[Life-threatening respiratory insufficiency; rare primary manifestation of the antisynthetase syndrome]

The antisynthetase syndrome (AS) is a rare auto-immune disease characterised by inflammatory myopathies, interstitial lung disease, inflammatory arthritis, Mechanic's Hands and Raynaud phenomenon. AS infrequently presents with life-threatening lung disease as its primary or sole manifestation. By means of two clinical case reports, an overview is given of recent advances in diagnosis and treatment of AS-related interstitial lung disease. We emphasise the importance of considering AS as a differential diagnosis if lung disease does not respond to standard treatment in a relatively young patient, certainly if there is even a mild suggestion of myopathy, arthritis or cutaneous involvement.

Comparative Effects of Staphylokinase and Alteplase in Rabbit Bleeding Time Models

Background: The pathogenesis of bleeding associated with thrombolytic therapy remains largely unknown, although spontaneous bleeding appears to correlate with bleeding time prolongation. Here, the comparative effects on cuticle bleeding times (CBT) and ear puncture bleeding times (EBT) of recombinant staphylokinase (Sak) and alteplase (recombinant tissue-type plasminogen activator, rt-PA) at equivalent doses, alone and in combination with aspirin and heparin, were studied in rabbits.

Methods and Results: Groups of 4 to 9 rabbits were allocated to one of the 8 following intravenous infusions: saline; aspirin 15 mg/kg and heparin - 100 IU/kg bolus and 10 IU/kg infusion over one hour; 1.5 mg/kg rt-PA; 1.5 mg/kg rt-PA plus aspirin and heparin; 4.5 mg/kg rt-PA; 0.5 mg/kg Sak; 0.5 mg/kg Sak plus aspirin and heparin and 1.5 mg/kg Sak. Bleeding times were determined 30 and 15 min before and 5,15,30 and 60 min after the administration over one min of saline, rt-PA or Sak, by simultaneously severing a nail cuticle (CBT) and by puncturing the ear (EBT). Bleeding times were unaffected by saline and by both doses of Sak in monotherapy. Heparin-aspirin and low dose rt-PA significantly lengthened EBT but not CBT. Both CBT and EBT were significantly prolonged (to a mean of >4 times pretreatment at 5 min) after high-dose rt-PA and after the combined administration of heparin and aspirin with either Sak or rt-PA. rt-PA provoked significantly longer bleeding than Sak in the CBT (p = 0.001; mean estimated difference = 23 min), but not in the EBT. rt-PA but not Sak degraded plasma fibrinogen dose-dependently. CBT correlated inversely with fibrinogen (r = −0.66, p = 0.001) but EBT did not.

Conclusions: At equivalent doses Sak displays a significantly higher fibrin specificity and prolongs bleeding time less than rt-PA, particularly in the nail cuticle bleeding time model in which larger vessels are injured that require fibrinogen for hemostasis.

Prevalence and Induction of Circulating Antibodies against Recombinant Staphylokinase

Streptokinase (SK) is a routinely used thrombolytic agent but it is immunogenic and allergenic; staphylokinase (STA) is a potential alternative agent which is under early clinical evaluation. The comparative prevalence of antibodies against recombinant STA (STAR) and against SK was studied in healthy subjects and their induction with intravenous administration in small groups of patients.

Enzyme-linked immunosorbent assays, using microtiter plates coated with STAR or SK and calibration with affinospecific human antibodies, revealed 2.1 to 65 μg/ml (median 11 μg/ml) anti-STAR antibodies and 0.9 to 370 μg/ml (median 18 μg/ml) anti-SK antibodies (p <0.001 vs anti-STAR antibodies) in plasma from 100 blood donors, with corresponding values of 0.6 to 100 μg/ml (median 7.1 μg/ml) and 0.4 to 120 μg/ml (median 7.3 μg/ml), respectively, in 104 patients with angina pectoris. Three out of 17 patients with Staphylococcus aureus bacteremia had significantly increased anti-STAR antibody levels (150, 75 and 75 μg/ml), and STAR neutralizing activities (2.2, 3.6 and 4.1 μg STAR neutralized per ml plasma, respectively). In 6 patients with acute myocardial infarction, given 10 mg STAR intravenously over 30 min, median anti-STAR antibody levels were 3.5 μg/ml at baseline, 2.9 μg/ml at 6 to 8 days and 1.2 μg/ml at 2 to 9 weeks, with median corresponding titers of STAR neutralizing activity at 2 to 9 weeks of 42 μg/ml plasma. Conversely, in 5 patients treated with 1,500,000 units SK over 60 min, median anti-SK antibodies increased from 2.9 μg/ml at baseline to 360 μg/ml at 5 to 10 days, with corresponding median SK neutralizing activities of 13 μg/ml. Antibodies against STAR did not cross-react with SK and vice versa.

Plasma from human subjects contains low levels of circulating antibodies against recombinant staphylokinase, and intravenous administration of this compound boosts antibody titers. These antibodies do however not cross-react with streptokinase, whereby the use of these two immunogenic thrombolytic agents would not be mutually exclusive.

