Neetika Garg

YouTube as a source of information on dialysis: A content analysis

End‐stage renal disease is a prevalent and growing health problem worldwide. With increasing Internet use, video‐sharing websites could potentially serve as a powerful platform for dissemination of information on dialysis. We conducted a cross‐sectional study to assess the accuracy, content and viewership of YouTube videos on dialysis.

Greater freedom of speech on Web 2.0 correlates with dominance of views linking vaccines to autism

INTRODUCTION It is suspected that Web 2.0 web sites, with a lot of user-generated content, often support viewpoints that link autism to vaccines. METHODS We assessed the prevalence of the views supporting a link between vaccines and autism online by comparing YouTube, Google and Wikipedia with PubMed. Freedom of speech is highest on YouTube and progressively decreases for the others. RESULTS Support for a link between vaccines and autism is most prominent on YouTube, followed by Google search results. It is far lower on Wikipedia and PubMed. Anti-vaccine activists use scientific arguments, certified physicians and official-sounding titles to gain credibility, while also leaning on celebrity endorsement and personalized stories. CONCLUSIONS Online communities with greater freedom of speech lead to a dominance of anti-vaccine voices. Moderation of content by editors can offer balance between free expression and factual accuracy. Health communicators and medical institutions need to step up their activity on the Internet.

Optimal management of hereditary hemorrhagic telangiectasia

Hereditary hemorrhagic telangiectasia (HHT), also known by the eponym Osler–Weber–Rendu syndrome, is a group of related disorders inherited in an autosomal dominant fashion and characterized by the development of arteriovenous malformations (AVM) in the skin, mucous membranes, and/or internal organs such as brain, lungs, and liver. Its prevalence is currently estimated at one in 5,000 to 8,000. Most cases are due to mutations in the endoglin (HHT1) or ACVRLK1 (HHT2) genes. Telangiectasias in nasal and gastrointestinal mucosa generally present with recurrent/chronic bleeding and iron deficiency anemia. Larger AVMs occur in lungs (~40%–60% of affected individuals), liver (~40%–70%), brain (~10%), and spine (~1%). Due to the devastating and potentially fatal complications of some of these lesions (for example, strokes and brain abscesses with pulmonary AVMs), presymptomatic screening and treatment are of utmost importance. However, due to the rarity of this condition, many providers lack an appreciation for the whole gamut of its manifestations and complications, age-dependent penetrance, and marked intrafamilial variation. As a result, HHT remains frequently underdiagnosed and many families do not receive the appropriate screening and treatments. This article provides an overview of the clinical features of HHT, discusses the clinical and genetic diagnostic strategies, and presents an up-to-date review of literature and detailed considerations regarding screening for visceral AVMs, preventive modalities, and treatment options.

Recurrence of IgA nephropathy after kidney transplantation in steroid continuation versus early steroid-withdrawal regimens: a retrospective analysis of the UNOS/OPTN database

In the past 20 years, there has been an increase in use of steroid‐withdrawal regimens in kidney transplantation. However, steroid withdrawal may be associated with an increased risk of recurrent IgA nephropathy (IgAN). Using United Network of (Organ Sharing/Organ Procurement and Transplantation Network) UNOS/OPTN data, we analyzed adult patients with end‐stage renal disease (ESRD) due to IgAN who received their first kidney transplant between 2000 and 2014. For the primary outcome, we used a competing risk analysis to compare the cumulative incidence of graft loss due to IgAN recurrence between early steroid‐withdrawal (ESW) and steroid continuation groups. The secondary outcomes were patient survival and death‐censored graft survival (DCGS). A total of 9690 recipients were included (2831 in ESW group and 6859 in steroid continuation group). In total, 1238 recipients experienced graft loss, of which 191 (15.43%) were due to IgAN recurrence. In multivariable analysis, steroid use was associated with a decreased risk of recurrence (subdistribution hazard ratio 0.666, 95% CI 0.482–0.921; P = 0.014). Patient survival and DCGS were not different between the two groups. In the USA, ESW in transplant for ESRD due to IgAN is associated with a higher risk of graft loss due to disease recurrence. Future prospective studies are warranted to further address which patients with IgAN would benefit from steroid continuation.

Defining the phenotype of antibody-mediated rejection in kidney transplantation: Advances in diagnosis of antibody injury

The diagnostic criteria for antibody-mediated rejection (ABMR) are constantly evolving in light of the evidence. Inclusion of C4d-negative ABMR has been one of the major advances in the Banff Classification in recent years. Currently Banff 2015 classification requires evidence of donor specific antibodies (DSA), interaction between DSA and the endothelium, and acute tissue injury (in the form of microvasculature injury (MVI); acute thrombotic microangiopathy; or acute tubular injury in the absence of other apparent cause). In this article we review not only the ABMR phenotypes acknowledged in the most recent Banff classification, but also the phenotypes related to novel pathogenic antibodies (non-HLA DSA, antibody isoforms and subclasses, complement-binding functionality) and molecular diagnostic tools (gene transcripts, metabolites, small proteins, cytokines, and donor-derived cell-free DNA). These novel tools are also being considered for the prognosis and monitoring of treatment response. We propose that improved classification of ABMR based on underlying pathogenic mechanisms and outcomes will be an important step in identifying patient-centered therapies to extend graft survival.

