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Preview: QJM - current issue

QJM: An International Journal of Medicine Current Issue





Published: Tue, 14 Feb 2017 00:00:00 GMT

Last Build Date: Tue, 14 Feb 2017 07:47:21 GMT

 






Cardiac magnetic resonance study of scorpion toxic myocarditis

2016-12-30

Scorpion envenomation may represent a life-threatening condition and, specifically in tropical, subtropical and sub-Saharan area, will be considered a public health problem. We describe a case of a 25-year-old Caucasian woman, suffering from severe scorpion envenomation by Leirus Quinquestratius. The patient presented a catecholamine induced myocarditis and myocardial dysfunction. Our observations, obtained by repeated cardiac magnetic resonance (CMR) assessments (11 days; 3, 9 and 15 months), firstly revealed a possible irreversible and sub-clinical myocardial damage. CMR seems to be a useful tool to assess cardiac damage in scorpion envenomation, particularly in terms of prevention of irreversible myocardial damage and dilated cardiomyopathy delayed development.



Coconut atrium

2016-12-27

A 69-year-old man with past medical history of rheumatic bivalvular disease with valve replacement in 1989 (mitral valve) and 1999 (aortic valve) and atrial fibrillation, was assessed because of dyspnea in context of heart failure. Evaluating the chest radiography performed during admission a pattern of C-shaped curvilinear cardiac wall calcification mimicking a coconut was discovered (Figure 1A). Afterward a CT scan to delimit this finding was made which confirmed deposition of calcification outlining the wall of the left atrium (Figure 1B). The patient was given a diagnosis of left atrium calcification. The first data of left atrial calcification (postmortem) was described by Oppenheimer1 in 1912 while Shanks et al.2 described it antemortem in 1938. This atrium calcification also called ‘coconut atrium’, ‘porcelain atrium’ or ‘moldlike calcification’ affects patients with chronic rheumatic pancarditis, predominantly in women.3 Almost all patients have previously undergone mitral valve replacement and presents 10 years atrial fibrillation average. Chest radiography is recommended to assess long-standing rheumatic valve disease with right heart failure. Surgical approach (total replacement) is not recommended because of the low probability of success, and it is an alternative when calcification of atrial wall is thick and transmural and has absence of a cleavage plane. Endoatriectomy is an option when calcification is non-transmural and spares the interatrial septum. Conservative treatment is usually be the most common option, which was chosen in this patient. Figure 1(A) C-shaped curvilinear cardiac wall calcification of the left atrium in chest radiography. (B) Left atrium calcification in CT scan.



Lion face in a uremia patient

2016-12-10

A 59-year-old woman presented with a progressive facial deformity since several months ago. She had end-stage renal disease undergoing regular hemodialysis for 6 years. The physical examination showed splayed dentition and hypertrophy of maxillary with flattening nasal that looked like ‘lion face’ (Figure 1A and B). The skull radiography (Figure 1B) showed overgrowth of maxillary (white arrow), salt and pepper sign (arrow head) that indicating diffuse heterogeneous and osteolytic change in calvarium, and calcification of ear cartilage (black arrow). The serum calcium concentration was 11.2 mg/dl (reference range, 8.4–10.2 mg/dl), and the serum parathyroid hormone concentration was 5421.1 pg/ml (reference range, 8–76 pg/ml). The diagnosis of renal failure related tertiary hyperparathyroidism was confirmed. Additionally, she had the presentation of leontiasis ossea which is defined as the overgrowth of the cranial and facial bone resulting in the expansion of the malar process and the reducing nasomaxillary angle. She received total parathyroidectomy with autotransplantation of 100 mg parathyroid gland. The pathologic examination revealed the hyperplastic parathyroid tissue. The post-operative course was smooth, and her clinical condition remained stationary during the follow-up. Figure 1(A) and (B) The physical examination showed splayed dentition and hypertrophy of maxillary with flattening nasal that looked like ‘lion face’, (C) The skull radiography showed overgrowth of maxillary (white arrow), salt and pepper sign (arrow head) that indicating diffuse heterogeneous and osteolytic change in calvarium, and calcification of ear cartilage (black arrow).



How to build a culture of health

2016-11-01

The health of a nation’s people is perhaps its most valuable asset. If people are not well, the economy suffers, families struggle, communities falter and national security is at risk. In 2014, the USA spent $3 trillion on health care, or $9523 per person—far more than any other country in the world. Yet the population is not healthy.