A Pilot Study on Bolus Administration of Recombinant Staphylokinase for Coronary Artery Thrombolysis

Recombinant staphylokinase (Sak) is a highly fibrin-specific thrombolytic agent but the optimal dose and mode of administration remain to be defined. Intravenous (i.v.) infusion over 5 min of 20 mg Sak in 12 patients with acute myocardial infarction induced complete coronary patency (TIMI perfusion grade 3) in 7 patients (58%) within 60 min. In 3 of the 5 patients with no or suboptimal flow (TIMI grade 0,1 or 2) at 60 min, an additional 10 mg i.v. bolus of Sak resulted in TIMI grade 3 flow at 90 min. No major treatment-related complication occurred. Residual fibrinogen and α2-antiplasmin levels at 90 min were 110 ± 6.0% and 98 ±4.1% (mean ± SEM) of baseline, respectively. Median antibody-related Sak-neutralizing activity was low at baseline (0.0 μg/ml) and after 1 week (0.5 μg/ml) but increased from day 10 on (to 4.0 μg/ml).

Thus, bolus thrombolysis with Sak may induce efficient coronary artery recanalization while preserving circulating fibrinogen and α2-antiplasmin. Comparative trials of coronary thrombolysis with double-bolus Sak appear to be warranted.

Outcome and One Year Follow-up of Intra-arterial Staphylokinase in 191 Patients with Peripheral Arterial Occlusion

Wild-type or equipotent variants of recombinant staphylokinase (rSak) were given intra-arterially (as a 2 mg bolus injection followed by an infusion of 1 mg/h or 0.5 mg/h overnight, with concomitant heparin [1000 IU/h]) to 191 patients of less than 80 years (62 ± 1 years, mean ± SEM), with a peripheral arterial occlusion (PAO) of less than 120 days (mean 14 ± 1 days, median 11 days, 5 to 95 percentiles 3 to 30 days). Ninety nine patients presented with acute or subacute ischemia, 57 with severe claudication, 33 with chronic rest pain and 2 with gangrene. Occlusion occurred in 122 native arteries and in 69 grafts. Revascularization was complete in 83 percent (158/191), partial in 13 percent (24/191) and absent in 4 percent (7/191) after administration of 12 ± 0.5 mg rSak over 14 ± 0.7 h. Complete revascularization of acute occlusions of popliteal or more distal arteries was less frequent (60 percent, 15/25) than of acute occlusions of more proximal native arteries (95 percent, 37/39, p <0.001) or grafts (89 percent, 50/56, p = 0.005). Additional endovascular procedures were performed in 47 percent and subsequent elective bypass surgery in 23 percent of patients. Major bleeding occurred in 12 percent (23/191), one month mortality was 3.1 percent (6/191) and one year mortality was 6.9 percent (12/174). However, four patients (2.1 percent) had an intracranial bleeding following therapy: a 85 year old woman with severe diabetic arteriopathy, who was included in violation of the protocol, a 79 and a 74-year-old woman and a 74-year-old man, all with severe hypertension and limb threatening ischemia; these four patients died within two months after treatment. Amputations were performed within the first year in 16 of 162 surviving patients (9.8 percent): in 7 percent (7/96) with an occluded native artery and 14 percent (9/66) with an occluded graft (p = 0.19). No significant difference in lysis rate, one month mortality or one year amputation-free survival was observed in occlusions of recent onset (<14 days, n = 126) as compared to occlusions of longer duration (<14 days, n = 65). Treatment was interrupted prematurely in 4 patients because of a suspected allergic reaction. Fibrinogen levels remained unaffected during treatment (3.3 ± 0.1 g/l before vs. 3.3 ± 0.1 g/l after infusion, n = 167).

In conclusion, rSak appears to be a highly effective thrombolytic agent in patients with PAO, resulting in a low one month mortality (3.1 percent) and a high one year amputation free survival (84 percent), with an acceptable incidence of major bleedings, but with occasional fatal intracranial hemorrhages.

Incidence and risk factors of fever in a contemporary cohort of HIV-patients with good access to antiretroviral therapy

OBJECTIVE

To study incidence and to determine risk factors of fever in a contemporary cohort of HIV-infected patients with access to antiretroviral therapy.

METHODS

Prospective study in a cohort of HIV-infected patients in Belgium from 2009 to 2013.

RESULTS

759 patients were followed for a total of 2136 patient years. The incidence of fever was low, with an incidence rate of 0.103 (95% CI 0.078; 0.135) febrile episodes per patient per year for temperature 38.3 °C or higher measured by a health care provider. Gender, age, ethnicity, and calendar year of measurement were no significant risk factors for fever in univariable analysis, but recent HIV diagnosis, prior AIDS, nadir CD4 cell count, last CD4 cell count, and viral load were, as were use of antiretroviral therapy, recent start of antiretroviral therapy and recent switch of antiretroviral therapy. Recent stop of antiretroviral therapy was no significant risk factor. In multivariable analysis prior AIDS, last CD4 and viral load remained significant risk factors, but use of antiretroviral therapy not.