Racial Differences in Outcomes after Acute Ischemic Stroke Hospitalization in the United States

BACKGROUND AND OBJECTIVES Racial differences in stroke outcomes have major health policy implications. There is paucity of contemporary data on racial differences in clinical outcomes and resource utilization in acute ischemic stroke hospitalizations in the United States. METHODS We used the 2011-2012 National Inpatient Sample to identify hospitalizations with a primary diagnosis of acute ischemic stroke. Primary outcomes were in-hospital mortality, utilization of thrombolysis, and endovascular mechanical thrombectomy (EMT). Secondary outcomes were length of stay (LOS) and average inflation-adjusted charges. RESULTS A total of 173,910 hospitalizations representing 835,811 hospitalizations nationwide were included in the study. Mean age was 70.9 years and 52.3% were women. Blacks (adjusted OR .71, 95% CI .64-.78, P < .001) and Asian or Pacific Islanders (adjusted OR .80, 95% CI .66-.97, P = .02) had a lower in-hospital mortality compared to Whites. Blacks were less likely to be treated with thrombolysis (adjusted OR .84, 95% CI .76-.92, P < .001) and EMT (OR .73, 95% CI .58-.91, P = .01). Average LOS and inflation-adjusted charges were significantly higher for racial minorities compared to Whites. CONCLUSIONS Blacks and Asians hospitalized for ischemic stroke are less likely to die in the hospital compared to Whites. Hospitalization for stroke in Blacks is associated with lower rates of reperfusion therapy, longer lengths of stay, and higher costs compared to Whites.

Weekend hospitalizations for acute aortic dissection have a higher risk of in-hospital mortality compared to weekday hospitalizations.

a Department of Medicine, Cambridge Health Alliance/Harvard Medical School, Cambridge, MA, United States b Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, United States c Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, United States d Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, United States e Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States

Opiate receptor antagonists for treatment of severe pruritus associated with advanced cholestatic liver disease.

Dear Editor: Intractable pruritus due to advanced cholestatic liver disease can lead to intense physical suffering in terminally ill patients. We report the case of a 90-year-old man who had distressful pruritus due to irreversible drug induced cholestasis. His symptoms failed to respond to antihistamines, bile acid binding resins, and SSRIs but responded dramatically to the opiate receptor antagonists methylnaltrexone and naloxone. Improved symptom control allowed the patient to sleep after weeks along with significant reduction in daytime symptoms. A 90-year-old Caucasian man with a history of type 2 diabetes and congestive heart failure due to critical aortic stenosis (aortic valve area of 0.7 cm) was admitted with severe itching, generalized icterus, and abdominal pain. Community acquired pneumonia was treated with a course of azithromycin two weeks prior to onset of symptoms. On physical exam he was afebrile with a heart rate of 84 and blood pressure of 104/80. There was generalized marked icterus and a 4/6 ejection systolic murmur loudest in the aortic area. Routine laboratory tests complete blood count and basic metabolic panel were unremarkable. Liver function tests showed that total bilirubin was 19.9 mg/dl, direct bilirubin was 17 mg/dl, alkaline phosphatase was 343 U/L, aspartate aminotransferase was 44 U/L, and alanine aminotransferase was 58 U/L. Computed tomography scan of the abdomen showed normal sized extra hepatic bile ducts without any hepatic or pancreatic mass lesions. Tests for antinuclear antibody, antimitochondrial antibody, anti-smooth muscle antibody, and antineutrophilic cytoplasmic antibody were negative. The patient and his family declined further investigations including a liver biopsy given his age and multiple comorbidities. His goals of treatment were set at comfort measures only. Azithromycin has been rarely reported to cause chronic cholestasis, and a clinical diagnosis of irreversible drug induced cholestasis was made in light of the temporal association with antibiotic use; other causes were unlikely in the absence of supporting clinical findings. Over the subsequent weeks hyperbilirubinemia and pruritus continued to worsen. Initial attempts at treatment with antihistamines, cholestyramine, and SSRIs were ineffective. He responded transiently to a methylnaltrexone (also used to treat opioid induced constipation) challenge administered subcutaneously. Subsequently, naloxone (0.4 mg/hr) continuous infusion subcutaneously was started, to treat pruritus, with a dramatic improvement in symptoms—and significantly improving the patient’s quality of life. His symptoms remained well controlled over the next few weeks. He died in the palliative care unit approximately four weeks from the diagnosis of irreversible drug induced cholestasis. Pruritus can often be the most distressful symptom of chronic cholestatic conditions such as drug induced cholestasis, primary biliary cirrhosis, and primary sclerosing cholangitis, often leading to sleep deprivation, depression, impaired quality of life, and even suicidal ideation. Intractable pruritus that is refractory of medical management is an indication for liver transplantation. In terminally ill patients where age or comorbidities preclude transplantation as a therapeutic option, symptom control assumes prime importance. The pathogenesis of pruritis in cholestasis involves the accumulation of bile acids, serotonin, endogenous opiates, and lysophosphatidic acid, which through a combination of peripheral nerve stimulation and central nervous system stimulation of l receptors produce the sensation of itch; however, the exact mechanism continues to remain unclear. A number of therapeutic options of variable efficacy are available for the treatment of pruritus in cholestasis, including bile acid binding resins, antihistamines, rifampin, SSRIs, and opiate receptor antagonists. In randomized controlled trials using opiate receptor antagonists, intravenous naloxone, oral naltrexone (also used to treat substance abuse disorders) and nalmefene achieved a statistically significant reduction in the sensation of pruritus along with a reduction in scratching behavior in patients with cholestasis. However, the use of these agents remains limited in the palliative care setting. This is partially due to concerns regarding a reversal of analgesic effects of opiates prescribed for pain. In our experience analgesia was not affected by naloxone treatment. It is likely that the small dose (0.4 mg/hr) and short half life of naloxone (1 hour to 1.5 hours) were insufficient to reverse the analgesic effect of exogenously administered opiates.

