Refael Segal

Early and late effects of low-dose aspirin on renal function in elderly patients

BACKGROUND Although low-dose aspirin is used by many elderly patients, monitoring of renal function is currently not recommended. We recently reported transient retention of uric acid and creatinine caused by aspirin in doses of 75 to 325 mg/d. We therefore evaluated the renal effects of aspirin (100 mg/d), including post-treatment effects. METHODS We studied 83 stable geriatric patients in long-term care (aged 56 to 98 years) who were treated with low-dose aspirin (100 mg/d) for 2 weeks and 40 control patients. Other medications and diet were kept constant. Biochemical monitoring including blood samples and 24-hour urinary collections for creatinine and uric acid at baseline and weekly for a total of 5 weeks. RESULTS After 2 weeks on aspirin, urinary excretion of creatinine decreased in 60 (72%) and excretion of uric acid decreased in 54 (65%) of the 83 patients, and their mean clearances decreased; during the same period, serum blood urea nitrogen, creatinine, and uric acid levels increased (P <0.05 for all). Deterioration from baseline levels was significantly greater (and more prevalent) in the aspirin-treated group than in the 40 control patients (P = 0.001 to 0.09). After withdrawal of aspirin these parameters improved. However, 3 weeks after stopping aspirin, 48% (35 of the 73 in whom this measurement was available) had a persistent decline in creatinine clearance from baseline, as compared with only 8% (3/36) controls (P <0.001). CONCLUSION Short-term low-dose aspirin treatment may affect renal function in elderly patients. These effects persist 3 weeks after cessation of the drug in some of these patients.

Anemia, serum vitamin B12, and folic acid in patients with rheumatoid arthritis, psoriatic arthritis, and systemic lupus erythematosus

ObjectiveAlthough anemia is frequent in inflammatory rheumatic diseases, data regarding vitamin B12 status is scarce. The purpose of this study was to analyze the incidence and nature of B12 and folic acid (FA) deficiencies in a cohort of rheumatic patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA), and systemic lupus erythematosus (SLE).MethodsLevels of B12, FA, and parameters of anemia were recovered or examined in 276 outpatients. In those with recent findings of low serum B12 levels, further studies of serum homocysteine (Hcy) and urine methylmalonic acid (MMA) levels were performed.ResultsThe incidence of anemia was high: 49%, 46%, and 35%, in RA, SLE, and PsA, respectively. Low levels of serum B12 were also frequent (24%), with almost similar occurrence in the three disease groups. Deficiency in FA was rare (<5%). Mean levels of both vitamins did not differ significantly among the three groups. No correlation between serum B12 levels and anemia was found. In the 15 patients with recently detected low B12 levels, Hcy and MMA were evaluated before and following B12 therapy. In ten of them, baseline Hcy levels were high, while MMA was increased in one patient only. Response to B12 administration, i.e., a decrease in Hcy and/or MMA levels, was noticed in four patients only, suggesting that only 26% of the low-serum-B12 patients had true B12 deficiency.ConclusionsThe incidences of anemia and decreased serum B12 levels were high in these three groups of rheumatic patients. However, true tissue deficiency seems to be much rarer.

Human leukocyte antigen distribution in Israeli patients with psoriatic arthritis

ObjectivesThis study was designed to investigate the distribution of human leukocyte antigen (HLA) classes I and II in a group of Israeli Jewish patients with psoriatic arthritis (PsA) and identify HLA markers related to disease manifestation in PsA.Patients and methodsHuman leukocyte antigens class I and class II (both serologically and from oligotyping) were tested in a group of 50 consecutive patients with PsA, 32 with skin psoriasis (PSO), and 255 healthy persons. Data on age, gender, disease duration, and pattern of rheumatological manifestations—oligoarthritis, polyarthritis, spinal involvement, involvement of distal interphalangeal joints (DIPs), and enthesitis—were registered.ResultsHuman leukocyte antigens A3, B13, and B38 alleles were found to be significantly prevalent in PsA compared with PSO patients and healthy controls. HLA-B27 was found in only two out of 50 patients with PsA. Patients with PSO and PsA had significantly increased incidence of HLA-DRB0101 and -DRB0301, while the frequency of HLA-DRB0403 was significantly higher among patients with PsA of Ashkenazi origin. We found a statistically significant association between DIP involvement and the presence of HLA-A26 and -B38, while HLA-DRB0301 was related to spinal involvement.ConclusionsPsoriatic arthritis in Israeli patients seems to be associated with the presence of HLA-A3, -B13, -B38, -DRB0101, and -DRB0301. HLA-B27 was not a marker of PsA in this cohort of patients, including patients with psoriatic spondyloarthropathy.

