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Preview: QJM - current issue

QJM: An International Journal of Medicine Current Issue





Published: Fri, 01 Dec 2017 00:00:00 GMT

Last Build Date: Fri, 08 Dec 2017 15:05:35 GMT

 



Blood transfusions—more is not better

Fri, 01 Dec 2017 00:00:00 GMT

In stable anaemia, why do clinicians still transfuse more than one unit? It is contrary to national guidelines, and it is well recognized that blood transfusion can cause harm and worsen patient outcomes. These adverse events include allergic and haemolytic reactions, graft-versus-host disease, acute inflammatory lung injury and worsening end-organ injury.



Diabetes in pregnancy: worse medical outcomes in type 1 diabetes but worse psychological outcomes in gestational diabetes

Wed, 02 Aug 2017 00:00:00 GMT

Abstract
Background
Women with diabetes experience an increased risk of adverse pregnancy outcomes.
Aim
We aim to describe and quantify the psychological impact of the diagnosis of diabetes in pregnant women with type 1 diabetes and gestational diabetes mellitus (GDM) compared to each other and to their counterparts without diabetes.
Design
This is a survey-based study with prospective collection of pregnancy outcome data.
Methods
A total of 218 pregnant women (50% with diabetes) were administered questionnaires relating to psychological health. Maternal and neonatal characteristics and pregnancy outcomes were collected. Associations between key psychometric and health outcome variables were examined.
Results
At least 25% of women in all three pregnancy groups had scores indicating affective distress in at least one domain. Compared to those with type 1 diabetes, women with GDM evidenced a greater number of uplifts in pregnancy (U = 94, P = 0.041), but also higher levels of overall anxiety (U = 92, P = 0.03) and stress (U = 82, P < 0.01). Women with GDM also had significantly elevated overall depression scores, compared with the control group (U = 34, P = 0.02). Both groups of women with diabetes had clinically elevated levels of diabetes-related distress. There were no associations between maternal psychological variables and pregnancy outcomes.
Conclusions
This work highlights a potential role for targeted psychological interventions to address and relieve symptoms of anxiety and depression among pregnant women with diabetes.



Steeple sign and acute laryngotracheobronchitis

Mon, 24 Jul 2017 00:00:00 GMT

A 7-year-old girl presented to the emergency department with a 2-day history of acute onset mild fever, hoarseness and barking cough. The physical examination revealed mild chest wall retraction and audible stridor, but no drooling or cyanosis. Frontal neck radiography showed narrowing of the subglottic airway (Figure 1). This finding was consistent with the ‘steeple sign’, suggestive of an acute laryngotracheobronchitis. On the basis of the clinical and radiographic findings, the patient was diagnosed as having an acute laryngotracheobronchitis. She was admitted to the hospital, and the symptoms gradually improved, after the administration of intranasal oxygen, oral dexamethasone and epinephrine nebulization. Laryngotracheobronchitis, also known as croup, is a viral infection of the upper airway with a characteristic cough, inspiratory stridor, hoarseness and dyspnoea. Before vaccination, croup was frequently caused by Corynebacterium diphtheriae infection and was often fatal.1 Diphtheria is now rare in the developed country due to the success of the vaccination. Approximately, 75% of croup cases are associated with parainfluenza virus.2 Several viruses such as influenza A and B, adenovirus and respiratory syncytial virus, can also cause croup and have a good overall long-term prognosis.3



