Recent Weight Loss Research Articles

Antihypertensive Deprescribing in Older Adult Veterans at End of Life Admitted to Veteran Affairs Nursing Homes

ObjectivesGeriatric palliative care approaches support deprescribing of antihypertensives in older nursing home (NH) residents with limited life expectancy and/or advanced dementia (LLE/AD) who are intensely treated for hypertension (HTN), but information on real-world deprescribing patterns in this population is limited. We examined the incidence and factors associated with antihypertensive deprescribing. DesignNational, retrospective cohort study. Setting and ParticipantsOlder Veterans with LLE/AD and HTN admitted to VA NHs in fiscal years 2009-2015 with potential overtreatment of HTN at admission, defined as receiving at least 1 antihypertensive class of medications and mean daily systolic blood pressure (SBP) <120 mm Hg. MeasuresDeprescribing was defined as subsequent dose reduction or discontinuation of an antihypertensive for ≥7 days. Competing risk models assessed cumulative incidence and factors associated with deprescribing. ResultsWithin our sample (n = 10,574), cumulative incidence of deprescribing at 30 days was 41%. Veterans with the greatest level of overtreatment (ie, multiple antihypertensives and SBP <100 mm Hg) had an increased likelihood (hazard ratio 1.75, 95% confidence interval 1.59, 1.93) of deprescribing vs those with the lowest level of overtreatment (ie, one antihypertensive and SBP ≥100 to <120 mm Hg). Several markers of poor prognosis (ie, recent weight loss, poor appetite, dehydration, dependence for activities of daily living, pain) and later admission year were associated with increased likelihood of deprescribing, whereas cardiovascular risk factors (ie, diabetes, congestive heart failure, obesity), shortness of breath, and admission source from another NH or home/assisted living setting (vs acute hospital) were associated with decreased likelihood. Conclusions and ImplicationsReal-world deprescribing patterns of antihypertensives among NH residents with HTN and LLE/AD appear to reflect variation in recommendations for HTN treatment intensity and individualization of patient care in a population with potential overtreatment. Factors facilitating deprescribing included treatment intensity and markers of poor prognosis. Comparative effectiveness and safety studies are needed to guide clinical decisions around deprescribing and HTN management.

Computed Tomography-Measured Psoas Muscle Density as a Predictive Factor for Hypophosphatemia Associated With Refeeding.

Initiation of parenteral nutrition (PN) after a period of starvation can be complicated by refeeding syndrome (RFS). RFS is associated with electrolyte abnormalities including hypomagnesemia, hyponatremia, and hypophosphatemia. Risk factors include recent weight loss, low body mass index, and electrolyte deficiencies; however, these associations are not strong. We hypothesized that a validated measure of nutrition risk, computed tomography (CT)-measured psoas muscle density, can be used to predict the development of hypophosphatemia associated with RFS. A retrospective analysis of surgical patients initiated on PN with an abdominal CT scan within the past 3 months was conducted. CT-measured psoas muscle density was assessed as a predictive variable for the development of electrolyte abnormalities. Daily electrolyte and clinical outcome measures were recorded. One hundred nine patients were stratified based on Hounsfield unit average calculation (HUAC). The lowest 25th percentile of patients had HUAC <25. Low HUAC was associated with a significant percent decrease in phosphate levels from baseline to PN day 3 (P < .01) and significant difference in serum phosphate value on PN day 3 (P < .01). The low muscle density quartile also experienced longer days on the mechanical ventilator (P = .01) compared with patients with a higher psoas muscle density. Psoas muscle density predicted the development of hypophosphatemia in patients initiated on PN. This measurement may aid in identifying patients at highest risk of experiencing RFS. Amean psoas HU <25 may prompt additional precautions, including additional phosphate replacement and slower initiation of PN.

Superior mesenteric artery syndrome.

Superior mesenteric artery (SMA) syndrome, though rare, should be considered in patients with duodenal obstruction with no other causes. History of recent weight loss and imaging modalities help in the diagnosis. Conservative management can be tried before going for surgery.

Early Signs of Impaired Gut Function Affect Daily Functioning in Patients With Advanced Cancer Undergoing Chemotherapy.

Gastrointestinal symptoms are common during chemotherapy, but underlying disturbances in gut function and their impact on daily life are unclear. This study investigates gut function in a heterogenous group of cancer patients with gastrointestinal symptoms during chemotherapy and its relation to anabolic response, muscle health, and daily functioning. In 16 patients with solid tumors (mostly stage III+IV) undergoing chemotherapy (T) and 16 healthy (H) matched controls, small-intestinal membrane integrity was measured by urine sugar tests. Protein digestion, absorption, and anabolic response to a conventional protein supplement were analyzed by stable-tracer methods. Muscle mass and strength and daily functioning were assessed. Eighty-one percent of T patients reported gastrointestinal symptoms. Small-intestinal membrane permeability was similar, but active glucose transport was lower in the T group (T, 35.5% ± 3.4% vs H, 48.4% ± 4.7%; P=.03). Protein digestion and absorption tended to be lower in the T group (0.67 ± 0.02 vs 0.80 ± 0.04; P=.08). Net protein anabolic response to feeding was comparable, although lower in cancer patients with recent weight loss. Gut permeability negatively correlated to hand grip strength, global health, and physical functioning, and active-transport capacity positively correlated to global health in the T group. Advanced cancer patients with gastrointestinal symptoms during chemotherapy, particularly those with recent weight loss, show signs of impaired gut function negatively affecting muscle health, daily functioning, and anabolic response to feeding.