The anti-cyclic citrullinated peptide response in tuberculosis patients is not citrulline-dependent and sensitive to treatment.

IntroductionPatients with tuberculosis (TB) frequently produce anti-citrullinated protein antibodies (ACPA). The objective of this study is to characterize the citrulline-dependence of the ACPA reactivity in sera of patients with mycobacterium infections.MethodsSerum samples of 134 patients with untreated mycobacterium infections (122 TB, 12 nontuberculous mycobacterium) were tested for antibodies against both the citrullinated (Cit) and the non-citrullinated (Arg) form of 2 cyclic synthetic peptides. In 33 patients, a follow-up sample was tested six months after starting anti-mycobacterial drugs.ResultsA substantial proportion of patients with mycobacterial infections demonstrated antibodies against 0401Cit, 0401Arg, 0722Cit and 0722Arg. Fourteen patients demonstrated anti-0401Cit, 83 anti-0401Arg, 22 anti-0722Cit and 61 anti-0722Arg, while none of these antibodies were detected in the 20 healthy controls. All the patients but one, who were anti-0401Cit and anti-0722Cit positive, demonstrated reactivity against the respective Arg peptide. In the subset of 33 patients with a follow-up test six months after starting treatment, the mean levels of antibodies to 0401Cit, 0401Arg, 0722Cit and 0722Arg significantly decreased after treatment. All the patients who were anti-0401Cit and anti-0722Cit positive turned negative after treatment. The presence of anti-0401Cit/Arg and anti-0722Cit/Arg was found to be significantly correlated with the presence of HIV.ConclusionsACPA may be found in patients with TB. In most of the cases, the reactivity is citrulline independent. A positive cyclic citrullinated peptide (CCP) test in these patients should therefore be interpreted with care, and preferably followed by a control ELISA with a non-citrullinated antigen.

Mortality after Nasogastric Tube Feeding Initiation in Long-Term Care Elderly with Oropharyngeal Dysphagia – The Contribution of Refeeding Syndrome

Background: The refeeding syndrome (RS) is an underappreciated but clinically important entity characterized by acute electrolyte abnormalities, mainly hypophosphatemia, fluid retention and dysfunction of various organs and systems, which can result in significant morbidity and occasionally death. Objective: To examine the incidence of death cases and death causes following nasogastric tube (NGT) feeding initiation in frail elderly with particular reference to RS. Methods: Forty patients with feeding problems for at least 72 h before restarting of alimentation by NGT were included. Excluded were those in any critical clinical situation. Clinical parameters and nutritional assessment were recorded before and after refeeding. Blood samples were taken before, daily for the first 3 days and 1 week after refeeding initiation. Results: During the 1st week of refeeding, 9 patients (22.5%) died and within 1 month 10 more, summing to 47.5%. Most deaths were due to infectious causes [15 out of 19, (79%)]; some were due to no obvious reason [4 out of 19, (21%)]. Significant electrolyte changes were observed in the 2–3 days following refeeding. Significant were the decreases in phosphorus and elevations in potassium and lymphocytes (day 7). We found no correlations between the severity of decreases in levels of phosphorus and mortality. Conclusions: Mortality after NGT feeding initiation was high, mainly due to infectious complications. However, in a considerable number of patients hypophosphatemia was noted, suggesting that RS could be a contributory factor of mortality. Since this is a treatable condition, more attention should be paid to detecting and coping with this problem.

Pathogenic Colonization of the Stomach in Enterally Fed Elderly Patients: Comparing Percutaneous Endoscopic Gastrostomy with Nasogastric Tube

OBJECTIVES: To compare the gastric juice microbiota of older people fed through a percutaneous endoscopic gastrostomy tube (PEG) with that of those fed through a nasogastric tube (NGT).

