Letters to the Editor
No Difference in Mortality From Nonvariceal Upper Gastrointestinal Hemorrhage Between Racial Groups: A Nationwide Time Trend Analysis, 2008-2018
There is limited literature on recent trends in racial differences in incidence of and mortality from nonvariceal upper gastrointestinal hemorrhage (NVUGIH). Therefore, we studied these trends in the United States between 2008 and 2018 by conducting a retrospective longitudinal trend analysis using the National Inpatient Sample.1 All adult patients (≥18 years old) with NVUGIH were identified by International Classification of Diseases, Ninth Revision (ICD-9) and Tenth Revision (ICD-10) codes for the corresponding years (Supplemental Methods, available online at http://www.mayoclinicproceedings.org ).Immunity Acquired From the First Wave of COVID-19 Against Reinfections Up to Omicron Predominance
The protective effects of prior infection with SARS-CoV-2 against reinfection are of great public health interest. Among the limited literature covering delta and omicron variant predominance, a nationwide study in Qatar reported that the protective effects derived from prior infection are 92% and 56% against the delta and omicron variants, respectively.1 Malato et al2 found that a previous infection could have 50% to 75% protective effects against the most recent BA.5 variant reinfection, with the greatest protection from previous BA.1/BA.2 omicron infection.Rumpel-Leede Sign: Consider Underlying Vitamin C Deficiency
To the Editor: I read with interest the article by Mohammad et al.1 The authors report the case of a man in his 60s, in whom a petechial rash appeared on his arm after measuring his blood pressure early in his hospitalization. In the context of normal laboratory results, this finding was interpreted as an example of the Rumple-Leede phenomenon (intracutaneous hemorrhage produced by prolonged proximal pressure, signifying increased capillary fragility). Given the specifics of this case (the patient had a history of intravenous drug use, retained needles in the forearm give a picture of self-neglect), consideration should be given to underlying vitamin C deficiency (scurvy), which can also be manifested in this manner.In Reply—Rumpel-Leede Sign: Consider Underlying Vitamin C Deficiency
We thank Dr Martin Windpessl for his interest in our case of Rumpel-Leede sign. As was pointed out, the cutaneous manifestation of a petechial rash should also suggest vitamin C deficiency. On discovery of the rash, our team did include vitamin C deficiency as part of the differential, consulted with the dermatology service, and sent a vitamin C level that returned within normal limits. We regret not being able to elaborate on this work-up in our initial manuscript because of the word limit associated with submissions of this nature.NT-proBNP and High-Sensitivity Cardiac Troponin T Fail to Detect Cardiac Involvement in Erdheim-Chester Disease
To the Editor: Erdheim-Chester disease (ECD) is a rare non–Langerhans cell histiocytosis belonging to the L-group of the 2016 revised histiocytosis classification.1 Although frequent and associated with clinical complications, cardiac involvement is underdiagnosed in ECD.2 Cardiac magnetic resonance (CMR) imaging is the most robust way to detect cardiac involvement.3 However, access to this technique is limited. We evaluated the utility of B-type natriuretic peptides and troponin for the diagnosis of cardiac involvement in ECD.Newly Recognized α-Gal Syndrome in the Upper Midwestern United States
α-Gal syndrome is a recently recognized entity in which allergy to mammalian meat may be acquired by exposure to the disaccharide galactose-α-1,3-galactose (α-gal) antigen through the saliva of the Lone Star tick. Subsequent exposure to the antigen in meat may result in the delayed presentation (3 to 6 hours after ingestion) of systemic hypersensitivity reactions (eg, urticaria, angioedema), gastrointestinal symptoms, or life-threatening anaphylaxis.1,2 Anaphylaxis is potentially fatal, and identifying the cause is critical.Impending Arteriovenous Fistula Bleeding With Skin Ulceration
Arteriovenous fistulas are a common form of autogenous access in patients requiring renal replacement therapy.1-3 Aneurysmal degeneration of segments of the outflow vein and outflow stenosis are frequently identified.4 Albeit rare, arteriovenous fistulas bleeding can be a devastating and fatal dialysis access complication. Skin thinning and ulceration are signs of increased risk for bleeding or impending rupture.5 Immediate investigation of the fistula for any concerning signs of bleeding is imperative and any issues should prompt swift referral.Introducing Artificial Intelligence into the Preventive Medicine Visit
The artificial intelligence–enhanced electrocardiogram (AI-ECG) has been validated for the identification of multiple cardiac pathologies.1-3 We developed an AI-ECG algorithm that closely predicts chronologic age and demonstrated that the difference between AI-ECG age and chronologic age, or delta age (the first minus the latter), predicts long-term survival. Furthermore, AI-ECG age has been associated with cardiovascular diseases and risk factors such as hypertension and dyslipidemia.4,5 As this AI tool reflects potentially valuable information about overall fitness and cardiovascular health, we discuss an exemplary case where the AI-ECG showed a change towards youth following risk factor modification.Complement C5 inhibition as a Novel Therapeutic Approach in Severe Pre-eclampsia