Vitamin B 12 deficiency may coexist with endocrine causes of hyperpigmentation

Mon, 24 Jul 2017 00:00:00 GMT

When knuckle hyperpigmentation is documented in a patient with vitamin B 12 deficiency1 there should be a correspondingly high index of suspicion for coexisting primary hypoadrenalism, given the fact that primary hypoadrenalism is a well-documented cause of knuckle hyperpigmentation in its own right.2 Coexistence of vitamin B 12 deficiency and primary hypoadrenalism occurs in patients with the type 1 autoimmune polyglandular syndrome,3 and awareness of this association mandates evaluation of the integrity of the hypothalamic-pituitary-adrenal axis in patients who have hyperpigmentation in the presence of vitamin B 12 deficiency.4 The index of suspicion for coexisting primary hypoadrenalism should be especially high if hyperpigmentation does not resolve within 6 months of initiation of vitamin B 12 replacement therapy. In one series, this was the case in 8.77% of 49 vitamin B12 deficient patients with hyperpigmentation.5 Also on an autoimmune basis, vitamin B 12 deficiency may coexist with thyrotoxicosis,6 the latter a recognized cause of generalized hyperpigmentation in its own right.7 Furthermore, in thyrotoxicosis hyperpigmentation may similar in pattern to the hyperpigmentation in Addison’s disease.8



A single unit transfusion policy reduces red cell transfusions in general medical in-patients

Fri, 21 Jul 2017 00:00:00 GMT

Abstract
Background
The NICE guidelines for blood transfusion and the patient blood management recommendations state that a single unit of red cells should be the standard dose for patients with stable anaemia who are not bleeding. Studies have shown that changing clinical transfusion practice can be difficult and that many clinicians’ order two units of blood as standard for patients needing a transfusion.
Aim
A collaborative project between NHS Blood and Transplant and Kings College Hospital started in September 2014 to evaluate the impact of a single unit policy on blood usage.
Design Methods
Training and education was undertaken for clinical staff on eight general medical wards and all staff working in the blood transfusion laboratory. We collected transfusion data for 12 months, (6 months before and after implementation).
Results
There was a decrease of 50% red cell unit usage between the two periods, equating to a unit cost saving of £28 670. The number of single unit transfusions, increased from 30 to 53% whilst the number of two units decreased from 65 to 43% (P < 0.001).
Discussion/Conclusion
This project has shown that transfusion practice can be changed and savings in blood usage can be achieved through the successful implementation of the single unit transfusions policy. Key to the implementation was engagement from key medical staff within the medical department in which the policy was implemented and support from the hospital transfusion team. Continued attention and training shall be needed to support these, and implement other, patient blood management recommendations.



Community acquired acute kidney injury: findings from a large population cohort

Fri, 21 Jul 2017 00:00:00 GMT

Abstract
Background
The extent of patient contact with medical services prior to development of community acquired-acute kidney injury (CA-AKI)is unknown.
Aim
We examined the relationship between incident CA-AKI alerts, previous contact with hospital or primary care and clinical outcomes.
Design
A prospective national cohort study of all electronic AKIalerts representing adult CA-AKI.
Methods
Data were collected for all cases of adult (≥18 years of age) CA-AKI in Wales between 1 November 2013 and 31 January 2017.
Results
There were a total of 50 560 incident CA-AKI alerts. In 46.8% there was a measurement of renal function in the 30 days prior to the AKI alert. In this group, in 63.8% this was in a hospital setting, of which 37.6% were as an inpatient and 37.5% in Accident and Emergency. Progression of AKI to a higher AKI stage (13.1 vs. 9.8%, P < 0.001) (or for AKI 3 an increase of > 50% from the creatinine value generating the alert), the proportion of patients admitted to Intensive Care (5.5 vs. 4.9%, P = 0.001) and 90-day mortality (27.2 vs. 18.5%, P < 0.001) was significantly higher for patients with a recent test. 90-day mortality was highest for patients with a recent test taken in an inpatient setting prior to CA-AKI (30.9%).
Conclusion
Almost half of all patients presenting with CA-AKI are already known to medical services, the majority of which have had recent measurement of renal function in a hospital setting, suggesting that AKI for at least some of these may potentially be predictable and/or avoidable.



