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Preview: QJM - current issue

QJM: An International Journal of Medicine Current Issue

Published: Wed, 31 May 2017 00:00:00 GMT

Last Build Date: Wed, 31 May 2017 10:51:32 GMT


Building a culture of health in society


Health no longer means an absence of disease. Health in modern society reflects where we live, where we work and how we relax. The QJM has recently highlighted the effect of socio-economic status, social isolation and workload on health of communities.1,2,3 A far more accurate predictor of mortality in areas of the USA is not your genetic make-up, but your zip code. In a seminal recent study, Case and colleagues showed that mortality for white middle-aged Americans is significantly increasing.4

Primary adrenal and chest wall tuberculosis presenting as an adrenal crisis


Learning points for cliniciansChest wall tuberculosis may resemble a pyogenic abscess or tumor and entertaining the possibility of tubercular etiology remains a clinical challenge. Adrenal tuberculosis is also difficult to diagnose because symptoms are non-specific. The diagnosis is therefore often delayed and patients may first present with a life-threatening crisis.

Spot sign, prognosis and intracerebral haemorrhage


QJM: An International Journal of Medicine 2017;110(1):51-52.

Bilateral adrenal haemorrhage


We thank Dr Jolobe for his question relating to our case review.1 Unfortunately none of our patients had a plasma glucose measurement at the time of random cortisol sampling, but they clinically did not have hypoglycaemia at earlier stages of the hospital admission. Although this is an interesting point, hypoglycaemia is an uncommon clinical manifestation of adrenal insufficiency in adults, unless the patient is in overt adrenal crisis,2 and has a much higher prevalence in the paediatric population. We feel that a low or borderline random cortisol value in an acutely ill patient is convincing for primary adrenal insufficiency (PAI) in a patient with bilateral adrenal masses, significantly elevated ACTH and plasma renin, and undetectable aldosterone levels. As per international guidelines, our patients were empirically started on hydrocortisone based on the high index of clinical suspicion of PAI,2 with results later robustly confirmed by short synacthen testing once clinically stabilized.

A novel PTEN mutation associated with colonic ganglioneuromatous polyps


Learning point for cliniciansOur case highlights a novel PTEN mutation with a rare manifestation of colonic GP. It should serve as a reminder for clinicians to further investigate colonic GP as they can be associated with various such syndromes.

Prepatellar subcutaneous calcifications in systemic sclerosis


Learning point for cliniciansSubcutaneous draining prepatellar calcinosis in limited cutaneous systemic sclerosis (lcSSc) is an unusual challenging condition. These calcifications may ulcerate, become infected, and may be misdiagnosed as septic joint. Medical and surgical treatments for this debilitating complication of SSc have been disappointing.

Venous thrombo-embolism: thalidomide and leprosy


Learning points for cliniciansThrombophilic effect of thalidomide therapy has been established in the setting of malignancy. In accordance to the dictum ‘prevention is better than cure’, our case emphasizes the role of thrombo-prophylaxis even in non-neoplastic conditions where thalidomide is used with steroids, immunomodulatory agents or in presence of other risks for thrombosis.

Bacterial sepsis, neutrophils and intracellular organisms


A 64-year-old male with a history of hepatitis C and alcoholic cirrhosis as well as hepatocellular carcinoma status post left lobectomy and transarterial chemoembolization was transported to our emergency department (ED) due to being unarousable. His initial vital signs were as follow: body temperature 34.7 °C, heart rate 102 beats per minute and blood pressure 126/71 mm of mercury. Physical examination revealed swelling of left lower extremity with some blisters around left knee. Laboratory tests showed leukocytosis (29 570/mm3) and lower platelet count (71 000/mm3). The blood smear revealed predominant neutrophilia (21% of segmented neutrohphils, 37% of band neutrophils and 39% of meta-myelocytes) with abundant toxic granulations (Figure 1A). The vacuoles containing bacilliform organisms (Figure 1A, arrow) as well as Döhle bodies, the pale blue cytoplasmic inclusions (Figure 1A, arrowhead), were found in neutrophils. Computed tomography of lower extremities revealed fluid accumulation over fascia layer (Figure 1B). Under impression of necrotizing fasciitis, empirical antimicrobial treatment with Ertapenem was prescribed and plastic surgeon was consulted; however, the disease deteriorated rapidly due to refractory septic shock and failure of multiple organs. The patient ultimately died in the ED. Both anaerobic cultures of blood and urine yielded Klebsiella pneumoniae after 3-day incubation.

