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Preview: QJM - current issue

QJM: An International Journal of Medicine Current Issue





Published: Wed, 06 Sep 2017 00:00:00 GMT

Last Build Date: Wed, 06 Sep 2017 10:51:11 GMT

 



After the Fukushima nuclear disaster of 2011—is Japan better prepared—perhaps not

2017-09-06

In 2011, a huge earthquake followed by a devastating tsunami seriously damaged the Fukushima-Daiichi nuclear power plant. In a poignant article previously published in the QJM, doctors in the local hospital at Fukushima told their story of professionalism in the most trying of times.1



Whole-genome sequencing identifies nosocomial transmission of extra-pulmonary M. tuberculosis —response

2017-06-27

We thank the colleagues for their interest in this case.1 In answer to their question, the patient never produced any sputum and there was no evidence of cavitation at any stage on three serial computed tomography scans of the thorax. In fact, the nodule got marginally smaller over time, and there is thus very little likelihood that respiratory transmission took place. It is much more likely that transmission occurred due to aerosolization of bacilli during wound dressing.



Flecainide overdose-induced Brugada electrocardiogram pattern

2017-06-27

A 64-year-old female with paroxysmal atrial fibrillation presented to the emergency department with atrial fibrillation and rapid ventricular rate (Figure 1A), which was refractory to her usual combination doses of ‘pill-in-pocket’ metoprolol (25 mg) and flecainide (100 mg). She had a structurally normal heart on recent transthoracic echocardiogram. Upon questioning, the patient received a staggered 600 mg of flecainide in total orally due to a misunderstanding regarding her usual dosing. An electrocardiogram (ECG) obtained at this time revealed widening of the QRS and STdoming in leads V1 and V2, in keeping with a characteristic Type 1 Brugada pattern (Figure 1B). These ECG changes spontaneously resolved within 24 h and sinus rhythm was restored. The patient was reviewed by our local electrophysiologist. There were no features in keeping with high risk Brugada syndrome. Counselling was provided to the patient with regards to avoiding QT prolonging medications, treating pyrexia aggressively, and discontinuing flecainide.



Necrotizing fasciitis caused by genogroup × Neisseria meningitidis

2017-06-21

Learning points for clinicians
  • Necrotizing fasciitis is infrequent but highly lethal.
  • Streptococcus pyogenes is the most common isolate but cultures are frequently negative.
  • Neisseria meningitis is a rare cause of necrotizing fasciitis.
  • Molecular biology of soft tissue could help to identify the origin and enable better management of necrotizing fasciitis.



Imaging, superior mesenteric vein (SMV) sign and bowel ischaemia

2017-06-21

A 90-year-old man presented to the emergency department with an onset of severe acute abdominal pain. On physical examination, there was a mild tenderness of his abdomen without guarding or rebound tenderness. Laboratory findings revealed metabolic acidosis with elevated anion gap and serum lactate levels. A non-contrast-enhanced abdominal computed tomography (CT) scan showed marked bowel wall thickening with mesenteric edema, and the diameter of the superior mesenteric vein (SMV) was smaller than that of the superior mesenteric artery (SMA) (i.e. smaller SMV sign, Figure 1). A contrast-enhanced CT scan revealed a filling defect in the proximal portion of the main trunk of the SMA, and the patient was finally diagnosed with acute SMA occlusion. The smaller SMV sign indicates decreased blood flow from the small intestine resulting from interruption of blood flow from the SMA and is associated with other disorders, including intestinal volvulus, non-occlusive mesenteric ischaemia, and severe dehydration. A delay in diagnosis of acute SMA occlusion leads to an extremely high mortality rate due to extensive intestinal infarction.1 Therefore, when the smaller SMV sign is present with severe abdominal pain without peritoneal signs, clinicians should consider acute SMA occlusion as a possible differential diagnosis and never overlook it.



Whole-genome sequencing identifies nosocomial transmission of extra-pulmonary Mycobacterium tuberculosis

2017-06-19

We read this report with interest,1 but believe more clinical information is needed to confidently exclude airborne transmission of Mycobacteriumtuberculosis.