CONCLUSION

In this contemporary cohort, incidence of fever was low but CD4 cell count less than 200/mm³ remained associated with the highest incidence of fever.

Outbreak of trichinellosis related to eating imported wild boar meat, Belgium, 2014

Trichinellosis is a rare parasitic zoonosis caused by Trichinella following ingestion of raw or undercooked meat containing Trichinella larvae. In the past five years, there has been a sharp decrease in human trichinellosis incidence rates in the European Union due to better practices in rearing domestic animals and control measures in slaughterhouses. In November 2014, a large outbreak of trichinellosis occurred in Belgium, related to the consumption of imported wild boar meat. After a swift local public health response, 16 cases were identified and diagnosed with trichinellosis. Of the 16 cases, six were female. The diagnosis was confirmed by serology or the presence of larvae in the patients' muscle biopsies by histology and/or PCR. The ensuing investigation traced the wild boar meat back to Spain. Several batches of imported wild boar meat were recalled but tested negative. The public health investigation allowed us to identify clustered undiagnosed cases. Early warning alerts and a coordinated response remain indispensable at a European level.

The Schnitzler syndrome: chronic urticaria in disguise: a single-centre report of 11 cases and a critical reappraisal of the literature

OBJECTIVES

The Schnitzler syndrome is a rare inflammatory disorder, with a chronic urticaria-like rash and an IgM (rarely IgG) monoclonal gammopathy as cardinal features. Interleukin-1 β is regarded as the key mediator and the interleukin-1 receptor antagonist anakinra has been proposed as first-line treatment. This case series of eleven patients is intended to enhance disease awareness and to compare our centre's experience with that of literature.

METHODS

We describe the clinical features and disease course of 11 patients with a definite Schnitzler syndrome, according to the Strasbourg diagnostic criteria, encountered in the University Hospital, Leuven, Belgium, between 1995 and 2015.

RESULTS

Eleven patients, with a median age of 55 years, were diagnosed with Schnitzler syndrome. All but one were diagnosed during the last decade. Of 6 patients treated with anakinra, 2 had a suboptimal response and 2 had poor tolerance (injection site reaction and neutropenia, respectively). Two of the 11 patients died as a consequence of the disease, culminating in Waldenström's macroglobulinaemia and AA amyloidosis, respectively.

CONCLUSIONS

The Schnitzler syndrome is rare, but probably underdiagnosed. In a patient with a chronic urticaria-like dermatosis, minor itch, intermittent fever and bone or joint aches, protein electrophoresis and immunofixation should be ordered. Especially, a finding of a monoclonal IgM kappa fits the diagnosis of Schnitzler syndrome. Anakinra may provide symptomatic relief, although the response is not always spectacular. The outcome is not always benign as fatal complications may occur.

Clinical presentation, causes and outcome of febrile episodes in a prospective cohort of HIV-infected patients

BACKGROUND

Fever was frequently caused by opportunistic conditions in HIV-patients in the early years of the epidemic. Little is known about diagnostic spectrum and outcome of febrile episodes in patients with good access to antiretroviral therapy.

METHODS

We prospectively studied clinical presentation, diagnosis and outcome of febrile episodes in a contemporary cohort of HIV-patients with good access to antiretroviral therapy. Fever was defined as temperature 38.3 °C or higher, measured by a health care provider.

RESULTS

We found 220 febrile episodes in 146 patients. In 25.9% of episodes the patient had a CD4 less than 200/mm³ and in 78.6% the patient was on antiretroviral therapy. There were multiple episodes in 44 patients. A diagnosis was established in 91.8%. Infection accounted for 82.3%, mainly respiratory tract infections, viral syndromes and abdominal infections. Malignancy, drug reactions and inflammatory conditions accounted together for less than 12% of episodes. Fifteen percent were attributed to opportunistic conditions. Episodes in patients with CD4 less than 200 were less likely to be caused by infection, but more likely to be caused by malignancy, drug reactions and opportunistic conditions. In 6.4% the patient died within six months after the onset of fever. Risk factors for death at six months in multivariable analysis were higher age and lower CD4.

CONCLUSIONS

HIV-patients with access to antiretroviral therapy present with fever mostly due to conditions common in the general population. HIV-patients with low CD4 remain at risk for fever due to opportunistic conditions and death.

Efficacy of anti-IL-1 treatment in familial Mediterranean fever: a systematic review of the literature

Introduction

In 5%–10% of patients with familial Mediterranean fever (FMF), colchicine is not effective in preventing inflammatory attacks. Another 5%–10% of patients are intolerant to effective doses of colchicine and experience serious side effects. Treatment with anti-interleukin-1 (IL-1) drugs may be an alternative for these patients, although it is not reimbursed for this indication in many countries.

Methods

We systematically searched PubMed, Web of Science, and Scopus for reports of anti-IL-1 treatment in FMF patients.

Results

Out of 284 potentially relevant articles, 27 eligible reports were identified and included in the data analysis.

