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Preview: QJM - current issue

QJM: An International Journal of Medicine Current Issue





Published: Wed, 25 Oct 2017 00:00:00 GMT

Last Build Date: Thu, 26 Oct 2017 05:52:36 GMT

 



This is how we can improve mortality for hospital inpatients with acute kidney injury

2017-10-25

As a non-nephrologist participating in general medical on-call, I am very much aware of the prevalence of acute kidney injury (AKI) in acute medical admissions. AKI in these patients is associated with over a 6-fold increase in mortality and an average 3.5-day increase in hospital stay. In a systemic analysis in the UK by the National Confidential Enquiry into Patient Outcomes and Death, they found that only 50% of hospital inpatients with AKI received ‘good care’.



Granulomatosis with polyangiitis as the differential diagnosis

2017-07-24

The case report of neurosarcoidosis with leptomeningeal, cavernous sinus, and pituitary involvement1 has a differential diagnosis which includes central nervous system involvement by granulomatosis with polyangiitis (GPA).2 In the latter syndrome, manifestations include cranial nerve palsies, cerebral pachymeningitis and cerebrospinal fluid (CSF) features such as increase in protein concentration and in CSF white cell count,2 reminiscent of the stigmata documented in the case report.1 Other features simulating those in the case report include magnetic resonance imaging stigmata of cerebral and spinal cord pachymeningitis, pituitary involvement,2 and encroachment on the cavernous sinus and sella turcica.3 Hilar lymph node enlargement, also documented in the case report,1 does not rule out GPA, given the fact that, in one study, three patients were identified who had enlarged hilar lymph nodes attributable to this disorder.4 Involvement of salivary glands characterized by the presence of giant cells5 is another feature of GPA which may be simulated by sarcoidosis. Finally, radiculopathy, described as a rare feature of neurosarcoidosis,1 has also been rarely documented in GPA.6 The latter report was that of a 43-year-old woman who complained of paraesthesiae and mild numbness in both lower limbs. An electromyogram showed lower lumbosacral radiculopathy.6 Although the presence of an elevated serum angiotensin converting enzyme1 would appear to militate against GPA, thereby favouring sarcoidosis, that parameter has a positive predictive power of the order of 83.8% for the diagnosis of sarcoidosis, and a false positive rate of 2% in normal controls.7



Use of POCUS Ultrasound in sepsis, bedside diagnosis of necrotizing fasciitis

2017-07-20

A 60-year-old female patient presented to the emergency department with a 3-day history of pain in the left leg. The patient described a 3-day history of pain in the left inner thigh that was treated by the GP for suspected cellulitis with flucoxacillin. On arrival by ambulance, the patient was tachycardic 130 bpm, blood pressure 76/34, tachypnea 29 rpm, temperature 34.1, oxygen saturation 93% on room air and bilateral livedo reticularis in both legs. The National Early Warning Score (NEWS) at arrival was 15. In the resuscitation room a ‘Rapid Ultrasound for Shock’ (RUSH) protocol was performed. The Pump: Cardiac Evaluation showed severely decreased left ventricular ejection fraction but no pericardial effusion or right ventricle strain, the Tank: Volume Status showed an inferior vena cava diameter of 1.2 cm with total collapse on inspiration and no free fluid on abdomen. The Pipes: circulatory system showed no evidence of deep vein thrombosis and no abdominal aortic aneurysm. Due to the history of suspected cellulitis and no clear source of infection, we added a bedside musculoskeletal point-of-care-ultrasound (POCUS) of both extremities. In the left inner thigh, findings were consistent with necrotizing fasciitis (NF) (Figure 1), including diffuse subcutaneous thickening, fluid accumulation along the deep fascial layer and gas bubbles. The patient was immediately taken to theatre and operated performing an extensive debridement of the left leg from the inguinal region extending medially to the mid-calf. Post-operative computed tomography (CT) showed extensive locules of gas effect in the anterior, posterior and medial compartments of the thigh (Figure 1). Despite intensive care with high doses of vasopressor the patient unfortunately died 24 h later.