Diospyrobezoar and a fondness for persimmons


A 78-year-old man presented to the emergency department with a 1-day history of severe epigastric abdominal pain and hematemesis. He was diagnosed as having type 2 diabetes mellitus, but he had no previous cardiovascular or gastrointestinal problems. He had never taken antiplatelet or anticoagulant agents. His vital signs were normal. On physical examination, he exhibited mild tenderness of his epigastrium without guarding or rebound tenderness. The plain radiograph showed no abnormality. The complete blood examination, including blood chemistry analysis, was unremarkable. Upper gastrointestinal endoscopy demonstrated a bezoar (Figure 1A) positioned in the stomach and an ulcer in the angular region. The bezoar was successfully removed by using endoscopic baskets. Component analysis of bezoar revealed that this bezoar comprised >95% of tannin. After questioning the patient further, he reported a long history of overindulgence of persimmons. He was finally diagnosed as having a diospyrobezoar. Gastrointestinal bezoars are congeries of indigestible components that develop in patients with an altered gastrointestinal anatomy, motility disorders, psychiatric diseases, and an overindulgent ingestion of high-fiber foods. They are mainly classified into phytobezoar, trichobezoar (formed from hair), and lactobezoar (formed from evaporated milk formulas) according to their composition.1 A diospyrobezoar is a subtype of phytobezoars caused by persimmons.2 The Japanese persimmon (Diospyros kaki) is native to Japan, China, Myanmar, and Nepal. It is the most widely cultivated species in the world. The consumption of persimmons in UK has surpassed that of mangoes and pineapples, as it has doubled in recent years. Although it is an infrequent entity in the clinical setting, the number of cases of Diospyrobezoars in UK will be increasing in the near future.

Neurosarcoidosis: leptomeninigeal, cavernous sinus and pituitary involvement


A 71-year-old woman born in Haiti, with no medical history, presented with facial pain associated with oculomotor palsy (left abducens nerve palsy, bilateral symptomatic trigeminal neuralgia). She also complained of progressive sensorimotor deficit of the lower limbs that had developed over 10 months, causing her difficulties to stand and walk without assistance.

The value of the PET scan in the diagnosis of vasculitis


A 90-year-old man presented with lower limb intermittent claudication worsening progressively over 2 months. He experienced diffuse pain in his calves and thighs with activity, which resolved after 5 min of rest. His pain had gradually worsened and made him unable to walk >100 m without rest. The ankle-brachial index suggested no arterial stenosis, and the cardio-ankle vascular index value was that of a healthy individual in their late seventies. The erythrocyte sedimentation rate (ESR) was 74 mm/h. Despite only mild atherosclerosis, rapidly progressive lower limb intermittent claudication was noted. In addition, the ESR was high. These combined findings were suggestive of lower extremity vasculitis. Because the ankle-brachial index suggested no arterial stenosis, we performed positron emission tomography/computed tomography (PET/CT), which metabolically confirms inflammation of the affected vessels, rather than computed tomography angiography or magnetic resonance angiography, which only identify stenosis and wall-thickening. PET/CT demonstrated intense fluorodeoxyglucose uptake in the left superficial temporal, right femoral, bilateral popliteal, and bilateral posterior tibial arteries, as well as in the thoracic and abdominal aorta on the same level (Figure 1). Additional physical examination revealed tenderness of the left superficial temporal artery, and giant cell arteritis (GCA) was diagnosed. Symptoms completely disappeared with prednisolone.

Anti-TNFα antibody-induced psoriasiform skin lesions in patients with inflammatory bowel disease: an Irish Cohort Study


Aim: To determine the prevalence of psoriasis in an IBD cohort with reference to clinical characteristics and anti-TNFα use.Methods: Patients with psoriasis and IBD were retrospectively identified from the IBD database at Tallaght Hospital from 2000 to 2015. Pertinent clinical data were obtained from patients notes including anti-TNFα exposure. Prevalence rates of genuine and reactive psoriasis were calculated and compared using Student’s T-test. A P values of <0.05 was considered significant.Results: In total, 1384 IBD patients were identified. The overall prevalence rate of IBD and psoriasis was 2.4% (n = 33), with 1.8% (n = 25) in the Crohn’s disease group and 0.6% (n = 8) in the ulcerative colitis group. Within the psoriasis group, 24% (n = 8 of 33) had reactive psoriasis. The prevalence rates of psoriasis in the non-biological and biological cohorts were similar 2.5% (25 of 981) and 2% (8 of 403), respectively. There was no significant association with reactive psoriasis and disease type. There was a trend towards higher rates of reactive psoriasis Adalimumab users, 3.6% (6 of 166) vs. 0.8% (2 of 237), OR = 4.283, P = 0.077, 95% CI 0.854–21.483 in infliximab users. In addition, in our cohort, smoking was not associated with any form of psoriasis in IBD, OR = 1.377, 95% CI 0.061–3.087, P = 0.437.Conclusion: In our large study, the prevalence rate of reactive psoriasis was similar to the background rate of psoriasis in the overall IBD cohort (2.0 vs. 2.4%). A 2% prevalence rate represents a common adverse event that clinicians should be aware of.

