Saturday, October 13, 2018

The cost of an outbreak of carbapenemase-producing Enterobacteriaceae


Report here.

Friday, October 12, 2018

Fludrocortisone versus midodrine for orthostatic hypotension



Abstract

Background Orthostatic hypotension causes ≈80 000 hospitalizations per year in the United States. Treatments for orthostatic hypotension include fludrocortisone, a mineralocorticoid analog that promotes sodium reabsorption; and midodrine, an α‐1 adrenergic agonist that is a direct vasoconstrictor. Although both medications are used to treat orthostatic hypotension, few studies have compared their relative safety.

Methods and Results We compared incidence rates of hospitalizations for all causes, and for congestive heart failure between users of fludrocortisone and users of midodrine in a retrospective cohort study of Tennessee Medicaid adult enrollees (1995–2009). Adjusted incidence rate ratios were calculated using negative binomial regression models. Subgroup analyses based on history of congestive heart failure were conducted. We studied 1324 patients initiating fludrocortisone and 797 patients initiating midodrine. Compared with fludrocortisone users, midodrine users had higher prevalence of cardiovascular conditions. Incidence rates of all‐cause hospitalizations for fludrocortisone and midodrine users were 1489 and 1330 per 1000 person‐years, respectively (adjusted incidence‐rate ratio 1.20, 95% confidence interval, 1.02–1.40). The respective rates of heart failure–related hospitalization were 76 and 84 per 1000 person‐years (adjusted incidence‐rate ratio: 1.33, 95% confidence interval, 0.79–2.56). Among patients with a history of congestive heart failure, the rates of all‐cause hospitalization for fludrocortisone and midodrine were 2448 and 1820 per 1000 person‐years (adjusted incidence‐rate ratio: 1.42, 95% confidence interval, 1.07–1.90), and the respective rates of heart failure exacerbation–related hospitalizations were 297 and 263 per 1000 person‐years (adjusted incidence‐rate ratio: 1.48, 95% confidence interval, 0.69–3.16).

Conclusions Compared with users of midodrine, users of fludrocortisone had higher rates of all‐cause hospitalizations, especially among patients with congestive heart failure.

Clinical Perspective

What Is New?

This is the first study to evaluate the comparative safety of fludrocortisone and midodrine, 2 drugs commonly used for the treatment of orthostatic hypotension.

Fludrocortisone use was associated with increased risk of all‐cause hospitalizations, particularly among patients with prevalent history of heart failure and orthostatic hypotension.

What Are the Clinical Implications?

Our findings should help inform healthcare providers about safety of fludrocortisone use in patients with orthostatic hypotension.

Our findings could be used to aid healthcare providers to make treatment decisions for patients with orthostatic hypotension.

In patients with heart failure and orthostatic hypotension, fludrocortisone should not be used.

Thursday, October 11, 2018

Oral agents for type 2 diabetes: ACP guidelines




Recommendation 1:


ACP recommends that clinicians prescribe metformin to patients with type 2 diabetes when pharmacologic therapy is needed to improve glycemic control. (Grade: strong recommendation; moderate-quality evidence)
Recommendation 2:


ACP recommends that clinicians consider adding either a sulfonylurea, a thiazolidinedione, an SGLT-2 inhibitor, or a DPP-4 inhibitor to metformin to improve glycemic control when a second oral therapy is considered. (Grade: weak recommendation; moderate-quality evidence.) ACP recommends that clinicians and patients select among medications after discussing benefits, adverse effects, and costs.


Appendix table 1 has a nice summary on outcomes.

Wednesday, October 10, 2018

Adrenal insufficiency due to chronic opiate use



Available data from small heterogeneous studies suggest that 9% to 29% of patients receiving long-term treatment with opiates have development of adrenal insufficiency. However, predictors and the timing of the OIAI onset are unclear. Given the widespread use of narcotics in every field of medicine, physicians should be aware of the potential for endocrine-related adverse effects, in particular OIAI. We suggest careful consideration of OIAI in any patient receiving long-term opiate therapy who manifests symptoms and signs suggestive of adrenal insufficiency. Prospective large studies need to be designed with the goals of elucidating factors associated with OIAI, developing the best approach to case detection of OIAI, and establishing an appropriate management and monitoring plan.