Type 2 split cord malformation: the ‘Martian’ sign

Fri, 21 Jul 2017 00:00:00 GMT

A 23-years-old female with congenital kyphoscoliosis was referred to us for further imaging and pain management. She had complained of mainly pain and numbness of the left lower limb. Magnetic resonance imaging (MRI) of the whole spine incidentally revealed type 2 split cord malformation; with longitudinal separation of the cord at the level of T4/5. The two hemicords are contained within the same dural sac. On axial T2 weighted MRI, the appearance of the two hemicords within the spinal canal was noted to have a stark resemblance to the face of a Martian (Figure 1A and B). We hence coined the name the ‘Martian’ sign to describe this novel radiological sign. Patient underwent nerve root injection and was pain free post-procedure; she remains under our follow-up. Type 2 split cord malformations (SCM) are rare spinal cord anomalies, characterized by the longitudinal separation of the spinal cord into two hemicords; which are contained within a single dural sac. Classification of SCM can be divided into two; namely type 1 when the two hemicords are enclosed within their own dural sac, and separated by a bony septum, whereas type 2 when both the hemicords are housed within a single dural sac.1,2



Ultrasound double contour sign and gout

Fri, 21 Jul 2017 00:00:00 GMT

An 82-year-old man presented with left hand swelling and pain for 2 days. He had a history of gouty arthritis and hypertension without regular medication. The physical examination showed tophi on both big toes and left hand swelling with limited motion. Laboratory assessments showed a serum uric acid level of 13 mg/dL. Sonography revealed the double contour sign (Figure 1A, white arrow), bone erosion, and a lesion with a snowstorm appearance in the third metacarpophalangeal joint (Figure 1A, asterisk). Ultrasound-guided arthrocentesis was performed (Figure 1A, red arrow); the aspirate was whitish milk-like material (Figure 1B). Monosodium urate (MSU) was confirmed by polarized light microscopy.



Dry ice (solid carbon dioxide) exposure with disastrous consequences

Wed, 19 Jul 2017 00:00:00 GMT

Learning points for cliniciansExposure to dry ice can cause carbon dioxide toxicity when transported in unsealed containers in enclosed spaces. Such inadvertent exposure in personal vehicles can lead to devastating outcomes.



An imported case of leprosy in a trainee from Indonesia to Japan

Wed, 19 Jul 2017 00:00:00 GMT

A 33-year-old Indonesian man who was visiting Japan as a trainee in agricultural sector presented to the outpatient department of dermatology with a 1-year history of progressive rash. The rash had originated on his trunk and had gradually spread to his chest, abdomen, back and arms (Figure 1). The patient was not on any medications. He also denied any history of an allergy. Polymorphic, confluent, partially raised, hypopigmented macules that had progressed slowly were observed. The lesions demonstrated associated scaling, alopecia, and anesthesia. Although a left greater auricular nerve enlargement was detected, the patient did not show muscle weakness in his extremities. Skin biopsy specimens were obtained and analyzed using polymerase chain reaction, Mycobacterium leprae DNA was detected in samples obtained from hypopigmented macules. Thus, the patient was diagnosed with leprosy of the borderline lepromatous type. He was treated with multidrug therapy (rifampicin, clofazimine and diaminodiphenyl sulfone), which is established as the mainstay for leprosy treatment by the World Health Organization (WHO).1 The patient was followed up in the outpatient clinic. One year later, his skin lesions were faded. Leprosy control has improved significantly due to national and subnational campaigns in most endemic countries. According to official WHO reports,2 the number of new cases reported globally in 2015 was 211 973 (2.9 new cases per 100 000 people). Although leprosy is almost eliminated from developed countries, younger clinicians should be cautious regarding this historical and notorious disease and not overlook it.



