Internal Medicine Consultation Research Articles

Current management of Staphylococcus aureus bacteremia in a Japanese university hospital.

Consultation with infectious disease specialists is associated with reduced patient mortality in the care of patients with Staphylococcus aureus bacteremia (SAB) through appropriate management of complications including infective endocarditis. This study aimed to determine the rates of confirmation of a negative blood culture, implementation of echocardiography, and administration of appropriate antibiotics in patients with SAB at a university hospital in Japan that provides general internal medicine and not an infectious disease consultation service. We conducted a retrospective cohort study at Dokkyo Medical University Hospital in Japan. Patients eligible for inclusion in the study were ≥20 years of age with ≥1 positive blood culture for S. aureus identified in a clinical microbiology laboratory. The primary outcome was the proportion of patients with confirmation of a negative blood culture, implementation of echocardiography, and administration of appropriate antimicrobial agents. A total of 109 patients with SAB were included in the analysis. Follow-up blood cultures were collected in 91 patients and negative results were documented in 88 patients. Follow-up blood culture collection was performed within 4 days of the initial blood culture collection in 49 patients. Echocardiography was performed appropriately in 40 patients. Appropriate antibiotic therapy was administered in 36 patients. Quality-of-care indicators were more commonly implemented in patients with SAB who received general internal medicine consultation than in those who did not.

Biochemical and nutritional determinants of non-alcoholic fatty liver disease in Omani adult patients: a case-control study

Background: Non-Alcoholic Fatty Liver Disease (NAFLD) is a risk factor for atherosclerosis, diabetes, kidney disease, and liver cirrhosis. Limited research exists on the biochemical and nutritional elements influencing NAFLD among adult patients in Oman. Objective: This study aimed to characterize the biochemical parameters and nutritional factors of Omani adults diagnosed with NAFLD at the Diwan Polyclinic in Muscat, Oman. Methods: This retrospective case–control study included 104 participants (52 cases and 52 controls) who have 2 or more risk factors for NAFLD and were referred to the Radiology department from January 2021 to January 2022 for abdominal ultrasound after Internal Medicine consultations. A validated scale, incorporating a semi-quantitative food frequency questionnaire, was employed. Results: The study revealed a significantly higher risk of NAFLD among men (69%) compared to women (31%). A common characteristic among participants was a prior diabetes diagnosis, 61.5% of the case group and 65% of the control group. While average liver enzyme levels were within the normal range for both groups, alanine transaminase levels were notably elevated in the case group. The case group exhibited a significantly higher average caloric intake than the control group. Conclusion: NAFLD is significantly more common among men. Alanine transaminase is significantly high in NAFLD group, which might be considered as a biochemical marker for NAFLD, but further investigations are needed. Moreover, high daily caloric intake is directly related to NAFLD.

Quel bilan proposer après une grossesse compliquée de pathologie vasculo-placentaire ?

Vasculo-placental disorders include pregnancy complications resulting from placental dysfunction of vascular origin, i.e. pre-eclampsia, HELLP syndrome, intrauterine growth retardation (IUGR), placental abruption and stillbirth of vascular origin. Pre-eclampsia should be investigated for antiphospholipid syndrome (APS) in case of severe pre-eclampsia and premature delivery before 34 weeks of gestation. In addition to testing for APS, pathological report of the placenta can identify some anatomical predispositions to placental vascular malperfusion, as well as chronic placental inflammatory lesions and excess fibrin deposits. The latter two are associated with IUGR and recurrent stillbirth, reflecting a dysimmune process of maternal origin. The internal medicine and obstetrics consultation, organized two months after delivery, combines the postnatal visit with an assessment of the causes of vasculo-placental disorders, and enables to inform patients about the management of future pregnancies and their cardiovascular health.

