Polymyositis and the Spectrum of Scleroderma Disorders

Polymyositis (PM) is usually associated to other autoimmune or connective tissue diseases. The authors report the case of a 59-year-old man with pulmonary fibrosis, who presented with constitutional symptoms and gradually developed proximal muscle weakness, Raynaud phenomenon, and dysphagia. Besides creatine kinase (CK) elevation, he had positive anti-Polymyositis-Scleromyositis (PM-Scl) and anti-Sjögren's-syndrome A (SSA) antibodies. Nailfold capillaroscopy showed a scleroderma pattern and muscle biopsy revealed necrosis, regeneration of muscle fibers, and inflammatory infiltrate. Prednisolone was started, with great improvement. Taking into account the overlap features between PM and systemic sclerosis sine scleroderma, it is important to closely monitor the patient for signs of pulmonary and cardiac decompensation

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

El peligro de los comensales: endocarditis complicada con espondilodiscitis por Staphylococcus capitis

Spondylodiscitis is an infrequent, but potentially serious infection. It is uncommon as a complication of infective endocarditis and seems to be associated with systemic embolization. This case reports to a patient presented with history of general deterioration and fever of unknown origin, complicatedwith lumbar pain, and a diagnosis of Staphylococcus capitis endocarditis complicated with spondylodiscitis was reached. This agent (usually a commensal) is an uncommon cause of both diseases, in the absence of prosthetic or surgery related infection. As such, this case highlights the importance of considering commensal agents as capable of causing potentially serious infections, as well as not immediately disregarding positive hemocultures for them, as contaminations.La espondilodiscitis es una infección infrecuente, pero potencialmente grave. Es poco común como complicación de la endocarditis infecciosa, pareciendo asociarse a embolización sistémica. Presentamos el caso de un paciente con historia de deterioro general y fiebre sin foco inicial, complicado con dolor lumbar; con diagnóstico definitivo de endocarditis infecciosa complicada con espondilodiscitis, por Staphylococcus capitis. Habitualmente un comensal, este germen es un patógeno raro en ambas infecciones en la ausencia de infección prostética o quirúrgica, enalteciendo la importancia de considerar comensales como potenciales causadores de infecciones graves, y no considerar inmediatamente hemocultivos positivos para esos agentes, como colonizaciones

Perfusion Magnetic Resonance as a Biomarker for Sorafenib-Treated Advanced Hepatocellular Carcinoma: A Pilot Study

Background: Sorafenib is the currently recommended therapy in patients with advanced hepatocellular carcinoma (HCC). Among the several biomarkers available for the evaluation of the therapeutic response and prognosis, there is perfusion magnetic resonance imaging (p-MRI) that, through measurement of the vascular permeability unit (ktrans), may retrieve useful information regarding the microvascular properties of focal liver lesions. The aim of this study was to evaluate the impact of sorafenib therapy in patients with advanced HCC using the p-MRI technique. Materials and Methods: In this retrospective study, 27 patients with the diagnosis of advanced HCC were included for palliative therapy using sorafenib. MRI of the liver was performed before the beginning of the oral therapy (T0), after 3 (T3), and after 6 months (T6). Dynamic acquisitions of the tumor (n = 50, during the first 2 min after contrast injection) were obtained in the coronal plane and were used to compute the parametric perfusion maps, acquiring the ktrans value using the extended Tofts pharmacokinetic model. Results: The value of ktrans obtained at T0 was significantly different from the value of ktrans obtained at T6 (p = 0.028). There were no significant differences between T0 and T3 (p = 0.115) or a correlation between ktrans at T0 and the size of the lesion (p = 0.376). The ktrans value at T0 in patients with progression-free survival (PFS) &#x3e; 6 months was not significantly different from the ktrans value in patients with PFS ≤6 months (p = 0.113). The ktrans value at T0 was not significantly different between patients who were previously submitted to chemoembolization and those who were not submitted (p = 0.587). Conclusion: In this pilot study, the ktrans value may serve as a biomarker of tumor response to antiangiogenic therapy, but only 6 months after its initiation. Clinical outcomes such as PFS were not predicted before the initiation of treatment