Conclusion

A complete response to therapy without a single attack during treatment was reported in 76.5% of patients on anakinra treatment and in 67.5% of patients during canakinumab treatment. In patients with established type AA amyloidosis, anti-IL-1 treatment can reverse proteinuria. Anti-IL-1 therapy seems to be a safe and effective alternative for patients with FMF who do not respond to or cannot tolerate colchicine.

Characteristics, causes, and outcome of 54 episodes of bloodstream infections in a cohort of HIV patients

BACKGROUND

Patients infected with human immunodeficiency virus (HIV) have an increased risk for bloodstream infections (BSIs). Published recent data on characteristics, etiology, and outcome of BSIs in HIV patients in high income countries are scarce.

METHODS

Blood cultures from 2001 to 2011 from adult HIV patients were retrieved. Blood cultures considered to be contamination based on isolates and clinical context were excluded. Clinical and microbiological characteristics of BSIs and patients were described, those of community-acquired and nosocomial episodes were compared, and risk factors for 6-month mortality were analyzed.

RESULTS

We found 54 episodes of true BSI in 46 patients. Demographics were similar to those of the source cohort of all patients followed between 2001 and 2011. In 63% there was prior AIDS, in 91% a CD4 nadir below 200/mm(3), and in 72% a latest CD4 count < 200/mm(3). In 13% of patients BSI preceded a new HIV diagnosis within 1 week. Main causative microorganisms were coagulase-negative staphylococci (26%), Streptococcus pneumoniae (20%), and Enterococcus spp. (13%). The most frequent diagnoses were pneumonia (28%) and catheter-related BSI (CRBSI) (28%); 56% of episodes were nosocomial. The 1-month mortality rate was 17%, with a cause of death apparently unrelated to the BSI in five of nine episodes. The 6-month mortality was 28%. Factors of co-morbidity or immunodeficiency other than HIV were significantly associated with 6-month mortality.

CONCLUSIONS

BSIs in HIV-infected patients occur predominantly in patients with advanced HIV infection. Community-acquired bacteremic pneumococcal pneumonia and nosocomial staphylococcal CRBSIs are the main causes. Mortality following BSI is high, and seems to be driven by underlying complicated HIV infection.

There is no benefit in routinely monitoring ANCA titres in patients with granulomatosis with polyangiitis

OBJECTIVES

To analyse the link between antineutrophil cytoplasmic antibody (ANCA) levels and risk of relapse in patients with granulomatosis with polyangiitis (GPA), as the clinical benefit of monitoring ANCA levels is uncertain.

METHODS

A retrospective analysis was made of all charts available from 43 patients diagnosed with GPA, fulfilling The American College of Rheumatology 1990 criteria, and followed between 1994 and 2012 at a general internal medicine department of a university hospital. Clinical and biochemical data (i.e. anti-proteinase 3 (PR3) levels) were collected and correlated.

RESULTS

43 relapses occurred in 25 patients (58.1% of 43 patients). When blood samples are routinely taken at a follow-up visit (i.e. low pre-test probability, ± 5.5%) in the GPA-population, a 75%-increase in the PR3-level or its reappearance has only limited positive predictive value (PPV 15.0% and 22.5% respectively) for predicting relapse. Adversely, when clinical suspicion of relapse is high (i.e. high pre-test probability, for example 50%), an increase of 75% or reappearance of PR3 makes relapse even more likely (PPV 77.5%, 81.6% respectively). Conversely, a high negative predictive value (NPV) of 99.3% and a negative likelihood ratio (LR-) of 0.12 suggest that, in the absence of PR3, relapse is unlikely if patients had detectable ANCAs at diagnosis.

CONCLUSIONS

Routine ANCA monitoring in patients diagnosed with GPA has limited value. However, targeted determination of ANCA levels may be useful if a relapse is clinically suspected (i.e. high pre-test probability).

Tackling fever and inflammation of unknown origin: the do's and don'ts

Fever and inflammation of unknown origin continue to challenge the clinician. The differential diagnosis is broad and potential diagnostic pitfalls abound. To guide the approach, the authors discuss the do's and don'ts.

Mortality in patients presenting with fever of unknown origin

BACKGROUND

Few data exist on the contemporary prognosis of patients presenting with fever of unknown origin (FUO).

METHODS

The data of 436 adult immunocompetent patients presenting with FUO between 2000 and 2010 and followed for at least 6 months were analyzed, with a focus on FUO-related deaths. The following variables were assessed in survivors and non-survivors: age, underlying diagnosis, and, in a nested case-control design, fever periodicity, selected laboratory parameters (including peripheral blood counts, enzymes, and inflammatory markers) and organomegaly.

RESULTS

Thirty FUO-related deaths occurred (6·9%). Malignancy accounted for 11% of fevers but for 60% of deaths. Especially non-Hodgkin lymphoma carried a disproportionally high death toll. In the non-malignant categories, fatality rates were below 6%. All patients discharged without diagnosis in spite of ample investigations (n = 164) survived. Besides malignancy, age, continuous (as opposed to episodic) fever, anaemia, leucopenia, LDH levels, and hepatomegaly were associated with mortality.