Delayed diagnosis and missed opportunities in the early detection of atrial fibrillation: a cross-sectional study

IntroductionWe analysed the frequency of atrial fibrillation (AF) delayed diagnosis and the factors associated with it in newly diagnosed patients. MethodsThis was a descriptive, cross-sectional, multicentre study. Data were collected from newly diagnosed patients with AF through medical records review and interviews during cardiology, internal medicine, primary care and emergency department consultations in Spain. ResultsA total of 201 physicians participated in the study (64.2% cardiologists, 21.4% internists). 948 patients (58% men; mean age 72.8 years) were included. In 41.8% of patients, AF was classified as paroxysmal at diagnosis, 30.9% as persistent and 27.3% as permanent. The diagnosis was coincidental in 37%. It was considered that a delayed diagnosis occurred in 49.3% of patients. This delay was associated with the presence of permanent or persistent AF, older age or valvular disease. 74.8% of patients had some contact with the healthcare system in the preceding year. The diagnosis could have been established between 1 and 6 months earlier in 50.7% of cases and more than six months earlier in 20.1%. 54.4% of the patients had experienced AF compatible symptomatology previously. Of these, 32.6% had a consultation without a diagnosis. ConclusionsIn a significant proportion of AF cases, there is a diagnostic delay. Many people with compatible symptoms neither seek consultations nor contact the healthcare system facilities. Consequently, the opportunity for early diagnosis is lost.

The Burden of Chronic Obstructive Pulmonary Disease COPD in Stable Patients and its Association with Inflammatory Biomarkers and Body Mass Index

Background: Chronic obstructive pulmonary disease (COPD) is a progressive airflow limitation that is preventable but not curable. It is associated with persistent symptoms that cause a considerable burden on individual productivity at work, and daily activities, and reduced quality of life, also burdening the healthcare system and society. Objectives: The study aims to measure the burden of COPD on patients in terms of daily activities and work productivity. It also seeks to investigate some inflammatory biomarkers' levels and their correlation with selected outcomes. Patients and Methods: A cross-sectional study on 120 stable COPD patients who were diagnosed and treated according to the GOLD guidelines at Kirkuk General Hospital's chest and Internal Medicine consultation clinics, and in private internist clinics in Kirkuk City, Iraq between January and April 2023. The Work Productivity and Activity Impairment Questionnaire (WPAI-COPD) measured the Burden of COPD. The symptom burden was assessed by the COPD assessment test (CAT). The level of IL-6 monoclonal antibodies was measured via a Roche Cobas 6000 analyzer and TNF-α using the ELISA sandwich technique. All these devices and machines were authorized by the Ministry of Health, Iraq. Results: The mean age was (54.1 ± 8.12) years, 62.5% being males and 37.5% being females; 41.7% were public sector employees, and 39.2% were self-employed. Due to COPD, the overall work loss was (45.9±18.91) days, the mean percentage of absenteeism was (10.9% ± 12.31%), activity impairment was (47.5% ±17.79%) among all patients, presenteeism was (40.8 ± 15.05%,) and COPD-related retirees were 14.2% of the study group. The mean CAT score (19.3±5.63) was high and the most troubling symptom among patients was chest tightness. WPAI-COPD scores were higher in older age and longer disease duration. The levels of biomarkers were above the reference ranges, the mean IL-6 level was (69.4 ± 35.29) pg/ml, and the mean TNF-α was (72.3 ± 22.45) pg/ ml. Conclusions: COPD patients exhibit a disease burden in terms of productivity loss at work and activity impairment that increases with aging and disease duration. COPD patients with low BMI are more prone to a decline in lung functions and to worse symptoms.

Multi-organ clinical ultrasound as a complement to the diagnostic process in an internal medicine consultation.

Evaluating outpatient cases in internal medicine consultations presents a significant diagnostic challenge. Ultrasound can be a highly useful tool in assessment and decision-making. A prospective observational study was conducted on a cohort of patients attending an internal medicine rapid assessment clinic. Eighty patients were prospectively recruited. A medical consultation was conducted as per usual clinical practice, followed by a POCUS evaluation; collecting pulmonary, cardiac, and abdominal data. All findings were analyzed and recorded, particularly those that were significant or altered the initial diagnosis, subsequent tests, or treatment. Significant ultrasound findings were found in 37.5% of the patients. Of all ultrasound scans, the most clinically relevant were in the heart region (31.9%), followed by the abdomen (26%). These findings led to a change in overall management in 27.5% of patients. Using logistic regression, a model was developed to estimate the presence of clinically relevant findings with an area under the curve (AUC) of 0.78 (95% CI 0.66-0.89; p < 0.001) with 80% Sensitivity and 66% Specificity. The systematic and standardized incorporation of clinical ultrasound in internal medicine consultations contributes to decision-making, can provide significant findings that allow for modifications in clinical suspicion and therapeutic management.