Understanding the cognitive experience of death and the near-death experience

2016-11-01

Transcendental mystical or spiritual experiences close to death have been described for millennia. However, following the birth of modern intensive care medicine four decades ago, the specific term ‘near-death experience’ (NDE) was coined.1 Current research indicates that, regardless of cultural background, adults and young children (<3 years) have described comparable experiences in association with death.1 These include: feelings of immense peace and love; a sensation of going through a tunnel; seeing a bright warm welcoming light that draws the person toward it; meeting a ‘being of light’; a feeling of entering a beautiful ‘heavenly’ domain; and encountering deceased relatives who are often perceived as greeting and welcoming the individual. A review of the person’s life from early childhood onward is another commonly reported experience, as is a sense of separating from the body and looking down from above, while observing events during their resuscitation. This has often been referred to using the ill-defined term of out of body experiences (OBEs).1



American health care paradox—high spending on health care and poor health

2016-10-24

Background: For decades, US taxpayers have been lamenting the high cost of health care. Since the mid-1980s, Americans have had double-digit spending on health care. Despite this investment, Americans are less healthy than their European and Scandinavian counterparts across an array of health measures.Aim: We sought to explore how inadequate attention to the social, behavioral and environmental determinants of health may contribute to the American health care paradox of high health care spending and poor health outcomes.Design: Mixed methodsMethods: We report previous findings related from a 10-year analysis of national-level health and social service spending and health outcome data from the Organization of Economic and Cooperation and Development (OECD). We also put forth case studies representing different socioeconomic strata to illustrate the relationship between health care and social service spending and health.Results: Although the US spending more of its GDP on health care than any other country, it is not a high spender when one sums spending on both health care and social services. The U.S. however has the lowest ratio of our social service spending to health care spending in the OECD, and countries with lower ratios on average have worse health outcomes. Cases from diverse socioeconomic strata demonstrate how limited attention to the social determinants of health can result in extremely high health care costs and poor health outcomes.Conclusions: Greater investment in addressing the social, behavioral and environmental determinants of health may foster better health without accelerating health care costs in America.



Adrenal lymphoma: presentation, management and prognosis

2016-10-18

Aim: This study aimed to identify the clinical, radiological and prognostic features of primary adrenal lymphoma (PAL) in order to diagnose the disease more accurately.Materials and methods: A retrospective multi-centre study was conducted on the clinical, biological and radiological features as well as the treatment and overall survival outcomes in PAL.Results: Between 1994 and 2014, 28 patients from five regions of eastern France were diagnosed with primary adrenal lymphoma. The revealing symptoms were a worsening general state (77%), weight loss (77%) and abdominal pain (42%). Biological features of PAL were almost omnipresent: increased LDH, β2 microglobulin, CRP or ferritinaemia levels. The PAL was bilateral in 20 cases (71%), adrenal insufficiency was searched for in 11 patients and found in eight (73%). CT scans showed masses of various sizes measuring up to 180 mm. On MRI, the lesions were hypointense in T1 and hyperintense in T2. When done, positron emission tomography with fluorodeoxyglucose (FDG-PET) showed locations not seen on the CT and revealed extra-adrenal locations in 70% of examinations. Adrenalectomy brought no benefit. The overall survival rate was poor (61.9% at 2 years) despite polychemotherapy.Conclusion: The clinical presentation of PAL comprised major general symptoms. Adrenal insufficiency was very common in patients with bilateral involvement but was not systematically tested. PET was an efficient examination to visualize extra-adrenal locations. The preliminary results of MRI to distinguish between PAL and adrenocortical carcinoma should be confirmed. Further studies are needed to establish an optimal strategy for the management of these primary adrenal lymphomas.



Impact of consultant specialty on discharge decisions in patients admitted as medical emergencies to hospitals in the United Kingdom

2016-10-18

Background: The Society for Acute Medicine’s Benchmarking Audit (SAMBA) annually examines Clinical Quality Indicators (CQIs) of the care of patients admitted to UK hospitals as medical emergencies.Aim: The aim of this study is to review the impact of consultant specialty on discharge decisions in the SAMBA data-set.Design and methods: Prospective audit of patients admitted to acute medical units (AMUs) on 25 June 2015 to participating hospitals throughout the UK with subgroup analysis.Results: Eighty-three units submitted patient data from 3138 patients.Nearly 1845 (58%, IQR for units 50–69%) of patients were referrals from Emergency Medicine, 1072 (32%, IQR for units 24–44%) were referrals from Primary Care. The mean age was 65 (SD 20). One hundred and forty-one (4.5%) patients were admitted from care homes and 951 (30%) of patients were at least ‘mildly frail’ and 407 (13%) had signs of physiological instability. The median and the mean time to being seen by a doctor were 1 h 20 min and 2 h 3 min, respectively. The median and the mean time to being seen by senior specialist were 3 h 55 min and 5 h 56 min, respectively. By 72 h, 29 (1%) patients had died in the AMU, 73 were admitted to critical care units, 1297 (41%) had been discharged to their own home and 60 to nursing or residential homes. For every 100 patients seen specialists in acute medicine discharged 12 more patients than specialists from other disciplines of medicine (P < 0.001). The difference remained significant after adjustment for case mix.Conclusion: Specialist in acute care might facilitate discharge in a higher proportion of patients.