Risk factors of venous thromboembolism in patients with benign and malignant musculoskeletal tumors: a dual database analysis.

Venous thromboembolism (VTE) is a potentially life-threatening condition associated with both orthopaedic surgery and tumour growth. In this study, we identify risk factors associated with VTE in patients with musculoskeletal tumours using two national datasets. The ACS-NSQIP and NIS databases were queried for patients undergoing surgery with a diagnosis of benign or malignant musculoskeletal tumours. Chi-square and binary logistic regression analyses were used to determine risk factors for VTE. The incidence of VTE was 2% in both databases. Patients with malignant tumours, those with tumours of the pelvis, sacrum, or coccyx, obesity, arrhythmias, paralysis, metastatic disease, coagulopathy, and recent weight loss were at increased risk for VTE. In patients with benign tumours, those who were African American, those with tumours of the pelvis, sacrum, or coccyx, diabetes, anaemia, and coagulopathy were at increased risk of VTE. Patients with malignant or benign lesion are at greater risk of VTE if they are age 30 and over, of the African American population, or with tumors of the pelvis/sacrum/coccyx, or any of the following comorbidities: pulmonary disease, paralysis, other neurological disorders, or coagulopathy.

Distal Thigh Pain-Running

HISTORY: A 29-year-old female presented with progressive right distal thigh pain. Her pain began gradually after increasing her mileage jogging approximately three months prior to presentation. Her pain was dull, non-radiating and worse at night as well as with running. She had no recent weight loss. There was no associated numbness or tingling. Her past medical history is significant for multiple miscarriages and infertility. PHYSICAL EXAMINATION: She had a non-antalgic gait. Inspection was negative for edema, masses, adenopathy or skin changes. There was pain with palpation of the supracondylar region of her medial right femur. Range of motion of bilateral hips and keens were full and pain free. Lower extremity strength was normal and symmetric. There was no laxity appreciated with varus/valgus stressing. Lachman and posterior drawer tests were negative. DIFFERENTIAL DIAGNOSIS: •Distal adductor tendinopathy •Femoral epicondyle stress fracture •MCL strain •Plica syndrome •Osteosarcoma TEST AND RESULTS: Knee Radiographs •Small eccentric lytic lesion in the distal right femoral diaphysis medially with associated indolent periosteal new bone formation and minimal surrounding sclerosis Femur MRI •Eccentric, T1 hypointense, T2 hyperintense 1.2 x 1.3 x 2.4 cm lytic mass right femoral with a thin rim of peripheral sclerosis and faint rim of T1 hyperintensity •Thinning of the lateral femoral cortex without definitive cortical breakthrough •Moderate surrounding marrow and periosteal edema •Mildly heterogeneous mass with peripherally located enhancement CT Guided Biopsy •Pathology positive for Langerhans cell histiocytosis FINAL/WORKING DIAGNOSIS: •Langerhans cell histiocytosis TREATMENT AND OUTCOMES: •Extended intralesional curettage for gross total resection with synthetic bone graft •Discharged home the next day with weight bearing as tolerated, walker and Aspirin 325mg BID for 4 weeks for DVT prophylaxis •Recovery complicated by soleal DVT and hematoma requiring aspiration •6 week post-op started full weight bearing and nonathletic activities •4 month follow up with stable x-rays, pain free and cleared to resume full activities •Plan for one year follow up with repeat radiographs and baseline MRI

SAT-487 Untreated Primary Hypothyroidism Presenting as Pica with Concurrent Hyponatremia and Rhabdomyolysis