Determining the clinical diagnosis underlying thrombotic microangiopathy (TMA), a pathologic entity, may be challenging, as is its effective management. This is especially true when TMA occurs in pregnancy. We report a case of a woman presenting in mid-pregnancy with severe pre-eclampsia and acute TMA who was successfully managed with eculizumab.SARS-CoV-2 mRNA Vaccination-induced Autoimmune Polyarthritis-like Rheumatoid Arthritis
The vaccine mRNA is sensed by multiple pattern recognition receptors of dendritic cells, leading to type I interferon secretion. This interferon response promotes the adaptive immune reaction to provoke antiviral response and probably interferonopathy including type 1 diabetes mellitus (T1DM), lupus, and thyroiditis.1 Indeed, not merely severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection but also vaccination induces disease flare-up in patients with rheumatoid arthritis (RA).2-4 We here report an elderly woman with autoimmune background who received the Pfizer BioNTech vaccine BNT162b2, resulting in new-onset autoimmune polyarthritis-like RA.Progression of Calcific Aortic Stenosis Detected by Artificial Intelligence Electrocardiogram
To the Editor: Aortic stenosis (AS) is one of the most common valvular heart diseases with insidious progression and significant morbidity. Because of the deleterious effect of the valve disease on the myocardium, early valve intervention is now recommended before the onset of symptoms,1,2 emphasizing the importance for detecting these individuals with AS early. Although current diagnostic approaches are technology-intensive with advanced imaging techniques, there remains a demand for an effective, inexpensive screening strategy for this clinical entity.Are Eosinophils Needed for Normal Health?
The recent state-of-the-art review on eosinophils in health and disease by Wechsler et al1 is a comprehensive statement of current thought. In their summary, the authors conclude that eosinophils may be involved in numerous homeostatic functions, including metabolism, tissue remodeling and development, neuronal regulation, epithelial and microbiome regulation, and immunoregulation, implicating a critical role for eosinophils in human health. This conclusion, however, would appear open to challenge because the monoclonal antibody, benralizumab, directed to the interleukin 5 receptor, totally abolishes eosinophils from the body.In Reply—Are Eosinophils Needed for Normal Health?
We thank Drs Gleich and Leiferman for their letter in response to our state-of- the-art review on eosinophils in health and disease.1 They question the concluding summary, that eosinophils may be involved in numerous homeostatic mechanisms, including metabolism, tissue remodeling and development, neuronal regulation, epithelial and microbiome regulation, and immunoregulation, implicating a role for eosinophils in human health. They raise this point as the anti–interleukin (IL)–5Rα monoclonal antibody benralizumab, which abolishes circulating eosinophils through induction of antibody-dependent cytotoxicity, has not been associated with an adverse effect profile.Left Ventricular Mass and Parameters of Body Composition in Older Adults
A progressive decrease in lean body mass (LBM) and an increase in fat mass (FM) occur with age. The concomitant change in left ventricular mass (LVM) is an independent predictor of cardiovascular morbidity/mortality, but its association with age-related changes in body composition has been scarcely addressed. The LVM increases with age, similar to the prevalence of arterial hypertension (AH) and diabetes mellitus (DM), as shown by echocardiographic studies on individuals with a wide age range.1-4 This approach highlights age-related changes, but not if they are prolonged in older life.Employer-Provided Professional Coaching to Improve Self-compassion and Burnout in Physicians
Occupational burnout is a highly prevalent manifestation of work-related distress among physicians, with important personal and professional consequences.1 Several recent studies have suggested that professional coaching is one strategy to help individual physicians navigate personal and professional challenges and reduce occupational burnout.2,3 Other studies report that although physicians have higher levels of personal resilience than US workers in other fields,4 they often have perfectionistic tendencies and low self-valuation levels.Survival Time in Hematologic Malignancies Obeys Newcomb-Benford Law
Newcomb-Benford law (NBL) states that the distribution of the first digit in most empirical numerical series is not uniform, and there is inherent predilection toward lower digit values.1 Specifically, the probability of the digit 1 being first is approximately 30.1%, whereas for the digit 9, the probability decreases to approximately 4.6%. Not all numerical sets abide by this law; however, for those that do, diversions indicate data modifications including potentially malicious behaviors such as using fraudulent data.Association Between Weekly Exercise Time and Mortality
