Tremblay and colleagues asked whether patients receiving either routine anticoagulation or antiplatelet therapy for existing conditions prior to becoming ill with COVID-19 have different outcomes ...from patients receiving neither therapy. After matching for existing comorbidities, this retrospective observational study finds no evidence for an effect of prediagnosis anticoagulation on mortality.
Background: Dermatomyositis (DM) is an idiopathic inflammatory myopathy with various cutaneous manifestations. There is a strong association between DM and malignancy with an estimated 5–7 fold ...increase in cancer incidence in DM patients compared to the general population. Dermatomyositis as a paraneoplastic manifestation has been reported in several malignancies notably ovarian, gastric, colon, cervical, pancreatic, and lung cancer but rarely in prostate cancer ('Table 1'). Case Presentation: A 64-year-old male with a past medical history of hypertension, gout, and type II diabetes was admitted to the hospital following a mechanical fall after which he sustained shoulder and facial trauma. On further evaluation, the patient was found to have dysphagia, dysphonia, proximal upper extremity and lower extremity weakness, and rashes. The dysphagia began one month prior to presentation and the rashes appeared two months prior. Physical exam was notable for erythematous and scaly-dry skin in V-neck pattern, gottron papules, facial and periorbital erythema with scaly skin, periungual erythema, oropharyngeal salivary pooling, proximal bilateral upper and lower extremity weakness with intact distal extremity strength, and wasting of the bilateral quadriceps and hamstrings. Labs were notable for elevated creatine kinase (CPK) 296, positive Anti-p155/140 antibodies which are directed against transcription intermediate family-1 (TIF-1). Further workup with a computed tomography scan (CT) of the abdomen and pelvis revealed extensive pelvic and abdominal lymphadenopathy, centered in the pelvis, and therefore suspicious for either nodal metastasis from prostate adenocarcinoma versus lymphoma. A right inguinal lymph node biopsy was done and confirmed the diagnosis of metastatic adenocarcinoma of the prostatic primary. Staging workup via bone scan and MRI showed diffuse osseous metastases in the thoracolumbar spine ('Figure 1'). Consequently, the patient was started on Bicalutamide and Leuprolide as therapy for the underlying prostate cancer by the inpatient oncology team. The neurology service was consulted for the muscle weakness and were immediately concerned for dermatomyositis. Hence, they recommended empiric treatment with steroids whish were initiated and a biopsy of the left deltoid muscle was obtained. Biopsy results revealed skeletal muscle with perifascicular atrophy and mild mixed inflammatory infiltrate, suggestive of DM ('Figure 2'). Hence, in the setting of the patient’s clinical presentation confirmed the diagnosis of DM likely paraneoplastic. The patient was started on intravenous immunoglobulins (IVIG) in addition to steroids for treatment of DM. The patient’s hospital course was complicated by worsening dysphagia necessitating percutaneous gastric tube placement (PEG), worsening dysphonia, as well as hypoxic respiratory failure requiring a brief intensive care unit admission and non-invasive positive pressure ventilation. The patient slowly regained his speech and his respiratory status improved. He was able to be discharged to a subacute rehab after 37 days of inpatient stay. The patient is still requiring a PEG tube for feeding but his dysphagia has significantly improved, and his rashes have almost resolved. His muscle strength is slowly recovering. He continues to get IVIG sessions and steroids as well as Leuprolide injections every three months for treatment of his metastatic prostate cancer. His prostate-specific antigen (PSA) a marker that is usually elevated in prostate cancer and was markedly elevated in this patient began to downtrend significantly which usually indicates a positive response to therapy. Conclusion: This case illustrates the importance of screening for an underlying malignancy in any patient presenting with DM. Because of the rarity of DM physicians should maintain a high index of suspicion and screen for more cancers than only those reported to be commonly associated with DM. Cases have shown that systemic manifestations of paraneoplastic DM tend to improve following treatment of the underlying malignancy.
Multiple sclerosis (MS) is a complex disease characterized by extensive phenotypic variability. Biomarkers to capture the different aspects of MS heterogeneity, and to help make a diagnosis and ...monitor disease progression, while providing insights into etiopathogenesis and response to treatment, are urgently needed. Omics technologies and research efforts with microRNAs have provide unparalleled opportunities for exploring altered protein profiles associated with molecular mechanisms of disease, substantially expanding the list of candidate biomarkers for MS. This review presents evidence from proteomic studies that have focused on identification of biomarkers released in biofluids as a result of the different pathophysiological processes of MS. Also discussed is the emerging role of miRNAs as complementary biomarkers related to cellular processes occurring in MS patients. Also provided is an overview of candidate biomarkers that have been proposed for elucidating pathophysiological processes and disease activity and for guiding clinical diagnosis and/or therapeutic interventions in MS.
