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P0127 KAWASAKI DISEASE AND ITS IMPACT IN THE ADULT: REPORT OF 2 CASES AND LITERATURE REVIEW
Abstracts from 8th Congress of the European Federation of Internal Medicine / European Journal of Internal Medicine 20S (2009), S1–S283
S47
and about 60% of our patients with a CHADS2 score of 2 or superior were discharged with warfarin. Physical and/or mental deterioration were important reasons not to start oral anticoagulation.
P0126 RECURRENCE IN MAJOR BLEEDING DURING ANTICOAGULANT TREATMENT IN PATIENTS WITH PULMONARY EMBOLISM. EXPERIENCES TO COMPARISON: "MAJBLEEDR-VTE" STUDY VERSUS “RIETE” DATABASE
Maurizio Maria Ciammaichella, Rosa Maida, Carla Patrizi, Giannantonio Cerqua. St. John Hospital, Emergency Medicine, Rome, Italy Contraindications to anticoagulation
stockings (TEDs). TED stocking was mainly used in stroke patients. No thromboprophylaxis was prescribed to 68 (48%) patients at risk of VTE. Discussion & conclusion: We have shown that nearly half of all hospitalised internal medicine patients at high risk of VTE did not receive thromboprophylaxis, a finding comparable to previous studies. VTE is a major public health issue and is easily preventable. We have incorporated a VTE risk assessment tool into our medical admissions proforma to ensure thromboprophylaxis is appropriately prescribed. We recommend that all hospitals admitting acutely ill patients in internal medicine should implement similar strategies. Keywords: venous thromboembolism, thromboprophylaxis
P0125 ATRIAL FIBRILLATION: A COMMON ARRHYTHMIA IN INTERNAL MEDICINE
José Tiago Sequeira Lopes Da Silva, Nicolas Bureo Gutierrez, Veronica Fernandez Auzmendi, Olga Gonzalez Casas, Fermin Olgado Ferrero, Dolores Magro Ledesma. Internal Medicine Department, Hospital Infanta Cristina, Badajoz, Spain Background: Atrial Fibrillation (A. Fib.) is the most common arrhythmia and one very important cause of admittance in Internal Medicine. It consumes many important resources and is a cause of serious complications. Aims: To study the characteristics of patients diagnosed of A. Fib. and the reason of their admittance in a Department of Internal Medicine, type of A. Fib. commonly seen, studies requested during their stay, treatment chosen, CHADS2 score and if anticoagulation was prescribed, and if not, why not. Methods: We performed a descriptive retrospective study of all patients discharged of our Department during February of 2.005 and August of 2.008 in which A. Fib. was considered one of the principal diagnosis. Results: During this 3 and half years, 158 patients with diagnosis of A. Fib. were admitted. 39 patients died, thus making that 119 were discharged during this period of time. 45 of them were men and 65 were women, with a mean age of 76 years. First detected A. Fib. (54 cases) and Permanent A. Fib. (46 cases) were more commonly diagnosed. Persistent and Paroxysmal A. Fib. corresponded to 10 and 9 cases, respectively. Studying their medical background, we noticed that 82 patients had been previously diagnosed of Hypertension, 45 were Diabetic, 18 had had Strokes and 23 suffered from Ischemic Heart Disease. Pulmonary Diseases (Chronic Obstructive Pulmonary Disease, Pulmonary Hypertension and Obstructive Sleep Apnea Syndrome) were also frequent in our patients. The primary reason of admittance was Congestive Heart Failure (61 patients), followed by Respiratory Infections (16 cases) and Stroke (15 admittances). All performed a thoracic radiography and an electrocardiogram. To 72 patients an echocardiogram was also requested, and 64 had their thyroid hormone levels studied. In 86 patients a rate control therapy was chosen with digoxin, beta-blockers or calcium channel blockers, while in 11 patients an antiarrhythmic drug, especially amiodarone, was prescribed. According to the CHADS2 score, in 105 patients anticoagulation was obliged, since the score was 2 or superior, but of these only 63 patients were discharged with warfarin. The primary reason not to use anticoagulants was old age/physical deterioration (16 patients) and dementia (8 patients). Anemia and current alcoholism were also important reasons. Antiplatelet therapy was decided in 31 patients. Summary: Patients admitted in Internal Medicine with A. Fib. are usually people of old age, frequently women, with a background of Hypertension, Diabetes, Cardiac Ischemia or Pulmonary Disease. Most of them were admitted due to Heart Failure secondary to A. Fib. not previously diagnosed. Digoxin and beta-blockers were more frequently prescribed than antiarrhytmic drugs
Background: The Authors have introduced the study "MAJBLEEDrVTE",from name "MAJOR BLEEDING recurrence-VENOUS THROMBOEMBOLISM" turned to 140 patients admitted to the unit “Degenza Breve/Sub-Intensiva C" in the period January 2005-December 2008 with pulmonary embolism and subjected to treatment with anticoagulant drugs: unfractionated heparin (UFH)+antivitamin K (AVK). Aims: Aims of the study are following:to verify the cases of recurrence in major bleeding in the 140 patients enlisted and treated with anticoagulant drugs (UFH+AVK); to confront study "MAJBLEEDr-VTE" with RIETE data on patients treated with anticoagulant drugs (UFH+AVK). Methods: The study "MAJBLEEDr-VTE" has enlisted 140 patients with pulmonary embolism who have been subordinated to anticoagulant treatment with UFH+AVK. Therefore,we have brought back in Table 1 the data extrapolated from the RIETE database inherent 24932 patients,updated to November 2008.In the database we have