CONCLUSIONS

Fatality rates of FUO have continuously declined over the past decades. Malignancy, including lymphoma, remains a cardinal cause of death. Patients with FUO discharged without diagnosis survive.

[Conservative medicine: an attitude that can be learned?]

The rising costs and potential harms of medical care are matters of growing concern. In a recent article from the USA, Sirovich et al. examined the association between the intensity of the training environment and clinical-management decisions made by recent graduates. They found that, regardless of overall medical knowledge, internists trained at programmes in hospital referral regions with lower-intensity medical practice are more likely to recognise situations in which conservative management is appropriate. These internists remain capable of choosing a more active approach when indicated. This study suggests that residents adopt the practice style experienced in their training environment. Sometimes less healthcare can actually result in better health. In contrast, an aggressive practice style may waste resources and harm patients through inappropriate intervention. The training environment appears to have a considerable impact on the wisdom of medical decision making.

Fever in HIV-infected patients: less frequent but still complex

Fever was a common symptom in patients with Human Immunodeficiency Virus (HIV) infection in the early phases of the epidemic. Fever of Unknown Origin (FUO) was frequent in HIV-patients and conditions causing FUO were often opportunistic conditions. The HIV-epidemic continues to expand, but access to effective antiretroviral therapy is also expanding, resulting in a growing number of HIV-infected patients less likely to be severely immunocompromised and less likely to present opportunistic conditions. Yet part of newly diagnosed patients continue to present with advanced HIV-infection and are still at high risk of opportunistic conditions. This epidemiological evolution strongly influences the spectrum of conditions causing fever and FUO in HIV-patients. While some patients with HIV-associated fever and FUO may still be suffering from opportunistic conditions classically associated with HIV-related FUO, many others will have causes of fever that are similar to the non-HIV-infected population or to classical FUO. Strategies for diagnosis and treatment of fever and its causes in HIV-infected patients need to take into account this evolution.

Canakinumab in Schnitzler syndrome

OBJECTIVES

Daily injections of anakinra, an interleukin-1-receptor antagonist, have been reported to control effectively the symptoms and signs of Schnitzler syndrome, a rare acquired autoinflammatory disorder, presenting in adulthood by intermittent fever, urticarial rash, and paraproteinemia, usually IgM. Canakinumab, a fully human interleukin-1β monoclonal antibody, approved for the cryoporin-associated periodic syndrome, may offer a practical advantage because its half-life of ∼28 days may allow less frequent dosing. The present trial was designed to test canakinumab in patients with Schnitzler syndrome.

METHODS

A patient with Schnitzler syndrome was treated with canakinumab, 150 mg subcutaneously injection every 8 weeks for 6 consecutive months. Injections were resumed in case of a flare following discontinuation.

RESULTS

Canakinumab induced a swift and sustained clinical response, with disappearance of fever and arthralgias, near abolishment of fatigue and rash, and substantial reduction of C-reactive protein levels. Interruption of canakinumab after four 8-weekly injections led to a flare 10 weeks after the last administration, which was countered as soon as canakinumab injections were resumed. The patient remained in complete remission. Canakinumab was well tolerated. No injection site reactions, other adverse events, or laboratory abnormalities were observed.

CONCLUSIONS

Canakinumab has potential for the treatment of Schnitzler syndrome (ClinicalTrials.gov.number, NCT01245127).

Adult-onset Still's disease: still a diagnosis of exclusion. A nested case-control study in patients with fever of unknown origin

OBJECTIVES

Several sets of criteria have been proposed to classify adult-onset Still's disease (AOSD), those of Yamaguchi being the most commonly used. The Yamaguchi criteria demand the exclusion of other conditions. A clinical scale, recently proposed by Crispin et al., but not yet validated, would allow a positive diagnosis of AOSD in a majority of patients, without the need of thorough diagnostic procedures.

METHODS

From a database of 447 patients with classical fever of unknown origin (FUO), collected over a 10-year period (2000-2009) at a general internal medicine department of a university hospital, 22 patients with AOSD according to the Yamaguchi criteria were extracted and compared with 44 controls, matched to index year. Clinical and laboratory parameters were recorded. Sensitivity, specificity and accuracy of the Yamaguchi criteria and of the clinical score were assessed.

RESULTS

Lower age, joint symptoms, rash, throat ache, neutrophilic leukocytosis, and elevated erythrocyte sedimentation rate were the principal characteristics supporting a diagnosis of AOSD in patients with FUO. Sensitivity, specificity, and accuracy of the Yamaguchi criteria were 95% or more. The clinical scale, while being specific (98%), lacked sensitivity (55%) and had lower accuracy (83%).

CONCLUSIONS

In patients with FUO, the Yamaguchi criteria are a time honored and reliable guide to a diagnosis of AOSD. The clinical scale may serve to rule in, rather than to rule out, AOSD. In many patients, Still's disease is still a diagnosis of exclusion.

