Armando Carvalho

Prevalence peptic lesion in asymptomatic, healthy volunteers

Abstract Aim. To investigate the presence of lesions of the upper gastrointestinal tract of asymptomatic, healthy volunteers undergoing clinical pharmacology studies. Material and Methods. A series of 53 volunteers (45 male, 23 Helicobacter pylori negative and 30 Helicobacter pylori positive) underwent upper gastrointestinal endoscopy. Helicobacter pylori status was assessed using two methods (rapid urease test and histology) from antral and corpus biopsies. Results. Peptic lesions were found in 24 (45%) subjects: erosive oesophagitis, gastric/duodenal ulcers and gastric/duodenal erosions were found in 23%, 9% and 36% of these volunteers, respectively. Helicobacter plyori -positive subjects had significantly ( p Helicobacter pylori negative individuals ( 12 30 vs 3 23 ). The presence of peptic ulcers and erosive oesophagitis was similar in Helicobacter pylori -positive and -negative individuals. Conclusions. The possibility that peptic lesions might exist in otherwise asymptomatic, asymptomatic, healthy individuals cannot be ruled out. Helicobacter pylori -positive individuals have a significantly higher incidence of gastric and duodenal lesions than Helicobacter pylori negative subjects.

Transfer of Metronidazole to Gastric Juice: Impact of Helicobacter pylori Infection and Omeprazole

Background: The effects of Helicobacter pylori infection associated with inhibition of gastric acid secretion on the distribution of medications used for H. pylori eradication are poorly understood. The aim of this study was to investigate the effects of a 7-day administration of 20 mg omeprazole on the transfer of metronidazole from plasma to the gastric juice of individuals with and without H. pylori infection. Methods: Fourteen H. pylori-positive and 14 H. pylori-negative male volunteers were enrolled in a study with an open, randomized, two-period crossover design with a 21-day washout period between phases. Plasma, salivary, and gastric juice concentrations of metronidazole in subjects with and without omeprazole treatment were measured with reversed-phase high-performance liquid chromatography/liquid chromatography. Results: Metronidazole peak concentration (Cmax

Severe hyponatremia in older patients at admission in an internal medicine department

Hyponatremia is common in older people, most often of multifactorial origin, and can be associated with poor clinical outcomes. The aim was to analyze the frequency of severe hyponatremia (sodium concentration below 125 mmol/L), risk factors and mortality association in hospitalized older patients. A retrospective study was performed in older patients (over 65 years) with hyponatremia, diagnosed at admission in an Internal Medicine Department during one year. A control group of 127 older patients without hyponatremia was considered. Statistical analysis of the data gathered was made with SPSS Statistics 20. The main results were: a group of 1060 patients with age superior to 65 years was identified (representing 72.26% of total admissions); incidence of hyponatremia in those patients was 27.55% and severe hyponatremia was 5.94%; diagnosis of hyponatremia was mentioned in the discharge note in 66.67% of cases; mortality was 27.0%, against 16.0% in the control group (p=0.057, Odds Ratio (OR)=1.940); drugs were a significant risk factor (p<0.001), specially thiazide diuretics (p=0.029, OR=2.774), angiotensin receptor blockers (ARB) (p=0.001, OR=4.097), proton-pump inhibitors (PPI) (p=0.007, OR=2.561) and spironolactone (p=0.011, OR=4.473); other relevant risk factors were: increased water intake (p=0.004), tube feeding (p<0.001), vomiting (p=0.032, OR=2.492), cirrhosis (p=0.008, OR=10.862) and hyperhidrosis (p=0.017, OR=2.542). We conclude that, although this group of patients had a high mortality, hyponatremia is often not investigated and not always mentioned as a diagnosis. Clinicians should have a clear appreciation of the roles that iatrogenic interventions and lapses in nutrition frequently play in upsetting the homeostatic balance in older patients.