Schizophrenia and Polycythemia Vera: A Case Report

IntroductionSchizophrenia is a severe mental disorder marked by abnormal interpretations of reality, often resulting in hallucinations, delusions, and disordered thinking that significantly impairs daily functioning and can be disabling. Lifelong treatment is necessary, and early intervention can help manage symptoms and improve long-term outcomes.Polycythemia Vera (PV) is a chronic myeloproliferative neoplasm causing an excess of red blood cells in the peripheral blood (polyglobulia). While the disease typically presents with symptoms, it can also be asymptomatic and discovered incidentally during routine laboratory tests, leading to a diagnosis of polycythemia when no secondary cause is apparent.While early 20th-century literature linked PV to intense neurological and psychiatric symptoms, contemporary studies rarely make such references.ObjectivesThe aim of this study is to explore, through a clinical case of a patient undergoing treatment for treatment-resistant schizophrenia with clozapine, and concurrently diagnosed with Polycythemia Vera, the potential causes of this condition. We seek to discern whether it represents mere comorbidities or if Polycythemia Vera is an adverse effect of antipsychotic treatment, particularly with clozapine.MethodsA 41-year-old patient, with a history of cranial trauma at the age of 5 and 19 years of treatment for schizophrenia, also has a tobacco use disorder. While hospitalized for the management of symptomatic reactivation of schizophrenia, despite being on clozapine, the patient underwent various therapeutic combinations with no observed clinical improvement. A few months later, follow-up blood tests indicated an elevation in all blood cell lines.An internal medicine consultation was sought, resulting in the diagnosis of Polycythemia Vera.ResultsThe evaluations conducted led us to the conclusion that there are two distinct nosological entities, with the treatment of the psychiatric condition revealing true polycythemia. Even after reducing the doses of clozapine and changing the atypical antipsychotic, all subsequent evaluations showed no effectiveness in managing the psychiatric disorder or improvement in the hematological condition.ConclusionsIn summary, schizophrenia is a severe and lifelong mental disorder requiring early intervention for symptom management. Polycythemia Vera (PV), a myeloproliferative disorder, typically presents with symptoms but can also be asymptomatic.While early literature linked PV to intense neurological and psychiatric symptoms, contemporary studies seldom reference such associations. The coexistence of schizophrenia and PV in a patient underscores the need for comprehensive and interdisciplinary care to address the complex interplay between mental and physical health. Further research is needed to deepen our understanding of concurrent psychiatric and hematological conditions.Disclosure of InterestNone Declared

Mental illness as a poor prognosis factor in cancer treatment: a review of the difficulties in diagnosing and treating cancer in patients with schizophrenia based on a clinical case

IntroductionPsychiatric patients, and schizophrenia patients in particular, have a lower average life expectancy than the general population, and the high prevalence of physical illnesses contributes to this. In the case of cancer, the incidence seems to be the same or lower compared to the general population, but on the other, the prognosis is frankly worse.ObjectivesWe aim to collect evidence about the relationship between cancer and schizophrenia.MethodsBased on a clinical case of a patient diagnosed with schizophrenia who died of an occult neoplasm, we conducted a narrative review of the literature concerning cancer screening, incidence, mortality and prognosis in patients with schizophrenia.Results A 39-year-old male patient was diagnosed with schizophrenia when he was 26 years older. The patient was single, had no children, lived alone and was retired due to his psychiatric condition.He was admitted to the inpatient ward in January 2023 due to a psychotic relapse after abandoning the prescribed treatment. He remained hospitalised for 14 days, and oral and injectable antipsychotic therapy was reinstated. He was discharged to the psychiatric day hospital unit to promote psychosocial rehabilitation. During this period, he complained about unspecified back pain but did not present any other physical symptoms.Two months later, he was evaluated by his psychiatrist as an outpatient, and his general condition had become significantly poorer. He had lost over 20 kilograms, his skin was pale, and he complained of back pain. He was referred to an internal medicine consultation. Still, before it was scheduled, he came to the emergency department and was admitted due to digestive bleeding, asthenia and low back pain, with a weight loss of around 25 kilograms.An abdominal mass was palpated on physical examination, and the chest x-ray showed a “balloon drop” pattern, indicating pulmonary metastases. Two days after being admitted to the internal medicine ward, he died of cardiac arrest.It is known that the stigma that mentally ill patients suffer often contributes to a delay in diagnosing medical illnesses. In addition, frequent social isolation and poor social family support do not help these patients seek medical care when their physical condition deteriorates. Low adherence to cancer screening and avoidance of routine health care often add to this delay.ConclusionsAs physicians who often deal with individuals with severe mental illnesses, psychiatrists should be extra aware of risk factors and keep a heightened suspicion of medical conditions. They should also promote the adoption of beneficial health behaviours and encourage participation in cancer screening and other relevant health programs.Disclosure of InterestNone Declared

