Systemic lupus erythematosus presenting as acute lupus pneumonitis in a young female

Acute lupus pneumonitis is a rare initial presentation of systemic lupus erythematosus (SLE). We report a 19-year-old female presenting with fever and recurrent hemoptysis with radiological evidence of parenchymal lung involvement with mild pleural effusion. Subsequent development of malar and discoid rash with anti-nuclear antibodies (ANA) and anti-dsDNA positivity clinched the diagnosis. Her clinical signs and symptoms resolved with a course of intravenous pulse methyl-prednisolone along with radiological resolution.KEY WORDS: Acute lupus pneumonitis, hemoptysis, systemic lupus erythematosus     

Health status of newly arrived refugees in Toronto,Ont: Part 1: infectious diseases

Objective

To determine the prevalence of selected infectious diseases among newly arrived refugee patients and whether there is variation by key demographic factors.

Design

Retrospective chart review.

Setting

Primary care clinic for refugee patients in Toronto, Ont.

Participants

A total of 1063 refugee patients rostered at the clinic from December 2011 to June 2014.

Main outcome measures

Demographic information (age, sex, and region of birth); prevalence of HIV, hepatitis B, hepatitis C, Strongyloides, Schistosoma, intestinal parasites, gonorrhea, chlamydia, and syphilis infections; and varicella immune status.

Results

The median age of patients was 29 years and 56% were female. Refugees were born in 87 different countries. Approximately 33% of patients were from Africa, 28% were from Europe, 14% were from the Eastern Mediterranean Region, 14% were from Asia, and 8% were from the Americas (excluding 4% born in Canada or the United States). The overall rate of HIV infection was 2%. The prevalence of hepatitis B infection was 4%, with a higher rate among refugees from Asia (12%, P < .001). Hepatitis B immunity was 39%, with higher rates among Asian refugees (64%, P < .001) and children younger than 5 years (68%, P < .001). The rate of hepatitis C infection was less than 1%. Strongyloides infection was found in 3% of tested patients, with higher rates among refugees from Africa (6%, P = .003). Schistosoma infection was identified in 15% of patients from Africa. Intestinal parasites were identified in 16% of patients who submitted stool samples. Approximately 8% of patients were varicella nonimmune, with higher rates in patients from the Americas (21%, P < .001).

Conclusion

This study highlights the importance of screening for infectious diseases among refugee patients to provide timely preventive and curative care. Our data also point to possible policy and clinical implications, such as targeted screening approaches and improved access to vaccinations and therapeutics.Canada accepts approximately 25 000 refugees from around the world each year.¹ The health characteristics of refugees often differ from those of Canadian-born individuals and nonrefugee immigrants, and studies have shown that refugees tend to experience poorer health outcomes.^2,3 The burden of disease depends on country of origin, exposures, previous living conditions and access to health care, migration pathways, and various other factors.³ Standardized health screening for refugee claimants before or on arrival in Canada is limited to the Immigrant Health Examination, consisting of a brief history and physical examination, chest x-ray scan (age 11 and older), urine test (age 5 and older), and syphilis and HIV testing (age 15 and older).⁴ Thorough and more comprehensive medical care is at the discretion of subsequent health care providers, when or if refugees are able to access care. Providers might be unfamiliar with the acute and chronic health conditions affecting these migrant populations.There are limited published data on the health of refugees and refugee claimants in Canada. This study reviews the prevalence of health conditions of newly arrived refugees and claimants at a refugee clinic in Toronto, Ont, with subanalysis by key demographic factors. Screening practices and key health indicators were guided by the 2011 Evidence-based Clinical Guidelines for Immigrants and Refugees from the Canadian Collaboration for Immigrant and Refugee Health.³ This first article in our 2-part series details infectious diseases, and our accompanying article (page e310) explores chronic conditions,⁵ both with a view to enhancing clinical care for refugees.     

Health status of newly arrived refugees in Toronto,Ont: Part 2: chronic diseases

Objective

To determine the prevalence of selected chronic diseases among newly arrived refugee patients and to explore associations with key demographic factors.

Design

Retrospective chart review.

Setting

Primary care clinic for refugee patients in Toronto, Ont.

Participants

A total of 1063 refugee patients rostered at the clinic from December 2011 to June 2014.

Main outcome measures

Demographic information (age, sex, and region of birth) and prevalence of abnormal Papanicolaou test results, anemia, elevated blood pressure (BP), and markers of prediabetes or diabetes (elevated random glucose, fasting glucose, or hemoglobin A_1c levels).

Results

More than half of our patients were female (56%) and the median age was 29 years. Patients originated from 87 different countries of birth. Top source countries were Hungary (210 patients), North Korea (119 patients), and Nigeria (93 patients). Most patients were refugee claimants (92%), as opposed to government-assisted refugees (5%). Overall, 11% of female patients who underwent Pap tests had abnormal cervical cytology findings, with the highest rates among women from Asia (26%, P = .028). The prevalence of anemia among children younger than 15 years was 11%; for children younger than 5 years the prevalence was 14%. Approximately 25% of women older than 15 years had anemia, with the highest rates among African women (37%, P < .001). Elevated BP was observed in 30% of adult patients older than 15 years, with higher prevalence among male patients (38%, P < .001) and patients from Europe (42%, P < .001). Laboratory markers of prediabetes or diabetes were identified in 8% of patients older than 15 years, with higher rates among patients from Europe (15%, P = .026).

