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WORLD HOSPITAL DIRECTORY
Internal Medicine Medical QJM: An International Journal of Medicine - current issue
<span class="paragraphSection">As of April 2024, Japan has implemented a reform that limits doctors’ overtime hours to 960 h per year, comparable to that of general workers. Medical care in Japan has been supported by the long working hours of doctors, which has led to growing concerns over the issues of overwork-related deaths and health problems among medical professionals. This reform was implemented to reform doctors’ working environment, as well as to maintain a sustainable medical care delivery system.<a href="#hcae243-B1" class="reflinks"><sup>1</sup></a> However, there is concern that this regulation may exacerbate the current shortage of obstetricians.</span>
<span class="paragraphSection"><div class="boxedTextSection">Learning points for cliniciansLupus anticoagulant hypoprothrombinemia syndrome (LAHPS) is an unusual pathology that mostly presents with bleeding manifestations.<a href="#hcae230-B4" class="reflinks"><sup>4</sup></a> Most cases are secondary to lupus or viral infections (seen in the pediatric age group).<a href="#hcae230-B5" class="reflinks"><sup>5</sup></a> The treatment is commonly done with high doses of corticosteroids. Second-line immunosuppressants like cyclophosphamide, Rituximab (as it has been approached in this case) generally give favorable results. In this case report, the patient presented with the most common manifestations of LAHPS, which is bleeding, and with the use of immunosuppressants, the patient showed significant improvement.</div></span>
<span class="paragraphSection">Takeda Science Foundation10.13039/1000074492024045547Japan Society for the Promotion of Science10.13039/50110000169122K09140</span>
<span class="paragraphSection"><div class="boxedTextSection">Learning points for cliniciansThyroid hormone synthesis disorders that are discovered in adulthood is often misdiagnosed as Hashimoto’s disease or adenomatous goiter. We report a case that was initially diagnosed as Hashimoto’s disease but is suspected to have mutations of Thyroid peroxidase, which encodes a membrane-bound glycoprotein.</div></span>
<span class="paragraphSection">The possibility that dengue might have been a trigger for sickle cell disease (SCD)-related pleural effusion<a href="#hcae222-B1" class="reflinks"><sup>1</sup></a> should generate a heightened vigilance for complications that might be common both to dengue fever (DF) and to SCD, especially in parts of the world where both dengue and SCD are coprevalent. One such complication is pericardial effusion, with or without tamponade, which has been reported both in DF<a href="#hcae222-B2" class="reflinks"><sup>2–7</sup></a> and in SCD.<a href="#hcae222-B8" class="reflinks"><sup>8–11</sup></a></span>
<span class="paragraphSection"><div class="boxedTextSection">Learning points<ul><li class="bullet">Thrombotic microangiopathy is an increasingly recognized complication of vasculotoxic snake envenomation, mainly with viper species. Its delayed onset during the resolution of venom-induced consumptive coagulopathy underscores the need for vigilant monitoring, particularly in high-risk groups like pregnant women.</li><li class="bullet">Plasmapheresis may offer potential benefits in severe snakebite-associated thrombotic microangiopathy, especially in pregnancy, given dual maternal-fetal health risks.</li></ul></div></span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Background</div>Nonimmune hydrops fetalis (NIHF) presents as life-threatening fluid collections in multiple fetal compartments and may be led by numerous etiologies.<div class="boxTitle">Aim</div>To establish the diagnostic yield of exome sequencing for single-gene disorders in unexplained NIHF and to evaluate the clinical utility of data reanalysis.<div class="boxTitle">Methods</div>A series of 53 unexplained cases of NIHF were enrolled, including 39 cases met a strict definition of NIHF and 14 cases with increased nuchal translucency (NT) and/or cystic hygroma in combination with other fluid collections. Trio ES from fetal samples and parental blood was performed, and clinical reports were returned by geneticists and genetic counselors. Multidisciplinary team forums were conducted for accurate diagnoses and improved patient management. The clinical follow-up assessments were conducted, and the reanalysis was performed for cases with a non-positive result.