Tuesday, October 09, 2018

Monday, October 08, 2018

Obfuscation of the language: assisted suicide and euthanasia are now medical assistance in dying (MAID)


Sunday, October 07, 2018

TAVR reverses the acquired Von Willebrand syndrome in severe aortic stenosis



Abstract

Background

In this study, we sought to analyze the incidence and relevance of von Willebrand factor (VWF) abnormalities in patients undergoing transcatheter aortic valve implantation (TAVI), especially on perioperative bleeding. Furthermore, we hypothesized that, similar to aortic valve surgery, TAVI results in a restoration of VWF abnormalities.

Methods and results

We performed a prospective analysis of periinterventional VWF parameters in 74 patients (80 ± 7 years, female in 37.5%) undergoing transfemoral TAVI for severe symptomatic aortic valve stenosis. At baseline, VWF:Ag was 210 ± 90 IU/dl with a mean VWF activity of 166 ± 106 IU/dl; activity-to-antigen ratio was 0.85 ± 0.45. Heyde's syndrome (severe aortic stenosis plus GI bleeding from angiodyplasia) was observed in 2/74 (2.7%). Whereas preprocedural loss of high-molecular-weight (HMW) VWF multimers was found in thirty-six patients (48.6%), none of the patients fulfilled criteria for possible acquired VW syndrome. After TAVI, an increase of both VWF:Ag and activity compared to baseline was observed (p less than 0.01). In patients with HMW multimer loss, post-interventional recovery of multimers occurred in all cases. In the two patients with Heyde's syndrome, a trend towards reduced VWF:Ag was seen, with loss of HMW multimers in one patient. Of interest, all patients suffering from periprocedural major bleeding (5/74; 6.8%) exhibited activity-to-antigen ratios less than 0.7, indicating subclinical VWF dysfunction.

Conclusion

Whereas clinically relevant VWF dysfunction is rare, loss of HMW VWF multimers is common in TAVI patients. Similar to surgery, TAVI leads to a restoration of this loss. Furthermore, VWF parameters may be useful parameter to evaluate risk of periprocedural bleeding.

PE related cardiac arrest



Abstract

Aim

Pulmonary Embolism (PE) is a relatively common cardiovascular condition, occasionally and tragically manifesting as Sudden Cardiac Arrest (SCA). The natural history of SCA complicating PE has been poorly evaluated.In this study, we described the management and outcome of PE-related SCA.

Methods

In this prospective population-­based study, we included all patients admitted at hospital alive after out­ of­ hospital SCA, in Paris and suburbs, France (6.6 million inhabits), from May 2011 to September 2015.

Results

Of 2926 patients hospitalized after SCA, 82 cases were diagnosed as PE-related SCA (2.8%, 95%CI = 2.2–3.4). Systemic thrombolysis was performed in 47 patients (57%), without significant increased risk of major bleeding among patients treated with thrombolysis. 12 patients (15%) were treated with ECLS, 29 patients (36%) had targeted temperature management, and 20 patients (24%) underwent coronary angiography. 94% of PE-related SCA had initial non-shockable rhythm, and were associated with better survival compared with other non-shockable SCA (crude OR = 3.0, 95%CI = 1.7–5.4, P less than 0.001; adjusted OR = 4.1, 95%CI 2.0–8.3, P less than  0.001). Among PE-related SCA, thrombolysis was independently associated with survival (OR = 12.5, 95%CI = 1.8–89.1, P = 0.01). Multiple sensitivity analysis was performed, with consistent results.

Conclusions

PE is responsible of approximately 3% of hospitalizations for SCA. Thrombolysis was associated with an increased survival in this population, reinforcing current guidelines advocating for such treatment in PE-related SCA.