Le myofibroblastome palissadique intraganglionnaire : une cause rare d’adénopathie inguinale

IntroductionLymphadenopathies are a major cause of consultation in internal medicine, with various causes of diagnosis. Unexplained persistent lymphadenopathy must be biopsied to rule out malignant tumor. Case reportWe report the case of a 53-year-old man, with inguinal lymphadenopathy evolving for more than one year. The patient had no associated symptoms and his blood tests were unremarkable. Due to the progression of the adenopathy and its hypermetabolism on PET-CT, an excisional biopsy was performed. Histological analysis revealed an intranodal proliferation of spindle cells with a palisading pattern. β-catenine and smooth muscle actin labelling were positive, leading to the diagnosis of intranodal palisaded myofibroblastoma, a benign tumour. ConclusionIntranodal palisaded myofibroblastoma is a rare benign cause of adenopathy, with often inguinal lymph node localization and slow growth and without risk of recurrence after surgical removal.

The role of Shock Index and its derivatives in predicting mortality in patients with upper gastrointestinal bleeding

Upper gastrointestinal bleeding (UGIB), a life-threatening emergency, causes significant morbidity, mortality, and healthcare costs. The mortality rate for UGIB is approximately 10%, but this rate rises to 15% in hemodynamically unstable patients. Identifying factors related to mortality and morbidity can help early detection of critical patient groups, guiding initial treatment approaches and patient management for clinicians. This study aims to investigate the performance of the Shock Index (SI) and its derivatives in predicting mortality. In the study, patients diagnosed with UGIB who presented to the Emergency Department (ED) between 2022 and 2024 were analyzed retrospectively. Patients aged 18 and over who were confirmed to have UGIB following internal medicine and/or gastroenterology consultation and were subsequently admitted to the hospital were included in the study. Of the 201 patients included in the study, 112 (55.7%) were male, with a mean age of 70.68±16.617. In-hospital mortality occurred in 17 patients (8.5%), and 30-day mortality was observed in 22 patients (10.9%). When examining the area under the curve (AUC), Age-SI (ASI) showed the best performance in predicting in-hospital mortality (AUC 0.837), followed by Age-Modified Shock Index (AMSI, AUC 0.829), MSI (AUC 0.810), and SI (AUC 0.806). ASI and AMSI can be calculated easily, cost-effectively, quickly, and practically at the time of ED presentation in UGIB patients, aiding in the early identification of critical patient groups and guiding clinicians.

