Coma caused by Shigella toxin-producing Escherichia coli in the absence of haemorrhagic uraemic syndrome (HUS)

Shigella toxin-producing Escherichia coli (STEC) is well known for its complications such as haemolytic uraemic syndrome (HUS), but neurological symptoms have also been reported. While most cases of infection with STEC occur with concurrent HUS, we describe a patient with severe neurological symptoms in the absence of HUS.

Dysautonomia: an Explanation for the Medically Unexplained?

Objective: To identify dysautonomia as a collection of conditions with variable presentation that may be mistaken for medically unexplained symptoms. Methods: Case series. Results: Tilt table testing and 24 h electrocardiographic monitoring provided useful diagnostic tools to confirm the diagnosis. Conclusion: A greater awareness and recognition of the disorders that result from dysautonomia and recognition of the disability that results from these disorders will improve patients’ quality of life.

Acute Cholecystitis as a Complication After Colonoscopy: A Case Report and Literature Review

Acute cholecystitis after colonoscopy is a rare event, with less than 10 cases described in the literature. We report the case of a male patient with silent gallstones who underwent colonoscopy for follow-up of his Crohn’s disease. The colonoscopy revealed erosions in the terminal ileum, from which biopsies were taken. A sessile polyp 4 mm in diameter at the recto-sigmoid junction was also removed. Less than 24 h after the colonoscopy, the patient complained of upper right quadrant pain, nausea and vomiting. Based on the clinical findings, laboratory data and ultrasonography, we diagnosed acute cholecystitis and excluded any complication after the colonoscopy. Laparoscopic cholecystectomy was performed and the patient was discharged.

A Painless Thoracic Aortic Dissection

Thoracic aortic dissection (TAD) has a very high mortality rate and is often missed due to the atypical presentation of patients. We present a case of a man with chronic hypertension, atrial fibrillation (AF) (on regular warfarin) and a previous endovascular aneurysm repair (EVAR), who presented with dyspepsia and was incidentally found to have a ruptured distal thoracic aneurysm on imaging with no obvious clinical signs on examination, nor abnormalities on admission chest x-ray (CXR).

Increasing Skin Pigmentation Following Severe Head Trauma: All That Glitters Is Not Gold!

We report the case of a 67-year-old man who was admitted to our Intensive Care Unit because of traumatic brain injury. During his prolonged hospitalization, gradual darkening of the skin all over his body was observed. An excess corticotropin (ACTH) production syndrome was considered. The patient’s hormone study showed high levels of ACTH (978 pg/ml) with normal cortisol levels. Extensive clinical and laboratory investigations revealed adenocarcinoma of the colon, which was likely the site of the ectopic ACTH production. This is a very rare manifestation of paraneoplastic syndrome during the course of colon adenocarcinoma. The most important feature of this case report is that this rare syndrome was accidentally discovered, in a patient hospitalized for unrelated reasons, by simple clinical investigation.

A Case Against Fancy Decorated Drinks: Multi-Organ Failure After Drinking a Mojito Cocktail

We present the first case of gastro-intestinal perforation caused by a mint twig decorating a cocktail drink. A 76-year-old man was enjoying his Mojito cocktail on a cruise ship near Mexico when he accidently swallowed a mint twig, resulting in ileum perforation. This led to a cascade of events, eventually resulting in life-threatening multi-organ failure. Given this rare but potentially severe complication and the increasing popularity of decorated drinks, a less ‘fancy’ presentation for cocktails and similar drinks may be warranted.

Paradoxical Deterioration During Anti-Tuberculous Therapy in Non-HIV-Infected Patients with Pleural Tuberculosis: A Pragmatic Approach

We report a case of paradoxical deterioration. A male patient diagnosed with pleural tuberculosis, but who was not infected with human immunodeficiency virus (HIV), experienced clinical deterioration 3 weeks after the initiation of anti-tuberculous treatment. After other diagnoses were ruled out, a paradoxical response to treatment was established and the patient was started on systemic corticosteroids. Paradoxical response to treatment should be considered in patients with clinical deterioration after they start on anti-tuberculous treatment.

