Donato, Anthony A.

ObjectivePsoriatic arthritis (PsA) and ankylosing spondylitis (AS) are chronic inflammatory diseases associated with a higher risk of cardiometabolic comorbidities compared to the general population. Individual studies examining mortality in these patients have produced conflicting results. The present study was undertaken to perform a systematic review and meta‐analysis to analyze the all‐cause and cause‐specific mortality in PsA and AS from the available literature.MethodsA comprehensive database search was performed for studies reporting all‐cause or cause‐specific mortality in patients with PsA and AS compared with the general population. Pooled relative risks (RRs) were calculated using a random‐effects model.ResultsWe included 19 studies (11 of PsA, 7 of AS, 1 of both). In PsA studies, there was no increased mortality compared to the general population (RR 1.12 [95% confidence interval (95% CI) 0.96–1.30]; n = 10 studies). We found a higher all‐cause mortality in female (RR 1.19 [95% CI 1.04–1.36]) but not in male (RR 1.02 [95% CI 0.66–1.59]) PsA patients. Cardiovascular‐, respiratory‐, and infection‐specific mortality risks were significantly higher for PsA patients (RR 1.21 [95% CI 1.06–1.38], RR 3.37 [95% CI 1.30–8.72], and RR 2.43 [95% CI 1.01–5.84], respectively), but not cancer‐related mortality (RR 1.01 [95% CI 0.91–1.11]). In AS, we found a higher risk of death from all causes (RR 1.64 [95% CI 1.49–1.80]; n = 6 studies) and cardiovascular causes (RR 1.35 [95% CI 1.01–1.81]; n = 3 studies) compared to the general population. All‐cause mortality was high in both male (RR 1.56 [95% CI 1.43–1.71]) and female (RR 1.85 [95% CI 1.56–2.18]) AS patients. The included AS studies did not report mortality data for non‐cardiovascular causes.ConclusionThis systematic review and meta‐analysis showed a significantly increased risk of overall mortality in AS but not PsA. Cardiovascular‐specific mortality was higher for both PsA and AS, which emphasizes the importance of early screening and management of cardiovascular risk factors.

Abstract Background Morbidity and mortality in tumor lysis syndrome (TLS) remains high despite increasing efforts for prevention, early detection and treatment in recent years. The current risk stratification system and treatment guidelines are largely consensus based without strong evidence. There is paucity of data on the in-hospital mortality and predictors of poor clinical outcome in this population. Methods We used the 2009-2011 Nationwide Inpatient Sample database to identify hospitalizations in patients ≥18 years with a diagnosis of TLS (International Classification of Diseases, 9th Revision, Clinical Modification [ICD-9-CM] code 277.88). Nationwide Inpatient Sample is the largest all-payer publicly available inpatient care database in the US. It contains data from five to eight million hospital stays from about 1,000 hospitals across the country and approximates a 20% sample of all US hospitals. The interval 2009-2011 was selected as ICD-9-CM code 277.88 for TLS was only introduced from the year 2009 onwards. Univariate and multivariate logistic regression were used to determine the independent predictors of in-hospital mortality. Data analysis was done using STATA version 13.0 (College Station, TX). Results Among the 997 admissions (mean age ± SD 67.58±3.33, 62.6 % males, and 80.4 % white) with TLS, in-hospital mortality was 14.44 %. Based on the results of univariate analyses (table 1), we used obesity, coronary artery disease, cardiac dysrhythmias, acute kidney injury and sepsis in the final regression model. We found that cardiac dysrhythmias (OR 4.79; 95% CI, 1.67-13.77; p=0.004) and sepsis (OR 19.70; 95% CI, 5.33-72.78; p<0.001) were independent predictors of increased in-hospital mortality in patients with TLS. Although certain myeloid and lymphoid malignancies are associated with higher risk of tumor lysis syndrome, we did not observe any statistically significant increased risk of mortality with one specific type of malignancy over the other. Similarly, none of the demographic characteristics (age <40 vs ≥40, sex or race), or hospital characteristics (rural vs urban, teaching vs non-teaching, small vs large bed-size or geographic region) predicted increased in-hospital mortality in these patients. Conclusion In this study of large national database, patients with TLS had an in-hospital mortality of 14.44 %. Independent predictors of in-hospital mortality were cardiac dysrhythmias and sepsis. Our findings might help physicians to identify sub-group of patients with TLS that are at increased risk of in-hospital mortality. Table 1 Baseline characteristics of patients with tumor lysis syndrome according to in-hospital survival Characteristics Survivors (n=853) Non-survivors (n=144) p Age( in years) Mean 68.40±3.06 67.58±3.33 0.73 Male sex 62.1 65.8 0.69 Race 0.16 White 81.52 73.54 Black 14.98 22.8 Hispanic 2.27 0 Others/unknown 1.22 3.66 Insurance status 0.41 Medicare 65.55 48.15 Medicaid 5.56 13.34 Private insurance 24.89 32.58 Self-Pay 0.65 2.99 No charge 0.63 0 Other 2.72 2.93 Region 0.13 Northeast 27.59 37.74 Midwest 28.23 12.92 South 31.34 39.9 West 12.84 9.44 Location/teaching status 0.59 Rural 7.87 10.16 Urban nonteaching 26.01 33.52 Urban teaching 66.12 56.32 Bed-size 0.84 Small 11.11 8.91 Medium 21.04 24.55 Large 67.85 66.54 Malignancies ALL 1.19 6.79 0.25 AML 2.34 6.99 0.29 CLL 27.86 16.83 0.18 CML 1.85 3.19 0.68 NHL 36.33 22.37 0.1 HD 0.53 0 0.32 Multiple Myeloma 7.39 6.56 0.82 Other hematologic malignancies 38.67 25.99 0.16 Solid tumors 35.87 26.8 0.32 Co-morbidities Smoking 15.89 21.87 0.46 Obesity 5.16 0 0.005 Dyslipidemia 27.8 16.86 0.18 Hypertension 54.17 49.19 0.63 Diabetes mellitus 27.81 16.65 0.15 PVD 1.71 3.19 0.65 CAD 13.78 3.19 0.02 AKI 60.06 79.54 0.03 CKD 28.81 25.23 0.65 Stroke 0.63 0 0.32 Sepsis 3.58 31.81 0.003 Cardiac dysrhythmias 17.96 43.42 0.04 Acute CHF 11.44 7.08 0.43 AKI=Acute Kidney Injury; ALL=Acute Lymphoblastic Leukemia; AML=Acute Myelogenous Leukemia; CAD=Coronary Artery Disease; CHF=Congestive Heart Failure; CKD=Chronic Kidney Disease; CLL=Chronic Lymphocytic Leukemia; CML=Chronic Myelogenous Leukemia; HD=Hodgkin Disease; NHL=Non Hodgkin Lymphoma; PVD=Peripheral Vascular Disease Disclosures No relevant conflicts of interest to declare.