Laundry Blues: a case of methemoglobinemia with laundry detergent and Tylenol ingestion

2017-06-16

Learning points for clinicianIn the appropriate clinical setting, discordance between arterial blood gas and oxygen saturation measured by pulse oximetry, clinician should have a low suspicion for methemoglobinemia. Methemoglobinemia is a life threatening condition which is easily treatable using methylene blue with immediate response.



Macromolecular creatine kinase type 1 in immune-mediated necrotizing myopathy

2017-06-13

Learning point for cliniciansClinicians should take into account macro-CK type 1 when diagnosing diseases with elevated CK levels, especially autoimmune diseases such as IMNM.



Green nail syndrome

2017-06-13

A 40-year-old woman presented to the dermatology outpatient department with greenish black discoloration of the nail plate of the right thumb and the index finger that occurred within a month (Figure 1). The patient had no significant medical history, had not received any medication, or had not experienced any previous fingernail injuries. As she is a homemaker, her hands are exposed to water, detergents and soaps for long periods. Bacteriologic culture of nail scrapings was positive for Pseudomonas aeruginosa and Candida glabrata. Based on the clinical and pathological findings, the patient was diagnosed as having green nail syndrome (chromonychia). Green nail syndrome is characterized by greenish black discoloration of the nail with onycholysis. P. aeruginosa, an aerobic Gram-negative coccobacillus and is the most common cause of this condition, secretes the blue-green pigments pyoverdin and pyocyanin.1P. aeruginosa is not part of the normal flora of healthy skin, and infections of intact nail are rare. Affected patients often have a long history of exposure to water, soaps, detergents or moist conditions, as demonstrated in the current case.1 Treatments consist of removing and cleaning the onycholytic portion of the nail, and keeping the nails dry to prevent P. aeruginosa colonization. Topical silver sulfadiazine, gentamicin, ciprofloxacin, bacitracin and polymyxin B are also often effective. Recently, application of tobramycin eye drop has been reported to be useful.2 When topical therapies fail, oral antibiotic ciprofloxacin has been effective in many cases. However, despite the various treatments options, removal of the whole nail is occasionally necessary.



Gastrointestinal stromal tumor with synchronous colorectal adenocarcinoma

2017-06-12

Learning point for clinicians
  • The diagnosis of coexistence of GI malignancies by vague clinical symptoms and signs can be very challenging, physicians should be pay more attention to it, since early detection of these malignancies can guide clinical treatment plan and save lives.



Purtscher-like retinopathy and transplant-associated thrombotic microangiopathy

2017-06-01

A 36-year-old man was referred to the ophthalmology unit for blurring of vision in both eyes. A diagnosis of acute lymphoblastic leukemia was made in the patient at the age of 35 years. Treatment with combined chemotherapy achieved a complete remission. The patient received an allogenic bone marrow transplant from an HLA-identical donor.



Acute granulomatous hepatitis in an immunosuppressed patient secondary to Q fever

2017-05-26

Learning points for cliniciansQ fever should be considered in immunosuppressed patients with potential high risk exposure such as working with or living downwind from farm animals, exposed to contaminated manure, straw or dust, or travelling to endemic areas, or abattoir workers. When Q fever is suspected, treatment should be started early, prior to confirmation of the diagnosis.



Granulomatosis with polyangiitis (GPA) presenting as thick-walled cavitary lung lesion