The haemophagocytic syndrome

The haemophagocytic syndrome or haemophagocytic lymphohistiocytosis (HLH) is a syndrome encompassing a heterogeneous group of disorders characterized by a persistent activation of benign macrophages, leading to uncontrolled secretion of cytokines and phagocytosis of blood cells. The syndrome can be primary due to mutations in different genes crucially involved in lymphocyte cytotoxicity and secondary in association with infectious, autoimmune or malignant disorders. In most cases HLH displays an aggressive disease course with a high fatality rate without treatment. Early recognition of the syndrome and prompt initiation of appropriate treatment, in most cases consisting of immunochemotherapy, are mandatory to ensure long-term survival.

Can a care pathway help streamline the care process for patients with chronic fatigue syndrome?

In this paper, the authors show how the implementation of a care pathway can streamline the care for chronic fatigue syndrome (CFS). The methodology of seven phases is used as a guide to develop, implement and evaluate the CFS care pathway. Some patients have already completed the care pathway. With the help of these case studies, a few strengths and weaknesses of the care process can be formulated. The development and implementation of the care pathway result in a structured process. Patients are diagnosed and treated based on an evidence-based method. The care path also leads to an enhancement of the interdisciplinary cooperation. Nevertheless, the criteria for inclusion and exclusion of patients are taken into account insufficiently. Moreover, family doctors should be involved more often. In the future, it is also important to pay more attention to the role of the family members during the treatment. The entire steering group now needs to engage in a discussion about the test pathway and then subsequently put it to use in daily practice. Additional challenges for the steering group include the objective evaluation and the continuous follow-up of the care pathway.

Lymph node biopsies in a general internal medicine department: algorithm or individualized decision-making?

BACKGROUND

Lymphadenopathy (LA) imposes a diagnostic challenge in internal medicine. Exclusion of malignancy is the primary concern.

METHODS

A retrospective case series, including 40 adult patients from the general internal medicine department who underwent lymph node biopsy (LNB) at a single university hospital. Demographics, clinical data and histopathological diagnoses were registered. By means of the latest medical record, we obtained a final diagnosis for each patient and subsequently searched for variables correlated with malignancy. Follow-up was at least one year in 95% of cases.

RESULTS

The prevalence of malignancy was 58%. Older age (p = 0.02) was significantly correlated with malignancy. The presence of painful lymphadenopathy at clinical examination (p = 0.02) was significantly associated with a benign outcome. No single or combination of baseline variables satisfactorily excluded malignancy. Histopathological analysis correctly predicted malignancy in 93% of cases. In two cases, an initial diagnosis of benign non-specific lymphadenopathy was reversed to non-Hodgkin lymphoma. In one case the pathological diagnosis was inconclusive.

CONCLUSION

Rather than following a universal algorithm to determine the need for LNB in patients with LA, we call for individualized decision-making in each case, carefully appreciating all available information. Additionally, one should keep in mind that false-negative results occur due to sampling errors. Therefore, a minimal number of cases should end with a final diagnosis of benign non-specific lymphadenopathy. Intensive, multidisciplinary cooperation with surgeon and pathologist is needed. Moreover, clinical follow-up should be at least one year.

Determinants of medication underuse and medication overuse in patients with chronic non-malignant pain: a multicenter study

BACKGROUND

In chronic non-malignant pain, medication is often used as an important cornerstone of the treatment. Medication non-adherence is a frequent problem in chronic conditions. In patients with chronic non-malignant pain, medication non-adherence ranges between 8% and 53%. Two types of non-adherence can be identified: underuse and overuse of pain medication.

OBJECTIVE

To examine determinants of both medication underuse and overuse non-adherence in patients with chronic non-malignant pain, with a focus on factors related to all five categories of determinants of medication non-adherence simultaneously, as proposed by the WHO.

DESIGN

A multicenter cross-sectional study.

SETTINGS

Three multidisciplinary outpatient pain centers in Flanders, Belgium.

PARTICIPANTS

A total of 265 patients with chronic non-malignant pain participated in the study.

METHODS

Medication non-adherence was assessed by a self-report interview. Associations of socio-economic, treatment related, condition related, patient related and health care system related factors with medication underuse or overuse were determined by building two separate multivariable binary logistic regression models.

RESULTS

Thirty eight percent of the patients were fully adherent. Based on multivariable analyses, underuse was significantly associated with more prescribed analgesics (OR=2.303), self-medication (OR=4.679), lower pain intensity (OR=0.821), active coping strategies (OR=1.132) and lack of information (OR=0.268). Overuse of medication was associated with more prescribed analgesics (OR=1.645) and current smoking (OR=2.744).

CONCLUSION

Patients underusing or overusing their medication do have a different risk profile. The set of determinants of non-adherence, proposed by WHO, is suitable to study determinants of underuse, but the framework is less suitable to study determinants of medication overuse.