Background:Psychosis is a rare but known presentation of hypothyroidism, whereas other mental health disorders are less commonly associated. Pica, the consumption of non-nutritive, non-food substances, has not been reported to be associated with hypothyroidism. We describe a case of untreated severe hypothyroidism in which the patient presented with pica that reversed with treatment with levothyroxine.Clinical case:A 65-year-old female with a history of cigarette smoking and chronic marijuana use was brought to the emergency department by family after she was found attempting to eat non-food objects such as pens and a toothbrush. She reported new onset unsteady gait and having frequent falls over the past several months in addition to being increasingly forgetful. She complained of fatigue and reported recent unintentional weight loss, but denied cold intolerance, skin or hair changes, or constipation. On admission, she was noted to be hypothermic with body temperature between 94-95 degrees Fahrenheit. Physical examination was essentially unremarkable with normal thyroid size and reflexes. No pretibial edema was noted. Admission labs showed hemoglobin of 14.0 g/dL with a white cell count of 8000 cells/uL, without evidence of anemia or infection. Sodium was low at 123 mmol/l and creatinine kinase was elevated at 989 U/L which peaked at 1356 U/L during her admission. CT of the head was negative for any acute intracranial process. Further workup was significant for TSH 85.6 mIU/L (0.27-4.20 mIU/L), free T4 <0.1 ng/dL (0.80-1.90 ng/dL), total T4 0.7 mcg/dL (5.1-11.9 mcg/dL), total T3 < 25 ng/dL (76-181 ng/dL), and TPO antibody 416 IU/ml (<9 IU/ml). AM cortisol was 27.0 ug/dL (6.2-19.4 ug/dL) at 8 AM, ruling out hypocortisolemia. The patient had not seen a medical provider in 10 years, had no recent health maintenance, and had no prior known history of thyroid disease. She was given IV fluids and started on oral levothyroxine 100 mcg daily due to the severity of hypothyroidism. Her sodium improved to 130 mmol/l over the next 4-5 days. Mental status returned to baseline with improvement in memory function and in gait and balance. Creatinine kinase trended down to 688 U/L over the next 2 days. She did not exhibit any additional behavior of eating non-food objects during the hospital stay. Patient was diagnosed to have severe hypothyroidism presenting as pica along with hyponatremia and rhabdomyolysis. Patient was discharged on levothyroxine 75 mcg daily.Clinical lessons/conclusions:Hyponatremia, rhabdomyolysis, and psychosis are relatively uncommon but known reported complications of untreated primary hypothyroidism. Acute psychosis has been reported as a presenting feature of undiagnosed hypothyroidism, but hypothyroidism presenting as pica as seen in our patient is extremely rare. This case highlights the importance of screening for hypothyroidism in patients presenting with unexplained pica.

SAT-125 A Tough NUT (Midline Carcinoma) to Crack

IntroductionNUT midline carcinoma (NMC) is a rare, highly aggressive cancer with poor prognosis. To date, there is no established therapeutic strategy; further studies are necessary to compare treatment modalities as well as investigate novel immunotherapeutic agents.Case presentationA 39-year-old female presented with a rapidly enlarging right neck mass and a recent 40-lb weight loss and was found to have a 5 cm poorly defined infiltrative hypoattenuating mass on CT scan concerning initially for anaplastic thyroid malignancy. Endocrinology and ENT were consulted and the patient underwent thyroid biopsy, which was positive for NMC. PET scan demonstrated hypermetabolic lymphadenopathy in the bilateral neck and mediastinum, but no distant metastases were identified. She then underwent total thyroidectomy with extensive dissection of the bilateral neck; pathology revealed one positive lymph node. On endobronchial biopsy, the mediastinal lymph nodes were benign. Immunohistochemistry revealed PD-L1 expression and gene assay showed an NSD3-NUTM1 fusion of the NUT gene. Oncology advised systemic treatment with carboplatin/taxol and considered Pembrolizimab, an anti-PD-L1 immunotherapy agent.DiscussionThe prognosis of NMC is less than 1 year and only 20-30 cases are reported per year in the USA. NMC is a poorly differentiated subtype of squamous carcinoma characterized by a chromosomal rearrangement of the NUT gene, involving molecular translocation with the BRD4 gene in 70% of cases. It remains challenging to treat NMC, as metastasis is present on diagnosis in most cases and there is currently no established approach. In a report of 40 patients from the NUT Midline Carcinoma Registry, surgical resection correlated with significantly improved survival in contrast to initial radiation or chemotherapy. Recently, BET domain inhibitors have emerged as a promising class of targeted agents for tumors with BRD4-NUT fusions. Their efficacy is unknown for other NUTM1 fusions. Both BET domain and histone deacetylase inhibitors are in clinical trials, and next-generation BET and CDK9 inhibitors have shown preclinical activity. Our patient likely benefited from early intervention with surgical therapy. Her PET scan findings suggest that re-sampling her mediastinal tissue would be prudent. Given her lack of BDR4-NUTM1 fusion, it is unknown if she would benefit from BET inhibitor.ConclusionNMC is an underrepresented cancer that warrants further investigation into treatment modalities and novel immunotherapies.ReferencesBauer, DE et al (2012). Clinicopathologic features and long-term outcomes of NUT midline carcinoma. Clinical cancer research,18(20),5773–5779.Liu S, et al (2018). NUT carcinoma: a rare and devastating neoplasm. Case Reports.Napolitano, M et al (2019). NUT midline carcinoma of the head and neck: current perspectives. OncoTargets and therapy,12,3235–3244.

