Severe hypoxaemia can predict unfavourable clinical outcomes in individuals with pulmonary embolism aged over 40 years

INTRODUCTION

Acute pulmonary embolism (APE) is an urgent clinical condition that can progress in a wide variety of ways. Therefore, we sought to develop an easy-to-apply algorithm, to be based on readily available clinical indicators, effective in predicting unfavourable outcomes.

METHODS

This was a retrospective cohort study based on systematically collected data in a database. The study included 102 patients with APE who were admitted to a tertiary care hospital. The following outcomes were defined as unfavourable shock, the need for mechanical ventilation, the use of thrombolytics, and death. Logistic regression analysis was used to explore variables significantly associated with outcome and to calculate post-test probabilities.

RESULTS

The prevalence of unfavourable outcomes was 25.5% (26 of the 102 patients with APE). The risk of an unfavourable outcome was reduced to 7.0% for patients with APE who were aged ≤ 40 years. In patients with APE who were aged > 40 years, the presence of hypoxaemia (i.e. peripheral oxygen saturation < 90%) alone increased the risk of an unfavourable outcome to 57.0%. A recent history of trauma and the presence of pre-existing lung or heart disease were significantly associated with unfavourable outcomes. The inclusion of those variables in the logistic regression model increased the post-test risk of an unfavourable outcome to 65.0%–86.0%.

CONCLUSION

Advanced age (i.e. > 40 years), the presence of hypoxaemia, a recent history of trauma and the presence of pre-existing lung or heart disease are risk factors for unfavourable outcome in patients with APE.     

Not all unexplained hypoxia is pulmonary embolism

Acute myocardial infarction is one of the conditions frequently managed in the emergency department. There are many complications associated with right ventricular infarction, and the incidence of right ventricular infarction associated with inferior myocardial infarction is as high as 51% based on electrocardiographic findings. We herein report the case of a 45-year-old Chinese man with inferior myocardial infarction complicated by right ventricular failure. He had hypoxaemia refractory to supplemental oxygen due to an acute right-to-left shunting through a patent foramen ovale (PFO). He underwent coronary angioplasty and closure of the PFO. It is crucial for the attending physician to consider the presence of a right-to-left shunt when there is persistent uncorrectable hypoxaemia despite maximal oxygen supplementation in the setting of right ventricular infarction, as there are clinical implications and certain clinical managing principles that should be applied.     

Clinics in diagnostic imaging (152). Right lower lobe segmental pulmonary embolus.

A 56-year-old man presented to the Accident and Emergency Department with pleuritic chest pain of sudden onset. He gave a history of short-distance air travel ten days earlier. Chest radiograph showed a peripheral-based opacity in the right lower zone, which was not seen in a previous study done three months ago, suggestive of Hampton’s hump. The D-dimer level was raised. Computed tomography pulmonary angiography confirmed the diagnosis of pulmonary embolism in a right lower lobe segmental branch, with adjacent collapsed lung, consistent with lung infarction. The patient was started on heparin injection with significant relief of his symptoms. The clinical and imaging features of pulmonary embolism are described, with emphasis on the historical radiographic signs and the current dual-energy computed tomography innovations.     

ECG series. Importance of QT interval in clinical practice

Long QT interval is an important finding that is often missed by electrocardiogram interpreters. Long QT syndrome (inherited and acquired) is a potentially lethal cardiac channelopathy that is frequently mistaken for epilepsy. We present a case of long QT syndrome with multiple cardiac arrests presenting as syncope and seizures. The long QTc interval was aggravated by hypomagnesaemia and drugs, including clarithromycin and levofloxacin. Multiple drugs can cause prolongation of the QT interval, and all physicians should bear this in mind when prescribing these drugs.     

Electrocardiographic changes in acute perimyocarditis

Pericarditis and myocarditis are characterised by electrocardiographic changes and elevated cardiac enzymes, respectively, and patients with perimyocarditis often complain of chest discomfort. These findings are nonspecific and often lead to diagnostic difficulties, as ST-elevation myocardial infarction commonly presents in a similar fashion. Clinical differentiation between perimyocarditis and myocardial infarction are especially important because adverse side effects can occur if reperfusion therapy is administered for a patient with acute pericarditis or if a diagnosis of acute myocardial infarction is missed. We herein describe a case of perimyocarditis with ST elevation and raised cardiac markers, which led to two emergency coronary angiographies that were subsequently found to be normal. We include the three serial electrocardiographies (ECGs) performed to show the characteristic features of perimyocarditis and further discuss the importance of identifying typical and atypical ECG features of pericarditis.     