Inflammation of unknown origin versus fever of unknown origin: two of a kind

OBJECTIVES

A vast literature exists on fever of unknown origin (FUO), characterized by prolonged and perplexing fevers >38.3 degrees C. In contrast, no studies are available to guide the approach to inflammation of unknown origin (IUO), defined as prolonged and perplexing inflammation with temperatures <38.3 degrees C. We aimed to determine the diagnostic yield, the case-mix, and the outcome of patients with IUO, relative to patients with FUO.

METHODS

We matched 57 patients with IUO to 57 patients with FUO of the same gender (54% male) and a similar age (median: 67 years).

RESULTS

A diagnosis was established in 35 patients with IUO (61%) and in 33 patients with FUO (58%) (p=.70). The case-mix did not differ significantly (p=.43). Non-infectious inflammatory disorders were the dominant diagnostic category in the IUO group (16 patients), while in the FUO group, similar numbers of malignancies [10], infections [9], and non-infectious inflammatory diseases [9] were diagnosed. (18)F-fluorodeoxyglucose-positron emission tomography (FDG-PET) scan contributed comparably to the diagnosis in both groups (in 18 of 50, 36%, patients with IUO and in 13 of 40, 33%, patients with FUO) (p=.83). In both groups, 7 patients (12%) died during an average follow-up of 1 year.

CONCLUSION

Diagnostic yield, case-mix, contribution of FDG-PET scan and vital outcome were similar in patients with IUO and FUO. These data suggest that the 38.3 degrees C boundary may be arbitrary and that the diagnostic approaches used in FUO can be applied to IUO.

New treatment options for immune-mediated hematological disorders

In recent years, there has been a tremendous increase in the number of clinical studies with monoclonal antibodies and small molecules in the treatment of hematological malignancies. Clinical observations have shown that some of these molecules may also aid in the treatment of immune-mediated hematological disorders. Moreover, immunotherapy has become an important treatment cornerstone in other, non-hematological, auto-immune diseases. This paper reviews the current state of the use of these new molecules in the treatment of the most frequently encountered immune-mediated hematological disorders: auto-immune hemolytic anemia (AIHA), idiopathic thrombocytopenic purpura (ITP), and thrombotic thrombocytopenic purpura (TTP).

Infective endocarditis

The diagnosis of infective endocarditis remains difficult. The complication rate is very high. Serious complications may occur and the overall mortality is still 20-25%. The sooner the treatment is started, the better the final result. Antibiotic therapy is essential but cardiac surgery is frequently necessary. Early surgery improves outcome. A multidisciplinary approach by internal medicine, cardiology and cardiac surgery facilitates the efficiency of diagnosis and treatment.

Involuntary weight loss. Does a negative baseline evaluation provide adequate reassurance?

BACKGROUND

Involuntary weight loss frequently poses a diagnostic challenge. Patient and physician alike want to exclude malignant and other major organic illness. The present study aimed to evaluate whether a negative baseline evaluation (consisting of clinical examination, standard laboratory examination, chest X-ray, and abdominal ultrasound) lowers the probability of evolving organic illness in patients with significant unexplained weight loss.

METHODS

Prospective observational study of 101 consecutive patients presenting to a general internal medicine department of a university hospital with an unexplained unintentional weight loss of at least 5% within 6-12 months. Laboratory tests of interest included C-reactive protein, albumin, haemoglobin, and liver function tests.

RESULTS

Weight loss of the 101 patients [age (mean, interquartile range): 64 (51-71) years, 46% male] averaged 10 (7-15) kg. Organic causes were found in 57 patients (56%), including malignancy in 22 (22%). In 44 patients without obvious organic cause for the weight loss (44%), a psychiatric disorder was implicated in 16 (16%) and no cause was established in 28 (28%), despite vigorous effort and follow-up of at least 6 months. Baseline evaluation was entirely normal in none of the 22 patients (0%) with malignancy, in 2 of the 35 (5.7%) with non-malignant organic disease, and in 23 of the 44 (52%) without physical diagnosis. Additional testing, oftentimes extensive, after a normal baseline evaluation led to one additional physical diagnosis (lactose intolerance).

CONCLUSION

In patients presenting with substantial unintentional weight loss, major organic and especially malignant diseases seem highly unlikely when a baseline evaluation is completely normal. In this setting, a watchful waiting approach may be preferable to undirected and invasive testing.

An elderly lady with a painful swollen face

Giant cell arteritis (GCA) is the most common vasculitis in the elderly. Common presenting symptoms include cranial ischemic complications, constitutional manifestations and polymyalgia rheumatica. Facial and cervical edema is increasingly recognized as an inaugural sign of GCA. We present a case with tender facial and cervical edema as the dominating symptom.

An unusual cause of syndrome of inappropriate antidiuretic hormone secretion

A 22-year-old woman was admitted to intensive care with severe hyponatraemia. She suffered from lower abdominal pain, vomiting and irritability since one week. Physical findings showed euvolemia and an altered mental status with severe agitation and slurred speech. Abdominal examination was painful but there were no signs of peritonitis. Laboratory data were compatible with the diagnosis of syndrome of inappropriate secretion of antidiuretic hormone. Since patient was in a premenstrual phase, recently started to take an oral contraceptive and since no abnormalities were seen on an abdominal CT scan, the presentation was considered suggestive of an acute porphyria attack. A urinary sample indicated markedly increased levels of delta-aminolevulinic acid, porphobilinogen and uroporphyrin. A low activity of the porphobilinogen deaminase enzyme confirmed the diagnosis of acute intermittent porphyria. The present case demonstrates the need for a high level of suspicion in order to diagnose this disorder in unexplained syndrome of inappropriate antidiuretic hormone secretion and prevent life-threatening complications.