Obesity related digestive diseases


From a free full text review:

Obesity is a growing medical and public health problem worldwide. Many digestive diseases are related to obesity. In this article, the current state of our knowledge of obesity-related digestive diseases, their pathogenesis, and the medical and metabolic consequences of weight reduction are discussed. Obesity-related digestive diseases include gastroesophageal reflux disease, Barrett’s esophagus, esophageal cancer, colon polyp and cancer, nonalcoholic fatty liver disease, hepatitis C-related disease, hepatocellular carcinoma, gallstone, cholangiocarcinoma, and pancreatic cancer. Although obesity-related esophageal diseases are associated with altered mechanical and humoral factors, other obesity-related digestive diseases seem to be associated with obesity-induced altered circulating levels of adipocytokines and insulin resistance. The relationship between functional gastrointestinal disease and obesity has been debated. This review provides a comprehensive evaluation of the obesity-related digestive diseases, including pathophysiology, obesity-related risk, and medical and metabolic effects of weight reduction in obese subjects.


Saturday, October 06, 2018

Practical aspects of outpatient management of PE



Highlights

•Selected patients with acute pulmonary embolism can be safely treated at home.
•Eligibility criteria are firstly pragmatic as those regrouped in the HESTIA rule.
•Severity criteria as a low PESI score are sometimes used in addition.
•A specific procedure for outpatient care of PE patients must be provided.

Abstract

Despite clear potential benefits of outpatient care, most patients suffering from pulmonary embolism (PE) are currently hospitalized due to the fear of possible adverse events. Nevertheless, some teams have increased or envisage to increase outpatient treatment or early discharge.

We performed a narrative systematic review of studies published on this topic. We identified three meta-analyses and 23 studies, which involved 3671 patients managed at home (n = 3036) or discharged early (n = 535). Two main different approaches were applied to select patients eligible for outpatient in recent prospective studies, one based on a list of pragmatic criteria as the HESTIA rule, the other adding severity criteria (i.e. risk of death) as the Pulmonary Embolism Severity Criteria (PESI) or simplified PESI. In all these studies, a specific follow-up was performed for patients managed at home involving a dedicated team. The overall early (i.e. between 1 to 3 months) complication rate was low, less than 2% for thromboembolic recurrences or major bleedings and less than 3% for deaths with no evidence in favour of one selection strategy or another.

Outpatient management appears to be feasible and safe for many patients with PE.

In the coming years, outpatient treatment may be considered as the first line management for hemodynamically stable PE patients, subject to the respect of simple eligibility criteria and on the condition that a specific procedure for outpatient care is developed in advance.





We could be treating more PE patients at home



Careful clinical assessment to determine which patients are at low risk is important but maybe that’s too much trouble for some.

Enoxaparin dose for VTE prophylaxis in obese patients



The higher dose in obese patients was associated with better anti-Xa levels and no increase in bleeding. This was a small study.


Friday, October 05, 2018

PE hiding out in COPD exacerbation





Background Patients with COPD experience episodes of increased inflammation, so-called acute exacerbations of COPD (AE-COPD). In 30% of AE-COPD cases, no clear cause is found. Since there is well-known cross talk between inflammation and thrombosis, the objectives of this study were to determine the prevalence, embolus localization, clinical relevance, and clinical markers of pulmonary embolism (PE) in unexplained AE-COPD.

Methods A systematic search was performed using MEDLINE and EMBASE platforms from 1974 to October 2015. Prospective and cross-sectional studies that included patients with AE-COPD and used pulmonary CT-angiography for diagnosis of PE were included.

Results The systematic search resulted in 1,650 records. The main reports of 22 articles were reviewed, and 7 studies were included. The pooled prevalence of PE in unexplained AE-COPD was 16.1% (95% CI, 8.3%-25.8%) in a total of 880 patients. Sixty-eight percent of the emboli found were located in the main pulmonary arteries, lobar arteries, or interlobar arteries. Mortality and length of hospital admission seemed to be increased in patients with unexplained AE-COPD and PE. Pleuritic chest pain and cardiac failure were more frequently reported in patients with unexplained AE-COPD and PE. In contrast, signs of respiratory tract infection was less frequently related to PE.

Conclusions PE is frequently seen in unexplained AE-COPD. Two-thirds of emboli are found at locations that have a clear indication for anticoagulant treatment. These findings merit clinical attention. PE should receive increased awareness in patients with unexplained AE-COPD, especially when pleuritic chest pain and signs of cardiac failure are present, and no clear infectious origin can be identified.


