QJM: An International Journal of Medicine

Ngiam, J N; Cheong, C W S; Leow, A S T; Wei, Y -T; Thet, J K X; Lee, I Y S; Sia, C -H; Tan, B Y Q; Khoo, C -M; Sharma, V K; Yeo, L L L

doi: 10.1093/qjmed/hcaa253pmid: 32810234

SummaryBackgroundTransient hyperglycaemia in the context of illness with or without known diabetes has been termed as ‘stress hyperglycaemia’. Stress hyperglycaemia can result in poor functional outcomes in patients with acute ischaemic stroke (AIS) who underwent mechanical thrombectomy. We investigated the association between stress hyperglycaemia and clinical outcomes in AIS patients undergoing intravenous thrombolysis (IVT).MethodsWe examined 666 consecutive patients with AIS who underwent IVT from 2006 to 2018. All patients had a glycated haemoglobin level (HbA1c) and fasting venous blood glucose measured within 24 h of admission. Stress hyperglycaemia ratio (SHR) was defined as the ratio of the fasting glucose to the HbA1c. Univariate and multivariate analyses were employed to identify predictors of poor functional outcomes (modified Rankin Scale 3–6 at 3 months) after IVT.ResultsThree-hundred and sixty-one patients (54.2%) had good functional outcomes. These patients tended to be younger (60.7 ± 12.7 vs. 70 ± 14.4 years, P < 0.001), male (70.7% vs. 51.5%, P < 0.001), had lower prevalence of atrial fibrillation (13.0% vs. 20.7%, P = 0.008) and lower SHR (0.88 ± 0.20 vs. 0.99 ± 26, P < 0.001). Patients with high SHR (≥0.97) were slightly older than those with low SHR (<0.97) and were more likely to have diabetes mellitus. On multivariate analysis, higher SHR was independently associated with poor functional outcomes (adjusted odds ratio 3.85, 95% confidence interval 1.59–9.09, P = 0.003).ConclusionSHR appears to be an important predictor of functional outcomes in patients with AIS undergoing IVT. This may have important implications on the role of glycaemic control in the acute management of ischaemic stroke.

Zhang, X; Sun, X; Chen, G

doi: 10.1093/qjmed/hcaa278pmid: 33010179

Summary Background/introductionKnee joint osteoarthritis is a chronic disease that affects the health in aging population.AimWe explore a minimally invasive surgery combining the use of ultrasonic drug penetration to treat early stage of knee joint osteoarthritis.DesignIn total, 75 patients were participated in acupotomy therapy and ultrasonic drug penetration to treat joint osteoarthritis. MethodsThe WOMAC (the Western Ontario and McMaster Universities Osteoarthritis Index) scores were used to assess the performance.ResultsThere was a significant difference in the WOMAC score between the two groups of patients (P < 0.05). The total performance rate was about 86.4% and 50% in experiment and control groups.ConclusionThe combination of acupotomy therapy and ultrasonic drug penetration has demonstrated to be effective and promising to treat knee joint osteoarthritis.

Chen, J -H; Lee, C T -C

doi: 10.1093/qjmed/hcaa306pmid: 33165591

Summary BackgroundBecause of the increasing incidence and overall burden of systemic lupus erythematosus (SLE), efforts have been made to identify the factors that contribute to SLE onset and progression.AimWe conducted a total population-based case–control study to explore the prior comorbidities associated with SLE.Design and methodsData were collected from Taiwan’s National Health Insurance Research Database. Newly diagnosed SLE patients from 1 January 2010, to 31 December 2013 (n = 2847), were exactly matched at a 1:4 ratio for gender, age, residence and insurance premium to form a non-SLE group. Multivariate conditional logistic regression with stepwise selection was used to find the prior-associated comorbidities.ResultsA total of 38 prior comorbidities were associated with SLE incidence (32 positive and 6 negative associations). Positively associated comorbidities could be categorized as autoimmune-related inflammation of multiple organs including skin, blood, liver, tooth, thyroid, musculoskeletal and connective tissue. Among them, diffuse diseases of connective tissue (International Classification of Disease, Ninth Revision, Clinical Modification 710) exhibited the most robust association (OR = 5.68, 95% CI = 4.02–8.03, P < 0.001) in the 5 years before the index date. Negatively associated comorbidities could be attributed to diabetes mellitus and pregnancy related symptoms.ConclusionsOur results supported that increased awareness of SLE may be warranted for patients with autoimmune-related comorbidities of multiple organs. However, diabetes mellitus and pregnancy related symptoms were negatively associated with SLE incidence in this study. Further studies are warranted to elucidate the possible underlying mechanism and for better understanding the pathogenesis of SLE.