Increasing incidence of chronic subdural haematoma in the elderly


Background: Chronic subdural haematoma (CSDH) is a condition predominantly affecting the elderly. We reported an incidence of 8.2 per 100 000 per year in people above the age of 65 in 2002.Aim: Since recent studies have demonstrated a higher incidence, we repeated our study to estimate the current incidence of CSDH amongst people above the age of 65 in North Wales.Design: We used radiological reports to identify patients with CSDH over a 1-year period.Methods: We collected data on demographics, clinical presentations, indications for brain imaging, drug history and 30-day outcome from the case notes and electronic records.Results: The population of North Wales was 687 937 of which 138 325 (20%) were above 65. There were 66 cases of CSDH giving an incidence of 48 per 100 000 per year. Mean age was 81 and there were 32 males and 34 females. Falls and confusion were the commonest indications to request a CT scan (90%). Other indications were drowsiness (9%) and focal neurological deficit (4%). 17 were on antiplatelets and 20 were on warfarin. Ten underwent surgical intervention. At 30 days 28 were discharged, 22 were still in hospital and 16 died.Conclusion: The incidence of CSDH is much higher than previously reported. Reasons include a low threshold for imaging patients with recurrent falls and confusion, increasing use of anti-thrombotics and ageing population. In many older patients CSDH is a marker of underlying co-morbidities rather than a primary event.



A 34-year-old male presented with right sided nasal obstruction of 2-years duration. He also noticed a change in quality of his voice in the form of a nasal tone. He gave a history of dip bath in a pond with stagnant water few years back. On examination there was a pinkish, friable mass filling the entire right nasal cavity reaching about 1 cm behind anterior nares. The mass was insensitive and did not bleed on probing. The mass was also seen in the oropharynx extending down through the posterior nasal apertures (Figure 1A). Blood investigations were within normal limits. The mass was excised under general anesthesia. Histopathology showed numerous sporangia with endospores confirming the diagnosis of rhinosporidiosis (Figure 1B).

Clinical and prognostic significance of anisocytosis measured as a red cell distribution width in patients with colorectal cancer


Purpose: colorectal cancer (CRC) is the third most commonly diagnosed cancer worldwide, and detection of new prognostic markers is mandatory for patients to receive optimal oncological treatment. The aim of the study was to assess clinical and prognostic value of red cell distribution width (RDW) in patients with CRC.Methods: RDW values in 90 patients with CRC undergoing surgery for primary disease were analyzed in pre- and postoperative setting, and correlated with clinical and hematological parameters.Results: Both pre- and postoperative RDW measurements were found to be associated with features of iron deficiency anemia, inflammatory response to tumor, advanced age and depth of tumor invasion. Optimal cutoff points were calculated to be 14% for preoperative and 13.6% for postoperative RDW measurements. Elevations in both pre- and postoperative RDW values had significant effects on survival in univariate and multivariate analyses. Effects were found to be independent of tumor related features, stage of the disease, development of anemia and aberrant inflammatory response to tumor.Conclusions: RDW is an integrative parameter reflecting tumor specific features and shows significant association with overall survival in patients with CRC. This is especially important in patients with stage 2 disease where elevation in preoperative RDW values can contribute to recognition of higher risk patients.

Pregnancy increases stroke risk up to 1 year postpartum and reduces long-term risk


Background: The incidence of stroke in pregnant women is low but trending upward. There are few studies of the topic in women of Asian ethnicity.Aim: We aim to evaluate stroke risk in Asian women during and after pregnancy.Design: Using the Taiwan National Health Insurance database, we designed a retrospective study that included 18–45-year-old pregnant women between the years 2000 and 2010. We selected a 1:1 age-matched control group of non-pregnant women. The endpoint was any type of stroke during pregnancy or the postpartum period; otherwise, the patients were tracked until 31 December 2010.Methods: The risk factors for stroke were found using Cox proportional regression to calculate the hazard ratio (HR) with a 95% CI compared with the control group.Results: The incidence of stroke within 1 year postpartum was 71/100,000. The risk of postpartum stroke within 1 year was an HR of 1.208 (95% CI: 1.001–5.129). The occurrence of stroke was associated with hypertension, diabetes mellitus, coagulation disorders, migraine, obesity, cerebrovascular malformation and parity. Women with third and fourth parity carried increased risks of 13.3% and 2.5%, respectively, compared with first parity women. In long-term follow-ups, stroke risk was significantly lower, with an adjusted HR of 0.362 (95% CI: 0.269–0.489).Conclusion: The risk of stroke was elevated during the first year postpartum, but lower in subsequent years. Stroke risk increased in multiparous (≥3) women. Physicians should be on alert for pregnancy complications and ensure appropriate management to prevent postpartum stroke.

