Ocular Sarcoidosis and Autoimmune Polyglandular Syndrome Type 2: A Case Report

PURPOSE

to describe a clinical case of ocular sarcoidosis in a patient with Autoimmune Polyglandular Syndrome Type 2 (APS-2).

METHODS

an 86-year-old female diagnosed with APS-2 was referred to our uveitis department with rapid visual loss in her left eye during a 3-month period. Her best-corrected visual acuity (BCVA) was counting fingers in her left eye (OS) and 20/40 in her right eye (OD). Slit-lamp biomicroscopy was unremarkable OD but revealed granulomatous keratic precipitates OS. Fundoscopy revealed bilateral optic disc oedema and +2 and 4+ vitritis (SUN classification) in her OD and OS, respectively.

RESULTS

the patient underwent chest X-Ray which revealed bilateral hilar lymphadenopathy and fibrosis. On high-resolution computed tomography of the lungs, ground-glass opacities were visible, and a diagnosis of ocular sarcoidosis was presumed. After exclusion of infectious diseases, the patient was treated with methotrexate and oral corticosteroids and there was substantial improvement of the optic nerve oedema and vitritis. At the most recent visit, 2 years later, OS BCVA was 20/50.

CONCLUSION

There may be an association between ocular sarcoidosis and APS or other autoimmune disorders.

Pharmacological Therapy Optimization for Heart Failure: A Practical Guide for the Internist

Heart failure carries significant morbidity and mortality and affects a large population of patients cared for predominantly by primary care physicians. The complexity of managing heart failure patients is increasing as new therapies continue to emerge. This review outlines important clinical pearls and proposes strategies for optimization of medical therapy.

Promoting Cardiac Rehabilitation in Acute Coronary Syndrome Patients: Quality Initiative Based on Education, Automated Referral, and Multidisciplinary Rounds

Cardiac rehabilitation is a class 1 recommendation for acute coronary syndrome (ACS) patients according to the American College of Cardiology/American Heart Association. However, only 1 in 5 ACS patients are referred for cardiac rehabilitation nationally, and even fewer at our institution. We sought to improve the number of referrals to cardiac rehabilitation for post-ACS patients admitted to our inpatient cardiology service, and ultimately their participation in the program. We designed a quality improvement initiative that included education of patients and house staff, automated referral order, and participation of cardiac rehabilitation staff members on multidisciplinary rounds. We compared the number of patients who received a referral to cardiac rehabilitation, had the first appointment scheduled before hospital discharge, and attended the program before and after our intervention. Six months after initiation of the project, the proportion of ACS patients referred to cardiac rehabilitation before hospital discharge increased from 10% to 43% (P < 0.001). The mean number of patients with a cardiac rehabilitation appointment scheduled before discharge was 2 before and 5 after the intervention (P < 0.001), and the mean number of patients who attended their scheduled appointment was 1 before and 3 after the intervention (P = 0.001). Run charts demonstrated that the number of referrals and the number of scheduled appointments remained above the median following the intervention. In conclusion, an initiative that included education, automated referrals, and direct one-on-one contact with cardiac rehabilitation staff before discharge increased the number of cardiac rehabilitation referrals, and appointments scheduled and attended in post-ACS patients.

Multiple myeloma with extensive AL amyloidosis presenting as chronic diarrhoea

We present a 52-year-old man admitted to the hospital with diarrhoea and lower extremity weakness ongoing for the past 3 months. The patient was found to have malabsorptive diarrhoea, hypoproliferative anaemia and renal insufficiency with proteinuria. Extensive workup was performed including a bone marrow biopsy with 20% plasma cells, renal and duodenal biopsies with Congo-red staining revealed amyloid deposition. The patient was diagnosed with multiple myeloma and amyloidosis with gastrointestinal, kidney and nerve involvement explaining his presentation with diarrhoea, renal insufficiency and weakness. Throughout his admission, there were incidental findings of asymptomatic hypoglycaemia (serum blood glucose <40 mg/dL), which was later found to be caused by anti-insulin monoclonal antibodies produced by the neoplastic plasma cells. This is an extremely rare manifestation of multiple myeloma with only a few cases reported in the literature.