A case of porto-sinusoidal vascular disease

Introduction: Porto-sinusoidal vascular syndrome is characterised by specific histological changes that do not include cirrhosis, with or without portal hypertension. Patients are usually asymptomatic until development of portal hypertension complications. Case description: A 69-year-old female with history of JAK2 positive essential thrombocythemia (ET) was referred to internal medicine consultation due to elevated liver enzymes. The patient had no previous history of liver disease. Seven months earlier, she had an ischaemic stroke and started treatment with atorvastatin. After discontinuing medication, liver enzymes returned to normal and atorvastatin-related drug-induced liver disease (DILI) was presumed. During a follow-up visit, iron deficiency anaemia was detected and an endoscopic study was performed. It revealed a gastric varix actively bleeding, which was successfully treated with cyanoacrylate. Two months later, the patient was admitted due to a new episode of variceal bleeding, and a portal hypertension complementary study was made. Discussion: Although the pathogenesis of porto-sinusoidal vascular disease (PSVD) remains poorly understood, vascular changes within the liver have been associated with several predisposing conditions, such as hypercoagulable states. Patients with ET, especially those with JAK2 mutation, are known to be at increased risk of non-cirrhotic vein thrombosis. Concerning PSVD, the association is not clear but it is believed that both PSVD and myeloproliferative neoplasms share a common denominator: a state characterised by hypercoagulability, inflammation, endothelial dysfunction and, in some cases, portal hypertension. Conclusion: Portal hypertension without cirrhosis is a rare condition, presenting diagnostic challenges and significant impact on the patient’s prognosis.

ARTERIAL HYPERTENSION IN DIABETICS: FREQUENCY AND ASSOCIATED FACTORS

Objective: Diabetic patients have an increased risk of developing hypertension. Its pathogenesis in diabetes is complex. It generally takes place in a context of metabolism and insulin resistance. The association of these 2 pathologies worsens the prognosis of these patients. The objective of this work was to evaluate the frequency of hypertension in diabetics, as well as the factors associated with its occurrence. Design and method: A retrospective study was conducted on 70 diabetic patients followed in the department and internal medicine consultations. All the patients benefited from an interrogation and a complete clinical examination. Results: A female predominance was noted (74.6%). The mean age was 55.8 ± 14 years. Our patients were mainly type 2 diabetics (88%), insulin-treated (78%), with an average seniority of 11.7 ± 7 years. More than half of the patients were known to be hypertensive (57.3%). Dyslipidemia was present in 66.7% of cases. The presence of hypertension was associated in a way statistically significant for age, BMI and presence of dyslipidemia, type and duration of diabetes. It was also significantly correlated with diabetic nephropathy, and the degree of renal insufficiency. Discussion: Hypertension is frequently associated with diabetes. It increases cardiovascular morbidity and mortality and accelerates the progression of atherosclerosis. Hypertension is also a contributory factor to diabetic nephropathy and renal failure. Conclusions: The management of hypertension in diabetics and other risk factors is a vital prognostic element in a patient already at high cardiovascular risk.

Fluidification du parcours ville-hôpital : analyse de la trajectoire des patients impliqués dans le dispositif RAPIDO après un an de mise en place

Internal medicine departments manage patients referred by emergency departments or private practitioners. Considering the overcrowding of emergency departments and lack of beds for inpatients, this specialty must be part of an "ambulatory shift", particularly by strengthening the links between community and hospital medicine. Our objective was to evaluate a new care pathway in internal medicine at Nîmes university hospital. Our department has developed the RAPIDO project (Réseau d'Aide à la PrIse en Charge Diagnostique et d'Orientation). The referring general practitioner contacts a senior internist on a dedicated phone line. After careful evaluation, he may offer a consultation within 15 days. A summary report is then given to the patient. Between November 2020 and November 2021, 254 patients were seen via RAPIDO. The average call-consultation time period was 6.4 (±4.5) days, for symptoms lasting for 2 weeks to 3 months in 43% (n=109) of cases. The reason for the call was a suspicion of systemic disease in 28% of cases (n=84), or a dysfunction of an organ in 16%. A diagnosis was made in 89% of cases. The budget of the whole procedure was balanced. A quick internal medicine consultation pathway for general practitioners seems to be a relevant, feasible and economically viable healthcare trajectory, which can be transposed to any type of healthcare institution, as soon as sufficient human resources are dedicated.