Bacteremia in a Multilevel Geriatric Hospital

BACKGROUND Bloodstream infection (BSI) is a major cause of morbidity and mortality in hospitals. Bacteremia in the elderly remains a diagnostic as well as a therapeutic challenge to the clinician. METHODS We investigate the clinical features, microbiological characteristics, and outcome of bacteremic episodes in a mixed LTC elderly population in a multilevel geriatric hospital. Data of patients with the diagnosis of BSI (during 2 years) was collected retrospectively from the records of the bacteriology laboratory of a 400-bed multilevel geriatric hospital. RESULTS During the 2 years of the study period, 3453 blood cultures have been performed; 368 positive blood cultures (10%) were detected in 309 patients. The total mortality rate at 2 weeks was 42%. One quarter of the deaths occurred in the first 3 days of the septic event (rapidly fatal period). Escherichia coli was the most common isolate (detected in 31% of cases). The second most common isolates were Staphylococcus aureus (19%; 63% of them MRSA) with a mortality of 39% and Proteus mirabilis (18%) with a 51% mortality rate. Urinary tract infection was the leading cause (70%), followed by decubitus ulcers (25%) and respiratory tract infections (12%). CONCLUSIONS the number of elderly skilled patients with severe and complex conditions in LTC facilities is increasing and more infections complicated by bacteremia are expected, requiring high clinical suspicion, close surveillance, and adequate reporting.

Postprandial hypotension in long-term care elderly patients on enteral feeding

OBJECTIVES: To examine the prevalence and nature of postprandial hypotension (PPH) in orally fed (OF), nasogastric tube (NGT)‐fed, and percutaneous endoscopic gastrostomy (PEG)‐fed older people.

Toxicity profile of dual methotrexate combinations with gold, hydroxychloroquine, sulphasalazine and minocycline in rheumatoid arthritis patients

Abstract The purpose of the present study was to evaluate the toxicity and tolerability of methotrexate (MTX)/ gold (G; group 1) combination therapy as compared to other MTX combinations [MTX with hydroxychloroquine (HCQ; group 2), MTX with sulphasalazine (SASP; group 3) and MTX with minocycline (MNC; group 4)]. The hospital records of 127 consecutive rheumatoid arthritis (RA) patients who were treated with these combinations during a period of 24 months were retrospectively reviewed. The toxicity and tolerability of the MTX/G combination was compared to the other dual MTX combinations and also to MTX alone using data previously reported by us on 126 RA patients treated with single MTX therapy. The mean exposure time to treatment was 16 months in group 1 and 13 months in the other dual MTX combinations. During the period of follow-up, the combination was stopped in 22 out of 42 patients in group 1 (52%) in comparison with 54 patients out of 86 patients (63%) in the other dual regimen groups. The discontinuation rate was highest in group 4 (due to side effects and lack of compliance) and this was statistically significant in comparison with group 1. The proportion of adverse events was lowest in group 1 (14%) and highest in groups 3 and 4 (25%). Side effects were reversible and comparable with those of MTX alone (23%). No fatal or life-threatening side effects were recorded during any of these MTX combination therapies. We concluded that the combinations of MTX with G, HCQ, SASP and MNC in RA were relatively well tolerated. No increase in toxicity compared with MTX alone was observed. The lowest rate of side effects was noted in group 1, while group 4 presented the highest discontinuation rate.

Biochemical, immunological and enzymatic components of saliva in prolonged naso-gastric-fed elderly patients

Background and aims: We have previously shown that naso-gastric tube (NGT)-fed patients harbor pathogenic flora in their oropharynx. The purpose of this study was to examine comparatively the biochemical, immunological and enzymatic components of the saliva of these patients with that of orally-fed counterparts. Methods: The study group consisted of 19 elderly NGT-fed patients and 18 comparable patients on oral feeding. Unstimulated whole saliva was collected and analyzed according to accepted methods for sodium, potassium, chloride, uric acid, total protein, albumin, amylase, lysozyme, and immunoglobulins, IgM, IgG, IgA, as well as secretory IgA. Results: None of the above tested salivary components significantly differed between the two groups. Only uric acid levels were significantly lower (50%, p<0.05) in NGT-fed patients. Conclusions: Uric acid is the main antioxidant component of saliva and, as such, it may be related to pathogenic bacterial colonization of the oropharynx in NGT-fed patients, with the risk of aspiration pneumonia.