Paraquat poisoning in amedical ward

Os autores apresentam uma análise retrospectiva dos casos de intoxicação por paraquat internados num serviço de Medicina Interna dum hospital central. O estudo engloba um período de 7,5 anos, incluindo 26 casos, 16 homens e 10 mulheres, com idades compreendidas entre os 16 e os 74 anos. O tempo médio decorrido entre a ingestão do tóxico e a prestação dos primeiros cuidados médicos foi, nos doentes que recorreram nas primeiras 24 horas, de 1,8 horas, havendo 3 que só mais tarde recorreram ao hospital. As quantidades de tóxico ingeridas foram calculadas segundo os dados fornecidos pelos doentes e mostraram uma grande dispersão, tendo, no entanto, a maior parte deles ingerido entre 20 e 100 ml. Durante o internamento, faleceram 13 doentes (50%), que tiveram uma sobrevivência média de 7 dias. Os restantes 13 doentes tiveram alta hospitalar, tendo uma sobrevivência média conhecida de 10 meses. Foram comparados entre si os grupos dos doentes falecidos e dos sobreviventes, concluindo-se que o factor decisivo para a mortalidade foi a quantidade de tóxico ingerida. O aparecimento de dispneia, oligúria ou icterícia foi indicador de mau prognóstico, enquanto os valores laboratoriais, à entrada no Serviço de Urgência, de LDH, TGO e pCO2 estavam significativamente mais alterados nos doentes que vieram a falecer. Quando a dose ingerida foi elevada, as medidas terapêuticas, mesmo as mais agressivas, não alteraram o curso da doença. Finalmente, os autores discutem os resultados encontrados, comparando-os com os de outros estudos.The authors present a retrospective study of paraquat poisoning cases admitted at an Internal Medicine department of a central hospitaL This analysis includes a 7.5 years period, involving 26 cases, with male sex predominance (16 patients) and ages between 16 and 74 years old. The mean time elapsed between the toxic ingestion andfirst health care was 1,8 hours ifthey were admiUed in the first 24 hours; three patients arrived later to the hospitaL The quantities of poison ingested were variable, but more frequently between 20 and 100 mL Thirteen in-patients were death while the other 13 were discharged from hospital with good health (known middle survivai time of 10 months). The 2 groups were compared and the single prognostic factor was the ingested quantity ofparaquat. Dyspnea, oliguria andjaundice were the clinical manifestations with prognostic value, while values of LDH, AST and p02 (at admission on Urgency Room) were also prognostic indicators. Any medical measure seemed to modify the disease course when a high dose was ingested

Conversas com... sobre a didática e a perspectiva multi/intercultural

Focaliza como a perspectiva multi/intercultural está sendo incorporada pelos profissionais do campo da didática. A partir da análise de 20 depoimentos, discute-se como esses profissionais estão percebendo as contribuições e os temas que emergem quando se analisam as relações entre didática e multiculturalismo e também os riscos e os desafios inerentes a essa temática. Entre preocupações e possibilidades, os entrevistados apontam questões de particular importância, tais como: tensão entre social e cultural, articulação igualdade e diferença, bem como a problemática do universalismo versus relativismo cultural. São aspectos relevantes que vimos trabalhando em diferentes projetos de pesquisa, em particular no projeto Ressignificando a didática na perspectiva multi/intercultural, com o objetivo de ultrapassar uma visão dicotômica entre esses pólos. Nossa intenção é contribuir para a construção de uma didática crítica atravessada pela perspectiva multi/intercultural