A Rare Presentation of Leptospirosis

Leptospirosis has a wide spectrum of clinical manifestations. Acute renal failure, an important complication, generally involves interstitial and tubular damage. We describe the case of a 42-year-old man who was admitted with fever, back pain and periorbital oedema. He had hypertension, thrombocytopenia, acute renal failure, hypoalbuminaemia, hypertriglyceridaemia and proteinuria >4.00 g/l. The renal biopsy showed mesangioproliferative glomerulonephritis. Due to the epidemiological context and clinical picture, ceftriaxone was started with rapid clinical improvement. Blood PCR for leptospira came back positive. The presentation of leptospirosis as nephrotic syndrome is rare and this diagnosis should be considered before performing a renal biopsy.

Simultaneous Acute Pulmonary Embolism and Isolated Septal Myocardial Infarction in a Young Patient

We report here the case of a young patient with a simultaneous isolated septal myocardial infarction (MI) and pulmonary embolism (PE). The aim was to describe a rare clinical entity and to explain why these two pathologies were present at the same time in a young patient.
 A review of literature was established. An interventional cardiologist, an interventional radiologist and a lung specialist were consulted. The diagnostic workup revealed only heterozygous Factor Leiden V mutation. This presentation was probably fortuitous, but worth reporting to our opinion.

Behind Recurrent Thromboembolic Events

We describe the case of a 68-year-old man, who presented with an ischemic stroke due to cardiac embolization related to mitral valve endocarditis. Blood cultures were always negative and post-operative valve histology did not show microorganisms. The patient also presented further recurrent peripheral embolic events. These clinical aspects were the first sign of a pancreas adenocarcinoma, which was only diagnosed in the clinical autopsy. In conclusion, these clinical findings of recurrent thromboembolic events with no microorganisms isolated suggests the diagnostic of a marantic endocarditis.