Schattner, A

doi: 10.1093/qjmed/hcaa272pmid: N/A

I always enjoy reading case reports. Placing the unique in the perspective of the ‘typical’ syndrome has great teaching value. However, I am never fooled by the invariably smooth ‘flow’ of the unfolding story leading elegantly in a straight line to the final, captivating diagnosis. Authors tend to gloss over blind alleys, ignore diagnostic delays, overlook procedure-associated harm and not mention brilliant diagnoses that happened incidentally. Thus, case reports are mostly stories of success which may sometimes be only remotely reminiscent of the actual patient experience and the physician’s pathway to the diagnosis. Recently, tootired to move after a long day in the ward in Covid-19 times, I slumped in my chair, and strangely, found myself reflecting on ‘diagnosis’ and how my attitude towards it changed and developed over the 40-odd years since I began medical practice. Physicians love to classify everything, so I was not surprised to realize that apropos diagnosis, I could identify four distinct consecutive periods in my attitude and practice. First came the Age of Innocence. I was fresh out of medical school, and very confident. Too confident. I was certain that wherever I go, I could apply the tools I recently acquired—history-taking (‘anamnesis’) and physical examination, and make the correct diagnosis. Limitations were not recognized. Complexities were not acknowledged. Neither were partial presentations of disease, so common in everyday practice. For example, to diagnose right CHF, I believed the patient ought to have an elevated jugular venous pressure, as well as congested enlarged and tender liver, peripheral edema and cardiomegaly on the chest film. In real-life, however, few patients show the full spectrum and pitting bipedal edema alone could make the diagnosis, provided alternative explanations were ruled out. I nominated it the age of innocence since I mistakenly believed then that diagnosis was a clear straightforward accomplishment, free from ambiguity or inherent complexity. This was not true, but the confidence and enthusiasm it infused I cherish even today. This illusion did not last long. During my residency years, I soon learned that diagnosis was a much more complex process. At that time, the practice of medicine became much more numerical, scientific and accurate. While studying Williams’ Textbook of Endocrinology I noticed that the many signs and symptoms of thyrotoxicosis were presented in a succinct table, and opposite each, came the percentage of patients showing the manifestation. Tachycardia was seen in 97%, and the frequency of thyromegaly and warm, moist skin was identical. I realized that with this type of information I could effectively rule out the diagnosis at the bedside. Even when I found out later that this was an over-simplification (e.g. ‘apathetic’ thyrotoxicosis and mild hyperthyroidism), I still remember the thrill of the revelation. Thus began the second era, the Age of Sophistication, an inseparable asset from then on. Terms such as sensitivity and specificity of a test were mastered for many laboratory, imaging and examination findings that were previously used indiscriminately. Positive and negative likelihood ratios and predictive values were calculated and combined where applicable to interpret unequivocal situations.1 Kappa values quantitating inter-observer agreement were recognized and incorporated. This revolution enhanced the evidence-base of diagnosis, possibly at some expense of the art. With accumulating experience, came the Age of skepticism. I realized that sophisticated diagnostic methods are definitely not infallible, that physicians often use 'auegenblick' heuristics that are prone to bias and diagnosis is not uncommonly erroneous (10–15% in different settings), although the physician may have lost contact with the patient and not know it. In tandem, deeper reflection yielded multiple mechanisms of diagnosis-associated harm, hitherto under-appreciated.2 Uncertainty remained prevalent, and when encountered, incidental findings were followed vigorously just because they were there. False-negatives were also not infrequent—not due to poor test performance but because the one crucial test was not requested. As a by-product and to preserve patients’ rights, patients were often told more information than they desired, impairing their coping and quality of life. Skepticism came with the realization that patient safety and well-being was often compromised in the diagnostic process, no matter how considerate physicians tried to be. Finally, the Age of Maturity took over. Having assimilated the sophisticated outlook on tests and the skepticism that goes with the ‘other side of the coin’ of diagnosis, I now derive a growing interest in the patient’s personal story, and in seeing the illness script unfolding from the patient’s point-of-view (‘narrative’). This point-of-view encourages a much more personal relationship during the diagnostic ordeal that patient and physician experience together adding to a feeling of 'bonding', to the patient’s satisfaction and to mine.3 Thus, each ‘Age’ constituted an important phase adding an indispensable dimension to the clinical encounter. Practitioners who are able to incorporate all stages as early as possible in their daily patient encounters will surely be an asset to their patients and likely to deliver high-quality patient-centered care while retaining their own enthusiasm, curiosity and humanism. Funding None. Conflict of interest. None declared. References 1 Halkin A Reichman J Schwaber M Patiel O Brezis M. Likelihood ratios: getting diagnostic resting into perspective . QJM 1998 ; 91 : 247 – 58 . Google Scholar Crossref Search ADS PubMed WorldCat 2 Schattner A Magazanik N Haran M. The hazards of diagnosis . QJM 2010 ; 103 : 583 – 7 . Google Scholar Crossref Search ADS PubMed WorldCat 3 Schattner A. The silent dimension: expressing humanism in each medical encounter . Arch Intern Med 2009 ; 169 : 1095 – 9 . Google Scholar Crossref Search ADS PubMed WorldCat © The Author(s) 2020. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. 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