2017-05-26

A 58-year-old female with a history of psoriatic arthritis on immunosuppressive therapy presented to the clinic with flu-like symptoms, cough, and blood-tinged sputum for one week. She denied chills, night sweats, wheezing, chest pain, weight loss, joint pain, or muscle aches. She had smoked for 31 pack-years and quit 1 year earlier. She was born and lived in upstate New York with no previous exposure to tuberculosis (TB). She had no exposure to chemicals or bird or bat droppings. There was no recent history of travel to any fungal endemic areas. Her home medications included albuterol, fluticasone-salmeterol, montelukast, omeprazole and citalopram. Her physical examination was completely normal, and she had a white blood cell count of 13.8 × 109/l with a platelet count of 63 × 103/µl. She was prescribed amoxicillin/clavulanate for presumed pneumonia. Because of the persistence of symptoms, imaging studies were done. Chest x-ray showed a cavitary lesion with an air-fluid level in the right upper lobe (Figure 1A ). Computed tomography of the chest demonstrated a cavitary mass with irregular thick walls and air-fluid level, as well as a 1.1 × 0.8 cm rounded subpleural nodule in the anterior left upper lobe (Figure 1B). Bronchoscopic washings were negative for malignancy and infectious workup for bacteria including TB and fungi were negative. Biopsy of the left lung nodule showed extensive necrotizing suppurative granulomatous inflammation consistent with granulomatosis with polyangiitis. Her proteinase 3 ANCA levels were also elevated which supported the diagnosis. The patient was started on rituximab and prednisone with improvement in her symptoms. Differential diagnosis of a cavitary lesion in the lung is broad. Infectious causes include bacterial pathogen, fungal or TB infection. Noninfectious causes include malignancy and systemic inflammatory diseases, such as rheumatoid arthritis or granulomatosis with polyangiitis.1 Granulomatosis with polyangiitis is a multisystem disease that involves multiple organs especially the lungs and kidneys. The frequent lung manifestations are nodules and infiltrates. Cavitation of the nodules occurs in 25% of nodules when they are > 2 cm,2 and the presentation of a solitary cavitary lesion is a rare phenomenon.3



Idiopathic segmental anhidrosis

2017-05-25

A 32-year-old man presented with a 2-year history of left hemifacial hyperhidrosis induced by exercise or hot environments. He reported episodes of heat intolerance and anhidrosis over the right side of his face. His past medical history was unremarkable. Physical examination revealed no evidence of a somatic neurological deficit or autonomic failure. Laboratory data, chest contrast computed tomography and cervical magnetic resonance imaging showed no abnormalities. Thermography revealed that the right facial surface temperature was higher in the anhidrotic area (red) than in the sweating area (yellow to blue) (Figure 1). Idiopathic segmental anhidrosis (ISA) was diagnosed.



Calcified cerebral embolism: what the clinician needs to know

2017-05-13

We present the case of an 83-year-old female admitted to the emergency department with sudden onset of confusion, dysarthria and right arm and leg weakness. A non-contrast computed tomography brain (NCCTB) scan showed multifocal calcifications along the expected course of both middle cerebral arteries and the right posterior cerebral artery typical for calcific cerebral emboli (Figure 1a-arrows). Review of admission chest radiograph revealed a markedly calcified mitral valve (Figure 1b-arrow).



Metastatic testicular cancer, a Horner’s syndrome and brachial plexopathy

2017-05-02

Learning points for cliniciansThe underlying condition in this case was silent until localizing neurological signs prompted investigation. The combination of a Horner’s syndrome with brachial plexopathy represents a high suspicion of malignancy due to the close anatomical proximity of these neurological pathways and susceptibility to compression or erosion.



The effect of Ramadan fast on the incidence of renal colic emergency department visits

2017-04-13

Abstract
Background: Renal colic (RC) is one of the most common reasons for emergency department (ED) visits. Although RC is associated with high ambient temperature and with physiological changes that occur during fast, the literature on between Ramadan and RC incidence is scarce.Aim: To investigate the association of ED visits with RC during Ramadan fast.Methods: We obtained health data of patients visited the ED of a large tertiary centre during the years 2004–15, with a primary diagnosis of RC. To estimate the association of RC and Ramadan, we utilized bi-weekly RC incidence Poisson models adjusted for ambient temperature and seasonality in two ethnic groups residing in the region: Muslims and Jews.Results: We identified 10 435 unique patients with 18 163 ED visits with primary diagnosis of RC. Although Muslims represent 18.5% of the population in the region, approximately 25% of the ED visits with RC attributed to this group. There was a positive and significant association of temperature and ED visits within all subgroups after adjusting for seasons. Positive association with Ramadan was observed during the first 2 weeks of fast within Muslims (R.R 1.27, 95% C.I 1.03–1.50) but not within Jewish community (R.R 1.061, 95% C.I 0.855–1.238).Conclusion: Our study demonstrates a significant and positive association between RC and Ramadan, while controlling to ambient temperature. In view of these findings, different prevention strategies should be investigated.