Multiple oesophago-respiratory fistulae: sequelae of pulmonary tuberculosis in retroviral infection

Pulmonary tuberculosis (PTB) is a common infectious disease worldwide. However, mediastinal tuberculous lymphadenitis complicated by oesophageal involvement and oesophago-respiratory fistula is now uncommon due to improved anti-tuberculous regimes and better general awareness. The overall incidence of acquired oesophago-respiratory fistula due to infection is low, and therefore, the lesion is not often a frontrunner in differential diagnosis. Still, tuberculous oesophago-respiratory fistulae can potentially occur in patients with retroviral disease, as they tend to have atypical and more virulent manifestations. In this study, we report the case of multiple oesophago-respiratory fistulae in a patient with PTB and retroviral disease, and highlight the computed tomography features of these lesions as an atypical presentation of PTB in retroviral disease. Clinicians should suspect oesophago-respiratory fistulae if patients present with Ono’s sign, and remain particularly vigilant for patients with underlying PTB and retroviral disease, as early diagnosis and treatment could help to reduce mortality.     

Thoracic endometriosis with catamenial haemoptysis and pneumothorax: computed tomography findings and long-term follow-up after danazol treatment

Thoracic endometriosis (TE) is an uncommon disorder affecting women of childbearing age. We herein report clinical and thin-section computed tomography (CT) findings of two cases, in which one woman presented with catamenial haemoptysis (CH) alone and another woman presented with bilateral catamenial pneumothoraces (CP) coinciding with CH, a rare manifestation of TE. The dynamic changes demonstrated on thin-section chest CT performed during and after menses led to accurate localisation and presumptive diagnosis of TE in both patients. Following danazol treatment, the patient with CH alone had a complete cure, while the patient with CP and CH had an incomplete cure and required long-term danazol treatment. We discuss the role of imaging studies in TE, with an emphasis on the appropriate timing and scanning technique of chest CT in women presenting with CH, potential mechanisms, treatment and patient outcomes.     

Demographic profile,clinical characteristics,motivations and weight loss outcomes of patients in a nonsurgical weight management programme

INTRODUCTION

Weight management programmes (WMPs) can help overweight individuals lose weight, and thus prevent complications associated with obesity. Herein, we describe the demographic profile, clinical characteristics, motivations and expectations, and outcomes of patients enrolled in a nonsurgical WMP.

METHODS

This was a retrospective study of consecutive patients with a body mass index (BMI) of > 23 kg/m² enrolled in the four-month WMP at the Health For Life Clinic, Alexandra Hospital, Singapore, between 1 and 31 August 2009. Demographic data, medical history and source of referral were recorded. Details on personal motivations and weight loss goals were obtained from the completed self-administered questionnaires of the WMP participants. Weight, waist circumference, fat percentage and BMI were measured at the start and end of the WMP. A weight loss of ≥ 5% was deemed as a successful outcome.

RESULTS

A total of 58 patients (mean age 37.2 years) were included in our study. Of these 58 patients, 58.6% were of Chinese ethnicity and 55.2% were male. Many patients (32.8%) attributed their weight gain to work- or study-related stress, and a minority to poor eating habits (12.1%) or a lack of exercise (10.3%). Patients’ motivations included a desire for better health (53.4%) and better fitness (15.5%). However, only 53.4% patients scored their motivation as high (i.e. a score of > 7). The mean expected weight loss was 9.9 kg at 4 months, and 14.1 kg at 12 months. Among the 40 patients (69.0%) who completed the programme, the mean percentage weight loss was 1.8 ± 4.3%. A weight loss of ≥ 5% was achieved by 8 (13.8%) patients.

CONCLUSION

Although the patients in our study cohort were young and educated, only a portion of them appeared to be highly motivated to lose weight, despite joining the WMP. There is a need for patients to be guided on how to set realistic weight loss goals.     

Clinics in diagnostic imaging (155). Incidental PDA with secondary pulmonary arterial hypertension.

We report the case of a 70-year-old man with an asymptomatic large patent ductus arteriosus (PDA) incidentally detected on triple-rule-out computed tomography (CT). CT clearly demonstrated a vascular structure connecting the descending thoracic aorta to the roof of the proximal left pulmonary artery, consistent with a PDA. Secondary pulmonary arterial hypertension was also evident on CT. The patient was eventually diagnosed with acute coronary syndrome and was successfully treated with coronary artery bypass graft surgery and concomitant patch closure of the PDA. This article aims to outline the imaging features of PDA and highlight the information provided by CT, which is crucial to treatment planning. The pathophysiology, clinical manifestations and closure options of PDA are also briefly discussed.     

Relationship between pulmonary function and degree of spinal deformity,location of apical vertebrae and age among adolescent idiopathic scoliosis patients

INTRODUCTION

This retrospective review aimed to examine the relationship between preoperative pulmonary function and the Cobb angle, location of apical vertebrae and age in adolescent idiopathic scoliosis (AIS). To our knowledge, there have been no detailed analyses of preoperative pulmonary function in relation to these three factors in AIS.