<div class="boxTitle">Results</div>Diagnostic variants were identified in 22.6% (12/53) of the cases, and variants of potential clinical significance were detected in an additional 13.2% (7/53) of the cases. Of them, three possible diagnoses (3/41, 7.3%) were obtained during reanalysis. Notably, half of the diagnosed cases were from the group exhibiting only skin edema and increased NT and/or cystic hygroma. The diagnostic rate in this group was 42.8% (6/14), while in the classically defined NIHF group, the rate was 15.4% (6/39). The pregnancy termination and live birth rates of the cases with positive genetic testing results were found to be statistically significantly different from those with negative results (91.7% vs. 53.6% and 8.3% vs. 36.6%, <span style="font-style:italic;">P </span><<span style="font-style:italic;"> </span>0.05 for both).<div class="boxTitle">Conclusion</div>ES provides high incremental diagnostic yield for NIHF after standard-of-care testing, and reevaluating non-diagnostic exomes in light of updated knowledge can maximize diagnostic yield. Identifying the etiology of NIHF facilitates prenatal diagnosis, improves the management of NIHF cases and predicts recurrence risk in future pregnancies.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Background</div>From November 2022 to February 2023, China has experienced a surge period of COVID-19 pandemic and doctors and nurses working in hospitals have suffered from serious psychological crisis because of the medical crowding, which may result in the occurrence of suicidal ideation (SI). This study aims to explore the prevalence and influencing factors of SI during this surge phase.<div class="boxTitle">Methods</div>A multicenter cross-sectional study was conducted in China from 5 January 2023 to 9 February 2023. Data were collected by online questionnaires, with SI measured by a single item. Ordinal logistic regression analysis and stratified analyses were preformed to identify influencing factors.<div class="boxTitle">Results</div>A total of 5696 doctors and nurses were retained for further analysis, with 25.28% reporting SI during the COVID-19 surge phase. Participants experiencing anxiety symptoms or supporting other departments treating COVID-19 patients were more likely to report SI. Additionally, higher levels of resilience, mindfulness, and perceived social support were protective factors against SI.<div class="boxTitle">Conclusion</div>During the COVID-19 surge phase, over a quarter of doctors and nurses in China suffered from SI, which should be of great concern. Tailored interventions should be implemented to alleviate SI among doctors and nurses when new infectious diseases outbreak in the future.</span>
<span class="paragraphSection">Thirty-one-year-old female, presented with insidious onset gradually progressive pain in bilateral shoulders, bilateral groyne and bilateral knees for the last 6 months. It was not associated with any history of pain or swelling of joints. She was diagnosed as case of autoimmune hepatitis 4 months ago and was started on high-dose oral corticosteroids and continued on tapering dose of steroids. Musculoskeletal examination revealed painful restriction of bilateral shoulder and hip joints along with widespread pain. Rest of the systemic examination was normal. Her haematological, biochemical parameters, metabolic parameters and acute phase reactants were normal. Her X-ray bilateral shoulder, hip and knee joints were non-contributory. Her magentic resonance imaging right shoulder revealed geographic areas of altered signal intensity involving right humerus head (hyperintense on T2WI/STIR and hypointense on T1WI) suggesting stage IV osteonecrosis of right humerus head (<a href="#hcae182-F1" class="reflinks">Figure 1A</a>). In view of widespread pain, bone scan was done which revealed significantly increased osteoblastic activity at bilateral shoulder, hip and knee joints suggestive of multifocal osteonecrosis (MFON). Single photon emission computed tomography (SPECT) bone scintigraphy was done in view of widespread pain, revealed “doughnut like appearance or ring sign” (increased uptake in the periphery with centrally photogenic region) of the right hip joint and confirmed the diagnosis of MFON (<a href="#hcae182-F1" class="reflinks">Figure 1B</a>). Her oral steroids was reduced to minimal dose and was referred to the orthopaedic consultation was taken. She was advised the initial trial of conservative management with watchful observation. We highlight this case to sensitize clinicians about this rare entity, especially in the setting of autoimmune diseases on long-term steroids.</span>