Differential diagnosis between sarcoidosis and granulomatosis with polyangiitis in a patient with leptomeningeal, cavernous sinus and pituitary lesions

2017-07-11

We are grateful to Dr Jolobe for having raised the very interesting point of differential diagnosis between neurosarcoidosis and granulomatosis with polyangiitis (GPA) in the patient we recently reported in QJM.1 Actually, the two diseases share several features and they are sometimes difficult to distinguish. For instance, although common in neurosarcoidosis, spinal cord pachymeningitis and pituitary gland enlargement are also found in 11% and 6% of GPA patients, respectively.2 However, these manifestations are much rarer in GPA than extensive white matter lesions (40%) and ischemic strokes (60%), which were not observed in our patient. Leptomeningeal involvement is also a typical feature of sarcoidosis that is very rarely reported in GPA.3,4 Similarly, neurological symptoms are seen in both diseases; however, peripheral nerve involvement, such as mononeuritis multiplex, largely predominates on central neurological involvement in GPA.2 Conversely, the patient we reported presented several of the most frequent symptoms of neurosarcoidosis such as limb sensory disturbance and cranial nerve palsy.5



Miliary tuberculosis

2017-07-04

A 90-year-old man presented to the emergency department with a 2-week history of fever, intermittent cough and progressive dyspnoea. He had no previous medical history and was negative for human immunodeficiency virus infection. Chest radiography showed diffuse, bilateral, millet-seed sized lung nodules (Figure 1A). Thoracic high-resolution computed tomography revealed innumerable tiny micronodular lesions throughout the lung and peribronchovascular thickening in the perihilar regions (Figure 1B). Sputum and urine culture were positive for Mycobacterium tuberculosis. Based on the clinical and radiographic findings, the patient was diagnosed as having miliary tuberculosis. Miliary tuberculosis refers to clinical condition resulting from haematogenous dissemination of M.tuberculosis, and has become a rare disease in the developed countries, but is still common in areas where tuberculosis is endemic, especially in sub-Saharan Africa and in Southeast Asia.1 The signs and symptoms of military tuberculosis can vary depending on which organs are affected, including a cough, fever, weight loss, night sweats, pleurisy, haemoptysis and dyspnoea. These symptoms being non-specific are often missed. Sharma et al.2 have reported that up to 50% of cases are not diagnosed antemortem. Tuberculosis is an old disease, but not a disease of the past. The emergence of multidrug resistant tuberculosis is a serious public health problem. Early identification of miliary tuberculosis can facilitate appropriate management and treatment, which can reduce its prevalence and improve public health.



Marfan syndrome

2017-07-04

A 12-year-old male presented to our clinic with a chief complaint of decayed teeth. Clinical examination revealed high-arched palate, arachnodactyly, positive Steinberg test (Figure 1A, black arrow) which is performed by instructing the patient to fold his thumb into the closed fist and the test is positive if the thumb tip extends from palm of hand. Patient also had mild pectus excavatum (Figure 1B, black arrow) with Haller index of 2.75 (Normal 2.5) and normal lung capacity. Two-dimensional echocardiogram for aortic dilation revealed a Z-score of 3.12 and slit lamp eye test showed ectopic lentis. The intraocular pressure was 15 mmHg (Normal 12–22 mmHg) with visual acuity of 20/30 (Normal 20/20). Patient also had a positive familial history for Marfan syndrome. Diagnosis arrived was Marfan syndrome by taking into consideration the 2010 Revised Ghent Nosology diagnostic criteria.1 For case to be diagnosed as Marfan syndrome Z-score must be ≥ 2 above 20 years old or ≥ 3 below 20 years old. There is no cure for Marfan syndrome but the treatment should focus on preventing various complications of the disease. Ectopic lentis was treated by new eyeglasses. Cardioselective beta blocker atenolol was prescribed to the patient for prevention of aorta dilation. No treatment was required for pectus excavatum. After a follow-up period of 1 year the patient remained stable.



An unusual adrenal cause of hypoglycaemia

2017-06-29

Learning point for cliniciansThe accurate diagnosis of spontaneous hypoglycaemia requires a combination of clinical awareness and careful biochemical evaluation to determine aetiology. Further investigation and considerations are necessary if imaging findings are inconsistent with the most frequent responsible pathology.



Last resort: successful AngioVac of fungal tricuspid valve vegetation

2017-06-27

Learning point for cliniciansFungal endocarditis remains the most serious form of infective endocarditis, with a high mortality rate. It is a ‘stand-alone indication’ for surgical replacement of an infected valve.1 Surgical management of acute infective endocarditis is a major challenge, with respect to multi-organ failure, surgical complications and risks of recurrences.