METHODS

A total of 38 patients with thoracic or thoracolumbar scoliosis were included. Curvature of spinal deformity was measured using the Cobb method. Forced vital capacity (FVC) and forced expiratory volume in one second (FEV1) were used to evaluate preoperative pulmonary function. Statistical methods were used to analyse the relationship between preoperative pulmonary function and the factors that may contribute to poor pulmonary function.

RESULTS

The mean age of the patients was 16.68 ± 6.04 years. An inverse relationship was found between the degree of the Cobb angle and FVC as well as FEV1; however, the relationships were not statistically significant (p = 0.057 and p = 0.072, respectively). There was also a trend towards a significant negative correlation between the thoracic curve and FVC (p = 0.014). Patients with larger thoracic curves had lower pulmonary function. A one-year increase in age significantly decreased FVC by 1.092 units (p = 0.044). No significant relationship between age and preoperative FEV1 was found. The median FVC was significantly higher in patients with affected apical vertebrae located at levels L1–L3 than at T6–T8 or T9–T12 (p = 0.006).

CONCLUSION

Lung function impairment was seen in more severe spinal deformities, proximally-located curvature and older patients.     

Overlap syndrome between chronic obstructive pulmonary disease and obstructive sleep apnoea in a Southeast Asian teaching hospital

INTRODUCTION

Overlap syndrome between obstructive sleep apnoea (OSA) and chronic obstructive pulmonary disease (COPD) is important but under-recognised. We aimed to determine the prevalence of overlap syndrome and the predictors of OSA in patients with COPD.

METHODS

Patients aged ≥ 40 years were recruited from a dedicated COPD clinic and underwent overnight polysomnography. A diagnosis of OSA was made when apnoea-hypopnoea index (AHI) was ≥ 5.

RESULTS

In all, 22 patients (aged 71 ± 9 years), predominantly men, were recruited. Mean values recorded were predicted forced expiratory volume in the first second percentage 55 ± 15; body mass index 23.7 ± 6.5 kg/m²; Epworth Sleepiness Scale score 5.6 ± 5.8; and AHI 15.8 ± 18.6. Among the 14 patients with OSA (prevalence of overlap syndrome at 63.6%), the mean number of hospital visits for COPD exacerbations in the preceding one year was 0.5 ± 0.7. Patients with overlap syndrome had worse modified Medical Research Council dyspnoea scale scores and a lower percentage of rapid eye movement (REM) sleep than patients without. There were no other statistical differences in lung function or sleep study indices between the two patient groups.

CONCLUSION

The majority of our patients had overlap syndrome and minimal exacerbations, and were not obese or sleepy. Significant differences between patients with and without overlap syndrome were seen in two aspects – the former was more dyspnoeic and had less REM sleep. Our findings suggest that standard clinical predictors cannot be used for patients with overlap syndrome, and therefore, a high index of suspicion is needed.     

An unusual presentation of recurrent uterine rupture during pregnancy

We describe a case of recurrent uterine rupture at the site of a previous rupture. Our patient had a history of right interstitial pregnancy with spontaneous uterine fundal rupture at 18 weeks of pregnancy. During her subsequent pregnancy, she was monitored closely by a senior consultant obstetrician. The patient presented at 34 weeks with right hypochondriac pain. She was clinically stable and fetal monitoring showed no signs of fetal distress. Ultrasonography revealed protrusion of the intact amniotic membranes in the abdominal cavity at the uterine fundus. Uterine rupture is a rare but hazardous obstetric complication. High levels of caution should be exercised in patients with a history of prior uterine rupture, as they may present with atypical symptoms. Ultrasonography could provide valuable information in such cases where there is an elevated risk of uterine rupture at the previous rupture site.     

Recurrent wheeze and cough in young children: is it asthma?

A clinical diagnosis of asthma is often considered when a child presents with recurrent cough, wheeze and breathlessness. However, there are many other causes of wheeze in a young child. These range from recurrent viral infections to chronic suppurative lung disease, gastro-oesophageal reflux disease and rare structural abnormalities. Arriving at a diagnosis includes taking into consideration the symptomatology, triggers, atopic features, family history, absence of red flags and therapeutic trial, where indicated.     

Primary sarcomatoid carcinoma of the mandibular gingiva: clinicopathological and radiological findings

Sarcomatoid carcinoma is a rare, malignant biphasic neoplasm with an epithelial and a spindle cell component. Primary sarcomatoid carcinomas arising from mandibular gingiva are known to be extremely rare, with only one case reported to date. Herein, we discuss the radiographic and computed tomographic appearances and pathological features of primary mandibular sarcomatoid carcinoma, which was confirmed by clinicopathology, in a 72-year-old man. In addition, we present a brief review of the relevant literature.     