Acute kidney injury in an internal medicine ward in a Portuguese quaternary hospital

BACKGROUNDnThe term acute kidney injury (AKI) was proposed to reflect the wide spectrum of traditional acute renal failure. RIFLE classification stratifies AKI into three classes of severity and two classes of outcome. AKIN classification proposes an improvement regarding RIFLE in the stratification of AKI, while recently published KDIGO guidelines comprise characteristics of both RIFLE and AKIN. There are no published studies on the utility and measure of agreement between classifications in patients admitted to internal medicine wards.nnnMETHODSnProspective study undertaken in two internal medicine wards in a Portuguese hospital. Patients admitted for a minimum of 72 h, with a diagnosis of AKI or acute-on-chronic kidney disease at admission or during hospitalisation, were included. RIFLE, AKIN and KDIGO criteria were applied for identification of AKI and stratification into risk groups.nnnRESULTSnSixty-nine patients were included, with a mean age of 79.7±10.0 years and mean GFR of 21.7±8.8 mL/min/1.73 m2. Hypovolaemia due to dehydration was the main cause of AKI (53.6%) and, thereby, RIFLE classification identified a higher number of patients as having AKI, compared to AKIN (94.2% vs. 84.1%). Most patients (69.6%) recovered to their baseline renal function, however fifteen patients (21.7%) died, 53.3% presenting more severe kidney disease.nnnCONCLUSIONSnOur results demonstrate good concordance and correlation between RIFLE, AKIN and KDIGO criteria for the diagnosis of AKI (p<0.001 at initial and final assessment). The authors support the need for further improvement of the classification, ultimately through the use of new biomarkers capable of earlier identification of patients at risk.

Cachexia, vomiting and an unexpected abdominal mass

An 86-years-old male was admitted with a weight loss of 28% in the last 10 months, with a two-month history of anorexia and recurrent postprandial vomiting (2–3/ day). Four months earlier, he sought medical attention complaining of unspecific abdominal symptoms. The patient’s blood tests, abdominal X-ray and colonoscopy, were all normal. He had a past medical history of type 2 diabetes mellitus, hypertension and dyslipidemia, under treatment with insulin, candesartan and simvastatin. Physical examination was remarkable for cachexia, with a body mass index of 15.7 kg/m2 and a solid, irregular and painless mass in the epigastrium. Blood tests were positive for a normocytic normochromic anemia, γGT 1.5x upper limit of normal and HbA1c of 8%. Chromogranin A value of 1137 ng/mL (reference range <85). Abdomen ultrasound revealed a lobulated heterogeneous mass in the epigastrium with a hypoechogenic nodule extending to both the liver lobes. An abdominal computed tomography scan (Figure 1) revealed 8x6 cm mass arising from the tail of the pancreas, with internal calcifications, which entraped and compressed splenic vessels. Computed tomography scan showed an heterogenous liver mass, resulting of

A link between asthenia, pallor, and jaundice.

A 45 year old white man presented to the emergency department with progressively worsening weakness and chest discomfort on moderate intensity physical activity over the past two months. He also reported paleness and “yellowish eyes” in the past month. He had a history of anxiety, treated with alprazolam as needed.nnAt presentation, his vital signs were normal. On physical examination he had mild generalised pallor, scleral icterus, and tender non-painful hepatomegaly.nnHe was admitted to the internal medicine ward for further evaluation.nnLaboratory studies showed haemoglobin 70 g/L (reference range 13-17), mean corpuscular volume 111.5 fL (83-101), haematocrit 19.4% (40-50%), leucocyte count 3.3×109/L (4-10), platelet count 151×109/L (150-450), reticulocyte production index 0.52 (>2), lactate dehydrogenase 1460 U/L (125-220), total bilirubin 35.92 μmol/L (5.13-20.52), direct bilirubin 11.97 μmol/L (1.71-8.55), haptoglobin 12.24). The peripheral blood smear showed macrocytosis and hypersegmented neutrophils.nnAntibodies against parietal cells were positive; Coombs test and anti-intrinsic factor antibodies were negative.nnUpper gastrointestinal endoscopy showed atrophic gastritis of the body and fundus. Staining for Helicobacter pylori was negative (fig 1⇓). Biopsy confirmed the presence of type A atrophic gastritis with moderate intestinal metaplasia.nnnnFig 1 xa0Gastric body fragments showing glandular atrophy plus moderate intestinal metaplasia and a moderate mononuclear infiltrate of the lamina propria (haematoxylin and eosin stain, original magnification ×100)nnnn1. What is the most likely diagnosis?nn2. What strategy can primary care practitioners take to reach the diagnosis?nn3. What are the differential diagnoses?nn4. How is this condition managed?nn5. How is this condition followed up?nn### 1. What is the most likely diagnosis?nn#### Short answernnPernicious anaemia with intramedullary haemolysis as a result of ineffective erythropoiesis.nn#### DiscussionnnPernicious anaemia is a macrocytic anaemia caused by vitamin B12 (cobalamin) deficiency, as a consequence of an intrinsic factor …

