference was detected in any abnormal liver function test among patients with either RA or psoriasis.

CONCLUSION

Our study did not corroborate previous findings of significant differences between psoriasis patients and RA patients concerning susceptibility to hepatotoxicity from MTX therapy. The only significant factor predicting a higher risk of hepatic damage was female gender.

Secondary syphilis presenting as SAPHO syndrome features

The SAPHO syndrome may evolve following low virulent infections. This report describes a patient who developed a clinical syndrome that complied with the formal diagnostic criteria of the SAPHO following an infection with syphilis. His clinical manifestations gradually resolved following antibiotic therapy. This interesting association underlines the pathogenic circumstances linking infections and various rheumatic conditions. It is less evident whether resolution of the symptoms was ascribed to the eradication of the bacteria or perhaps due to cessation of the auto-inflammatory reaction to the infection induced. In our description we suggest a correlation between infection with Treponema pallidum and the induction of SAPHO syndrome.

Physical activity protects male patients with post-traumatic stress disorder from developing severe fibromyalgia

OBJECTIVES

Fibromyalgia syndrome (FMS) has been associated with various psychiatric and other, ill-defined disorders. We recently showed that fibromyalgia is more prevalent in men suffering from combat-related Post Traumatic Stress Disorder (PTSD). In this paper we analyze the relationship between engagement in physical activity, the psycho-metric traits of PTSD and the future development of FMS.

METHODS

Fifty-five male patients, all known to have combat-related PTSD, were investigated for the presence of fibro-myalgia according to the American College of Rheumatology (ACR) criteria. Each patient completed questionnaires characterizing his quality of sleep, and the Sheehan Disability Scale measuring performance in the familial, social and vocational spheres. Additionally, each of the enrollees was interviewed by an experienced psychiatrist, who then completed a Clinician Administered PTSD Scale, a Clinical Global Impression Scale, and calculated an SF-36 score. Each patient was asked whether he exercised often, occasionally or not at all. The data was analyzed by the chi2 test and by ANOVA.

RESULTS

PTSD patients who also suffered from FMS had a more severe form of disease as measured by the Clinician Administered PTSD Scale (CAPS) score, 88.2 +/- 14.0 (n = 28) compared to 97.6 +/- 13.2 of patients with PTSD and FMS (n = 27) (p = 0.013, F(d.f 2)-6.61, ANOVA test). Interestingly, engaging in physical exercise was also associated with less severe disease. When the patients were analyzed based on their tender point count (0-5, 6-10, or > 11), the number of tender points decreased with increasing physical activity (p = 0.02, chi2(d.f.-4) = 11.3).

CONCLUSION

Physical exercise in male patients with combat-related PTSD provides protection from the future development of fibromyalgia. Furthermore, physical activity is related in this group of patients to a better perception of their quality of life.

Vitamin D and autoimmunity: new aetiological and therapeutic considerations

Vitamin D is frequently prescribed by rheumatologists to prevent and treat osteoporosis. Several observations have shown that vitamin D inhibits proinflammatory processes by suppressing the enhanced activity of immune cells that take part in the autoimmune reaction. Moreover, recent evidence strongly suggests that vitamin D supplementation may be therapeutically beneficial, particularly for Th1-mediated autoimmune disorders. Some reports imply that vitamin D may even be preventive in certain disorders such as multiple sclerosis and diabetes type 1. It seems that vitamin D has crossed the boundaries of calcium metabolism and has become a significant factor in a number of physiological functions, specifically as a biological inhibitor of inflammatory hyperactivity.