Lindsay’s nail

2017-06-27

A 60-year-old man with diabetes and chronic kidney disease undergoing maintenance hemodialysis presented to our hospital with chronic nail changes that had been present for at least 2 years. He had not experienced any previous fingernail injuries. The nail examination showed the whiteness of the proximal portion of the nail bed and reddish-brown discoloration of the distal half of the nail bed in all his fingernails (Figure 1). The discoloration of the nails did not fade with pressure. On the basis of the clinical history, the patient was diagnosed as having Lindsay’s nails. Although the pathophysiological mechanism of Lindsay’s nail is still unknown, the distal reddish-brown changes might be related to increased melanin deposition, caused by increased concentration of β-melanocyte-stimulating hormone. Lindsay’s nail can be found in 20% of patients on renal replacement therapy1 (peritoneal dialysis, hemodialysis and renal transplantation). There is no specific therapy for Lindsay’s nails but the discoloration sometimes disappears completely after successful renal transplantation.



Fournier’s gangrene

2017-06-26

Learning points for cliniciansFournier’s gangrene is a lift-threatening disorder and surgical emergency. Image studies typically demonstrate gas accumulation in the affected region. Once recognized, aggressive resuscitation, broad-spectrum antibiotics and prompt surgery implemented.



MALT lymphoma of the conjunctiva

2017-06-22

A 71-year-old Moroccan man presented to the ophthalmology department with a 2 years history of slowly growing swelling in the plica semilunaris of the right eye. Physical examination found a reddish painless mass in the inside corner of the eye without cervical lymphadenopathy (Figure 1A). An orbital magnetic resonance imaging (MRI) showed a mass of 16 × 9.4 mm in the inner corner of the right eye without invasion of the eyeball or orbital muscles. Biopsy was performed and pathologic analysis with immunohistochemistry study revealed a mucosa associated lymphoid tissue (MALT) lymphoma. Chest, abdomen and pelvis computed tomography showed no extension of disease to other organs. The disease was staged IE according to Ann Arbor staging classification. Initial antibiotic therapy to treat Chlamydophila psittaci was unsuccessful. Then the patient was treated with radiation therapy at the dose of 16 Gy, 3.2 Gy per fraction for 5 fractions. After 1 month, a clinical complete response was observed (Figure 1B) and an orbital MRI showed a significant reduction of the size of the lesion with a thickness of 2 mm vs. 9 mm initially.



Brucellosis: myriad ways of presentation

2017-06-20

Learning points for cliniciansDon’t forget brucellosis in the differential of fever of unknown origin in patients from endemic areas, especially if there is a history of ingestion of unpasteurized milk or cheese. The bacilli has ability to virtually infect any organ and may cause fatal illness. The social history may be diagnostic here.



Beau’s lines

2017-06-20




The question mark sign of large vessel vasculitis on 18F-FDG PET/CT

2017-06-16

A 77-year-old woman with a non-specific history of malaise and raised inflammatory markers was referred to gastroenterology. There were no specific findings on history or physical examination but a markedly elevated C-reactive protein (CRP) of 140 mg/l was confirmed and the patient was referred for whole body 18F-FDG PET/CT. This demonstrated significantly increased FDG uptake in the aortic wall (Figure 1A, sagittal PET, SUVmax = 6.7) which extended into the carotid, brachiocephalic, axillary (Figure 1B, coronal fused PET/CT), iliac and femoral arteries but spared the abdominal branches. The pattern of FDG uptake produced a striking question mark appearance of the aorta on sagittal images.



A whole system approach to improving mortality associated with acute kidney injury

2017-05-18

Abstract
Background
Acute kidney injury (AKI) is in the main managed by non-nephrologists, many who feel challenged by or lack awareness of the complexity that the renal element adds to their patients’ care. National reports have raised major concerns about the quality of care and have predicted that mortality reductions of 30% are achievable with good medical practice.
Aim
This quality improvement project evaluated whether a whole system approach could improve outcomes for patients with AKI.
Design and methods
Quality improvement methodology was used to understand hospital patterns, processes and professional knowledge. Change concepts were developed which included management of patients at risk, staff education and awareness program, development of a patient specific electronic alert to prompt diagnosis, easy to remember care bundle (ABCDE-IT), dedicated outreach team and patient and family empowerment leaflet.
Results
Statistical process control analysis was used to verify outcomes over time. A shift in the in-hospital mortality rate corresponded to a relative 23.2% reduction in mortality and was sustained over the next 33 months (P < 0.0001). The favourable shift in mortality was temporally distinct from the improved AKI detection rate. This timeframe corresponded to lying below the 99.8% lower confidence limit in comparison with all English acute trusts for comparative AKI specific SHMI/HSMR mortality rates. Length of stay also reduced shortly after onset of the project by 14.1% or 2.6 day reduction (P < 0.0001).
Conclusion
This project demonstrated that an integrated, whole-system approach is necessary to ensure sustained improvements in AKI mortality and length of stay.