Does how the patient feels matter? A prospective observational study of the outcome of acutely ill medical patients who feel their condition has improved on their first re-assessment after admission to hospital

2017-04-11

Abstract
Background: Although asking how a patient feels is the first enquiry most clinicians make the value of the answer has never been examined in acutely ill patients.Methods: Prospective observational study that compared the predictive value of how well acutely ill medical patients felt after admission to a resource poor sub-Saharan hospital with their mental alertness, mobility and vital signs.Results: In total, 403 patients were studied. Patients who felt better when re-assessed 18.0 SD 9.1 h after admission to hospital were less likely to die in hospital (OR 0.18 95% CI 0.08–0.43, P = 0.00001) and more likely to be independent of others at discharge (OR 5.64 95% CI 3.04–10.47, P = 0.00001). Feeling better was an independent predictor of in-hospital death along with vital sign changes and gait stability, and an independent predictor of independence at discharge along with vital sign changes, gait stability and female gender.Conclusion: In this patient cohort a subjective feeling of improvement at the first re-assessment after admission to hospital is a powerful independent predictor of reduced in-hospital mortality.



Acute kidney injury electronic alerts in primary care ‐ findings from a large population cohort

2017-04-11

Abstract
Background: Electronic reporting of AKI has been used to aid early AKI recognition although its relevance to CA-AKI and primary care has not been described.Aims: We described the characteristics and clinical outcomes of patients with CA-AKI, and AKI identified in primary care (PC-AKI) through AKI e-Alerts.Design: A prospective national cohort study was undertaken to collect data on all e-alerts representing adult CA-AKI.Method: The study utilized the biochemistry based AKI electronic (e)-alert system that is established across the Welsh National Health Service.Results: 28.8% of the 22 723 CA-AKI e-alerts were classified as PC-AKI. Ninety-day mortality was 24.0% and lower for PC-AKI vs. non-primary care (non-PC) CA-AKI. Hospitalization was 22.3% for PC-AKI and associated with greater disease severity, higher mortality, but better renal outcomes (non-recovery: 18.1% vs. 21.6%; progression of pre-existing CKD: 40.5% vs. 58.3%). 49.1% of PC-AKI had a repeat test within 7 days, 42.5% between 7 and 90 days, and 8.4% was not repeated within 90 days. There was significantly more non-recovery (24.0% vs. 17.9%) and progression of pre-existing CKD (63.3% vs. 47.0%) in patients with late repeated measurement of renal function compared to those with early repeated measurement of renal function.Conclusion: The data demonstrate the clinical utility of AKI e-alerts in primary care. We recommend that a clinical review, or referral together with a repeat measurement of renal function within 7 days should be considered an appropriate response to AKI e-alerts in primary care.



Neuropsychiatric symptoms in Alzheimer’s disease: associations with caregiver burden and treatment outcomes

2017-04-10

Abstract
Background: Caregivers play a major role in providing care for patients with Alzheimer’s disease (AD) and are themselves at higher risk of health comorbidities.Aim: To address the impact of neuropsychiatric symptoms of patients in different stages of AD on their caregivers’ burden.Design: This prospective study enrolled 260 AD patients with clinical dementia rating (CDR) of 0.5, 1 and 2 at a tertiary medical center.Methods: All patients were tested using the mini-mental state examination (MMSE), the cognitive abilities screening instrument (CASI), the neuropsychiatric inventory (NPI) and the CDR scale. Data regarding therapeutic outcomes of anti-Alzheimer’s drugs were also collected. Caregivers were tested using NPI.Results: The mean follow-up interval was 25.0 ± 12.2 months, and two patients died during follow-up. NPI-burden was positively correlated with NPI-sum (r = 0.822, P <0.001) but negatively correlated with years of education (r = −0.140, P =0.024), CASI score (r = −0.259, P <0.001) and MMSE score (r = −0.262, P <0.001). Multiple linear regression analysis showed that only NPI-sum was independently associated with mean NPI-burden. Both higher mean CASI and MMSE scores had better therapeutic outcome of anti-Alzheimer’s drugs (P =0.001 and P=0.005, respectively).Conclusions: The severity of neuropsychiatric symptoms in patients with AD was positively associated with caregiver’s stress, and patients with better cognitive functions, under treatment with anti-Alzheimer’s drugs, had better therapeutic outcomes. To reduce the impact of neuropsychiatric symptoms, it is crucial to detect dementia in its early phases and provide early intervention with anti-Alzheimer’s drugs, which might help decrease the caregiver burden, thereby improving their quality of life.