Autoimmune hepatitis in an Internal Medicine ward

Introdução: A hepatite auto-imune (HAI) é uma inflamação hepática de causa desconhecida, caracterizada pela presença de hepatite de interface na biopsia hepática, de hipergamaglobulinemia e de auto-anticorpos característicos. Objectivo: Avaliar as características clínicas, laboratoriais e histológicas, a resposta à terapêutica e o prognóstico da hepatite auto-imune. Métodos: Análise dos processos clínicos dos doentes com hepatite auto-imune admitidos no Serviço de Medicina III dos HUC entre 1987 e 2002. Resultados – Foram diagnosticados 29 casos, 28 do sexo feminino e 1 do masculino, com a idade média de 34,2±16,4 anos. A forma de apresentação foi fulminante em 6,9% dos doentes, aguda em 20,7% e insidiosa ou crónica em 72,4%. Os sintomas mais comuns foram: astenia (65,6%), anorexia (48,3%), náuseas e vómitos (48,3%); 24,1% dos doentes eram assintomáticos. Pelo score do International Autoimmune Hepatitis Group, o diagnóstico era definitivo em 69% dos casos e provável em 31%. Tinham HAI tipo I 86,2% dos doentes, 3,5% eram do tipo II e 10,3% não apresentavam auto-anticorpos convencionais. O anti-VHC era positivo em 2 doentes, o AgHBs em 1 e o IgM anti-VHA em 1. Apresentavam cirrose 27,6% dos doentes. Treze iniciaram terapêutica com prednisolona e 15 com prednisolona + azatioprina, com resposta completa em 39,3% dos casos, parcial em 7,1%, ausência de resposta em 25% e resposta seguida de recaída em 28,6%. O transplante hepático foi realizado em 4 doentes (13,8%). Com um período médio de seguimento de 69 meses (variando entre 1 e 213 meses), a mortalidade foi de 13,8%: 2 doentes por falência hepática, 1 por sepsis e 1 por meningite herpética. Conclusões: À data do diagnóstico, 24,1% dos doentes eram assintomáticos e 27,6% tinham cirrose; a terapêutica com prednisolona e azatioprina foi mais eficaz que a prednisolona isolada; houve necessidade de transplante hepático em 13,8% dos doentes; a evolução foi favorável na maioria dos casos.Introduction: Autoimmune Hepatitis (AIH) is a hepatocellular inflammation of unknown cause, characterised by the presence of interface hepatitis on liver biopsy, and hypergammaglobulinaemia and autoantibodies in serum. Objective: To characterise clinical, laboratory and histological features, as well as the outcome, of AIH. Methods - Retrospective analysis of AIH cases admitted between 1987 and 2002 in an Internal Medicine Ward. Results: Twenty nine patients (pts), with a mean age of 34.2 ±16.4 years and a male-to-female ratio 1:28. The onset was fulminant in 6.9%, acute in 20.7% and insidious or chronic in 72.4%. Asthenia (65.6%), anorexia (48.3%), nausea and vomiting (48.3%), were the most common symptoms; 24.1% were asymptomatic. Applying the scoring system of the International Autoimmune Hepatitis Group, the diagnosis was definitive in 69% and probable in 31%. HAI type I was diagnosed in 86.2%, 3.5% were type II and in 10.3% none of the standard antibodies were found. Two pts were positive for anti-VHC, 1 for HbsAg and 1 had a recent history of hepatitis A. Initial therapy was prednisolone in 13 pts and prednisolone + azathioprine in 15. Complete response was achieved in 39.3%, partial response in 7.1%, failure in 25% and relapse in 28.6%. Four patients underwent liver transplantation. During a mean follow-up period of 69 months (range, 1 to 213 months), the mortality was 13.8%: 2 pts died from hepatic failure, 1 from sepsis and 1 from herpetic meningitis. Conclusions: At the time of diagnosis, 24.1% of the patients were asymptomatic and 27.1% had cirrhosis; therapy with prednisolone and azathioprine was more effective than prednisolone monotherapy; liver transplantation was required in 4 patients; the evolution was favourable in the majority of cases