Early manifestation of myocardial involvement in systemic sclerosis

INTRODUCTION

Systemic sclerosis (SSc) is a systemic autoimmune disease involving multiple organs. We present a rare case of SSc in which clinical manifestations of cardiac fibrosis occurred early in the disease course.

CASE REPORT

We report the case of a 40-year-old Caucasian man, previously diagnosed with SSc, who presented with decompensated heart failure. Transthoracic echocardiography was remarkable for severe right ventricular systolic dysfunction, abnormal ventricular septal motion, severe functional tricuspid regurgitation and normal pulmonary artery systolic pressure. Left ventricular ejection fraction was 45%. Right heart catheterization revealed no signs of pulmonary hypertension. Cardiac magnetic resonance (CMR) showed diffuse myocardial infiltration, later confirmed as myocardial fibrosis by endomyocardial biopsy.

CONCLUSIONS

Myocardial fibrosis is an important cause of early heart failure in SSc patients and is associated with poor prognosis. Echocardiography and CMR help establish the diagnosis and enable an appropriate therapeutic strategy to be developed in such cases.

Epidemiology of Clostridium difficile infection in Portugal: Experience at a tertiary care hospital

BACKGROUND

Clostridium difficile is the main cause of healthcare-associated diarrhoea. Its incidence, severity and relapse rates increased over the past two decades.

AIM

To study epidemiologic characteristics and treatment of Clostridium difficile infection (CDI) and compare with a previous cohort from the same hospital.

METHOD

Retrospective analysis of clinical records of CDI diagnosed from 2010 to 2015 and comparison with data from 2004 to 2009.

RESULTS

259 cases were diagnosed, compared to 83 in 2004-2009. There was no difference in mean annual incidence (8.66 versus 7.11 per 1000 patients; p = .116), but a dramatic increase was observed in 2009/2010 (peak incidence: 21.63 cases per 1000 admissions). Females were more affected (61.4% versus 69.9%; p = .177). Median age was 80 and 83 (p = .097). We observed an increase in median number of antibiotics previously used (2 versus 3; p = .147) and in community-associated CDI (6% versus 19.7%; p = .003). There was a continued increase in the use of carbapenems and quinolones until 2010 and a high percentage of refractory cases in 2010. Female gender (p = .043), long-term care facility (LTCF) residency (p = .022) and a higher number of previous antibiotics (median of 3; p = .025) were independent predictors for refractory and recurrent CDI.

CONCLUSIONS

CDI incidence achieved a peak in 2009/2010 coinciding with the introduction of alcohol-based hand products, increase in quinolone and carbapenem prescription and a possible outbreak of an epidemic strain. Female gender, LTCF residency and exposure to three or more antibiotics are risk factors for refractory and recurrent CDI. We emphasize the need to restrict use of large spectrum antibiotics.

Rede Nacional de Cuidados Continuados e Tempo de Internamento dos Doentes com Acidente Vascular Cerebral 2010-2011

Introduction: The National Post Hospital Care Project was created to provide a continuity of care after hospitalization or to functionally dependent people. Currently there is a great difficulty in the integration of patients. The objective of this paper is to compare the impact of the referral to the Project versus being discharged home, in the length of stay of stroke patients between 2010 and 2011.Material and Methods: Retrospective study of patients admitted to the Neurology Infirmary A and Stroke Unit of Coimbra’s University Hospital, in 2010 and 2011. The cases analyzed were 1 209, featuring demographic data, length of stay, Rankin Score (mRS) and destination after discharge. The data was analyzed comparing the two years concerning the length of stay of stroke patients referred to the Project and those discharged home, given the their Rankin Score.Results: In 2011, the number patients referred to the National Post Hospital Care Project was higher, 23.5% compared to 21.4%. The length of stay for the same Rankin Score of the patients referred to National Post Hospital Care Project, remained higher than those discharged home: for a Rankin Score of 1: 11, versus 26 days for the Project; Rankin Score 2: 13, versus 29 days for the project; Rankin Score 3: 13, versus 23 days for the Project; Rankin Score 4: 17, to 33 days for the Project, Rankin Score 5: 27, versus 39 days to the Project. After comparison between the length of stay of patient discharged of and those referred to the National Post Hospital Care Project, it was estimated that the referral represented an hospitalization excess of 1 718 days in 2010 and 1 198 days in 2011.Conclusion: The National Post Hospital Care Project is unable to meet the actual needs although the waiting time has reduced, possibly due to the increased number of beds and the possibility of patients waiting at home.