MON-LB121 New Onset Insulin Dependent Diabetes Mellitus Secondary to Treatment With Immune Checkpoint Inhibitor

Background: Checkpoint inhibitors, immunomodulatory antibodies that are used to enhance the immune system, have substantially improved the prognosis for patients with advanced malignancy like melanoma and lung cancer. Despite important clinical benefits, checkpoint inhibition is associated with a unique spectrum of side effects termed immune-related adverse events (irAEs). IrAEs include dermatologic, gastrointestinal, hepatic, endocrine, and other less common inflammatory events. Among them is endocrine toxicity, most commonly targeting the thyroid, pituitary, or adrenal glands. New-onset diabetes mellitus has been reported in only around 1% of patients in a recent study.Although rare, fulminant and even fatal toxicities may occur with immune checkpoint inhibitors, and therefore, prompt recognition and management is important. Here we are going to present a patient with new onset Insulin dependent Diabetes mellitus secondary to immunotherapy.It usually presents with diabetic ketoacidosis (DKA) and follows a rapid course. Awareness and prompt management are therefore key. History and investigations:62 year old lady diagnosed with Right Uveal melanoma more than 2 years ago and was treated with Enucleation followed by Rt prosthetic eye. Subsequently patient developed metastatic melanoma with subcutaneous lesion in right paravertebral region, right humoral head and right gluteal muscle. It was unclear whether patient had metastatic uveal or cutaneous melanoma. Other PMH includes were Hypertension and Anxiety.Patient was started on Ipilimumab (CTLA-4 inhibitor) and Nivolumab (PD1 inhibitor) 6 months ago, and Ipilimumab was stopped 8 weeks ago due to side effects but continued with Nivolumab. Other current medications were Amlodipine 10 mg once daily and AmitriptylinePatient was complaining of extreme fatigue last one week and was diagnosed with Hypothyroidism with TSH >100 mIU/L (Normal 0.27-4.2) and FT4 5.4 pmol/L (Normal 12.0-22.0), subsequently patient was started on Levothyroxine 50 mcg once daily.Patient presented to emergency department with polyuria and polydipsia last 5 days and also blurred vision for last 3 weeks. Patient did not notice any recent weight loss and had widespread pain, worse on skin lesions and hip joints but did not had any other specific complaints.Patient was current smoker with more than 40 pack year history and was taking 25 units of Alcohol per week for many years. Patient did not had any significant family history including any history diabetes in the family.On examination, patient was clinically dry with capillary refill time was 5 seconds.Investigations showed-Venous blood gas-Blood Glucose - Hi (mmol/L out of range), later 22.7 mmol/LPh- 7.291, PCO2 6.14 kPa, HCO3 19.3 mmol/L, Lactate 2.2 mmol/LBlood ketones- Hi (mmol/L out of range), later >7 mmol/LOther investigations showed-Na 131 mmol/L (Normal 135-145), K 5.4 mmol/L (Normal 3.5-5.1), Urea 7.1 mmol/L (Normal 1.7-8.3)Creatinine 139 umol/L (Normal 49-92)Bilirubin 12 umol/L (Normal 0-20), ALT 56 IU/L (Normal 10-35), ALP 157 IU/L (Normal 35-104)Amylase 59 IU/L (Normal 28-100), Albumin 48 g/L (Normal 34-50), Adjusted Calcium 2.56 mmol/L (Normal 2.2-2.6)9 am Cortisol 826 nmol/L (Normal 133-537), ACTH 28 ng/l (Normal 7.2-63.3)FSH 78.7 IU/L (Normal 25.8-134.8), LH 37.6 IU/L (Normal 7.7-58.5)IGF1 9.6 nmol/L (Normal 3.5-32.0), Prolactin 476 mIU/L (Normal 102-496)HbA1C 10.6% / 93 mmol/mmol (Normal 20-42)Serum Anti-GAD titre- 5 IU/L (Normal 0-10)Patient was started on treatment for Diabetic Ketoacidosis (DKA) with intravenous fluid and also fixed rate Insulin infusion according to protocol. Patient responded well to treatment and biochemical profile improved with initial treatment, subsequently patient was started on regular basal bolus Insulin regime with the help from the diabetes team. Discussion:Here we have presented a case with new onset Insulin dependent Diabetes Mellitus induced by immune checkpoint inhibitor. This kind of Diabetes progress rapidly to severe insulin deficiency compared to spontaneous Type 1 Diabetes, frequently patient present with DKA and do not go into remission. As this condition can develop rapidly, it is suggested that glucose level is to be monitored regularly and also to check HbA1C prior to initiating the immunotherapy. Their management requires complex Insulin regime to get good glycaemic control and add significant comorbidity along with the underlying cancer. The exact pathophysiologic mechanism and predictive biomarkers have not yet been established. The end result is permanent Insulin dependence. In future better characterization and further study is required to improve diagnosis and management, also to follow the natural history of this condition.Reference:1) Kotwal A, Haddox C, Block M, et alImmune checkpoint inhibitors: an emerging cause of insulin-dependent diabetesBMJ Open Diabetes Research and Care 2019;7:e000591. doi: 10.1136/bmjdrc-2018-0005912) Immune checkpoint inhibitors and type 1 diabetes mellitus: a case report and systematic review.de Filette JMK1, Pen JJ2, Decoster L3, Vissers T4, Bravenboer B1, Van der Auwera BJ5, Gorus FK5, Roep BO6,7, Aspeslagh S3, Neyns B3, Velkeniers B1, Kharagjitsingh AV1,