Update on procalcitonin use to facilitate antibiotic stewardship


Obesity, body fat distribution and cancer risk



Background:

We evaluated the associations of anthropometric indicators of general obesity (body mass index, BMI), an established risk factor of various cancer, and body fat distribution (waist circumference, WC; hip circumference, HC; and waist-to-hip ratio, WHR), which may better reflect metabolic complications of obesity, with total obesity-related and site-specific (colorectal and postmenopausal breast) cancer incidence.

Methods:

This is a meta-analysis of seven prospective cohort studies participating in the CHANCES consortium including 18 668 men and 24 751 women with a mean age of 62 and 63 years, respectively. Harmonised individual participant data from all seven cohorts were analysed separately and alternatively for each anthropometric indicator using multivariable Cox proportional hazards models.

Results:

After a median follow-up period of 12 years, 1656 first-incident obesity-related cancers (defined as postmenopausal female breast, colorectum, lower oesophagus, cardia stomach, liver, gallbladder, pancreas, endometrium, ovary, and kidney) had occurred in men and women. In the meta-analysis of all studies, associations between indicators of adiposity, per s.d. increment, and risk for all obesity-related cancers combined yielded the following summary hazard ratios: 1.11 (95% CI 1.02–1.21) for BMI, 1.13 (95% CI 1.04–1.23) for WC, 1.09 (95% CI 0.98–1.21) for HC, and 1.15 (95% CI 1.00–1.32) for WHR. Increases in risk for colorectal cancer were 16%, 21%, 15%, and 20%, respectively per s.d. of BMI, WC, HC, and WHR…

Conclusions:

BMI, WC, HC, and WHR show comparable positive associations with obesity-related cancers combined and with colorectal cancer in older adults.


Thursday, October 04, 2018

PCSK 9 inhibitors





Reported penicillin allergy was a driver of carbapanem use


Review article on obesity


Here’s a nice review in JACC. The accompanying audio file is free.

Wednesday, October 03, 2018

Dealing with penicillin allergy


Pathways, protocols, core measures, bundles and check lists


The latest on oral anticoagulant reversal



Highlights

•The use of PCC for VKA-associated INR elevation is effective and well-studied.
•Use of Four factor-PCC is superior to FFP for reversal of VKA-associated INR elevation.
•There are no studies on clinical efficacy of non-specific agents for DOAC reversal.

Abstract

Introduction

Approximately 4–6% of patients treated with oral anticoagulants (OAC) will suffer from major hemorrhage or be in need of urgent surgery necessitating anticoagulant reversal therapy. Several new oral anticoagulants and reversal agents have been introduced that make it difficult for physicians to stay updated on the current evidence of reversal management. This study aims to review the recent literature on oral anticoagulation reversal therapy and to present the current evidence in an easily approachable manner.

Materials and methods

A systematic literature search was conducted using PubMed and EMBASE to identify the latest publications on both vitamin K antagonist (VKA) and direct oral anticoagulant (DOAC) reversal strategies. All studies on humans who received any acute reversal management of VKA treatment were included, except case studies. Since only two studies on acute reversal of DOAC treatment have been published, clinical trials on healthy volunteers were also included.

Results

Twenty-one studies with a total of 4783 VKA treated patients, and 12 studies with a total of 529 DOAC treated patients were included. Elevated INR values due to VKA treatment could be reversed (INR less than or equal to 1.5) in 63.1% (95% CI: 61.0–65.2) of study subjects after treatment with 4F-PCC, as compared with 12.2% (95% CI: 8.2–16.2) after treatment with fresh frozen plasma (FFP), (p less than  0.001). Thromboembolism occurred in 1.6% (95% CI: 1.2–2.1) of VKA-patients treated with 4F-PCC, and in 4.5% (95% CI: 2.3–6.7) of FFP-treated patients. To date, reversal of laboratory parameters has been demonstrated for two reversal agents specific to DOACs: idarucizumab for dabigatran reversal and andexanet-alfa for factor Xa-inhibitor reversal.

Conclusions

This review supports the use of PCC for VKA reversal, specifically for 4F-PCC over FFP for laboratory reversal. There are no studies on clinical efficacy of non-specific agents for DOAC reversal and the evidence for laboratory reversal is not consistent.