Pseudomembranous colitis

Wed, 19 Jul 2017 00:00:00 GMT

An 85-year-old man presented to the emergency department with a 3-week history of fever, severe watery diarrhea and collapse. The patient received antibiotics for infectious pneumonia 1 week before onset. A stool sample was positive for Clostridium difficile (C. difficile) antigen, but negative for C. difficile toxin. From his clinical history, we suspected pseudomembranous colitis and performed a colonoscopy. This revealed inflamed mucosa, with yellowish pseudomembranous plaques and a hemorrhagic sigmoid colon (Figure 1). Based on the colonoscopic findings, we definitively diagnosed the patient with pseudomembranous colitis. Pseudomembranous colitis, also known as C. difficile colitis, is a severe form of antibiotic-associated diarrhea or colitis that is, increasingly encountered in hospitalized patients. C. difficile is found in approximately 13% of patients with hospital stays of up to 2 weeks, and in 50% of those with hospital stays longer than 4 weeks.1 Early identification of C. difficile infection can help prevent the spread of C. difficile in hospitals. However, definitive diagnosis may be delayed due to a lack of suspicion or reduced diagnostic accuracy of initial examinations. For example, diarrhea is a usual presenting symptom of pseudomembranous colitis. In some cases, patients will have an atypical presentation without diarrhea but with ascites, abscesses, perforation, or toxic megacolon, with its potentially fatal outcomes.2 Recurrence can occur in up to 30% of cases.3 It can be difficult to determine if this is due to a failure to eradicate C. difficile, or due to a new infection. Recent innovations in biologic therapy show that actoxumab/bezlotoxumab (a monoclonal antibody against C. difficile toxin A/B) is effective at preventing recurrent C. difficile infections, although it is expensive. It is therefore important for clinicians to definitively diagnose C. difficile infection for judicious application of costly medications. Although colonoscopy is an invasive test that is generally not considered for initial diagnosis of C. difficile infection, it can be beneficial for a patient with suspected having C. difficile infection, with consistent symptoms, negative testing and failed response to conventional therapy.



A corollary to the prudent approach to anticoagulation

Tue, 18 Jul 2017 00:00:00 GMT

The recommendation for a prudent approach to advocating anticoagulation in the frail elderly1 should have, as its corollary, the caveat that dual antiplatelet therapy (consisting of aspirin and clopidogrel) is not an alternative strategy free of the risk of subdural haematoma. The risk of subdural haematoma incurred by patients on antiplatelet therapy was highlighted by a case–control study which covered the period 2000–2015. That study enrolled 101 010 patients aged 20–89 with a first ever subdural haematoma as the principal discharge diagnosis. These patients were matched by age, sex and calendar year to 400 380 individuals from the general population.2 In that study the risk of subdural haematoma was higher with current use of low dose aspirin (cases: 27.6%, controls: 22.4%; adjusted odds ratio (OR), 1.24 [95% confidence interval (95% CI), 1.15–1.33]), clopidogrel (cases: 5%, controls: 2.2%; adjusted OR, 1.87 [95% CI, 1.57–2.24]). For low dose aspirin subdural haematoma was inversely related to duration of current use. For example, for a duration of <1 month (cases: 1.8%, controls: 0.8%; adjusted OR, 2.66 [95% CI, 2.20–3.22]) compared with a duration of > 3 years (cases: 8.1%, controls:7.9%; adjusted OR, 0.99 [95% CI, 0.88–1.10]). For clopidogrel, however, the risk of subdural haematoma remained constant (adjusted OR range 1.46–2.18) and was independent of the duration of current use.2 These results undermine the case for the use of combined aspirin and clopidogrel therapy in non-valvular atrial fibrillation (NVAF),3 a strategy that does not mitigate the risk of NVAF-related extracranial embolism.3



Increasing incidence of chronic subdural haematoma in the elderly

Mon, 17 Jul 2017 00:00:00 GMT

Dear Editor



Response to ‘Vitamin B12 deficiency may coexist with endocrine causes of hyperpigmentation’

Sun, 16 Jul 2017 00:00:00 GMT

Knuckle pigmentation is usually recognized as an external clue to underlying systemic illness. In vitamin B12 deficiency, cutaneous hyperpigmentation is seen in about 10% cases and involves knuckle pads, palmar creases, flexures surfaces, face and oral mucosa.1,2 A recent study also showed a strong association of skin hyperpigmentation and cytopenia(s) with megaloblastic anemia.2



Myocarditis and purpura fulminans in meningococcaemia

Fri, 14 Jul 2017 00:00:00 GMT

Learning point for clinicians
  • Myocarditis is a common but less recognized complication following meningococcal sepsis leading to high mortality.
  • High index of suspicion with early recognition of meningococcemia and appropriate therapy leads to prompt resolution of disease with minimal sequelae.