The associations of sugar-sweetened, artificially sweetened and naturally sweet juices with all-cause mortality in 198,285 UK Biobank participants: a prospective cohort study

BackgroundRecent efforts to address the obesity epidemic have focused on sugar consumption, especially sugar-sweetened beverages. However, sugar takes many forms, is only one contributor to overall energy consumption and is correlated with other health-related lifestyle factors. The objective was to investigate the associations with all-cause mortality of sugar- and artificially sweetened beverages and naturally sweet juices.MethodsSetting: UK Biobank, UK. Participants joined the UK Biobank study from 2006 to 2010 and were followed up until 2016; 198,285 men and women aged 40–69 years were eligible for this study (40% of the UK Biobank), of whom 3166 (1.6%) died over a mean of 7 years follow-up. Design: prospective population-based cohort study. Exposure variables: dietary consumption of sugar-sweetened beverages, artificially sweetened beverages, naturally sweet juices (100% fruit/vegetable juices) and total sugar intake, self-reported via 24-h dietary assessment tool completed between 2009 and 2012. Main outcome: all-cause mortality. Cox regression analyses were used to study the association between the daily intake of the above beverages and all-cause mortality. Models were adjusted for sociodemographic, economic, lifestyle and dietary confounders.ResultsTotal energy intake, total sugar intake and percentage of energy derived from sugar were comparable among participants who consumed > 2/day sugar-sweetened beverages and > 2/day fruit/vegetable juices (10,221 kJ/day versus 10,381 kJ/day; 183 g versus 190 g; 30.6% versus 31.0%). All-cause mortality was associated with total sugar intake (highest quintile adj. HR 1.28, 95% CI 1.06–1.55) and intake of sugar-sweetened beverages (> 2/day adj. HR 1.84, 95% CI 1.42–2.37) and remained so in sensitivity analyses. An association between artificially sweetened beverage intake and mortality did not persist after excluding deaths in the first 2 years of follow-up (landmark analysis) nor after excluding participants with recent weight loss. Furthermore, the inverse association between fruit/vegetable juice intake and mortality did not persist after additional adjustment for a diet quality score.ConclusionsHigher mortality is associated with sugar-sweetened beverages specifically. The lack of an adverse association with fruit/vegetable juices suggests that source of sugar may be important and the association with artificially sweetened beverage may reflect reverse causation.

Surgical Outcomes in Patients With Malignant Small Bowel Obstruction: A National Cohort Study.

The study objectives were to characterize surgical outcomes for malignant small bowel obstruction (MaSBO) as compared to other small bowel obstructions (SBO) and to develop a prediction model for postoperative mortality for MaSBO. MaSBO is a morbid complication of advanced cancers for which the optimal management remains undefined. Patients who underwent surgery for MaSBO or SBO were identified from the National Surgical Quality Improvement Program (2005-2017). Outcomes [30-day morbidity, unplanned readmissions, mortality, postoperative length of stay (LOS)] were compared between propensity score-matched MaSBO and SBO patients. An internally validated prediction model for mortality in MaSBO patients was developed. Of 46,706 patients, 1612 (3.5%) had MaSBO. Although MaSBO patients were younger than those with SBO (median 63 vs 65 years, P < 0.001), they were otherwise more clinically complex, including a higher proportion with recent weight loss (22.0% vs 4.0%, P < 0.001), severe hypoalbuminemia (18.6% vs 5.2%, P < 0.001), and cytopenias. After matching (N = 1609/group), MaSBO was associated with increased morbidity [odds ratio (OR) 1.2, P = 0.004], but not readmission (OR 1.1, P = 0.48) or LOS (incidence rate ratio 1.0, P = 0.14). The odds of mortality were significantly higher for MaSBO than SBO (OR 3.3, P < 0.001). A risk-score model predicted postoperative mortality for MaSBO with an optimism-adjusted Brier score of 0.114 and area under the curve of 0.735. Patients in the highest-risk category (11.5% of MaSBO population) had a predicted mortality rate of 39.4%. Surgery for MaSBO is associated with substantial morbidity and mortality, necessitating careful patient evaluation before operative intervention.