The potential impact of sleep-related movement disorders on stroke risk: a population-based longitudinal study

2017-05-08

Abstract
Background
Sleep-related movement disorders (SRMD) have been shown to increase the risk of cardiovascular diseases. However, the relationship between SRMD and stroke remains unclear.
Aim
To explore the relationship between SRMD and stroke in the general population.
Design
Two cohorts of patients with SRMD and without SRMD were followed up for the occurrence of hemorrhagic and ischemic stroke.
Methods
The study cohort enrolled 604 patients who were initially diagnosed as SRMD between 2000 and 2005. 2,416 age- and sex-matched patients without prior stroke were selected as the comparison cohort. A Cox-proportional hazard regression analysis was performed for multivariate adjustment.
Results
Patients with SRMD had a higher risk for developing all-cause stroke [adjusted hazard ratio (HR) = 2.29, 95% confidence interval (CI) = 1.42–3.80]. Patients of below 45 years old had the greatest stroke risk (HR = 4.03, 95% CI = 3.11–5.62), followed by patients aged ≥65 years (HR = 2.64, 95% CI = 1.12–3.44) and 45–64 years (HR = 1.07, 95% CI = 1.02–1.71). The age-stratified analysis suggested that the increased risk of hemorrhagic stroke was more significant than ischemic stroke among all age groups. Furthermore, males with SRMD were at greater risk to develop all-cause stroke (HR = 2.98, 95% CI = 1.74–4.50) than that of females (HR = 1.94, 95% CI = 1.01–3.77).
Conclusions
Patients with SRMD were found to have an increased risk of all-cause stroke along with a higher possibility of hemorrhagic stroke over ischemic stroke.



Investigation of the benefits of early malnutrition screening with telehealth follow up in elderly acute medical admissions

2017-05-04

Abstract
Background
The benefit of providing early nutrition intervention and its continuation post-discharge in older hospitalized patients is unclear. This study examined efficacy of such an intervention in older patients discharged from acute care.
Methods
In this randomized controlled trial, 148 malnourished patients were randomized to receive either a nutrition intervention for 3 months or usual care. Intervention included an individualized nutrition care plan plus monthly post-discharge telehealth follow-up whereas control patients received intervention only upon referral by their treating clinicians. Nutrition status was determined by the Patient Generated Subjective Global Assessment (PG-SGA) tool. Clinical outcomes included changes in length of hospital stay, complications during hospitalization, Quality of life (QoL), mortality and re-admission rate.
Results
Fifty-four males and 94 females (mean age, 81.8 years) were included. Both groups significantly improved PG-SGA scores from baseline. There was no between-group differences in the change in PG-SGA scores and final PG-SGA scores were similar at 3 months 6.9 (95% CI 5.6–8.3) vs. 5.8 (95% CI 4.8–6.9) (P = 0.09), in control and intervention groups, respectively. Median total length of hospital stay was 6 days shorter in the intervention group (11.4 (IQR 16.6) vs. 5.4 (IQR 8.1) (P = 0.01). There was no significant difference in complication rate during hospitalization, QoL and mortality at 3-months or readmission rate at 1, 3 or 6 months following hospital discharge.
Conclusion
In older malnourished inpatients, an early and extended nutrition intervention showed a trend towards improved nutrition status and significantly reduced length of hospital stay.