Prognostic value of plasma D-dimer level in adults with community-acquired pneumonia: A prospective study

Community-acquired pneumonia (CAP) is associated with considerably high morbidity and mortality rates particularly in older patients. Despite advances in antibiotic treatment, prompt diagnosis and treatment are crucial for better outcomes. The accuracy of pneumonia severity scores, namely CURB-65 and pneumonia severity index (PSI) is debateable, and can lead to underestimates of the severity of the disease, leading to inadequate stratification. This explains the increased interest in new biomarkers with better prognostic value and accuracy. One of these new, potentially helpful biomarkers, which has not yet been fully validated, is plasma level of D-dimer (DD). The relationship between DD and CAP is still unclear and has only been evaluated by a limited number of studies, the majority of which have displayed it as a marker of prognosis and treatment response. In order to enhance our knowledge about this matter, we conducted a prospective analysis in adult patients with CAP, admitted to our Internal Medicine ward between December 2013 and April 2014. CAP was defined as a recent chest radiography opacity consistent with acute lung infection associated with typical respiratory symptoms, such as fever and pleuritic pain, and a lack of an alternative diagnosis. The diagnosis was confirmed by the authors in every single case through clinical reports and chest radiography reviews. Our study aimed to investigate the correlation between DD levels and the severity of CAP, assessed by CURB-65 and PSI scores, radiological extent of the disease and in-hospital mortality. In addition to these variables, we performed a standard evaluation that included past medical history, severity risk factors and laboratory findings, specifically DD, at hospital admission. Data analysis was executed by SPSS. A total of 102 patients (65 men and 37 women) were involved. There were no significant age differences between the two groups (mean age 81.57 ± 10.57 years versus 78.59 ± 12.65 years, respectively). DD showed an asymmetric distribution with a median (range) of 1.55 g/ml, (0.17 g/ml -14.69 g/ml). DD was negative (< 0.60 g/ml) in 20% of the patients. Differences of DD levels, PSI and CURB-65 score concerning age ranges were also taken into consideration. All the patients were divided into 4 age ranges (>30-64; 65-74; 75-84; > 85 years) and there were no meaningful differences between these groups. There was also no meaningful statistical difference in DD levels related to gender. Patients were assigned into two different radiographic pattern groups: unilobar and multilobar pneumonia. Although the median DD in the multilobar group was higher (2.06 g/ml versus 1.23 g/ml), as reported by others studies, such as Levi et al. 4 and Ribelles et al., no correlation between DD and the extent of the disease was found. DD increases had some degree of correlation with the CURB-65 score increases (p < 0.008) which is consistent with previous findings, as published by Snijders et al. In fact, the addition of D-dimer has slightly increased the performance of CURB-65, concerning the severity of CAP. On the other hand, no correlation was found with PSI score, which contradicts results from other studies, such as Ribelles et al. The relationship between DD and mortality was also assessed. The area under the curve (AUC) of the receiver operating characteristic (ROC) was used to calculate the mortality predictive value. DD and PSI score showed a low mortality predictive value but, on the other hand, CURB 65 and addition of DD levels to CURB 65 had a substantial positive predictive value (Fig. 1). Several authors have addressed the relationship between DD and clinical outcomes. Ribelles et al. 5 found a strong correlation between mortality rates and DD in CAP, while Kollef et al. 7 demonstrated that increased DD were associated with worse clinical outcomes. This was not confirmed by our study, since we did not find a significant correlation between DD levels of patients who died and those who showed overall improvement. In conclusion, in our study, DD did not exhibit prognostic value in adult patients with CAP, despite multiple comorbidities, and also did not correlate with the severity of the disease, radiological extent and in-hospital mortality rates.

Anti-Signal Recognition Particle Myopathy in a Geriatric Patient

Anti-signal recognition particle (SRP) myopathy is a rare idiopathic inflammatory myositis that usually affects middle-age women, and is characterized by rapidly progressive proximal and symmetrical muscle weakness, elevated creatine kinase levels, severe necrotizing immune-mediated myopathy, presence of anti-SRP autoantibodies and poor response to steroid therapy. We report a geriatric case of a previously independent patient, presenting with slow onset of proximal paraparesis, myalgia and severe gait impairment. The patient was treated with steroid and azathioprine, with laboratory and pain response but modest muscle strength improvement. The clinical presentation of this unusual patient was atypical, which hampered the correct diagnosis.