538 Successful Wound Closure in Patients with Large Total Body Surface Area (TBSA) Calciphylaxis with Aggressive Medical and Surgical Therapy

Abstract Introduction Calcific Uremic Arteriolopathy (CUA), commonly known as Calciphylaxis, is a rare disorder characterized by ischemic necrosis of the skin and histologically by arteriolar calcification. CUA is most commonly seen in patients with end-stage renal disease (ESRD), but can be seen in other patients as well. CUA is an extremely morbid condition and carries a high mortality rate, up to 80% in some studies, even in patients with limited disease. In light of this, many surgeons have adopted a “do-not-touch” approach. Over the past five years, our institution has seen an increase in the referrals of patients with large total-body-surface-area (TBSA) CUA. Methods Retrospective review of all patients with biopsy-proven (by dermatopathology) large, &amp;gt;5% TBSA CUA admitted to a Verified Adult and Pediatric Burn Center from 2015 to present. Demographics, laboratory data, treatment modalities, infectious complications and outcomes, including mortality and wound closure were recorded. Secondary observations included exposure to anticoagulants and recent significant weight loss. Results A total of eight patients with large TBSA CUA were admitted after being transferred from outside hospitals. Average TBSA affected was 13.76% (range 5–27%). Six of these patients (75%) were noted to have non-uremic calciphylaxis. One patient (12.5%) had elevated parathyroid hormone (PTH) levels and hyperphosphatemia while one patient each had isolated hypercalcemia and hyperphosphatemia. All patients had positive wound cultures on admission, and one patient (12.5%) developed a bacteremia in hospital. There were no central line associated bloodstream infections, catheter associated urinary tract infections or ventilator associated infections. All patients underwent surgical debridement (average 4.125, range 2–5), and 5 patients (62.5%) underwent grafting, (average 1.6, range 2–5) and subsequently proceeded to wound closure. In-hospital mortality was 25% and another patient was referred to a hospice facility after being readmitted with medical complications related to her calciphylaxis. Secondary findings included 50% of the patients recently experienced significant weight loss (&amp;gt;100 lbs) and 25% of the patients were taking warfarin within 6 months of presentation. Percent TBSA involvement did not correlate with mortality. Conclusions Utilizing a multi-modal management strategy that includes surgical debridement and skin grafting, patients with large total body surface area calciphylaxis can progress to wound closure. Applicability of Research to Practice Findings may influence surgeons to be aggressive surgically with patients with calciphylaxis leading to improved morbidity and mortality. Improved medical multi-modal therapy has been shown to influence outcomes as well.

Osteoporosis in cirrhotics before and after liver transplantation: relation with malnutrition and inflammatory status

Background: Liver cirrhosis is associated with osteoporosis and liver transplantation (LT) with increased bone loss. This study aimed to in LT candidates investigate the potential relation between bone mineral density (BMD) and BMD loss in those who undergo LT, with malnutrition, systemic inflammation, and hormonal status.Methods: We included 102 consecutively recruited cirrhotic LT candidates between May 2004 and April 2007. BMD was assessed by means of dual energy X-ray absorptiometry (DXA). Malnutrition was defined by means of anthropometry and assessment of recent weight loss. In 75/102 patients, serum-thyroid stimulating hormone (TSH), free triiodthyronine (T3) and free thyroxine (T4) and growth hormone (GH), cortisol, free testosterone, dehydroepiandrosterone sulfate, estradiol, interleukin-6, and tumor necrosis factor (TNF)-α was assessed. Overall 57/102 patients received a LT and 47/102 were followed for one year post-LT. At follow-up, nutritional status and BMD were assessed in all patients (n = 47) while 34/47 had available blood samples for analysis.Results: Forty (40%) LT- candidates had osteopenia or osteoporosis and 34 (38%) were malnourished. Malnutrition was associated with osteopenia/osteoporosis (odds ratio: 3.5, 95% CI 1.4, 9.9). Hip BMD Z-score decreased −0.25 (95% CI −0.41, −0.09) from baseline to one year post-LT. High baseline TNF-α correlated with a more marked decline in BMD (Partial correlation (r) = −0.47, p < .05) as did high baseline cortisol levels (r = −0.49, p < .05).Conclusion: Malnutrition in liver cirrhosis seems to be associated with osteopenia/osteoporosis, and systemic inflammation (higher TNF-α) and systemic stress (higher cortisol) to bone loss in patients who undergo LT.

Thrombocytopenia and endocarditis in a patient with Whipple\u2019s disease: case report

BackgroundWhipple’s disease (WD) is a rare multisystem infectious disorder that is caused by the actinomycete Tropheryma whipplei. It presents with joint pain followed by abdominal pain, diarrhea, malabsorption and finally failure to thrive. Diagnosis requires tissue sampling and histology with periodic acid-Schiff [PAS] staining. Thrombocytopenia associated with endocarditis associated with WD has been reported twice.Case presentationA 56 year old Caucasian male presented with years of steroid treated joint pain and recent onset diarrhea, weight loss and abdominal pain. Ultimately he was found to have a platelet count of 4000 with concomitant endocarditis and embolic stroke. Small bowel biopsy confirmed the diagnosis of WD approximately 1 year after his first visit. His platelets improved with antibiotic treatment but he eventually expired 16 months after his initial consult and 5 months after his definitive diagnosis.ConclusionWD can remain undiagnosed and untreated until late in the course of the illness. A high index of suspicion is recognized as necessary for early diagnosis to begin treatment. Critical thrombocytopenia associated with endocarditis is a rare and potentially poor prognostic sign in late stage Whipple’s disease.