Oxidative stress and its haemodynamic consequences in chronic kidney disease

Chronic kidney disease (CKD) is associated with increased cardiovascular risk in comparison with the general population. This can be observed even in the early stages of CKD, and rises in proportion to the degree of renal impairment. Not only is cardiovascular disease (CVD) more prevalent in CKD, but its nature differs too, with an excess of morbidity and mortality associated with congestive cardiac failure, arrhythmia and sudden death, as well as the accelerated atherosclerosis which is also observed. Conventional cardiovascular risk factors such as hypertension, dyslipidaemia, obesity, glycaemia and smoking, are highly prevalent amongst patients with CKD, although in many of these examples the interaction between risk factor and disease differs from that which exists in normal renal function. Nevertheless, the extent of CVD cannot be fully explained by these conventional risk factors, and non-conventional factors specific to CKD are now recognised to contribute to the burden of CVD. Oxidative stress is a state characterised by excessive production of reactive oxygen species (ROS) and other radical species, a reduction in the capacity of antioxidant systems, and disturbance in normal redox homeostasis with depletion of protective vascular signalling molecules such as nitric oxide (NO). This results in oxidative damage to macromolecules such as lipids, proteins and DNA which can alter their functionality. Moreover, many enzymes are sensitive to redox regulation such that oxidative modification to cysteine thiol groups results in activation of signalling cascades which result in adverse cardiovascular effects such as vascular and endothelial dysfunction. Endothelial dysfunction and oxidative stress are present in association with many conventional cardiovascular risk factors, and can be observed even prior to the development of overt, clinical, vascular pathology, suggesting that these phenomena represent the earliest stages of CVD. In the presence of CKD, there is increased ROS production due to upregulated NADPH oxidase (NOX), increase in a circulating asymmetric dimethylarginine (ADMA), uncoupling of endothelial nitric oxide synthase (eNOS) as well as other mechanisms. There is also depletion in exogenous antioxidants such as ascorbic acid and tocopherol, and a reduction in activity of endogenous antioxidant systems regulated by the master gene regulator Nrf-2. In previous studies, circulating markers of oxidative stress have been shown to be increased in CKD, together with a reduction in endothelial function in a stepwise fashion relating to the severity of renal impairment. Not only is CVD linked to oxidative stress, but the progression of CKD itself is also in part dependent on redox sensitive mechanisms. For example, administration of the ROS scavenger tempol attenuates renal injury and reduces renal fibrosis seen on biopsy in a mouse model of CKD, whilst conversely, supplementation with the NOS inhibitor L-NAME causes proteinuria and renal impairment. Previous human studies examining the effect of antioxidant administration on vascular and renal function have been conflicting however. The work contained in this thesis therefore examines the effect of antioxidant administration on vascular and endothelial function in CKD. Firstly, 30 patients with CKD stages 3 – 5, and 20 matched hypertensive controls were recruited. Participants with CKD had lower ascorbic acid, higher TAP and ADMA, together with higher augmentation index and pulse wave velocity. There was no difference in baseline flow mediated dilatation (FMD) between groups. Intravenous ascorbic acid increased TAP and O2-, and reduced central BP and augmentation index in both groups, and lowered ADMA in the CKD group only. No effect on FMD was observed. The effects of ascorbic acid on kidney function was then investigated, however this was hindered by the inherent drawbacks of existing methods of non-invasively measuring kidney function. Arterial spin labelling MRI is an emerging imaging technique which allows measurement of renal perfusion without administration of an exogenous contrast agent. The technique relies upon application of an inversion pulse to blood within the vasculature proximal to the kidneys, which magnetically labels protons allowing measurement upon transit to the kidney. At the outset of this project local experience using ASL MRI was limited and there ensued a prolonged pre-clinical phase of testing with the aim of optimising imaging strategy. A study was then designed to investigate the repeatability of ASL MRI in a group of 12 healthy volunteers with normal renal function. The measured T1 longitudinal relaxation times and ASL MRI perfusion values were in keeping with those found in the literature; T1 time was 1376 ms in the cortex and 1491 ms in the whole kidney ROI, whilst perfusion was 321 mL/min/100g in the cortex, and 228 mL/min/100g in the whole kidney ROI. There was good reproducibility demonstrated on Bland Altman analysis, with a CVws was 9.2% for cortical perfusion and 7.1% for whole kidney perfusion. Subsequently, in a study of 17 patients with CKD and 24 healthy volunteers, the effects of ascorbic acid on renal perfusion was investigated. Although no change in renal perfusion was found following ascorbic acid, it was found that ASL MRI demonstrated significant differences between those with normal renal function and participants with CKD stages 3 – 5, with increased cortical and whole kidney T1, and reduced cortical and whole kidney perfusion. Interestingly, absolute perfusion showed a weak but significant correlation with progression of kidney disease over the preceding year. Ascorbic acid was therefore shown to have a significant effect on vascular biology both in CKD and in those with normal renal function, and to reduce ADMA only in patients with CKD. ASL MRI has shown promise as a non-invasive investigation of renal function and as a biomarker to identify individuals at high risk of progressive renal impairment.

Certificação de idoneidade formativa do serviço de medicina interna do Hospital de São Bernardo

Na formação inicial de Enfermagem os ensinos clínicos são um momento de consolidação de saberes teóricos e simultaneamente um momento de aquisição de saberes práticos em contexto real de trabalho. Este momento de formação é supervisionado por Enfermeiros da prática clínica que assumem um importante papel no processo de formação dos estudantes de enfermagem. Para consolidar este processo de ensino/aprendizagem a Ordem dos Enfermeiros desenvolveu um extenso trabalho que visa a certificação de Enfermeiros Supervisores, em que propõe que os Licenciados em Enfermagem, realizem um período de Exercício Profissional Tutelado, acompanhados por esse mesmo Enfermeiro Supervisor. Para que esse período ocorra é necessário a convergência de dois fatores, um é a existência de um Enfermeiro Supervisor certificado pela Ordem dos Enfermeiros, outro é a certificação do serviço onde esse exercício profissional tutelado decorra, num espaço onde exista Certificação de Serviço com Idoneidade Formativa certificada pela Ordem dos Enfermeiros. Para que tal aconteça é necessário que o supervisor e o serviço cumpram os critérios preconizados pela Ordem dos Enfermeiros. Este trabalho surge com o objetivo de certificar o Serviço de Medicina Interna do Hospital de São Bernardo como unidade de saúde com Idoneidade Formativa certificada pela Ordem dos Enfermeiros para o Exercício Profissional Tutelado, naquele que é inerente ao Modelo de Desenvolvimento Profissional proposto pela Ordem dos Enfermeiros

