CHUSJ - Medicina Interna
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- Is there a C-reactive protein value beyond which one should consider infection as the cause of acute heart failure?Publication . Pereira, Joana; Ribeiro, Ana; Ferreira-Coimbra, Joao; Barroso, Isaac; Guimaraes, Joao-Tiago; Bettencourt, Paulo; Lourenco, PatriciaBACKGROUND: Heart Failure (HF) is a low grade inflammatory condition. High sensitivity C-reactive protein (hsCRP) is an established marker of inflammation. A cut-off value of hsCRP beyond which an infection should be sought has never been studied in HF. We aimed to determine the best hsCRP cut-off for infection prediction in acute HF. METHODS: We analyzed patients included in an acute HF registry - EDIFICA (Estratificação de Doentes com InsuFIciência Cardíaca Aguda). Admission hsCRP measurement was available as part of the registry's protocol. Patients with acute coronary syndrome as the cause of acute HF were excluded from the registry. Infection was considered according to the diagnosis registered in the discharge record. A receiver-operating characteristic (ROC) curve was used to determine the best hsCRP cut-off for infection prediction. RESULTS: We studied 615 patients. Mean age was 76 years, 45.2% were male, 60.3% had systolic dysfunction. Median admission hsCRP was 20.3 (9.5-55.5)mg/L; in 41.6% the cause of decompensation was an infection. The area under the ROC curve for admission hsCRP in the prediction of infection was 0.79 (0.76-0.83); the best hsCRP cut-off was 25 mg/L with a sensitivity of 72.7%, specificity 77.2%, positive predictive value 69.4% and negative predictive value 79.9%. Age and elevated hsCRP independently associated with an infection as the precipitant of acute HF. CONCLUSIONS: We suggest 25 mg/L as a cut-off beyond which an infection should be sought underlying acute HF. Almost 80% of the patients with hsCRP< 25 mg/L are not infected and 69.4% of those with higher hsCRP have a concomitant infection.
- Azathioprine-induced interstitial nephritis in an anti-neutrophil cytoplasmic antibody (ANCA) myeloperoxidase (MPO) vasculitis patientPublication . Pires da Rosa, Gilberto; Marques, Sofia; Coelho, Fátima; Pereira, Edite; Ferreira, Ester; Rodrigues-Pereira, Pedro; Dias, Dias; Bettencourt, PauloAzathioprine (AZA) is used in a wide array of autoimmune diseases, still corresponding to the mainstay maintenance therapy in anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides. Although generally well-tolerated, several side effects are recognized. We report the case of a 50-year-old Caucasian man with kidney-limited ANCA myeloperoxidase (MPO) vasculitis who presented with general malaise, fever, worsening renal function, and elevated inflammatory markers 2 weeks after the initiation of therapy with oral AZA. Although a disease relapse was suspected, renal biopsy revealed an eosinophilic infiltrate, suggestive of acute interstitial nephritis. After suspension of AZA, a sustained improvement of renal function and normalization of inflammatory markers was observed. A diagnosis of allergic interstitial nephritis secondary to AZA was established, corresponding to the first biopsy-proven case described in an ANCA MPO vasculitis patient. Although rare, renal toxicity of AZA must be present in the clinician's mind, avoiding the straightforward assumption of disease relapse in the case of worsening renal function.
- Congenital anomalies of the coronary arteriesPublication . Silva, Andreia; Baptista, Maria João; Araújo, EmanuelCongenital coronary artery anomalies are modifications of their origin, course or structure and its incidence varies between 0,2 and 5,6% of the general population. Although the majority is asymptomatic, they are the second leading cause of sudden cardiac death in young athletes. The aim of this study is to highlight the main anomalies with hemodynamic significance, including the anomalous origin of a coronary artery from the opposite sinus and anomalous origin of the left coronary artery from pulmonary artery. The anomalous aortic origin of a coronary artery from the opposite sinus accounts for 14-16% of all cardiac deaths, that unexpectedly occur in healthy children or young athletes during or immediately after exercise. The mechanism responsible for the compression/occlusion of the coronary artery originating from the opposite sinus is still unclear and there are several proposed mechanisms. The clinical presentation of these patients is variable and physical examination is normal in most individuals. Transthoracic echocardiogram is the diagnostic test most commonly used. Treatment and management are controversial topic. The anomalous origin of the left coronary artery from pulmonary artery is a very rare condition and without surgery, most infants die within the first 12 months of life. The echocardiogram is also the method of choice for diagnostic confirmation. The diagnosis of this congenital anomaly in an infant, usually seriously ill, is an indication for urgent surgery. Because these anomalies produce hemodynamic changes, it is important an early diagnosis and treatment.
- Psoriasis and comorbidities: general practitioners’ awarenessPublication . Costa-Silva, Miguel; Vide, Julia; Lopes, Sofia; Azevedo, Filomena; Magina, SofiaINTRODUCTION: Systemic inflammatory diseases such as psoriasis, systemic lupus erythematosus (SLE), and rheumatoid arthritis (RA) are associated with an increased prevalence of cardiovascular diseases (CVD) and other comorbidities. The primary aim of this study was to assess the screening practices of general practitioners (GPs) with regard to the most frequent comorbidities in patients with psoriasis. METHODS: We adapted, with permission, a questionnaire that was used by Parsi et al. in 2012, which was then distributed to GP residents and consultants. RESULTS: Overall, 372 questionnaires were collected. Significantly more physicians screen for CV risk factors in patients with RA and SLE than in patients with psoriasis. There was no statistically significant difference between GP residents in the initial and final phase of residency, or between GP residents and consultants regarding awareness of increased prevalence of CVD in psoriasis or comorbidity screening practices in psoriasis patients. CONCLUSIONS: Most GP residents and consultants that participated in this study are not aware of an increased CV risk in patients with psoriasis and assign greater importance regarding this risk to other inflammatory diseases such as RA and SLE.
- Standardization of laboratory lipid profile assessment: A call for action with a special focus on the 2016 ESC/EAS dyslipidemia guidelines – Executive summary: A consensus endorsed by the Cardiovascular Risk and Prevention Group of the Portuguese Internal Medicine Society, the Portuguese Atherosclerosis Society, the Portuguese Society of Cardiology, the Portuguese Society of Laboratory Medicine, and the Portuguese Association of Clinical ChemistryPublication . Marques da Silva, Pedro; Sequeira Duarte, João; von Hafe, Pedro; Gil, Victor; Nunes de Oliveira, Jorge; de Sousa, GermanoEven with improvements in lifestyle interventions, better control of cardiovascular (CV) risk factors, and improvements in CV outcomes, cardiovascular disease (CVD) remains the leading cause of morbidity and mortality in Portugal and Europe. Atherogenic dyslipidemias, particularly hypercholesterolemia, have a crucial causal role in the development of atherosclerotic CVD. The clinical approach to a patient with dyslipidemia requires an accurate diagnosis, based on harmonized and standardized lipid and lipoprotein laboratory assessments. Results and reports of these tests, together with assessment of total CV risk and the respective therapeutic targets, will help ensure that clinical guidelines and good clinical practices are followed, increasing the reliability of screening for lipid disorders, producing more accurate diagnoses and CV risk stratification, and improving CV prevention. To this end, this consensus aims to provide clinicians with practical guidance for the harmonization and standardization of laboratory lipid tests, focusing on the most recent dyslipidemia management guidelines.