Conclusion

This study found a notable burden of chronic diseases among refugee patients, including anemia, elevated BP, and impaired glycemic control, as well as abnormal cervical cytology findings. These results underscore the importance of accessible, comprehensive primary care for refugees, with attention to prevention and management of chronic diseases in addition to management of infectious disease.Canada accepts approximately 25 000 refugees from around the world each year.¹ However, there is a paucity of Canadian data on the health of this vulnerable population. This is the second article of a 2-part series examining the health status of newly arrived primarily refugee claimants in Toronto, Ont. We examine the prevalence of conditions for which refugee patients are routinely screened, largely based on the 2011 Evidence-based Clinical Guidelines for Immigrants and refugees from the Canadian Collaboration for Immigrant and Refugee Health.² Our first article explored the prevalence of key infectious diseases (page e303).³ In this article, we examine the rates of several chronic diseases and their association with key demographic factors, including sex, age, and region of birth.Globally, there is a rising burden of chronic disease, including in the low- and middle-income countries from which many refugees originate.⁴ Refugees might also be at increased risk of developing chronic disease as they resettle in Canada and adapt to different lifestyles and diets. Through enhanced understanding of the chronic health conditions affecting this population, we aim to improve clinical care for refugees.     

STABILIZATION OF THORACOLUMBAR SPINAL INJURIES

Spinal Cord injury cases are being managed in Base Hospital Delhi Cantt since Oct. 97. 27 cases of thoracolumbar injuries were admitted in this hospital during the period Oct 97 to Aug 99. 20 patients underwent surgical treatment (9 thoracic and 11 lumbar) and 7 were treated conservatively. All these operations were done within 3 weeks following trauma, and methylprednisolone therapy was instituted in those who reached the hospital early. Contraindications to surgery included stable fracture, bed sores, any focus of sepsis and generalized bone disorders. Transpedicular fixation with Dyna-lok system was done in 10 cases, universal spinal system was applied in 6 cases and Harrington instrumentation was carried out in 4 cases. Decompression laminectomy was done in all cases. Patients with incomplete cord injury showed neurological improvement and early rehabilitation was possible after surgery.KEY WORDS: Harrington instrumentation, Pedicle screw and plate, Spine trauma, Thoracolumbar fractures     

Cognitive impairment after transurethral resection of the prostate (TURP)

Purpose: It has been suggested that cognitive impairment may occur following transurethral resection of the prostate (TURP) operations due to the effects of anaesthesia or hyponatraemia or both. The aim of the study was to investigate whether TURP was associated with long-term memory complaints or cognitive impairment. Method: Patients who had received a TURP or transurethral resection of a bladder tumour (TURT) in the previous 10 months were sent a questionnaire on memory problems and mood. Seventy-six TURP patients and 38 TURT patients returned the completed questionnaires. A sample of each patient group (30 TURP, 29 TURT) was assessed on standardized tests of cognitive abilities. Results: There was no significant difference between the TURP and TURT patients on the Everyday Memory Questionnaire completed by themselves or by a family member (p?&gt;?0.05). On formal cognitive testing there were no significant differences between the groups, except on the overall grading of the Kendrick Assessment Scales of Cognitive Ageing, in which TURP patients performed at a significantly lower level than TURT patients. Conclusions: The results suggest that patients are no more likely to complain of memory problems following a TURP than with any other operative procedure. There was a slight difference in cognitive abilities but this did not indicate significant impairment of cognitive function.     

Imaging in Juvenile Nasopharyngeal Angiofibroma: Clinical Significance of Ramharan and Chopstick Sign

Imaging plays an important role in the diagnosis, staging and prognosis of JNA. Certain radiological changes as seen on CECT were observed to be consistent in our case series. This study analysed preoperative and postoperative CECT of large series of JNA patients to evaluate the sites and pattern of spread of tumor. We evaluated the clinical significance of pterygoid wedge in preoperative and postoperative imaging and thus elucidating two new radiological signs. Retrospective analysis of the pre operative and post operative imaging data of 242 patients with JNA. The findings in the scan were clinically correlated with the endoscopic intraoperative findings. Preoperative evaluation of the pterygoid wedge revealed widening on the involved side in 99.1% of our cases which is 1.8 times greater compared to the uninvolved side. The possibility of residual/recurrent tumor was found to be significantly higher in those where the pterygoid wedge was not removed by drilling (p < 0.001) Drilling of the pterygoid wedge intra operatively, reduced the rate of residual/recurrence from 31.9 to 3.07%. Widening of the pterygoid wedge seen in the preoperative CECT, referred as RAM HARAN sign occurs in JNA. It has a significant diagnostic value as a radiological sign in JNA. Drilling of the pterygoid wedge intraoperatively reduces the rate of recurrence of JNA. Appearance of the two pterygoid plates on postoperative CECT, as two parallel lines, referred as Chopstick sign, has a remarkable prognostic value as a radiological sign in JNA.