Citations

AbstractBackgroundPatients presenting to the emergency department (ED) with acute vertigo or dizziness represent a diagnostic challenge. Neuroimaging has variable indications and yield. We aimed to conduct a systematic review and meta‐analysis of the diagnostic test accuracy of neuroimaging for patients presenting with acute vertigo or dizziness.MethodsAn electronic search was designed following patient–intervention–control–outcome (PICO) question—(P) adult patients with acute vertigo or dizziness presenting to the ED; (I) neuroimaging including computed tomography (CT), CT angiography (CTA), magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), and ultrasound (US); (C) MRI/clinical criterion standard; and (O) central causes (stroke, hemorrhage, tumor, others) versus peripheral causes of symptoms. Articles were assessed in duplicate. The Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines were followed. Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) was used to assess certainty of evidence in pooled estimates.ResultsWe included studies that reported diagnostic test accuracy. From 6309 titles, 460 articles were retrieved, and 12 were included: noncontrast CT scan—six studies, 771 patients, pooled sensitivity 28.5% (95% confidence interval [CI] 14.4%–48.5%, moderate certainty) and specificity 98.9% (95% CI 93.4%–99.8%, moderate certainty); MRI—five studies, 943 patients, sensitivity 79.8% (95% CI 71.4%–86.2%, high certainty) and specificity 98.8% (95% CI 96.2%–100%, high certainty); CTA—one study, 153 patients, sensitivity 14.3% (95% CI 1.8%–42.8%) and specificity 97.7% (95% CI 93.8%–99.6%), CT had higher sensitivity than CTA (21.4% and 14.3%) for central etiology; MRA—one study, 24 patients, sensitivity 60.0% (95% CI 26.2%–87.8%) and specificity 92.9% (95% CI 66.1%–99.8%); US—three studies, 258 patients, sensitivity ranged from 30% to 53.6%, specificity from 94.9% to 100%.ConclusionsNoncontrast CT has very low sensitivity and MRI will miss approximately one in five patients with stroke if imaging is obtained early after symptom onset. The evidence does not support neuroimaging as the only tool for ruling out stroke and other central causes in patients with acute dizziness or vertigo presenting to the ED.

Background: Peripheral artery disease (PAD) affects >200 million people worldwide and is associated with high mortality and morbidity. We sought to identify genomic variants associated with PAD overall and in the contexts of diabetes and smoking status. Methods: We identified genetic variants associated with PAD and then meta-analyzed with published summary statistics from the Million Veterans Program and UK Biobank to replicate their findings. Next, we ran stratified genome-wide association analysis in ever smokers, never smokers, individuals with diabetes, and individuals with no history of diabetes and corresponding interaction analyses, to identify variants that modify the risk of PAD by diabetic or smoking status. Results: We identified 5 genome-wide significant ( P association ≤5×10 −8 ) associations with PAD in 449 548 (N cases =12 086) individuals of European ancestry near LPA (lipoprotein [a]), CDKN2BAS1 (CDKN2B antisense RNA 1), SH2B3 (SH2B adaptor protein 3) - PTPN11 (protein tyrosine phosphatase non-receptor type 11), HDAC9 (histone deacetylase 9), and CHRNA3 (cholinergic receptor nicotinic alpha 3 subunit ) loci (which overlapped previously reported associations). Meta-analysis with variants previously associated with PAD showed that 18 of 19 published variants remained genome-wide significant. In individuals with diabetes, rs116405693 at the CCSER1 (coiled-coil serine rich protein 1 ) locus was associated with PAD (odds ratio [95% CI], 1.51 [1.32–1.74], P diabetes =2.5×10 −9 , P interactionwithdiabetes =5.3×10 −7 ). Furthermore, in smokers, rs12910984 at the CHRNA3 locus was associated with PAD (odds ratio [95% CI], 1.15 [1.11–1.19], P smokers =9.3×10 −10 , P interactionwithsmoking =3.9×10 −5 ). Conclusions: Our analyses confirm the published genetic associations with PAD and identify novel variants that may influence susceptibility to PAD in the context of diabetes or smoking status.

Abstract Aim: The prevalence of celiac disease in patients with iron deficiency (ID) in the United States is unknown. Estimating the prevalence of Celiac disease (CD) in patients with ID could help to determine the need to screen these patients for occult CD. In 2017, the United States Preventive Services Task Force stated that the current evidence is inadequate to assess the balance of benefits and harms of screening for CD in asymptomatic persons. Also, there are no current guidelines to advise physicians regarding the screening of patients with iron deficiency for occult CD. Methods: Data were obtained from the National Health and Nutrition Examination Survey (NHANES) database, a nationally representative health survey conducted from 2009 to 2010. We included 2,105 females aged 6 years or older. Iron deficiency was defined as serum ferritin level <20 ng/ml, and patients were considered positive for celiac disease when positive for both immunoglobulin A tissue transglutaminase antibody (IgA Ttga) and IgA endomysial antibody (IgA EMA). Subjects with Iron deficiency were divided into two groups (ID and Non-ID). The association of CD and ID, i.e., the primary outcome, was obtained after adjusting other covariates using logistic regression. Results: The mean age of our study population was 29.7 years; 28.0 years in the ID group and 30.3 in the non-ID group (p<0.001). Non-Hispanic whites constituted 41%of the total study sample. The demographic characteristics of the study population are shown in table 1. There were 569 (27%) females who had ID and 1536 (73%) who did not have ID. The overall prevalence of CD in the study population was 0.33% (7/2105). The prevalence of CD in ID females was 0.9% (5/569), and the prevalence of CD in non-ID females was 0.1% (2/1536) with an odds ratio (OR) of 6.79 (95% confidence interval, 1.31-35.2). After adjusting for selected covariates, the prevalence of CD was higher in female subjects with ID with OR of 12.5 (95% CI 1.74-90). Although these results showed that CD did increase the risk of having ID in females, it did not show any difference in hemoglobin between celiac positive and celiac negative females with an odds ratio of 1.75 (95% CI 0.61-5.05). Discussion In this study, one in 113 iron-deficient females met the criteria for the diagnosis of occult CD compared to one in 676 non-iron deficient females. So, screening for occult CD could help in diagnosing the cause of ID and subsequently help in treatment. Celiac serology offers a non-invasive test to detect gluten hypersensitivity in females with ID. There is no study looking into the downside of screening for CD in asymptomatic people. However, potential disadvantages of CD screening may include increased anxiety, over-diagnosis, unnecessary serologic tests and increased need for unnecessary endoscopies with biopsy. The strength of this study is that it includes a representative sample from a national database, which was adjusted for minority groups. However, this study also had several limitations. The number of cases of CD was very small due to the relatively low prevalence of CD in the United States (0.71%). Another limitation was our criteria for the diagnosis of CD based on serology only without histological confirmation, as a duodenal biopsy is an invasive test difficult to perform in a population-based study. However, this limitation is partially balanced by the sequential serological testing of IgA EMA in IgA tTGA positive individuals. Another potential limitation is that patients with IgA deficiency were missed by the study as IgA deficiency was not tested. Conclusions: Although the overall prevalence of celiac disease in the United States is low in the female population, the prevalence is higher in subjects with Iron deficiency. We suggest that CD testing should be considered in patients with refractory ID when other obvious causes have been ruled out. Further prospective studies are needed to validate this finding. Disclosures No relevant conflicts of interest to declare.