Tuesday, October 02, 2018

Pan CT scanning to look for occult malignancy after a diagnosis of unprovoked VTE


Periprocedural management of anticoagulation in non-valvular a fib: what the hospitalist needs to know


This expert consensus decision pathway is available as free full text here. It is in line with published guidelines and other posts I have written on this topic. This applies only to non-valvular a fib as the anticoagulation indication.


Monday, October 01, 2018

The pancreatitis activity scoring system (PASS)


Pancreatitis is both vexing and fascinating. The spectrum of severity and complications is wide. Unfortunately, all too often it is not apparent on day one. Complications typically unfold, one organ system at a time, over several days. When admitting a patient with pancreatitis from the ER it is all but impossible to answer the question “Where will this patient be in four days?” Home? Or in the ICU on mechanical ventilation? The Ranson score, for example, requires assessment out to 48 hours in order to predict mortality. Since Ranson there have been many attempts to develop easier to use tools to assess severity and predict complications. One of the latest is the PASS. The PASS can predict severity on day one according to this report. This free full text article explains the score in more detail. My concern is that it is difficult to use and incorporates subjective components (numeric pain scale).


Nut consumption and health




Background

Although nut consumption has been associated with a reduced risk of cardiovascular disease and all-cause mortality, data on less common causes of death has not been systematically assessed. Previous reviews missed several studies and additional studies have since been published. We therefore conducted a systematic review and meta-analysis of nut consumption and risk of cardiovascular disease, total cancer, and all-cause and cause-specific mortality.
Methods

PubMed and Embase were searched for prospective studies of nut consumption and risk of cardiovascular disease, total cancer, and all-cause and cause-specific mortality in adult populations published up to July 19, 2016. Summary relative risks (RRs) and 95% confidence intervals (CIs) were calculated using random-effects models. The burden of mortality attributable to low nut consumption was calculated for selected regions.

Results

Twenty studies (29 publications) were included in the meta-analysis. The summary RRs per 28 grams/day increase in nut intake was for coronary heart disease, 0.71 (95% CI: 0.63–0.80, I2 = 47%, n = 11), stroke, 0.93 (95% CI: 0.83–1.05, I2 = 14%, n = 11), cardiovascular disease, 0.79 (95% CI: 0.70–0.88, I2 = 60%, n = 12), total cancer, 0.85 (95% CI: 0.76–0.94, I2 = 42%, n = 8), all-cause mortality, 0.78 (95% CI: 0.72–0.84, I2 = 66%, n = 15), and for mortality from respiratory disease, 0.48 (95% CI: 0.26–0.89, I2 = 61%, n = 3), diabetes, 0.61 (95% CI: 0.43–0.88, I2 = 0%, n = 4), neurodegenerative disease, 0.65 (95% CI: 0.40–1.08, I2 = 5.9%, n = 3), infectious disease, 0.25 (95% CI: 0.07–0.85, I2 = 54%, n = 2), and kidney disease, 0.27 (95% CI: 0.04–1.91, I2 = 61%, n = 2). The results were similar for tree nuts and peanuts. If the associations are causal, an estimated 4.4 million premature deaths in the America, Europe, Southeast Asia, and Western Pacific would be attributable to a nut intake below 20 grams per day in 2013.

Conclusions

Higher nut intake is associated with reduced risk of cardiovascular disease, total cancer and all-cause mortality, and mortality from respiratory disease, diabetes, and infections.

Sunday, September 30, 2018

The pain scale shares the blame for the opioid crisis


Pain is not a vital sign





Continuing our look back at the pain dogma of years past.


Nontuberculous mycobacteria: clinical profiles and mortality


Study here.

Saturday, September 29, 2018

Pain management reversal





Here’s more on this topic. Diametrically opposed to what they were preaching at hospitalist meetings a decade ago.




Pain dogma reversal at SHM


Medscape reported on the pain management sessions at SHM 2017 in an article titled Rethinking Pain Can Help Hospitalists Fight Opioid Crisis. I did not attend that year but from the sound of the article it was more like a complete reversal than a rethinking, and a reversal is what is needed.