Medication adherence in patients with chronic non-malignant pain: is there a problem?

Health care providers, treating patients with chronic non-malignant pain, often experience that medication is not as effective as expected. It is important to realize that the effectiveness of a pharmacological treatment can be influenced by the way the medication is taken. Medication adherence is a topic that gains more attention, especially in chronic conditions, because it affects treatment outcome. A systematic review of studies on medication adherence in patients with chronic non-malignant pain was performed to gain insight in the prevalence of the problem, the impact on treatment outcome, influencing variables and interventions. Searching several electronic databases (Medline, CINAHL, Psychinfo and Cochrane), 14 relevant articles were found. The results indicate that medication non-adherence is common in patients with chronic non-malignant pain. Both overuse and underuse of medication occurs. However, due to the scarce literature and important methodological limitations, it is not possible to make firm conclusions concerning the impact on outcome, influencing variables and optimal intervention strategies. This review highlights some important gaps in the adherence literature in a chronic non-malignant pain population and sets the stage for future research.

Management of prosthetic valve infective endocarditis

This study analyzed the profile and outcome of surgically versus medically treated patients with prosthetic valve infective endocarditis (PVE). From 2000 to 2006, 80 patients >16 years of age (median 71) with definite PVE according to modified Duke criteria were included. The medically treated group was separated into deliberately conservative and perforce conservative treatments, the latter group including patients with contraindications to a cardiosurgical intervention. The most frequent causative micro-organisms were staphylococci. Forty-six percent of patients were surgically treated, 34% had deliberately conservative treatment, and 20% had perforce conservative treatment. Six-month mortality was 29%; 27% of surgically treated patients died, 4% deliberately conservatively patients died, and 75% perforce conservatively treated patients died. Septic shock, multiorgan failure, and type of treatment were significantly associated with death in univariable analysis. Multivariable analysis revealed that type of treatment (perforce conservative) and septic shock predicted death in patients with PVE. Survival was most favorable in deliberately conservatively treated patients, including PVE due to Staphylococcus aureus. In conclusion, there remains a role for watchful waiting in patients with PVE without evidence of major complications. Moreover, patients with uncomplicated S. aureus PVE can be treated successfully without cardiac surgery. Conversely, patients with major complicated PVE should preferentially undergo surgery. Predictors of mortality in patients with PVE included septic shock and perforce conservative treatment.

Living donor kidney transplantation: analysis of the first 40 cases performed in UZ Leuven

Living donation kidney transplantation has been popular worldwide to try to increase the donor pool. In Belgium, the rate of living donation kidney transplantation has been traditionally relatively low compared to other countries. This is--in part--due to the relatively higher cadaveric organ offer that is available in Belgium (around 25 donors per million inhabitants), compared to other countries. However, the increasing waiting times on cadaveric waiting list and the superiority of the results of live donation versus cadaveric kidney transplantation have led to a reappraisal of this strategy. In our center a living donation kidney transplant programme was started in 1997. Since then 40 cases of live donation kidney transplantation have been performed and are reported herein.

Abscess in infective endocarditis: the value of transesophageal echocardiography and outcome: a 5-year study

BACKGROUND

In patients with infective endocarditis (IE), detection of abscess remains difficult. We investigated abscess detection by transesophageal echocardiography (TEE) and predictors of abscess and death in patients with IE.

METHODS

A 5-year study included 115 patients with definite IE according to the modified Duke criteria who underwent TEE and cardiac surgery.

RESULTS

Abscess was found perioperatively in 44 patients (38%). Twenty-one abscesses (48%) were detected by TEE. Sixty-one percent of missed abscesses were localized on the posterior mitral annulus. In 64% of unrecognized mitral valve abscesses, the abscess was localized around calcification in the posterior mitral annulus. Fourteen patients (54%) had prosthetic valve dehiscence, and 8 (57%) had abscess as well. Overall 6-month mortality was 17% and predictable by age (odds ratio 1.1, 95% CI 1-1.001, P = .01), abscess (odds ratio 5.3, 95% CI 1.5-19, P = .01), and the causative microorganism (P = .035), in particular staphylococci. In patients with a missed abscess, surgical delay was significantly longer (P = .04) and mortality was nonsignificantly higher (P = .2) than in patients with a preoperatively detected abscess.

CONCLUSIONS

Detection of abscess by TEE seemed to be underestimated. In most cases, abscess was missed in the presence of calcification in the posterior mitral annulus. Age, abscess, and staphylococcal infection predicted 6-month mortality. Early surgery may improve outcome in patients with an abscess.