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Patient: Female, 89 Final Diagnosis: Tumor lysis syndrome (TLS) Symptoms: Dyspnea Medication: Steriods Clinical Procedure: HD Specialty: Nephrology Objective: Unusual clinical course Background: Tumor lysis syndrome is common in hematological malignancy, but less frequent in chronic and solid tumors. Almost always it is observed after chemotherapy or radiotherapy initiation, but rarely occurs spontaneously. Case Report: A 89-year-old female with stable chronic lymphocytic leukemia was admitted to the hospital because of worsening dyspnea and dry cough. Her vital signs were normal, except for sinus tachycardia. On physical examination, she appeared distressed, dyspneic, sweaty but afebrile, anxious, but alert and well oriented. Lung examination revealed reduced air entry with bibasilar crackles. No peripheral edema was seen, pulses were normal, and no signs of deep vein thrombosis were observed. Laboratory analysis revealed leukocytosis; but normal hematological and biochemical parameters. Intravenous (IV) furosemide and antibiotics (IV ceftriaxone and orally azithromycin) were started along with steroid therapy (methylprednisolone 62.5 mg, IV). The treatment with steroids lasted for 1 day only, and in the following day, the patient was switched to prednisone (20 mg/day orally) for only 1 additional day. White blood cell count increased on day 1, 2 and 3 after admission, along development of hyperuricemia, hyperphosphatemia, hyperkalemia, acute renal failure and elevated troponin levels. Hemodiafiltration/hemodialysis was initiated, and the patient was discharged after serum concentrations of these electrolytes and kidney function were restored. One month after discharge, the patient denied any malaise and was at stable condition. Conclusions: Herein, we present a case of a patient with stable chronic lymphocytic leukemia, who developed spontaneous tumor lysis syndrome after short low dose of steroid therapy. This case highlights the importance of including spontaneous tumor lysis syndrome in the differential diagnosis of any acute renal failure in the constellation of any malignancy.

BACKGROUND: Acute upper gastrointestinal bleeding (UGIB) remains a major cause of hospital admission worldwide. The recent UK National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report on severe gastrointestinal bleeding used the Shock Index to assess bleeding severity and found an association between Shock Index and mortality. However, this has never been prospectively validated as a predictor of outcome in UGIB.AIMS: To compare the Shock Index with existing pre-endoscopic UGIB risk scores in predicting outcomes after UGIB METHODS: In an international, prospective study of 3012 consecutive patients with UGIB, we compared the Shock Index with existing scores including the Glasgow Blatchford score (GBS), admission Rockall score, AIMS65, and the newly described "ABC" score. Pre-determined endpoints were need for major (≥4 units red cells) transfusion, need for endoscopic therapy and 30-day mortality.RESULTS: The Shock Index was inferior to the GBS in predicting need for major transfusion (area under the receiver operator characteristic curve [AUROC] 0.655 vs 0.836, P < 0.001) and need for endotherapy (AUROC 0.606 vs 0.747, P < 0.001). The Shock Index was inferior to all other scores for 30-day mortality: for example, AUROC 0.611 vs 0.863 for ABC score (P < 0.001). Adding the Shock Index to the ABC score did not improve accuracy of the ABC score in predicting mortality (AUROC 0.864 vs 0.863, P = 0.95).CONCLUSION: The Shock Index performed poorly with AUROCs

Despite considerable efforts to control tuberculosis (TB) among Ethiopian immigrants in Israel, an outbreak of TB among second-generation Ethiopian immigrants that involved native Israelis occurred between January 2011 and December 2019. The aim of this article is to report on this outbreak and discuss the patient and health system barriers that led to its propagation. Overall, 13 culture-positive TB patients were diagnosed in this outbreak. An additional 36 cases with identical mycobacterium tuberculosis genotypes were identified through cross-checking with the National TB Laboratory Registry. Among the 32 close contacts of the index case, 18 (56.3%) reported for screening and treatment of latent TB infection (LTBI) was recommended for 11 (61.1%) of them. However, none completed treatment and eight eventually developed TB. Of the 385 close contacts identified in this outbreak, 286 (74.3%) underwent contact investigation, 154 (53.8%) were recommended LTBI treatment, but only 26 (16.9%) completed the treatment. Routine contact investigation and treatment practice measures failed to contain the cascade of infection and disease, leading to the spread of the infecting strain of TB. This report highlights the challenges to identify the high-risk group and address barriers to care among such a vulnerable population.

Objective: The present study assesses whether phosphodiesterase type 5 (PDE-5) inhibitor or carnitine exert nephroprotective effects against clinical contrast-induced nephropathy (CIN). Materials and Methods: The present study consisted of three groups of CKD patients. The first group was control group, who were treated with N-acetyl-L-cysteine 1 day before and on the day of radiocontrast administration. The second one was carnitine group, where the patients were infused with carnitine over 10 min 2 h prior to the radiocontrast administration and 24 h post CT. The third one was PDE-5 inhibitor group, where patients were given tadalafil 2 h prior to the administration of the radiocontrast and in the subsequent day. Urine and blood samples were collected before and at the following time sequence: 2, 6, 12, 24, 48, and 120 h after the contrast administration, for creatinine and NGAL determination. Results: Pretreated with N-acetyl-L-cysteine prior to administration of contrast media (CM) to CKD patients caused a significant increase in urinary but not of plasma neutrophil gelatinase-associated lipocalin (NGAL) and serum creatinine (SCr). In contrast, pretreatment with carnitine prevented the increase in urinary NGAL and reduced SCr below basal levels. Similarly, tadalafil administration diminished the elevation of CM-induced urinary NGAL. Conclusions: These results indicate that carnitine and PDE-5 inhibitors may comprise potential therapeutic maneuvers for CIN.