Starting in about 1999, when this movement was launched, uncontrolled pain was the big public health crisis. Now it’s the opioid crisis. How interesting.



From the beginning of the “fifth vital sign” movement SHM (then known as NAIP, the National Association of Inpatient Physicians) was in lockstep and served up its share of the prevailing dogma. It’s particularly interesting that this occurred when evidence based medicine was the hot new thing, just 7 years following its launch. Near the top of everyone’s mind was the notion that science was here to replace dogma. Except, apparently, when the discussion was about pain. As I read the Medscape piece numerous then and now contrasts started swirling through my mind. I wish I still had my notes from NAIP and SHM sessions of past years but I don’t so I’ll have to do this from memory. I’ll cite a couple of comments from the article followed by my recollections of meetings past:



From the 2017 sessions:



"The message to patients should not be that the goal is to become pain free," she explained. "We should not be expecting opioids to decrease pain by more than 20% to 30%."



Old dogma: nearly all pain can be eliminated and no hospitalized patient should have to endure pain.


"The pattern of reflexively prescribing opioids when a patient in the hospital reports a high pain score needs to be broken, she said."


Old dogma: opioids are just fine. Concerns about addiction are  largely driven by myth. Take patients’ reports of their pain at face value.




Did anyone at SHM stand up and say “we were wrong”?




Nucleated red cells on the peripheral smear in critically ill patients


Friday, September 28, 2018

Pacemaker troubleshooting: commonly encountered situations


Experience in outpatient treatment of PE



Highlights



More patients with confirmed PE were managed as outpatients over 10 years.


Outpatients with confirmed PE had unchanged mortality.


Readmission rates for outpatients with confirmed PE were stable.


Major bleeding rates among outpatients were very low.

Abstract

Introduction

In clinical trial settings, outpatient management of pulmonary embolism (PE) is feasible and safe, but less is known on its use in routine care. We determined trends in outpatient management of PE and associated mortality in a large non-select patient population.

Methods

All residents of Quebec, Canada with a first-ever work-up for suspected PE in the emergency department (ED) over 10 years were included. Patients could transition to outpatient management and from unconfirmed to confirmed PE in a time-varying fashion. Comparing the years 2005–9 with 2000–4, we assessed the odds ratio (OR) for outpatient management, and relative risk (RR) for all-cause mortality, readmissions for PE, and major bleeding in 30 days. We adjusted the RR for a mortality risk score.

Results

Of 15,217 patients included, 7583 were outpatients (7.5% confirmed PE) and 7634 were inpatients (60.6% confirmed PE). In all, 10.9% of patients with confirmed PE were outpatients, but outpatient management of confirmed PE was more likely in the latter study period (OR 1.73, 95%CI 1.44–2.09). Among outpatients with confirmed PE, mortality (RR 0.84, 95%CI 0.15–4.61) and readmission (RR 1.25, 95%CI 0.45–3.48) rates were stable, and only 3 major bleeding events were noted. Inpatients with confirmed PE had stable mortality rates (RR 0.95, 95%CI 0.72–1.24).

Conclusion

Outpatient PE management increased over 10 years while remaining fairly uncommon. Nevertheless, stable mortality and readmission rates indicate this practice is safe in routine care, and add to the growing evidence in support of outpatient PE management.



Novel antidotes for calcium blocker and beta blocker overdoses: lipid rescue and high dose insulin


Thursday, September 27, 2018

Wednesday, September 26, 2018

Non MI troponin elevations in patients 50 yo or younger



Abstract

Background: While increased serum troponin levels are often due to myocardial infarction (MI), increased levels may also be found in a variety of other clinical scenarios. Although these causes of troponin elevation have been characterized in several studies in older adults, they have not been well characterized in younger individuals.

Methods: We conducted a retrospective review of patients 50 years of age or younger who presented to two large tertiary care centers between January 2000 and April 2016 with elevated serum troponin levels. Patients with prior known coronary artery disease (CAD) were excluded. The cause of troponin elevation was adjudicated via review of electronic medical records. All-cause death was determined using the Social Security Administration’s death master file.