De novo thrombotic microangiopathy after kidney transplantation

Thrombotic microangiopathy (TMA) is a serious complication of transplantation that adversely affects kidney transplant recipient and allograft survival. Post-transplant TMA is usually classified into two categories: 1) recurrent TMA and 2) de novo TMA. Atypical hemolytic uremic syndrome (aHUS) resulting from dysregulation and over-activation of the alternate complement pathway is a rare disease but the most common diagnosis associated with recurrence in the allografts. De novo TMA, on the other hand, represents an overwhelming majority of the cases of post-transplant TMA and is a substantially more heterogeneous entity than recurrent aHUS. Here, we review the etio-pathogenesis, diagnosis and treatment options for de novo post-transplant TMA. It is usually in the setting of calcineurin inhibitor use, mammalian target of rapamycin inhibitor use, or antibody mediated rejection; recently genetic mutations in complement regulatory genes for Factor H and Factor I similar to those described in aHUS have been reported in up to a third of these patients. Systemic signs of TMA are frequently absent, and a renal allograft biopsy is often needed to establish the diagnosis. Although withdrawal of the offending agents is usually the first line of treatment and resolution of laboratory abnormalities has been documented with this approach in several case reports and case series, available retrospective data demonstrate lack of benefit in long-term graft outcomes. Co-stimulation blockage with belatacept provides an effective alternate immunosuppressive strategy for these patients. Anti-complement therapy with eculizumab is effective in some cases; further work is required to define which patients with TMA (with and without concomitant antibody-mediated rejection) would benefit from receiving this treatment, and what biomarkers can be used to identify them.

Acute Pericarditis-Associated Hospitalization in the USA: A Nationwide Analysis, 2003-2012

Background and Objectives: Epidemiologic data on hospitalizations for acute pericarditis are scarce. We sought to study the trends in these hospitalizations and outcomes in the USA over a 10-year period. Methods: We used the 2003-2012 Nationwide Inpatient Sample database to identify admissions with a primary diagnosis of acute pericarditis. Outcomes included hospitalization rate, case fatality rate (CFR), length of stay (LOS), hospital charges, complications and diagnostic and therapeutic procedures. Results: We observed an estimated 135,710 hospitalizations for acute pericarditis among patients ≥16 years during the study period (mean age 53.5 ± 18.5 years; 40.5% women). The incidence of acute pericarditis hospitalizations was significantly higher for men than for women [incidence rate ratio (IRR) 1.56; 95% confidence interval (CI) 1.54-1.58; p < 0.001]; it decreased from 66 to 54 per million person-years (p < 0.001). CFR and LOS declined significantly during the study period (CFR: 2.2% in 2003 to 1.4% in 2012; LOS: 4.8 days in 2003 to 4.1 days in 2012; p < 0.001 for both). The average inflation-adjusted health-care charge increased from USD 31,242 to 38,947 (p < 0.001). Conclusion: The hospitalization rate, CFR and LOS associated with acute pericarditis have declined significantly in the US population. Average charges for acute pericarditis hospitalization have increased.