Observational data suggest an acquired prothrombotic state may contribute to the pathophysiology of COVID-19. These data include elevated D-dimers observed among many COVID-19 patients. We present a ...retrospective analysis of admission D-dimer, and D-dimer trends, among 1065 adult hospitalized COVID-19 patients, across 6 New York Hospitals. The primary outcome was all-cause mortality. Secondary outcomes were intubation and venous thromboembolism (VTE). Three-hundred-thirteen patients (29.4%) died, 319 (30.0%) required intubation, and 30 (2.8%) had diagnosed VTE. Using Cox proportional-hazard modeling, each 1 μg/ml increase in admission D-dimer level was associated with a hazard ratio (HR) of 1.06 (95%CI 1.04–1.08, p < 0.0001) for death, 1.08 (95%CI 1.06–1.10, p < 0.0001) for intubation, and 1.08 (95%CI 1.03–1.13, p = 0.0087) for VTE. Time-dependent receiver-operator-curves for admission D-dimer as a predictor of death, intubation, and VTE yielded areas-under-the-curve of 0.694, 0.621, and 0.565 respectively. Joint-latent-class-modeling identified distinct groups of patients with respect to D-dimer trend. Patients with stable D-dimer trajectories had HRs of 0.29 (95%CI 0.17–0.49, p < 0.0001) and 0.22 (95%CI 0.10–0.45, p = 0.0001) relative to those with increasing D-dimer trajectories, for the outcomes death and intubation respectively. Patients with low-increasing D-dimer trajectories had a multivariable HR for VTE of 0.18 (95%CI 0.05–0.68, p = 0.0117) relative to those with high-decreasing D-dimer trajectories. Time-dependent receiver-operator-curves for D-dimer trend as a predictor of death, intubation, and VTE yielded areas-under-the-curve of 0.678, 0.699, and 0.722 respectively. Although admission D-dimer levels, and D-dimer trends, are associated with outcomes in COVID-19, they have limited performance characteristics as prognostic tests.
•We present a retrospective analysis of admission D-dimer, and D-dimer trends, among adults hospitalized for COVID-19.•1065 inpatients from 6 hospitals were included; outcomes included mortality, intubation, and VTE.•Admission D-dimers and D-dimer trends were associated with outcomes in COVID-19.•However, D-dimer levels and trends were limited prognostic tests in COVID-19.•The role of D-dimer levels in COVID-19 clinical decision making remains unclear.
Mounting evidence suggests the safety and efficacy of medical marijuana (MM) in treating chronic ailments, including chronic pain, epilepsy, and anorexia. Despite incremental use of medical and ...recreational cannabinoids, current limited evidence shows generalized unpreparedness of medical providers to discuss or recommend these substances to their patients. Herein, the present study aims to examine internal medicine residents' knowledge of marijuana and their attitude towards its medical use.
This is a descriptive cross-sectional study. A survey with 12 standardized queries was created and distributed among the internal medicine residents from Mount Sinai Morningside-West (MSMW) program from July 2020 to December 2020. Participants included preliminary and categorical residents from post-graduate years one to three. The survey consisted of self-assessment of residents' knowledge on the indication, contraindication, adverse effects of MM.
Eighty-six (59%) out of 145 residents completed the questionnaire. Despite most trainees (70%) having considered certifying the use of MM for their patients, over 90% reported none to little knowledge on its use. Approximately 80% of the surveyed residents expressed willingness to receive an appropriate educational curriculum.
To the best of our knowledge, this is the first study that indicated a critical lack of medical marijuana-related knowledge in surveyed internal medicine residents. In a population with growing cannabis consumption, physician training on the indication, toxicity, and drug interaction of cannabinoids is warranted.
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Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Adenylate kinase 5 (AK5) antibodies are biomarkers of a poorly responsive to immunotherapy, non-paraneoplastic, autoimmune limbic encephalitis. We detected 6 patients (all female, median age: ...72 years 49–80) with identical CSF antibody staining by indirect immunofluorescence on mouse tissues. We identified AK5 as the antigen and confirmed with standardized assays. Three patients with clinical information had limbic encephalitis, inflammatory CSF and mesiotemporal lobe T2 hyperintensities that evolved to atrophy on brain MRI. One patient had burning smell sensation with no evidence of seizures. Despite immunotherapy, minimal improvement was noticed in one patient; all had severe memory deficits remaining.
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•AK5 autoimmunity associates with a poorly responsive to immunotherapy, non-paraneoplastic, autoimmune limbic encephalitis.•AK5-IgG was confirmed in 6 females with identical IgG binding pattern on mouse brain and typical clinical presentation•Smelling disturbances might be an early sign of AK5 autoimmunity and might have an olfactory bulb origin.•Despite immunotherapy, all patients had severe memory deficits remaining.
Hepatocellular carcinoma (HCC) is the most common primary liver cancer and is associated with high mortality rate. Incidence remains high due to the persistent prevalence of viral hepatitis, ...alcoholic cirrhosis, and non-alcoholic fatty liver disease (NFLD). Despite screening efforts, the majority of patients present with advanced disease, add to the high risk of recurrence after curative surgery. Conventional chemotherapy did not alter the nature history of advanced and metastatic HCC. The discovery of multiple tyrosine kinase inhibitors (TKIs) led to the approval of sorafenib as first efficacious therapy. A new era in the treatment paradigm of HCC is evolving. Since the advent of sorafenib as an active treatment option for patients presenting with advanced or metastatic disease, several agents have been examined. This was linked with many failures, and success stories to celebrate. Herein, we describe the historical progress and current advances of systemic therapies post-sorafenib. Lenvatinib, regorafenib, cabozantinib, ramucirumab, pembrolizumab, and nivolumab, are all presently added and available therapeutic options in the advanced setting. The evaluation of novel treatment combinations including anti-angiogenic, TKIs plus checkpoint inhibitors, add to dual checkpoint inhibitors is evolving rapidly starting with the advent of the combination of atezolizumab plus bevacizumab. Combining local and systemic therapies is being actively investigated, as an option for locally advanced disease conventionally treated with locoregional approaches. The horizon remains promising and continues to evolve for HCC a disease long considered with unmet needs.
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