The effect of exercise interventions on inflammatory biomarkers in healthy, physically inactive subjects: a systematic review

2017-05-02

Abstract
Background
Increases in physical activity ameliorate low-grade systemic inflammation in disease populations such as type 2 diabetes mellitus and coronary artery disease. The effects of aerobic and resistance training (RT) on inflammatory biomarker profiles in non-disease, physically inactive individuals are unknown.
Methods
A systematic review of randomized controlled trials measuring the effect of aerobic and resistance exercise on pro-inflammatory biomarkers in healthy, inactive adult populations was conducted. The available peer-reviewed literature was searched from January 1990 to June 2016 using the electronic databases PubMed and Scopus. A narrative synthesis of review findings was constructed with discussion of the impact of aerobic, resistance and combined training on C-reactive protein (CRP), interleukin-6 (IL-6), interleukin-8, interleukin-1β and tumour necrosis factor-α.
Results
The initial search revealed 1596 potentially relevant studies. Application of the study eligibility criteria led to the full-text review of 54 articles with 11 studies deemed suitable for inclusion. Review of related articles and the reference lists of the 54 full-text articles led to the inclusion of 2 additional studies. The review revealed inconsistent findings relating to the effect of aerobic training and RT on CRP and IL-6. Studies of older-aged adults (>65 years old) demonstrated the greatest and most consistent reduction in inflammatory biomarkers post-training intervention.
Conclusions
A paucity of evidence exists relating to the effect of exercise training on inflammatory markers in non-disease, physically inactive adults. The available evidence suggests potential for the greatest benefit to be seen in older populations and with higher intensity aerobic exercise.



Agreement between renal prescribing references and determination of prescribing appropriateness in hospitalized patients with chronic kidney disease

2017-04-18

Abstract
Background
Chronic kidney disease (CKD) is a risk factor for adverse drug events. The clinical significance of discordance between renal prescribing references is unknown.
Aim
We determined the prevalence of potentially inappropriate prescribing (PIP) in CKD, measured agreement between two prescribing references, and assessed potential for harm consequent to PIP.
Design
Single-centre observational study.
Methods
A random sample of hospitalized patients with CKD were grouped according to baseline CKD stage (3, 4, or 5). Prescriptions requiring caution in CKD were referenced against the Renal Drug Handbook (RDH) and British National Formulary (BNF) to identify PIP (non-compliance with recommendations). Inter-reference agreement was measured using percentage agreement and Kappa coefficient. Potential for harm consequent to PIP was assessed by physicians and pharmacists using a validated scale. One-year mortality was compared between patients with or without PIP during admission.
Results
Among 119 patients (median age 73 years, 50% male), 136 cases of PIP were identified in 78 (65.5%) patients. PIP prevalence, per patient, was 64.7% using the BNF and 28.6% using the RDH (fair agreement, Kappa 0.33, P <  0.001). The majority (63.2%) of PIP cases detected exclusively by the BNF carried minimal or no potential for harm. PIP was not significantly associated with one-year mortality (34.7% vs. 21.1%, P = 0.14).
Conclusions
PIP was common in hospitalized patients with CKD. Substantial discordance between renal prescribing references was apparent. The development of universally-adopted, evidence-based, prescribing guidelines for CKD might optimize medications safety in this vulnerable group.



The impact of the Psychoactive Substances Act 2016 on the online availability of MDMB-CHMICA

2017-02-28

Abstract
Background
In May 2016, the UK Government enacted the Psychoactive Substances Act which made it an offense to produce or supply many drugs including new psychoactive substances (NPS).
Aim
We aimed to assess the impact of the Act on the availability of the synthetic cannabinoid receptor agonist methyl 2-[[1-(cyclohexylmethyl)indole-3-carbonyl]amino]-3,3-dimethylbutanoate (MDMB-CHMICA) from internet-based suppliers.
Design
Internet snapshot availability study.
Methods
We conducted two snapshot availability surveys looking at the number of websites offering to sell MDMB-CHMICA: the first in March prior to implementation of the Act and the second in June, 1 month post-implementation.
Results
In March and June 2016, we identified 47 and 38 websites, respectively, which offered to sell MDMB-CHMICA. There were no significant differences in the price of the drug nor the forms available for purchase. In the June survey there was a significant decrease in the number of websites which openly stated they were based in the UK (from 14 down to 2), three websites stated that they did not supply customers based in the UK and two websites stated they had ceased sales of MDMB-CHMICA due to the Act.
Conclusions
This study showed a small but limited reduction in the availability of MDMB-CHMICA from internet-based suppliers following implementation of the Act.



“Gluten sensitivity” – a 21st century epidemic

2017-02-07

The number of people who believe that they are sensitive to wheat gluten has reached almost epidemic proportions. ‘Gluten-related disorders’ is the umbrella-term describing problems resulting from the ingestion of gluten-containing food.