[National Post Hospital Care Project and length of hospitalization of patients with stroke 2010-2011]

INTRODUCTION

The National Post Hospital Care Project was created to provide a continuity of care after hospitalization or to functionally dependent people. Currently there is a great difficulty in the integration of patients. The objective of this paper is to compare the impact of the referral to the Project versus being discharged home, in the length of stay of stroke patients between 2010 and 2011.

MATERIAL AND METHODS

Retrospective study of patients admitted to the Neurology Infirmary A and Stroke Unit of Coimbra's University Hospital, in 2010 and 2011. The cases analyzed were 1 209, featuring demographic data, length of stay, Rankin Score (mRS) and destination after discharge. The data was analyzed comparing the two years concerning the length of stay of stroke patients referred to the Project and those discharged home, given the their Rankin Score.

RESULTS

In 2011, the number patients referred to the National Post Hospital Care Project was higher, 23.5% compared to 21.4%. The length of stay for the same Rankin Score of the patients referred to National Post Hospital Care Project, remained higher than those discharged home: for a Rankin Score of 1: 11, versus 26 days for the Project; Rankin Score 2: 13, versus 29 days for the project; Rankin Score 3: 13, versus 23 days for the Project; Rankin Score 4: 17, to 33 days for the Project, Rankin Score 5: 27, versus 39 days to the Project. After comparison between the length of stay of patient discharged of and those referred to the National Post Hospital Care Project, it was estimated that the referral represented an hospitalization excess of 1 718 days in 2010 and 1 198 days in 2011.

CONCLUSION

The National Post Hospital Care Project is unable to meet the actual needs although the waiting time has reduced, possibly due to the increased number of beds and the possibility of patients waiting at home.

Predicting Acute Pancreatitis Severity: Comparison of Prognostic Scores

Background

Acute pancreatitis has a broad clinical spectrum, from mild illness to multiple organ failure and death. Prognostic scores have been developed or adapted to predict disease severity. This study aimed to compare the prognostic scores according to sensitivity and specificity, receiver operating characteristic curves and area under the curve. Statistical correlation with disease severity, length of hospital stay, mortality and complication rates.

Methods

Retrospective analysis of the clinical data of patients admitted to an Internal Medicine ward with the diagnosis of acute pancreatitis over a ten year period. Evaluation of prognostic scores: Ranson, Glasgow-Imrie, Balthazar, APACHE II (admission and at 48 hours) and C-reactive protein (48 hours), was carried out as well as statistical analysis using Microsoft Excel 2007® and SPSS 16®. The confidence interval used was 95%.

Results

Data from 193 clinical files was collected. However, 67 were excluded due to lack of information. According to the Atlanta criteria, 90 cases were deemed as mild and 36 severe. The mortality rate was 6% and the local complication rate was 9.3%. Ranson, Glasgow and APACHE II scores had significant correlation with mortality. Apart from C-reactive protein levels at 48 hours, all scores had significant correlation with disease severity. The scores with best area under the curve correlation were APACHE II (48 hours): 0.892, Ranson: 0.879, and APACHE II (admission): 0.861.

Conclusions

The most accurate prognostic scores in this study were APACHE II (48 hours) and Ranson. APACHE II at admission was a good indicator, impaired only by high false positive ratio.