Background Iron deficiency (ID) is often an indicator of underlying pathology. Early detection and treatment avoids long term morbidity, and allows for prompt iron repletion avoiding ID anaemia (IDA) and need for blood transfusion. Aim We aimed to evaluate the management of ID in two internal medicine units [General Medical (GM) & Gastroenterology (GE)] in a large metropolitan hospital and compare it to international guidelines.3,4 Method All consecutive inpatient admissions under GM & GE units were retrospectively reviewed until 40 patients in each service were identified with anaemia and/or microcytic hypochromic blood counts. Patient records and electronic discharge summaries were then reviewed to assess the recognition, investigation and management of these abnormalities. Results Overall, only 60% (48/80) of the cases of microcytic hypochromic picture +/− anaemia were recognised. Cases were more likely to be detected under the GE unit; 77.5 % [31/40] vs 42% [17/40] in GM (p

Introduction The 2015 NCEPOD report ‘Time to Get Control’ highlighted the need to improve the quality of care of patients with acute upper GI bleeding (AUGIB). The BSG Endoscopy Quality Improvement Project created an evidence based care bundle for AUGIB targeting ward based management of patients within the first 24 hours (The UK AUGIB bundle). The impact of implementation of the UK AUGIB bundle has not been assessed in clinical practice. Methods An audit of the impact of the UK AUGIB bundle was undertaken in 15 Scottish hospitals on behalf of the Scottish Society of Gastroenterology. Data were collected relating to demographics and management of patients with AUGIB within the first 24 hours of presentation, for a six-week period pre- and post-implementation of the UK AUGIB bundle. A period of bundle promotion was undertaken in all centres between the data collection cycles. Outcome measures included documentation of bundle implementation, risk scores and transfusion strategy. Caldicott approval was obtained in each site. Results A total of 459 patients were included in the pre-bundle audit period, and 434 patients in the post-bundle audit period. Following implementation the AUGIB bundle was utilised in 41.2% of patients. The table 1 demonstrates patient demographics and the impact of bundle implementation. Data were analysed using STATA 14.0. Chi-2 tests were used for categorical variables. For continuous variables, t-tests and Wilcoxon rank sum tests were used according to variable distribution. No significant differences were observed in use of PPI in high risk bleeders, use of terlipressin/antibiotics in variceal haemorrhage or resumption plan for antithrombotics, with high pre-bundle performance in these domains. Conclusions Implementation of the UK AUGIB bundle in Scottish hospitals resulted in significant improvements in quality standards including documentation of risk scoring, target haemoglobin, transfusion thresholds and re-bleed plan.

Introduction In the UK, radiofrequency ablation (RFA) is established as treatment of choice for flat oesophageal neoplasia or after removal of focal lesions by endoscopic mucosal resection (EMR) to eradicate Barrett’s mucosa. Standard practice is treatment with the HALO 360 Express RFA catheter. A specific complication of RFA is oesophageal stricture development. The UK national RFA registry has quoted a 11–17% rate of strictures requiring dilatation, with higher rates in patients treated with 12J rather than 10J paired ablations(p Methods In December 2017, we adapted our practice to include irrigation with 30cc normal saline between 10J ablations as a cooling phase during the HALO 360 express procedure and removed the cleaning phase between ablations. We have audited patient and disease demographics and outcomes data, especially oesophageal stricture rate, for all patients who had first HALO 360 express between 1/12/16-1/12/18 in our hospital. This represents 12 months before and after technique modification. Statistical analysis of variables was calculated using fisher’s exact test, Wilcoxon ranksum, and logistic regression analysis. Results In the capture period, 36 patients had standard treatment, and 48 patients underwent modified technique. In the latter group, a significantly longer mean Barrett’s segment was treated (6.1 cm vs 8.2 cm; p=0.01). We identified a stricture rate of 22.2% (8/36) in the standard treatment group, and 4.2% (2/48) in the modified group (p=0.014). Stricture rate was significantly higher (p=0.026) with increasing Prague circumferential and maximum Barrett’s length (p=0.023). There was no statistical difference in stricture rate when prior EMR or degree of dysplasia was considered. A logistic regression model showed 85% reduced odds of stricture using the modified treatment (p=0.036) after adjusting for age, procedure type, grade of dysplasia, prior EMR, and Prague measurements. Conclusions Our audit demonstrates an improved outcome with the novel treat-cool-treat technique, with significantly lower rate of stricture development with this modified practice. This has an important bearing on patient care, as dilatation carries its own risk of complication. These findings suggest a benefit to the use of this novel adaptation of standard HALO 360 RFA treatment in Barrett’s neoplasia.