IgG4-related disease and ANCA positivity: an overlap syndrome?

Tue, 11 Jul 2017 00:00:00 GMT

Learning point to cliniciansDue to their various clinical expressions, the distinction between IgG4-related disease (IgG4-RD) and ANCA associated vasculitis is not always easy. However, the differential diagnosis is essential in terms of treatment and prognosis. Herein, we report a case of biological and histological proven IgG4-RD mimicking a clinical but not histological p-ANCA MPO granulomatosis with polyangiitis and discuss the association of entities.



Internal carotid artery dissection and Villeret’s syndrome

Tue, 11 Jul 2017 00:00:00 GMT

Learning point for cliniciansAcute general medicine is a discipline that manages a variety of clinical syndromes. Therefore, good general medicine practice requires flexibility and judgement rather than the routine use of sophisticated investigations. Logical analysis of the clinical features of this case allowed a rational choice of imaging which confirmed the diagnosis. This case is a testimony to the use of basic anatomy and physiology to identify and manage an acute clinical problem.



Anabolic steroid abuse: what shall it profit a man to gain muscle and suffer the loss of his brain?

Fri, 30 Jun 2017 00:00:00 GMT

Learning Point for CliniciansThe use of anabolic androgenic steroids may be an underestimated cause of cerebral venous thrombosis. The pervasive yet clandestine use of these and other endocrine modulating drugs amongst athletes challenges the epidemiological study of their pro-thrombotic consequences and by extension the astuteness of the clinician in such a circumstance as depicted in this case.



Eating frequency predicts changes in regional body fat distribution in healthy adults

Wed, 21 Jun 2017 00:00:00 GMT

Abstract
Background
Eating frequency (EF) has been associated with generalized obesity.
Aim
We aimed to prospectively investigate potential associations of frequency of eating episodes with regional fat layers.
Design
EF was evaluated at baseline in 115 subjects free of clinically overt cardiovascular disease (54 ± 9.1 years, 70 women) in a prospective, observational study.
Methods
Metabolic parameters known to be associated with dietary factors and anthropometric markers including ultrasound assessment of subcutaneous (Smin) and pre-peritoneal (Pmax) fat and their ratio Smin/Pmax (AFI) were evaluated at baseline and at follow-up, 5 years later.
Results
EF at baseline positively correlated with Pmax, even after adjustment for potential confounders. EF above median was also an independent predictor for Pmax (beta coefficient = −0.192, P = 0.037) and AFI (beta coefficient = 0.199, P = 0.049) at follow up. Multivariable linear mixed models analysis demonstrated that subjects with increased EF presented a lower progression rate of Pmax (beta = −0.452, P = 0.006) and a higher progression rate of AFI (beta = 0.563, P = 0.003) over time, independently of age, sex, progression of BMI, energy intake, smoking and changes in parameters of glucose metabolism.
Conclusions
High EF is associated with lower progression rate of pre-peritoneal fat accumulation. Future interventional studies should further investigate the clinical utility of these findings.



Impact of admission serum potassium on mortality in patients with chronic kidney disease and cardiovascular disease