Acquired angioedema due to C1 inhibitor deficiency (C1INH-AAE) is a rare and potentially fatal syndrome of bradykinin-mediated angioedema characterized by episodes of angioedema without urticaria. It typically manifests with nonpitting edema of the skin and edema in the gastrointestinal (GI) tract mucosa or upper airway. Edema of the upper airway and tongue may lead to life-threatening asphyxiation. C1INH-AAE is typically under-diagnosed because of its rarity and its propensity to mimic more common abdominal conditions and allergic reactions. In this article, we present the case of a 62-year-old male with a history of recently diagnosed chronic lymphocytic leukemia (CLL) who presented to our hospital with recurrent abdominal pain, initially suspected to haveClostridium difficilecolitis and diverticulitis. He received a final diagnosis of acquired angioedema due to C1 esterase inhibitor deficiency due to concomitant symptoms of lip swelling, cutaneous nonpitting edema of his lower extremities, and complement level deficiencies. He received acute treatment with C1 esterase replacement and icatibant and was maintained on C1 esterase infusions. He also underwent chemotherapy for his underlying CLL and did not experience further recurrence of his angioedema.

Necrotizing fasciitis is a fulminant soft tissue infection characterized by rapid progression and high mortality. Rituximab is a generally well-tolerated immunosuppresive medication used for B-cell malignancies and some rheumatological disorders. We report a case of a 69-year-old male with chronic lymphocytic leukemia who suffered necrotizing fasciitis of his left lower extremity secondary to Clostridium septicum 7 weeks after treatment with rituximab. Despite immediate intravenous antimicrobial therapy and emergent fasciotomy with extensive debridement, his hospital course was complicated by septic shock and he required an above-the-knee amputation. Physicians need to be aware of the possibility of necrotizing fasciitis in patients presenting with skin infections after rituximab therapy.

Pulmonary toxoplasmosis is a serious pulmonary condition caused by the protozoan Toxoplasma gondii. It typically affects immunocompromised patients presenting acutely with cough, fever, myalgias, arthralgias and lymphadenopathy, and chronically with persistent cough and dyspnoea. Because of its protean features, it can mimic many more common lung conditions in the immunocompromised patient, including atypical pneumonia, Pneumocystis pneumonia and interstitial lung disease. In this article, we present the case of a 55-year-old woman who presented to our hospital with persistent dyspnoea and cough, initially suspected to have an arthritis-related interstitial lung disease. She received a final diagnosis of pulmonary toxoplasmosis after lung biopsy demonstrated Toxoplasma cysts, later confirmed by serology. Treatment with trimethoprim–sulfamethoxazole resulted in significant improvement of her respiratory symptoms after 3 months.