Effectiveness of cardiogoniometry compared with exercise-ECG test in diagnosing stable coronary artery disease in women

2016-09-23

Aims: To investigate the effectiveness of cardiogoniometry, a novel, non-invasive method, in diagnosing coronary artery disease (CAD) in women and compare it with exercise-ECG test, by using coronary angiography as a reference method.Methods: It was a single-centre, case-series study including consecutive female patients with stable angina pectoris (AP) undergoing coronary angiography. Exercise-ECG test, done according to the Bruce protocol, and cardiogoniometry were obtained prior to coronary angiography. Clinically significant CAD has been defined as one or more coronary lesions with >70% stenosis.Results: Study included 114 consecutive female patients with median age of 64.0 (58.0–71.0) years, out of which 32 (28.1%) had CAD. Cardiogoniometry yielded a total accuracy of 74.6% with a sensitivity of 75.0% (95% CI 56.6–88.5) and specificity of 74.4% (95% CI 63.6–83.4). Exercise-ECG test yielded a total accuracy of 45.1% with a sensitivity of 68.1% (95% CI 42.7–83.6) and specificity 36.6% (95% CI 25.2–50.3). Cardiogoniometry showed higher accuracy than exercise-ECG test (P < 0.001). Pathological cardiogoniometry was associated with almost nine times higher risk for CAD (OR 8.7, 95%CI 3.4–22.3, P < 0.001), which remained significant after adjustment for age, and hypokinesia.Conclusion: Cardiogoniometry is a non-invasive, easy-to-use and free-of-risk method which showed high effectiveness in diagnosing stable CAD in women and superior to exercise-ECG test. Cardiogoniometry could be introduced as a part of the diagnostic algorithm of screening women for stable CAD and is suitable for use in the primary setting, especially in women unable to undergo stress-testing.



Age and the economics of an emergency medical admission—what factors determine costs?

2016-09-20

Background: The ageing of the population may be anticipated to increase demand on hospital resources. We have investigated the relationship between hospital episode costs and age profile in a single centre.Methods: All Emergency Medical admissions (33 732 episodes) to an Irish hospital over a 6-year period, categorized into three age groups, were evaluated against total hospital episode costs. Univariate and adjusted incidence rate ratios (IRRs) were calculated using zero truncated Poisson regression.Results: The total hospital episode cost increased with age (P < 0.001). The multi-variable Poisson regression model demonstrated that the most important drivers of overall costs were Acute Illness Severity—IRR 1.36 (95% CI: 1.30, 1.41), Sepsis Status −1.46 (95% CI: 1.42, 1.51) and Chronic Disabling Disease Score -1.25 (95% CI: 1.22, 1.27) and the Age Group as exemplified for those >85 years IRR 1.23 (95% CI: 1.15, 1.32).Conclusion: Total hospital episode costs are a product of clinical complexity with contributions from the Acute Illness Severity, Co-Morbidity, Chronic Disabling Disease Score and Sepsis Status. However age is also an important contributor and an increasing patient age profile will have a predictable impact on total hospital episode costs.



Comparing clinical presentations, treatments and outcomes of hepatocellular carcinoma due to hepatitis C and non-alcoholic fatty liver disease

2016-09-10

Introduction: Hepatocellular carcinoma (HCC) is increasing in incidence in the UK and globally. Liver cirrhosis is the common cause for developing HCC. The common reasons for liver cirrhosis are viral hepatitis C (HCV), viral hepatitis B and alcohol. However, HCC caused by non-alcoholic fatty liver disease (NAFLD)-cirrhosis is now increasingly as a result of rising worldwide obesity.Aim: To compare the clinical presentation, treatment options and outcomes of HCC due to HCV and NAFLD patients.Methods: Data were collected from two liver transplant centres in the UK (Birmingham and Newcastle upon Tyne) between 2000 and 2014. We compared 275 patients with HCV-related HCC against 212 patients with NAFLD- related HCC.Results: Patients in the NAFLD group were found to be significantly older (P < 0.001) and more likely to be Caucasian (P < 0.001). They had lower rates of cirrhosis (P < 0.001) than those in HCV-HCC group. The NAFLD group presented with significantly larger tumours (P = 0.009), whilst HCV patients had a higher alpha fetoprotein (P = 0.018). NAFLD patients were more commonly treated with TACE (P = 0.005) than the HCV patients, whilst the HCV group were significantly more likely to be transplanted (P < 0.001). In patients selected for liver transplantation, 5-year survival rates in NAFLD were not significantly different from HCV-HCC (44 and 56% respectively, P = 0.102).Conclusion: In this study, NAFLD patients presented with larger tumours that were less likely to be amenable to curative therapy, as compared with HCV patients. Despite this disadvantage, patients with NAFLD had similar overall survival compared to patients with HCV.



Celebrating Mendel’s 150th anniversary

2016-07-02

If Darwinian evolution be natural selection combined with heredity then the single statement which embraces the whole field of heredity must prove as epoch-making to the biologist as the law of gravitation to the astronomer.1K. Pearson, mathematician and statistician (1857–1936).



NOTCH2 genetic mutation and acro-osteolysis—the Hajdu–Cheney syndrome

2016-01-30

A 34-year-old male who works professionally as a computer graphic designer was examined. The patient has a positive family history, as similar symptoms have been observed in the father. The gestation and early psychomotor development of the patient were normal. In the second decade of life, a progressive bone disorder occurred, initially in the form of acro-osteolysis within the distal phalanges of the hands and feet.