Fri, 16 Jun 2017 00:00:00 GMT

Abstract
Background
Little is known about the effect of admission potassium (K) on risk of in-hospital mortality in chronic kidney disease (CKD) and cardiovascular disease (CVD) patients.
Aim
The aim of this study was to assess the relationship between admission serum K and in-hospital mortality in all hospitalized patients stratified by CKD and/or CVD status.
Design and Methods
All adult hospitalized patients who had admission serum K between years 2011 and 2013 were enrolled. Admission serum K was categorized into seven groups (<3.0, 3.0–3.5, 3.5–4.0, 4.0–4.5, 4.5–5.0, 5.0–5.5 and ≥5.5 mEq/L). The odds ratio (OR) of in-hospital mortality by admission serum K, using K 4.0–4.5 mEq/L as the reference group, was obtained by logistic regression analysis.
Results
73,983 patients were studied. The lowest incidence of in-hospital mortality was associated with serum K within 4.0–4.5 mEq/L. A U-shaped curve emerged demonstrating higher in-hospital mortality associated with both serum K < 4.0 and >4.5 mEq/L. After adjusting for potential confounders, both serum K < 4.0 mEq/L and >5.0 mEq/L were associated with increased in-hospital mortality with ORs of 3.26 (95% CI 2.03–4.98), 2.40 (95% CI 1.89–3.04), 1.38 (95%CI 1.15–1.66), 1.89 (95% CI 1.49–2.38) and 3.62 (95%CI 2.73–4.76) when serum K were within <3.0, 3.0–3.5, 3.5–4.0, 5.0–5.5, and ≥5.5 mEq/L, respectively. In CVD patients, the highest in-hospital mortality was associated with serum K < 3.0 mEq/L (OR 1.70, 95%CI 1.31–2.18). In CKD patients, the highest in-hospital mortality was associated with serum K ≥ 5.5 mEq/L (OR 3.26, 95%CI 2.14–4.90).
Conclusion
Admission serum K < 4.0 mEq/L and >5.0 mEq/L were associated with increased in-hospital mortality. The mortality risk among patients with various admission potassium levels was affected by CKD and/or CVD status.



Bone marrow involvement in systemic lupus erythematosus

Fri, 19 May 2017 00:00:00 GMT

Abstract
Background
Besides peripheral cytopenias, bone marrow abnormalities, such as fibrosis, pure red cell aplasia and aplastic anemia have been reported in patients with systemic lupus erythematosus (SLE), suggesting that bone marrow may be a 25 target organ in SLE.
Aim
Our objective was to describe this bone marrow involvement.
Methods
This registry is a nationwide retrospective study. Centers provided data concerning medical history, SLE manifestations, type of hematologic disorder, treatments and outcome. Bone marrow aspirations and/or biopsies were transferred for centralized review.
Results
Thirty patients from 19 centers were included. Central hematologic manifestations comprised bone marrow fibrosis (n = 17; 57%), pure red cell aplasia (n = 8; 27%), myelodysplastic syndrome (n = 3; 10%), aplastic anemia and agranulocytosis (n = 1; 3% each). Bone marrow involvement was diagnosed concomitantly with SLE in 12 patients. Bone marrow biopsies showed fibrosis in 19 cases, including one case of pure red cell aplasia and one case of agranulocytosis and variable global marrow cellularity. Treatments included corticosteroids (90%), hydroxychloroquine (87%), rituximab (33%), intravenous immunoglobulins (30%), mycophenolate mofetil (20%) and ciclosporine (20%). After a median follow-up of 27 months (range: 1–142), 24 patients manifested complete improvement. No patient died.
Conclusions
This registry comprises the largest series of SLE patients with bone marrow involvement. It demonstrates the strong link between SLE and bone marrow fibrosis. Patients with atypical or refractory cytopenia associated with SLE should undergo bone marrow examination to enable appropriate, and often effective, treatment. Long-term prognosis is good.



Management of post-operative acute kidney injury

Tue, 18 Oct 2016 00:00:00 GMT

Abstract
Post-operative acute kidney injury (AKI) is a common complication of surgery with significant short- and long-term adverse consequences. The adoption of diagnostic criteria for AKI (RIFLE, AKIN and KDIGO) has facilitated comparison of data reported by different centres, confirming that even mild AKI is associated with excess mortality. It remains unclear whether this is caused by the kidney injury itself or whether AKI is simply a marker of underlying disease severity. There is no trial evidence to support the use of any specific therapeutic intervention in post-operative AKI. Best current treatment is, therefore, preventative by optimizing hydration and avoidance of nephrotoxins, emphasizing the importance of earlier detection and identification of individuals at high risk for AKI. In this review, we examine the latest literature on the management of post-operative AKI in adult patients, specifically the diagnosis and definition of AKI, epidemiology and pathogenesis and risk stratification in cardiac and non-cardiac surgery. We also review the latest evidence on pharmacological and non-pharmacological interventions.