Epidemiology of Chest Pain at the University Hospital Center-Référence Nationale (CHU-RN) of N&amp;apos;Djamena

Introduction: Chest pain is a frequent reason for consultation in Internal Medicine and especially in cardiology. Few data are available on this condition in Chad. The aim of this work was to describe its epidemiological characteristics. Patients and methods: This was a descriptive and analytical cross-sectional study covering a consecutive series. Included were patients aged at least 18 years, seen in a cardiology consultation for non-traumatic chest pain and having performed an ECG and cardiac ultrasound. Results: A total of 146 patients were included in the study. The mean age was 46.1± 16.3 years. The sex ratio was 0.8 in favor of women. Arterial hypertension was the main cardiovascular risk factor found (41.9%). The pain was epigastric in 41.9% of cases and retrosternal in 23.7% of cases. Dyspnea was the most common associated sign (29.9%). Etiologies were dominated by cardiac (56.4%) and digestive (46.2%) causes. The main cardiovascular etiology was coronary insufficiency (42.4%). Regarding digestive causes, they were dominated by gastropathies and gastroduodenal ulcer disease (40.2%). In 17.1% of cases the chest pain was of pulmonary origin. Conclusion: Chest pain is a frequent reason for consultation. The etiologies are diverse. Apart from the cardiovascular causes likely to compromise the vital prognosis, we must not lose sight of the digestive and pulmonary causes.

Abstract P4-03-22: Linking Internal Medicine Care to Metastatic Breast Cancer Patients for Success: LIMBS

Abstract Background: The Advanced Breast Cancer (ABC) program at The University of Texas MD Anderson Cancer Center was created by metastatic breast cancer (MBC) patients for MBC patients. The ABC Program seeks to improve quantity and quality of life for patients living with MBC. MD Anderson actively treats 2,076 patients living with MBC. ABC program patient advocates voiced the need to increase MBC patients’ access to internal medicine services coordinated with oncology care. Significance: Previous literature suggests patients living with MBC have difficulty receiving oncology coordinated internal medicine services due to their terminal diagnosis and indefinite prescription of anti-cancer treatment. Comorbidities in this setting are known to be associated with inferior outcomes. ABC Program patient advocates reported various challenges seeking care from community based medical professionals including, timely awareness of their local provider on the status of their cancer. Other challenges included the lack of familiarity of some providers with novel MBC cancer treatment, side effects, and interactions of their cancer treatment with non-cancer conditions and treatment. Therefore, with the increasing life expectancy of MBC patients, there is a growing realization of the importance of managing the medical comorbidities in coordination with the MBC patient’s cancer treatment. Purpose: To increase access and coordinate internal medicine services for MBC patients with medical comorbidities. Interventions: In partnership with ABC Program patient advocates, the Linking Internal Medicine and Metastatic Breast cancer for Success (LIMBS) clinic was created in February 2021. The LIMBS clinic aimed to bridge the gap in lack of oncology coordinated internal medicine service for MBC patients. Evaluation: Breast Medical Oncology providers requested LIMBS clinic consults for 108 patients for comorbidity management since the clinic inception. This is a 44% increase in internal medicine consultations prior to LIMBS clinic creation (60 vs 108). The LIMBS clinic consults resulted in 474 follow up visits. Compared to MBC patients at MD Anderson, LIMBS patients were more likely to be African American (20% vs 13%) and were more likely to be older (59 years vs 57 years). Gender, marital status, and clinical trial enrollment did not differ between LIMBS patients and MBC patients. LIMBS patients had significantly higher rates of hypertension (46% vs 19%), Type II DM (19% vs 6%), hyperlipidemia (13% vs 10%), and hypothyroidism (13% vs 6%) compared to MBC patients in general. LIMBS patients had lower rates of anxiety (8% vs 11%) and depression (2% vs 7%) when compared to the MBC patients in general. The top 10 comorbidities for all MBC patients versus LIMBS patients are listed in Table 1. Discussion: It is feasible to build and integrate internal medicine with breast medical oncology services for patients with metastatic breast cancer. Future research should focus on exploring, describing, and meeting the internal medicine needs of MBC patients. Future initiatives are needed to bridge the gap in care for oncology coordinated internal medicine services between community and tertiary care centers. Table 1. Top 10 Comorbidities of all MBC patients versus LIMBS clinic patients Note. This table demonstrates the top 10 comorbidities for MBC population and the LIMBS population. Citation Format: Abbey Kaler, Akshara Singareeka Raghavendra, Ginny T. Kirklin, Dawn Cunningham, Ellen Manzullo, Debu Tripathy, Zayd Razouki. Linking Internal Medicine Care to Metastatic Breast Cancer Patients for Success: LIMBS [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P4-03-22.