Application of a policy framework for the public funding of drugs for rare diseases

BACKGROUND: In many countries, decisions about the public funding of drugs are preferentially based on the results of randomized trials. For truly rare diseases, such trials are not typically available, and approaches by public payers are highly variable. In view of this, a policy framework intended to fairly evaluate these drugs was developed by the Drugs for Rare Diseases Working Group (DRDWG) at the request of the Ontario Public Drug Programs. OBJECTIVE: To report the initial experience of applying a novel evaluation framework to funding applications for drugs for rare diseases. METHODS: Retrospective observational cohort study. MEASURES: Clinical effectiveness, costs, funding recommendations, funding approval. KEY RESULTS: Between March 2008 and February 2013, eight drugs were evaluated using the DRDWG framework. The estimated average annual drug cost per patient ranged from 28,000 to 1,200,000 Canadian dollars (CAD). For five drugs, full evaluations were completed, specific funding recommendations were made by the DRDWG, and funding was approved after risk-sharing agreements with the manufacturers were negotiated. For two drugs, the disease indications were determined to be ineligible for consideration. For one drug, there was insufficient natural history data for the disease to provide a basis for recommendation. For the five drugs fully evaluated, 32 patients met the predefined eligibility criteria for funding, and five were denied based on predefined exclusion criteria. CONCLUSIONS: The framework improved transparency and consistency for evaluation and public funding of drugs for rare diseases in Ontario. The evaluation process will continue to be iteratively refined as feedback on actual versus expected clinical and economic outcomes is incorporated. © 2014 Society of General Internal Medicine.

Smoking, depression, and suicide risk in the nursing staff of a Third-Level Hospital

Objective: To determine the association between smoking, depression and suicide risk in the Nursing Staff of a University Hospital. Materials and method: this was a non-experimental, correlational cross-range study with observational analysis carried out between May 2012 and May 2013. We studied 232 nurses of the “Dr. José Eleuterio gonzález” University Hospital. two self-administered scales were applied, one for depression and one for suicide risk. Another hetero-applied scale of nicotine dependency was also used, and the subjects’ socio-demographic records were reviewed. Results: A total of 527,232 nurses were studied. A smoking prevalence of 22.8% (53 subjects), an operational depression prevalence of 15.1% (35 subjects), and a suicide risk of 5.1% (12 subjects) were found. Gender and age, speciically being male and young (mean age 29.2 years) were found to increase the risk of smoking. We also found that those nurses who had a partner and had a higher level of education smoked less compared to those who did not have a partner or had a lower degree of education. there were hospital departments where there was a higher prevalence of smoking, such as Internal Medicine and Shock trauma. No association between smoking and the presence of depression was found. Regarding depression, we found that those nurses who worked in the Department of Pensioners were more likely to develop operational depression than those working in any other department. We also found that the risk of presenting operational depression decreases as age increases. About suicide risk, a statistically signiicant association between smoking and suicide risk was found. We also found an association between operational depression and suicide risk.Conclusions: It is recommended to consider nicotine dependence as a fundamental part of psychopathology assessment because of its strong association with suicide risk. this study emphasizes the complexity of the issue of the comorbidity of smoking and psychopathology and the need to continue research lines.

Colombia Médica

Colombia Médica is an international peer-reviewed medical journal that will consider any original contribution that advances or illuminates medical science or practice, or that educates to the journal's’ readers.The journal is owned by a non-profit organization, Universidad del Valle, and serves the scientific community strictly following the International Committee of Medical Journal Editors (ICMJE) recommendations on publication ethics policies for medical journals. Colombia Médica publishes original research articles, viewpoints and reviews in all areas of medical science and clinical practice. However, Colombia Médica gives the highest priority to papers on general and internal medicine, public health and primary health care. Colombia Médica (ISSN 1657-9534) is indexed/tracked/covered by PubMed, MEDLINE, EMBASE, Scopus, Thomson Reuters (ISI) and Google Scholar.