Evaluation of the threshold value for the modified early warning score (MEWS) in medical septic patients: a secondary analysis of an Italian multicentric prospective cohort (SNOOPII study)


Background: Due to aging and resources limitation, septic patients are often admitted to medical wards (MWs). Early warning deterioration is a relevant issue in this setting. Unfortunately, a suitable prognostic score has not been identified, yet.Aim: To explore the ability of Modified Early Warning Score (MEWS) to predict the in-hospital mortality in septic patients admitted to MWs.Design: Secondary analysis of a multicentric prospective study.Methods: Consecutive septic patients with positive blood culture admitted to 31 Italian MWs were included. Baseline characteristics, clinics, isolates, rate of transfer to ICU, MEWS was collected on admission according to the study protocol. The accuracy of MEWS in predicting the in-hospital mortality was assessed with the area under the receiver-operating characteristic curves. Sensitivity, specificity, positive and negative predictive value (PPV and NPV), likelihood ratio (LR) were calculated for different MEWS cut-offs and age/comorbidities subgroups.Results: In total 526 patients were included in this analysis. Median MEWS was (range 0–11). In-hospital mortality was 14.8% and transfer to ICU 1.3%. Mortality progressively increased according to MEWS (3% in MEWS 0 vs. 27% in MEWS >5; Chi square for trend P < 0.05). The AUC of MEWS in predicting in-hospital mortality was 0.596 (95% CI, 0.524, 0.669). MEWS did not appear to have an adequate sensitivity, sensibility, PPV, NPV and LR both in the whole population and in the pre-specified subgroups.Conclusions: Our findings do not seem to support the use of MEWS to predict the in-hospital mortality risk of sepsis in MWs.

A pivotal moment


Extensive research demonstrates that health is influenced by a complex web of interrelated factors; no longer is health considered to be merely the absence of illness. These interrelated factors represent all aspects of our daily lives, including where we live, learn, work, and play. In fact, in many nations across the global, where we live, indicated by our parcel or zip codes, rather that our genetic codes, may prove to be a better predictor of how long and how well we live. And, consider the recent study by economists Anne Case and Angus Deaton.1 They found that the decades-long decline in the death rate of middle-aged white Americans had reversed in recent years. This reversal—unique to the USA—is tied to drug and alcohol use, suicide, chronic liver disease, and cirrhosis. Notably, this trend was not witnessed among African Americans or Hispanics.1 Our evolving view of health and these data have caused the essential question for improving population health to become: ‘What are the social, political, and cultural drivers of health inequities and how do we eliminate them’?

Subclinical cardiovascular disease in patients with chronic obstructive pulmonary disease: a systematic review


Background: Cardiovascular disease (CVD) accounts for a significant portion of deaths in patients with COPD; however, evidence for early detection strategies for CVD in this population remain limited. Our paper aims to summarize existing data regarding subclinical CVD in patients with COPD with a view to identifying screening strategies in these patients.Methods: A systematic review of published literature was conducted for studies examining the relationship of COPD and markers of subclinical disease such as coronary artery calcification (CAC), carotid intima media thickness (cIMT), endothelial dysfunction, arterial stiffness as measured by pulse wave velocity (PWV) and augmentation indices (AIx). Both MEDLINE and EMBASE databases were searched till October 2015.Results: A total of 22 studies were included in the review. Compared with control subjects, patients with COPD had significantly higher cIMT (SMD 0.53, 95% CI 0.16–0.90), PWV (SMD 0.91, 95% CI 0.67–1.16) and AIx (SMD 0.86, 95% CI 0.52–1.19). Additionally, an overall higher prevalence of subclinical CVD as assessed by CAC, ABI and FMD was noted in our review.Conclusion: Although our findings need further evaluation in prospective studies, our review presents significant evidence in support of increased subclinical CVD burden in COPD patients independent of smoking status. Further large-scale case–control studies are required to highlight the significance of subclinical CVD screening in COPD patients.