Mikhael Laskine

Extracorporeal Membrane Oxygenation in Diffuse Alveolar Hemorrhage Secondary to Systemic Lupus Erythematosus

Diffuse alveolar hemorrhage (DAH) is a rare and potentially deadly complication of systemic lupus erythematosus (SLE). We report two adult cases where extracorporeal membrane oxygenation (ECMO) was used as rescue therapy for severe respiratory failure in this setting. We discuss the risk related to coagulation disturbance and the need for the circuit anticoagulation in this particular setting. We also briefly discuss the clinical problem of lack of knowledge on the bioavailability of the immunosuppressive treatment with the use of ECMO. We think that ECMO should be used as rescue therapy in patients with DAH caused by SLE, but strategies for anticoagulation require further precision.

Unreliability of Home Blood Pressure Measurement and the Effect of a Patient-Oriented Intervention

BACKGROUND Home blood pressure (BP) measurement (HBPM) is recommended for the diagnosis and follow-up of high BP. It is unclear how this aspect of BP monitoring has evolved over the years and whether interventions could influence patient adherence to HBPM guidelines. METHODS After a questionnaire-based cross-sectional study performed in 2010, a passive, multimodal intervention, focused on improving adherence to HBPM guidelines, was implemented. A second study was conducted in 2014 to measure its effect. RESULTS In 2010 and 2014, 1010 and 1005 patients, respectively, completed the questionnaire. In 2010 and 2014, 82% and 84% of patients, respectively, self-measured their BP. Reporting of HBPM and adherence to recommended procedures was suboptimal. Only 34.0% of patients in 2010 and 31.7% in 2014 brought > 80% of their measurements to their doctor. Only 49.6% in 2010 and 52.9% in 2014 prepared > 80% of the time for HBPM. Only 48.1% in 2010 and 52.1% in 2014 rested for 5 minutes > 80% of the time before HBPM. Only 15% of patients in 2010 and 18% in 2014 were defined as sufficiently compliant with all HBPM procedures. Paired analysis of a subset of 535 patients who participated in the 2010 and 2014 studies showed no clinically significant differences in reliability between the 2 surveys. CONCLUSIONS Adherence to HBPM guidelines was suboptimal in 2010 and still is in 2014 despite a passive, multimodal intervention. Active training in HBPM procedures should be studied. Greater automation could improve HBPM reliability.

Comparison of Different Automated Office Blood Pressure Measurement Devices: Evidence of Nonequivalence and Clinical Implications

BACKGROUND Automated office blood pressure (AOBP) measuring devices are increasingly recommended as preferred blood pressure (BP) diagnostic tools, but it is unclear how they compare and how clinical environments impact their performance. METHODS This prospective randomized factorial parallel 4-group study compared BP estimates by BpTRU (VSM MedTech, Vancouver, BC, Canada) and Omron HEM 907 (Omron Healthcare, Kyoto, Japan) devices in closed vs open areas. Patients diagnosed with hypertension were recruited during office visits. After baseline open-room AOBP measurement with the BpTRU, patients had a second BP measurement with either the BpTRU or HEM 907 in either open or closed areas. Absolute BP levels and differences between the first and second measurements were compared. Diagnostic performance was also assessed. RESULTS Two hundred fifty-eight patients were studied. Their mean age was 66.2 ± 12.0 years, and 62% were men. The mean of first AOBP estimates was 127.4/73.3 mm Hg. Analyses of subsequent measurements revealed no influence of open or closed areas on BP means and diagnostic performance. Conversely, the Omron HEM 907 exceeded BpTRU systolic BP measurements by 4.6 mm Hg (< 0.01) in closed areas and by 3.9 mm Hg (< 0.01) in open areas. The discrepancy between devices was amplified at lower BP levels. CONCLUSIONS Although different areas did not influence BP estimates, the Omron HEM 907 significantly exceeded BpTRU measurements on average and especially at lower BP levels. These differences should be considered when interchanging devices and could have clinical decision impacts in a population of patients treated for hypertension. Our results support the constant use of only 1 device type in a given clinic.

Recurrent arterial and venous thromboemboli as initial presentation of acute promyelocytic leukemia.