Results: Of the 6081 cases meeting inclusion criteria, 3574 (58.8%) patients had an MI, while 2507 (41.2%) had a non-MI cause of troponin elevation. Over a median follow-up of 8.7 years, all-cause mortality was higher in patients with non-MI causes of troponin elevation compared with those with MI (adjusted HR: 1.32, 95% CI: 1.17-1.49, p less than 0.001). Specifically, mortality was higher in those with CNS pathologies (adjusted HR: 2.21, 95% CI: 1.86-2.62, p less than 0.001), non-ischemic cardiomyopathies (adjusted HR: 1.70, 95% CI: 1.40-2.06, p less than 0.001), and ESRD (adjusted HR: 1.36, 95% CI: 1.07-1.73, p=0.012). However, mortality was lower in patients with myocarditis compared with those with an acute MI (adjusted HR: 0.43, 95% CI: 0.31-0.60, p less than 0.001).

Conclusion: There is a broad differential for troponin elevation in young patients, which differs based on demographic features. Most non-MI causes of troponin elevation are associated with higher all-cause mortality compared with acute MI.

Tuesday, September 25, 2018

Non-gastrointestinal presentations of celiac disease



Abstract

Purpose

The purpose of our study is to investigate the delay in diagnosis of patients with biopsy-proven celiac disease in those who present with gastrointestinal complaints vs nongastrointestinal complaints at our tertiary care center. Celiac disease is an autoimmune disorder that affects approximately 1% of the population worldwide. Celiac disease can have variable clinical presentations; it can be characterized by predominately gastrointestinal symptoms, or it may present without any gastrointestinal symptoms.

Methods

We retrospectively reviewed the charts of 687 adult patients who carried the diagnosis of celiac disease. Patients included had biopsy-proven celiac disease and were categorized based on presence or absence of gastrointestinal symptoms prior to their diagnosis.

Results

There were 101 patients with biopsy-proven celiac disease that met inclusion criteria. Fifty-two patients presented with gastrointestinal symptoms and 49 had nongastrointestinal complaints. Results from Mann-Whitney statistical analysis showed a median delay in diagnosis of 2.3 months for the gastrointestinal symptoms group and 42 months for the nongastrointestinal group (P less than .001); 43.2% of patients with nongastrointestinal symptoms had abnormal thyroid-stimulating hormone, as opposed to 15.5% in the gastrointestinal symptom group (P = .004). Of patients with nongastrointestinal symptoms, 69.4% had anemia, compared with 11.5% of the gastrointestinal symptom group (P less than .001). The majority of patients in the nongastrointestinal symptom group, 68%, were noted to have abnormal bone density scans, compared with 41% in the gastrointestinal symptom group. No sex differences were noted on chi-squared analysis between the 2 groups (P = .997).

Conclusions

Although there is growing awareness of celiac disease, the delay in diagnosis for patients without gastrointestinal symptoms remains prolonged, with an average delay of 3.5 years.

Clinical Significance


There is a mean delay in the diagnosis of celiac disease of 3.5 years in patients who present with nongastrointestinal symptoms.

Specifically, patients with thyroid abnormalities, anemia, or bone mineral density loss should be screened for celiac disease.

Celiac disease is an autoimmune disorder that affects approximately 1% of the population worldwide.1 As many as 6 of 7 cases of celiac disease remain undiagnosed.2 This discrepancy falls in line with the widely accepted “celiac iceberg” concept and may be due to the fact that patients have variable presentations of celiac disease. Manifestations of celiac disease range from typical gastrointestinal complaints characterized by malabsorption and diarrhea, to more silent forms in patients without overt gastrointestinal complaints. Nongastrointestinal presentations may include anemia, thyroid dysfunction, osteoporosis, liver function test abnormalities, and skin manifestations such as dermatitis herpetiformis. The variable presentations create a clinical challenge to physicians in reaching an early diagnosis. As a result, delay in diagnosis is not uncommon and does not go without consequence. Undiagnosed celiac disease can lead to osteoporotic fractures, infertility, unnecessary surgical procedures including bowel resection, and malignancy.1 As the majority of cases of celiac disease can be treated with a strict gluten-free diet alone, adherence to this diet can reverse the risk for adverse clinical outcomes.