Evaluation of dietary histories in cats presenting with chronic gastrointestinal clinical signs to a veterinary teaching hospital.

Although less frequently described than in dogs, it is also well recognised in cats that chronic gastrointestinal (GI) disease can fully respond to dietary changes only. So far, no study has assessed how much dietary information can be obtained during veterinary consultations. We retrospectively evaluated how much dietary information was available when owners presenting their cats to our gastroenterology (GE) and internal medicine (IM) service between October 2017 and January 2020 were questioned during consultations. Because of the larger IM caseload, for each week the first two cats presenting with chronic GI signs were selected for the IM group. Data from 80 cats presenting for first GE consultations were compared with data from 84 cats presenting with chronic GI signs for first IM consultations. Referrals comprised 42/80 (53%) GE cats and 53/84 (63%) IM cats. Referral documents mentioned the previously fed diet in 12/42 (29%) GE and 4/53 (8%) IM cats, and response to that previous diet trial was recorded in the referral documents of 4/12 (33%) GE and 3/4 (75%) IM cats. No cat had received more than one previous diet trial. During consultations, owners of 61/80 (76%) GE and 53/84 (63%) IM cats were asked about diet. Irrespective of referral status, previous dietary trials had been performed in 27/61 (44%) GE and 19/53 (36%) IM cats. The specific diet fed at the time of consultation could be named by 37/61 (61%) GE and 11/53 (21%) IM cat owners. Overall dietary information gained from referring veterinarians and owners was often incomplete. Although more information could be gained from owners during GE consultations vs IM consultations, awareness of the importance of diet in cats with GI disease still appears to be low among veterinarians and cat owners. Future studies need to assess if more complete dietary information can be obtained at the time of consultations with a prospective study design.

Internal medicine consultation for high-risk surgical patients: reflection on hospital mortality and readmission rates in a low-income country.

The objective of this study was to assess the impact of internal medicine consultation on mortality, 30-day readmission, and length of stay in surgical patients. This is a retrospective descriptive study developed in a public Brazilian teaching hospital with 850 beds. A total of 70,245 patients were admitted from 2010 to 2018 to the surgery departments. The main outcomes measured were patients' mortality, 30-day readmission, and length of stay. Mortality of high-risk patients was lower when followed by internal medicine consultation: patients with ASA≥3 (RR 0.89 [95% confidence interval (95%CI) 0.80-0.99], p=0.02), patients with ASA≥3 plus≥65 years (RR 0.88 [95%CI 0.78-0.99], p=0.04), patients with ASA≥3 plus high-risk surgery (RR 0.86 [95%CI 0.77-0.97], p=0.01), and patients with ASA≥4 plus age ≥65 years (RR 0.83 [95%CI 0.72-0.96], p=0.01). The 30-day readmission of high-risk patients was lower when followed by internal medicine consultation: patients with ≥65 years (RR 0.57 [95%CI 0.37-0.89], p=0.01) and patients with high-risk surgery (RR 0.63 [95%CI 0.46-0.57], p=0.005). The Poisson multivariate regression with adjustment in variances showed that all the variables (namely, age, ASA, morbidity index, surgery risk, and internal medicine consultation) were associated with higher mortality of patients; however, internal medicine consultation was associated with a reduction of mortality in high-risk patients (RR 0.72 [95%CI 0.65-0.84], p=0.02) and an increase of mortality in low-risk patients (RR 1.55 [95%CI 1.31-1.67], p=0.01). High-risk surgical patients may benefit from perioperative internal medicine consultations, which probably decrease hospital mortality and 30-day hospital readmission.