Unusual optic disc infarction in a case of arteritic anterior ischaemic optic neuropathy (AAION)

Herein, we report another case of arteritic anterior ischaemic optic neuropathy from Singapore, in which the initial optic disc swelling was extreme and the sequential disease resolved because the patient was already on maximum treatment. As the management of this biopsy-proven giant cell arteritis case was complicated by the presence of a number of other medical conditions, including end-stage renal failure, monitoring of the response to treatment proved problematic.     

Primary orbital hydatid cyst: computed tomography and magnetic resonance imaging findings

Orbital hydatid cyst is a rare form of hydatidosis, comprising less than 1% of all hydatid cysts reported. The first choice of treatment for orbital hydatid cyst is surgery. Preoperative diagnosis is important, so as to avoid rupture of the cyst and prevent the spread of the parasitic disease. Herein, we present the computed tomography and magnetic resonance imaging findings of a case of primary orbital hydatid cyst.     

超声造影在肺外周良恶性肿块鉴别诊断中的应用

目的  探讨超声造影技术（CEUS）在肺外周良、恶性肿块临床鉴别的意义及临床应用价值。方法  收集该院因肺部肿块住院患者,按增强CT扫描结果,选取肺外周肿块患者45例,行常规超声和CEUS检查,并以病理活检结果为金标准,评价CEUS在肺外周良、恶性肿块鉴别诊断中的临床价值。结果  良性肿块造影剂开始增强时间为（8.48±1.45）s;恶性肿块开始增强时间为（10.89±2.70）s;恶性肿块开始增强时间慢于良性肿块（P <0.05）。造影剂开始廓清时间恶性肿块为（100.63±13.63）s,良性肿块廓清时间为（137.57±12.61）s,造影剂消退时间慢于恶性肿块（P <0.05）。增强CT与CEUS诊断正确率分别为73.3%和77.8%,两者相结合诊断正确率为93.3%。增强CT联合CEUS诊断符合率显著高于单纯增强CT或CEUS诊断符合率（P <0.05）。增强CT联合CEUS诊断敏感性为95%,特异性为92%,经Kappa检验评估增强CT联合CEUS诊断肺外周肿块,具有极好的一致性。结论  超声造影对肺部良、恶性肿块的临床鉴别有重要作用,联合增强CT扫描可以更高地提高诊断正确率。

     

Does this patient really have chronic obstructive pulmonary disease?

Chronic obstructive pulmonary disease (COPD) is a condition commonly encountered by primary care practitioners. The disease should be detected in its early stages to prevent disease progression and to reduce the burden of symptoms. Early treatment also results in improved mortality and reduced morbidity. COPD should be differentiated from other similar conditions such as asthma, as the basis of treatment differs in these conditions, and misdiagnosis can lead to poorer patient outcomes. Non-pharmacological treatment such as smoking cessation and vaccinations are important in the management of COPD, while pharmacotherapy such as bronchodilators and antimuscarinics are the mainstay of therapy in COPD. Referral to a specialist is recommended when there is progression of the disease or uncertainty regarding the diagnosis.     

Haematological abnormalities in mitochondrial disorders

INTRODUCTION

This study aimed to assess the kind of haematological abnormalities that are present in patients with mitochondrial disorders (MIDs) and the frequency of their occurrence.

METHODS

The blood cell counts of a cohort of patients with syndromic and non-syndromic MIDs were retrospectively reviewed. MIDs were classified as ‘definite’, ‘probable’ or ‘possible’ according to clinical presentation, instrumental findings, immunohistological findings on muscle biopsy, biochemical abnormalities of the respiratory chain and/or the results of genetic studies. Patients who had medical conditions other than MID that account for the haematological abnormalities were excluded.

RESULTS

A total of 46 patients (‘definite’ = 5; ‘probable’ = 9; ‘possible’ = 32) had haematological abnormalities attributable to MIDs. The most frequent haematological abnormality in patients with MIDs was anaemia. 27 patients had anaemia as their sole haematological problem. Anaemia was associated with thrombopenia (n = 4), thrombocytosis (n = 2), leucopenia (n = 2), and eosinophilia (n = 1). Anaemia was hypochromic and normocytic in 27 patients, hypochromic and microcytic in six patients, hyperchromic and macrocytic in two patients, and normochromic and microcytic in one patient. Among the 46 patients with a mitochondrial haematological abnormality, 78.3% had anaemia, 13.0% had thrombopenia, 8.7% had leucopenia and 8.7% had eosinophilia, alone or in combination with other haematological abnormalities.

CONCLUSION

MID should be considered if a patient’s abnormal blood cell counts (particularly those associated with anaemia, thrombopenia, leucopenia or eosinophilia) cannot be explained by established causes. Abnormal blood cell counts may be the sole manifestation of MID or a collateral feature of a multisystem problem.