We read with great interest the work of Schnohr et al1 about the association between weekly exercise time and cardiovascular disease (CVD) mortality. During ±25 years of follow-up, 4779 deaths (54.9% of study population) were recorded, of which 2054 (23.6%) were CVD related. The authors reported a U-shaped association between weekly exercise time and CVD mortality and all-cause mortality, with the lowest risk for individuals exercising 2.6 to 4.5 h/wk. These findings remained consistent after correction for competing risks, stratified analyses, and analyses to account for reverse causation.In Reply—Association Between Weekly Exercise Time and Mortality
We would like to thank the esteemed Drs Aengevaeren, Eijsvogels, and Bakker for their insightful comments regarding our recently published manuscript.1 We chose the cohort doing 2.6 to 4.5 h/wk of exercise as the reference group because this approximates the 30 minutes daily of leisure-time physical activity recommended by national guidelines in Denmark.In reply—Exercise-Based Cardiopulmonary Rehabilitation: A Suitable Addition to Pharmacological Therapy for Pulmonary Hypertension
I am thankful for kind comments by Babu et al1 regarding our recent focused review of pulmonary hypertension. They have also provided an argument favoring the addition of exercise-based cardiopulmonary rehabilitation to medical therapy for pulmonary arterial hypertension (PAH), noting that this topic was not addressed in the review. There was no intention to provide a comprehensive review, and omitted certain topics that seemed more appropriate for guideline statements or Task Force reviews as highlighted by Babu et al.Exercise-Based Cardiopulmonary Rehabilitation: A Suitable Addition to Pharmacological Therapy for Pulmonary Hypertension
We read with great interest the article by Burger et al.1 The authors have conducted an intricate, focused review on the pathobiology and recent advances in the management of pulmonary arterial hypertension. The authors provide excellent insight toward the pathobiology of pulmonary arterial hypertension and focus on potential interventional targets and the basis for genetic predisposition. They also summarize the published and ongoing trials on newer pharmacological approaches targeting the various classes of pulmonary hypertension (PH).In Reply—Giant Cell Arteritis: The Place of 18F-FDG PET/CT and Serum Haptoglobin Level
We agree with Dr Yildiz1 regarding the ongoing need for identifying readily available, quantifiable blood biomarkers and noninvasive imaging modalities that provide validated assessment strategies to determine disease activity in large-vessel vasculitis, specifically in patients receiving tocilizumab. The findings by Unizony et al2 described by Dr Yildiz are noted and provide an area worthy of further investigation and confirmation. We chose to exclude guidance or suggestion of exploratory biomarkers in the recommendations of management because some proposed biomarkers are not commercially available to the practicing clinician.Giant Cell Arteritis: The Place of 18F-FDG PET/CT and Serum Haptoglobin Level
I read with great interest the article by Garvey et al.1 They mentioned that treatment with tocilizumab induced a direct inhibition of the acute phase response, and thus C-reactive protein levels are difficult to interpret. This is why identifying active disease or relapse is a challenge in these patients. 18F-Fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) has been proposed as a useful tool to assess response and relapse. However, several studies reported that a complete normalization of PET/CT activity occurred in less than 30% of patients while they are in clinical remission.Vax-Plasma in Patients With Refractory COVID-19
Convalescent plasma (CP) therapy uses neutralizing antibodies harvested from recovered patients to treat viral infections, including severe acute respiratory syndrome coronavirus (SARS-CoV) and influenza A.1 The emerging data from randomized controlled trials and observational studies suggest—consistent with historical precedent—that CP therapy has limited efficacy in severely ill patients with coronavirus disease 2019 (COVID-19) treated late in the disease course. However, early treatment with high-titer CP exhibits signs of efficacy.Representativeness of Racial and Ethnic Groups in COVID-19 Outpatient Trials in the United States
In the context of racial and ethnic disproportionalities throughout the coronavirus disease 2019 (COVID-19) pandemic, one would expect that clinical trials testing therapeutic agents against severe acute respiratory syndrome coronavirus 1 (SARS-CoV-2) would have fair or overrepresentation of minorities. However, that appears not to be the case.1mRNA COVID-19 Vaccine–Related Anaphylactoid Reaction and Coronary Thrombosis
The emergence of vaccines, with clear evidence of their efficacy, has been key to tackling the coronavirus disease 2019 (COVID-19) pandemic. However, as these vaccines are rolled out to larger numbers of patients, rare complications are inevitable, and clinicians should be aware of this possibility. We present a case of a young man who presented with an anaphylactoid reaction a day after having the Pfizer-BioNTech COVID-19 vaccine with thrombotic occlusion of his left anterior descending (LAD) artery.