A case of retroperitoneal panniculitis with paralytic ileus mimicking a high intestinal obstruction

Background: Retroperitoneal panniculitis is a rare, benign, and nonspecific inflammatory disease that affects the retroperitoneal adipose tissue. The specific cause of the disease is unknown. The diagnosis is evoked by computed tomography (CT) and is rarely confirmed by biopsies. Surgical resection is sometimes attempted for complicated forms. A case of a 22-year-old man was presented who was diagnosed with retroperitoneal panniculitis, further, a literature review was also conducted to compare various presentations, etiologies, and potential treatment modalities. Case presentation: A 22-year-old man presented to the emergency department with acute abdominal pain and episodes of postprandial vomiting. A physical examination revealed marked epigastric tenderness accompanied by abdominal distension. The blood examination revealed normal lipase and amylase levels. An abdominal contrast-enhanced CT showed retroperitoneal panniculitis complicated by a paralytic ileus. A self-limiting course of the disease was obtained by adopting a conservative approach. After 20 days, there were no abnormal findings on CT and the patient was referred to internal medicine consultation for additional care. Conclusion: Diagnosis of retroperitoneal panniculitis is a real challenge to surgeons, gastroenterologists, radiologists, and pathologists. Consequently, it is imperative that all hospital practitioners should distinguish between this benign lesion and malignant diseases.

Tip 2 diyabet ve atriyal fibrilasyon geçici iskemik atağa neden olabilir

Diabetes mellitus (DM) is still one of the common chronic problems not only in rural but also the urban cities. While the regulation of blood sugar metabolism is one of the target points, living with DM can trammel primary care physicians. &#x0D; 64 years old female patient who was diagnosed with DM and hypertension for at least 5 years has attended the surgery for nuisance and dysuria. Bacteriuria has detected and blood sugar was 550 mg/dl WBC= 12,48 CRP: 7 HbA1C: 10,4 % Her neurologic examination was normal except she has got urinary incontinence. She was hospitalized with a diagnosis of DM, HT, and cystitis. Metformin 2x1gr, 1x 40 mg, ceftriaxone 2x1gr, and insulin glargine were ordered. Diabetic patient education has been performed. During follow-up, her blood sugar regulation has been settled but she complained of palpitation, ECG has been performed and diagnosed as AF (atrial fibrillation). Her blood pressure was 120/80 and metoprolol infusion was made. INR: 1,44 sec PT=17sn creatine=0,9 mg/dl. Control ECG was at sinus rhythm. While she was in time of recovery, internal medicine consultation has performed and she was planned to discharge. She complained about "could not talk". In her neurologic examination, her left arm has lost strength (3/5) and she could hear and understand what was told but couldn't speak. She was transferred to another health center for detection and treatment as pre-diagnose of Transient Ischemic Attack (TIA). &#x0D; DM never walks alone. At primary health care centers physicians should be aware of chronic conditions as well as the new onset problems to manage.

Challenges and Experiences of Young Medical Specialists in Establishing Private Clinical Practice

Background: The field of medicine is constantly changing. Notable changes occur in the patterns of clinical practice, business of medicine, shift in demographics/generation of the health care workforce, emergence of sub-specialization; and advances in research and technology. These changes can affect the way young physicians establish their practice and this is an area not addressed by the medical education and training. Purpose: There is little data in the literature regarding the experience of young physicians in establishing clinical practice. This study was undertaken to answer the central question: Among physicians in the field of Internal Medicine with or without subspecialty who graduated from training in 2013 to 2018, what were the issues and challenges that they faced as they established their clinical practice in the urban or mixed setting? Methodology: Qualitative research-case study; Key informant interview was conducted among junior Internal Medicine consultants who satisfied the inclusion criteria. Data analysis used thematic analysis consisting of reading, writing notes, describing, and classifying transcripts according to categories and themes. Results: After a comprehensive analysis of narratives, five emergent themes surfaced: “Tough Days” (Period of figuring out the system; Need for Self-introduction; Few patients and Feelings of frustration and depression); “Torn and Divided” (Unpredictable work schedule and workload; Lack of time for issues outside career); “Temporary Debt” (Large start-up cost; Expensive maintenance); “Difficult but Tolerable” (Family support; Call-a-colleague; Debt of gratitude to mentors) and lastly “Dreams and To-do’s”. Conclusions: Our respondents have experienced substantial challenges in starting clinical practice. Learning the ways of the healthcare business, effectively promoting oneself to the community, dealing with the emotional turmoil of having few patients, coming up with a strategic schedule and area of practice, and looking for funds and paying it back, were the challenges and experiences of these young medical specialists as they establish their careers in the urban and/or rural setting. Key words: clinical practice, challenges, start-up, establishing practice