Arterial aging mediates the effect of TNF-α and ACE polymorphisms on mental health in elderly individuals: insights from IKARIA study

2017-04-03

Abstract
Background: Aging is characterized by an insidious decline in cognitive function. Several genetic and lifestyle factors have been implicated in the increased risk or early onset of dementiaAim: We sought to assess the role of tumor necrosis factor (TNF) and angiotensin-converting enzyme (ACE) polymorphisms on the development of impaired mental health in respect to indices of arterial aging in nonagenarian individuals.Design: 178 consecutive subjects above 75 years that permanently inhabit in the island of IKARIA, Greece were recruited.Methods: Aortic distensibility (AoD) was calculated and genetic evaluation was performed on the ACE Insertion/Deletion gene polymorphism (intron 16) and the G/A transition (position -308) of the TNF gene. Cognitive function was evaluated using the Mini-mental State Examination (MMSE).Results: The DD genotype for ACE was independently associated (b = −0.44, P = 0.007) with AD while AoD remained an independent determinant of mental status (OR = 1.82, P = 0.036). Interestingly though, when a combined genetic index (GI) was calculated for both genes (ACE and TNF), subjects being double homozygous (DD for ACE and GG for TNF) for these loci presented significantly decreased MMSE (adjusted OR = 0.259, P = 0.033). This GI independently associated with AD (beta coefficient = −0.785, P = 0.002). When AoD was included, GI lost its predictive role (OR = 0.784, P = 0.783) towards MMSE. AoD has marginal indirect mediating effect in the association of the GI with MMSE (P = 0.07).Conclusion: Vascular aging may modulates the genetic substrate of elderly subjects on the risk for developing dementia.



Codeine use, dependence and help-seeking behaviour in the UK and Ireland: an online cross-sectional survey

2017-04-03

Abstract
Background: Codeine misuse and dependence poses a clinical and public health challenge. However, little is known about dependence and treatment needs in the UK and Ireland.Aim: To characterize codeine use, dependence and help-seeking behaviour.Design: An online cross-sectional survey advertised on Facebook, Twitter, health and drug websites and e-mail circulars.Methods: The survey collected data on demographics and codeine use amongst adults from the UK and Ireland. The Severity of Dependence Scale measured the level of codeine dependence.Results: The sample of 316 respondents had a mean age of 35.3 years (SD = 12.3) and 67% were women. Of the 316 respondents, 54 scored ≥5 on the Severity of Dependence Scale indicating codeine dependence (17.1%). Our study found that codeine dependence is a problem with both prescribed and ‘over-the-counter’ codeine. Codeine dependence was associated with daily use of codeine, faking or exaggerating symptoms to get a prescription for codeine and ‘pharmacy shopping’ (P < 0.01). A higher number of respondents had sought advice on the Internet (12%) rather than from their general medical practitioner (GP) (5.4%). Less than 1% of respondents had sought advice from a pharmacist.Conclusions: Codeine dependent users were more likely to seek help on the Internet to control their use of codeine than from a GP, which may indicate a potential for greater specialized addiction treatment demand through increased identification and referrals in primary care.



Neurofibromatosis type 1 and disseminated malignant peripheral nerve sheath tumor

2017-03-24

Learning points for clinicians
  • Café-au-lait spot is a common pigmented skin lesion, however, presence of multiple café-au-lait (>6) suggests a consideration of neurofibromatosis type 1 (NF1).
  • New onset pain or sudden enlargement of a pre-existing neurofibroma, especially in the setting of NF1 suggests malignant peripheral nerve sheath tumor (MPNST) until proven otherwise. An immediate biopsy is mandatory.



Tsunami in 2011 to the earthquake in 2016 in Fukushima—are we better prepared?

2017-01-30

At 5:59 am on 22 November 2016, a magnitude 7.4 earthquake struck Fukushima, and resulted in tsunamis across the Eastern coast of Japan.1 These events were centered in areas affected by the 2011 triple disaster, yet the damage was fortunately limited with only 17 injuries and no deaths reported, without any recurrent accidents at the Fukushima Daiichi Nuclear Power Plant (FDNPP).1