<span class="paragraphSection">A 40-year-old female presented to our institution with irregular vaginal bleeding over 1 year ago. The pathological examination via colposcopy confirmed a diagnosis of non-keratinizing squamous cell carcinoma (moderately differentiated, stage IIIC), with the tumor measuring 7.3 × 5.8 × 4.7 cm. Moreover, bilateral iliac vascular metastasis was suspected, with the largest lymph node located near the left external iliac vessels. The patient subsequently underwent treatment at our hospital, including radiotherapy, chemotherapy, immunotherapy and targeted therapy. During the course of treatment, regular imaging studies were performed to monitor the progression and metastasis. These studies revealed multiple pulmonary nodules, enlarged cervical lymph nodes and bone metastases (<a href="#hcae178-F1" class="reflinks">Figure 1A–C</a>), with the largest located in the posterior segment of the right lower lobe, measuring ∼32 mm in maximum diameter, suggestive of lung metastasis. The patient subsequently developed bad cough, shortness of breath, fatigue and occasional sweating. Less than 3 months later, the appearance of clubbed digits (<a href="#hcae178-F1" class="reflinks">Figure 1D</a> and <a href="#hcae178-F1" class="reflinks">E</a>) and positive Schamroth sign (<a href="#hcae178-F1" class="reflinks">Figure 1F</a>) were observed. The patient had no prior history of clubbing or any common underlying diseases typically associated with this condition. The patient is currently continuing with the current treatment regimen and closely monitored in the outpatient department.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Background</div>Fluid therapy with normal saline (NS) in diabetic ketoacidosis (DKA) can cause hyperchloremic acidosis and delay DKA resolution. Balanced crystalloids may address this concern, though results with Ringer lactate and Plasma-Lyte have been mixed.<div class="boxTitle">Aim</div>This study aimed to compare the effectiveness of Sterofundin (SF) vs. NS in the management of DKA.<div class="boxTitle">Methods</div>A prospective, intervention trial with historical controls was conducted at the Postgraduate Institute of Medical Education and Research, Chandigarh, India. Patients aged 13 years or older with DKA were enrolled. The primary outcome was the time taken to DKA resolution, with a predefined superiority margin of a one-fourth reduction in resolution time. Secondary outcomes included total intravenous fluid and short-acting regular insulin requirements, the need for 0.45% saline, hospital stay duration and in-hospital mortality.<div class="boxTitle">Results</div>A total of 150 patients (mean age 36.8 years, 56.7% males) were included, with 75 receiving SF (intervention group) and 75 receiving NS (historical control group). The SF group showed a significantly shorter mean time to DKA resolution (13.8 ± 6.0 h) compared to the NS group (18.1 ± 5.5 h; <span style="font-style:italic;">P</span> < 0.001). SF patients required less total intravenous fluid (4500 vs. 6000 ml; <span style="font-style:italic;">P</span> = 0.004), less insulin (98 units vs. 112 units; <span style="font-style:italic;">P</span> = 0.017) and had a lower need for 0.45% saline (8% vs. 74.3%; <span style="font-style:italic;">P</span> < 0.001). Patients receiving SF had shorter hospital stays (4 [interquartile range, IQR 3–5] days vs. 4 [IQR 4–6] days; <span style="font-style:italic;">P</span> = 0.020). Mortality rates were similar between the groups (SF: 9.3%, NS: 8.1%; <span style="font-style:italic;">P</span> = 0.791).<div class="boxTitle">Conclusion</div>SF may be a superior alternative to NS for fluid therapy in DKA.</span>
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