We report a case of a 52-year-old Caucasian woman diagnosed with a synchronic arterial and venous thrombosis as an initial presentation of an acute promyelocytic leukemia (APL). After the diagnosis, the patient was treated with all trans-retinoic acid and arsenic chemotherapy concomitant to systemic anticoagulation. This treatment regimen led to a complete remission and absence of relapse of the thrombosis or APL during the follow-up. To our knowledge, this presentation is the second case in the literature. We use this opportunity to emphasize the importance of performing a complete medical evaluation in cases of unusual thromboembolic events.

Pure Red Cell Aplasia with Adult Onset Still’s Disease

Adult Onset Stills Disease (AOSD) is a rare inflammatory syndrome mostly seen in young adults. Known for its wide range of clinical manifestations, AOSD often presents with nonremitting systemic signs and symptoms. Many rare case associations have been described with AOSD, but only few with pure red cell aplasia (PRCA). We are presenting a fourth known case of a young female adult with AOSD and PRCA in the literature.

Preoperative antihypertensive medication intake and acute kidney injury after major vascular surgery

Objective: Postoperative acute kidney injury (AKI) is frequent after major vascular surgery and is associated with significant morbidity and mortality. It remains unclear whether the administration of combined oral antihypertensive medications on the day of surgery can increase the risk of postoperative AKI. Methods: We performed a retrospective cohort study of hypertensive patients undergoing elective major vascular surgery to determine the association between the number of antihypertensive medications continued on the morning of surgery and AKI at 48 hours postoperatively. Results: A total of 406 patients who had undergone suprainguinal vascular surgery were included, and 10.3% suffered postoperative AKI. In multivariable analysis, the number of antihypertensive medications taken on the morning of surgery was independently associated with AKI (P = .026). Compared with patients who took no medication, taking one medication (adjusted odds ratio [aOR], 1.58; 95% confidence interval [CI], 0.68–3.75) and taking two or more medications (aOR, 2.70; 95% CI, 1.13–6.44) were associated with a 1.6‐fold and 2.7‐fold increased risk of postoperative AKI, respectively. Other predictors of AKI were suprarenal surgery (aOR, 3.37; 95% CI, 1.53–7.44), age (aOR, 2.29 per 10 years; 95% CI, 1.40–3.74), length of surgery (aOR, 1.40 per 1 hour; 95% CI, 1.10–1.76), hemoglobin drop (aOR, 1.37 per 10 g/L; 95% CI, 1.10–1.74), and history of coronary artery disease (aOR, 2.33; 95% CI, 1.08–5.00). Conclusions: In patients undergoing major vascular surgery who are treated with chronic antihypertensive therapy, the administration of antihypertensive drugs on the morning of surgery is independently associated with an increased risk of postoperative AKI. Further prospective studies are needed to confirm this finding.

Fluctuating Hearing Loss Responding to Corticosteroids: A Case ofCogans Syndrome Concomitant with Crohns Disease

Hearing loss has a broad differential diagnosis. Hearing impairment responding to corticosteroids is suggestive of an underlying autoimmune cause. We report a rare case of Cogan’s syndrome in a 28-year-old woman with no previous personal medical history. She had experienced two years of fluctuating hearing loss and bilateral keratitis that would respond to high-dose prednisone prescribed by her otorhinolaryngologist. We performed a complete work-up and ruled out most common causes of autoimmune inner ear diseases. Patient was diagnosed with Cogan’s syndrome based on clinical findings and prescribed corticosteroid-sparing immunosuppressive medication. During follow-up, she developed worsening fatigue, new onset anemia, and melena. Endoscopic and pathologic findings were diagnostic of Crohn’s disease. This case emphasizes the high prevalence of concomitant autoimmune diseases.

Ketoacidosis in a Non-Diabetic Adult With Chronic EtOH Consumption

Although much more rare than its diabetic counterpart, ketoacidosis secondary to alcohol withdrawal in the context of fasting has its own complex pathophysiology and can easily mimic the acute insulin deficiency presentation. We present here a rare case of a non-diabetic alcoholic patient who presented in ketoacidosis after a period of reduced intake.

Primary pulmonary artery angiosarcoma mimicking pulmonary embolism in a 66-year-old man with dyspnea

A66-year-old man consulted his family physician because of progressive dyspnea. He had a history of hypertension and dyslipidemia, but no personal or family history of cardiac or respiratory diseases. He was a lifelong nonsmoker and had been a professional endurance swimmer. After his professional