Malnutrition in Older Patients With Hematological Malignancies at Initial Diagnosis - Association With Impairments in Health Status, Systemic Inflammation and Adverse Outcome.

Poor nutritional status is a common problem in cancer patients at advanced age, but the prevalence and impact of malnutrition in hematological malignancies remains underinvestigated. To evaluate nutritional status in older adults over age 70 with newly diagnosed hematological malignancies, we enrolled 147 patients and assessed weight loss, food intake, Mini Nutritional Assessment (MNA), and BMI. We compared nutritional status with demographic data, inflammation markers, and restrictions in multidimensional geriatric assessment. MNA classified 43% of patients being at risk of, and 15% having manifest malnutrition. A moderate/severe decrease in food intake was reported by 24% or 16%, a recent weight loss of 1 to 3 kg or >3 kg by 19% or 31%, and a BMI <23 kg/m2 by 29%. Lowered serum albumin (<3.5 g/dL) was prevalent in 14% of patients, and in 38% Glasgow Prognostic Score indicated hyperinflammation. Principal component analysis clustered malnutrition with inflammation markers and pronounced impairments, that is, fatigue, depression, comorbidities, reduced functional capacities. Severe decrease in food intake (HR: 3.3 (1.9-5.8), p < 0.001), >3 kg weight loss (HR: 2.3 (1.4-3.9), p = 0.001), impaired MNA (HR: 2.8 (1.3-6.2), p = 0.010), and low serum albumin (HR: 2.1 (1.1-4.0), p = 0.030) were significantly associated with shortened overall survival. Recent weight loss >3 kg (HR: 2.2 (1.1-4.3), p = 0.022), and low BMI (HR: 3.3 (1.8-6.0), p < 0.001) remained independent adverse parameters in multivariate Cox proportional hazard regression analyses. Malnourishment at initial diagnosis is frequent in older patients with hematological malignancies and represents an adverse prognosticator. Clustering of malnutrition with impairments and systemic inflammation suggests an underlying common pathway.

CD4+ regulatory T cells and CD4+ activated T cells in new active and relapse tuberculosis

The aim of the present study was to examine characteristics of tuberculosis (TB) patients with different clinical forms and to study the frequency of Regulatory T cells (Treg cells) and Activated T cells in patients with new active and relapse TB. Forty-five pulmonary TB patients and a control group of 15 healthy individuals were enrolled in this study. Of the 45 TB patients, 15 were new cases with drug-susceptible active TB and 30 were relapsed cases (15 drug-susceptible and 15 multidrug resistant-TB). The age of study participants ranged from 21 to 68 years old. According to sex presentation, males were appreciably highly affected than females with a sex ratio of 2. The patients reported a mean recent weight loss of 8.9 kg. The Erythrocyte Sedimentation Rate was high in TB group, far exceeding the normal value. The results revealed that the number of CD3+ CD4+ T-cellssignificantly decreased whereas the level of blood Treg cells and expression of activation markers CD38 and HLA-DR on CD4+ T-cells significantly increased in TB group compared with the controlgroup (p&lt;0.05). The frequency of Treg cells was significantly higher in the TB group than the control group. Both the patients with new active TB and relapse TB demonstrated significantly higher levels of CD4+FoxP3+ Treg compared to healthy subjects (p&lt;0.05). A high and significant percentage of Treg cells were found in patients with DS active TB than patients with MDR relapse TB. Interestingly, the frequency of CD4+FoxP3+ cells also differs according to the sputum smear microscopy status. The presence of high numbers of Treg cells and corresponding high immune activation may be an unfavourable factor that can predispose individuals to different clinical forms of TB, including relapse TB.

EXTENSIVE MALIGNANT EPITHELIAL LESION IN PATIENT WITH CHRONIC RENAL DISEASE

An 83-year-old light brown man was attended complaining of "pain on the right side of the mouth" for 1 year with difficulty feeding and chewing pain. Anamnesis revealed stage IV chronic renal disease, myocardial revascularization surgery, gastritis, depression, allergic rhinitis, recent weight loss, and previous smoking stopped 20 years ago. The extraoral examination showed facial asymmetry due to a swelling in the right mandibular body covered by normal skin. Intraoral examination evidenced an exophytic ulcer on the right edentulous mandibular alveolar ridge, extending from the parasymphysis to inferior retromolar region with verrucous aspect and irregular borders, hardened and painful to the palpation, and 7 × 3 cm in its largest diameter. Smear cytolopathology and incisional biopsy were performed. Diagnostic hypothesis was squamous cell carcinoma. The cytopathologic study revealed atypical cells strongly suggestive of malignant neoplasm. Histopathologic analysis confirmed the final diagnosis of moderately differentiated squamous cell carcinoma. The patient was referred for cancer treatment. An 83-year-old light brown man was attended complaining of "pain on the right side of the mouth" for 1 year with difficulty feeding and chewing pain. Anamnesis revealed stage IV chronic renal disease, myocardial revascularization surgery, gastritis, depression, allergic rhinitis, recent weight loss, and previous smoking stopped 20 years ago. The extraoral examination showed facial asymmetry due to a swelling in the right mandibular body covered by normal skin. Intraoral examination evidenced an exophytic ulcer on the right edentulous mandibular alveolar ridge, extending from the parasymphysis to inferior retromolar region with verrucous aspect and irregular borders, hardened and painful to the palpation, and 7 × 3 cm in its largest diameter. Smear cytolopathology and incisional biopsy were performed. Diagnostic hypothesis was squamous cell carcinoma. The cytopathologic study revealed atypical cells strongly suggestive of malignant neoplasm. Histopathologic analysis confirmed the final diagnosis of moderately differentiated squamous cell carcinoma. The patient was referred for cancer treatment.

ORAL MANIFESTATION OF DIFFUSE LARGE B-CELL LYMPHOMA

Oral manifestation of diffuse large B-cell lymphoma (DLBCL) usually represents late involvement of disseminated and advanced disease. In this case, the oral lesion was the first sign of the disease. A 66-year-old male patient complained of difficulty adapting the upper total prosthesis for the last month. No underlying diseases have been reported except recent fatigue and weight loss complaint. Physical examination revealed a submucosal tumor in the maxillary region, which was 4 cm, exophytic, painless, and of fibrous consistency, and mucosa of recoating with areas of ulceration. Computed tomography showed an infiltrative, unilocular, isodense, expansive lesion with maxillary bone alteration as well as multiple bilateral supra and infradiaphragmatic lymphadenopathy. An incisional biopsy of the lesion was performed, and the morphologic profile associated with the immunohistochemical profile favored the diagnosis of DLBCL. The patient was submitted to the rituximab, cyclophosphamide, doxorubicin (hydroxydaunorubicin), vincristine (Oncovin), and prednisone regimen associated with intrathecal chemotherapy with complete remission of the oral lesion.

Hospital Malnutrition, a Call for Political Action: A Public Health and NutritionDay Perspective.

Disease-related malnutrition (DRM) is prevalent in hospitals and is associated with increased care needs, prolonged hospital stay, delayed rehabilitation and death. Nutrition care process related activities such as screening, assessment and treatment has been advocated by scientific societies and patient organizations but implementation is variable. We analysed the cross-sectional nutritionDay database for prevalence of nutrition risk factors, care processes and outcome for medical, surgical, long-term care and other patients (n = 153,470). In 59,126 medical patients included between 2006 and 2015 the prevalence of recent weight loss (45%), history of decreased eating (48%) and low actual eating (53%) was more prevalent than low BMI (8%). Each of these risk factors was associated with a large increase in 30 days hospital mortality. A similar pattern is found in all four patient groups. Nutrition care processes increase slightly with the presence of risk factors but are never done in more than 50% of the patients. Only a third of patients not eating in hospital receive oral nutritional supplements or artificial nutrition. We suggest that political action should be taken to raise awareness and formal education on all aspects related to DRM for all stakeholders, to create and support responsibilities within hospitals, and to create adequate reimbursement schemes. Collection of routine and benchmarking data is crucial to tackle DRM.

A negative impact of recent weight loss on in-hospital mortality is not modified by overweight and obesity.

Obesity [Body Mass Index (BMI)>30kg/m2] is a risk factor for disease conditions enhancing hospitalization and mortality risks, but higher BMI was paradoxically reported to reduce mortality in several acute and chronic diseases. Unintentional weight loss (WL) is conversely associated with disease development and may worsen patient outcome, but the impact of weight loss and its interaction with obesity in modulating risk of death in hospitalized patients remain undefined. We investigated the ESPEN nutritionDay database of non-critically ill hospitalized patients to assess the impact of self-reported 3-month WL (WL1:2.5-6.6%; WL2: 6.6-12.6%, WL3: >12.6%) and its interaction with BMI in modulating 30-day in-hospital mortality. Multivariate Cox regression was used to estimate hazard ratios (HR), with stable weight (WL0) as reference category. In 110835 nDay patients, 30-day mortality increased with increasing WL. Male gender, increasing disease severity index PANDORA score (age, nutrient intake, mobility, fluid status, cancer and main patient group) and not having had surgery also predicted 30-day mortality. HR for 30-day mortality remained significantly higher compared to WL0 for WL2 and WL3 after multiple adjustment. Adjusted HR and its increments through increasing weight loss categories were comparable in lean (BMI<25), overweight (BMI 25-30) and obese individuals (BMI>30kg/m2). Impact of gender, PANDORA score and surgery on 30-day mortality were conversely comparable in the three BMI groups. These results indicate that self-reported WL could represent a relevant prognostic factor in every hospitalized patient. Overweight and obesity per se have no protective impact against WL-associated mortality.