searched the following analytical profile:Treatment prior to Major Bleeding: UFH + Anti-vitamin K drugs, Symptoms:Any symptoms,Treatment Phase in which bleeding occurred:Any treatment,Severity:Any,Site:Any.In Table 2 we have brought back,instead,the coming from data from MAJBLEEDr-VTE Study on 140 patients enlisted.We have searched the same analytical profile of RIETE database. Results: The coming from data from Registry RIETE and the MAJBLEEDrVTE Study have documented,according to the following analytical profile "treatment prior to bleeding:UFH+AVK drugs",0 cases of recurrence in major bleeding during associated treatment with unfractionated heparin to antivitamin K drugs.In the RIETE Registry five cases with Good Outcome have been analyzed: in one patient the therapy has been transiently suspended for 2 days,in two patients has been maintained the same therapy with 26450 IU to the dose of 434 IU/kg,in one patient the therapy has been switched to UFH (dose 24000 IU/die,414 IU/kg),in one patient the therapy has been switched to AVK drugs.The coming from data from the MAJBLEEDr-VTE Study have documented as in no case it has been necessary definitely to suspend the therapy with UFH+AVK,in two cases the therapy with UFH+AVK has been transiently suspended for 2 days,in two cases it has been switched to LMWH (dose 12000 IU/die,100 IU/kg), in two cases has been chosen the strategy with LMWH (dose 12000 IU/die,100 IU/kg) and caval filter system,in one case the therapy has been switched to AVK.Five patients with major bleeding have been afflicted with digestive haemorrhage (4 cases), haemoptysis (1 case).As for the data of the RIETE Registry also ours five patients have had a Good Outcome. Conclusions: The comparative analysis of the coming from data from the database of the RIETE Registry and from the MAJBLEEDr-VTE Study demonstrated as it has not been evidence of recurrence in major bleeding in no case as a result of treatment with UFH+AVK.
P0127 KAWASAKI DISEASE AND ITS IMPACT IN THE ADULT: REPORT OF 2 CASES AND LITERATURE REVIEW
Sebastian Schröder, Marta Garcia Vidal, Enrique Saiz Hervas, Julio De Miguel Prieto. Department of Internal Medicine, Hospital Universitario Príncipe De Asturias, Alcalá De Henares, Spain Background: Kawasaki disease (KD) first described in 1967 is an acute multisystem vasculitis with still unknown etiology although both clinical and epidemiological features strongly support an infectious cause. Diagnosis is based on clinical criteria. KD is primarily affecting young children however occasionally cases in adults were described. Objectives: To describe 2 cases of adult KD and to review the medical literature to better define the epidemiological, clinical and therapeutic aspects of adult KD. Methods: Report of two cases and review of the literature using a Medline search from 1967 to October 2008.
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Abstracts from 8th Congress of the European Federation of Internal Medicine / European Journal of Internal Medicine 20S (2009), S1–S283
Table 1. Diagnostic Guidelines for Kawasaki Disease Fever of 5 days or more without other explanation and at least 4 of the 5 following criteria*: 1. Polymorphic exanthema 2. Changes in peripheral extremities: Acute phase: erythema and/or indurative edema of the palms and soles Convalescent phase: desquamation from finger tips 3. Bilateral non-exudative conjunctival injection 4. Changes in the oropharynx: injected or fissured lips; strawberry tongue; injected pharynx 5. Acute nonsuppurative cervical lymphadenopathy (>1.5 cm in diameter) *Patients with fewer than 4 of these signs can be diagnosed as atypical Kawasaki disease if coronary artery abnormalities are pesent.
Results: We describe a 28 year old woman who fulfilled clinical criteria and a second case (36 year woman) with incomplete KD which was diagnosed after presenting myocardial infarction leading to detection of a coronary aneurysm.
Also coronary aneurysm is a rare complication in adult KD (5%) comparing to children (20-25%) echocardiography has its limitations detecting coronary abnormalities in adults and new non-invasive methods of coronary imaging (MRI and fast CT) and stress testing should complete the investigations. Including our two cases there are 84 reports of adult-onset KD. Interestingly 20 cases are associated to HIV infection occurring preferentially when immunosuppression is severe and HIV viral load is high. This suggests a role of immune status and/or the HI virus in the pathophysiology of KD. Treatment with intravenous immunoglobulin and Aspirin is effective in adult KD. Conclusions: The association of prolonged fever and clinical criteria should, after exclusion of the differential diagnoses, suggest a diagnosis of Kawasaki disease in the adult leading to diagnostic and therapeutic managements to prevent, even though extremely rare, formation of coronary disease. Keywords: Kawasaki disease, Coronary aneurysm.
P0128 AN INTERESTING CASE OF ALCOHOL WITHDRAWAL
Poonam Batra, Munish Batra. Aintree University Hospital
Table 2. Clinical and diagnostic findings
Clinical presentation Age (years)/Sex Fever > 5 days Rush Adenopathy Conjunctival Effusion Oropharynx Changes Extremity Changes Complications Diagnostics Hepatitis viruses Blood cultures EBV CMV Parvovirus B19 Herpes simplex Virus Varicella Zoster Virus HIV Anti–streptolysin O ANA ANCA Abdominal echography Echocardiography Coronariography Diagnosis delay (days)
Patient 1
Patient 2
28/F + + – + + + –
36/F + + – + – + NSTEMI, coronary aneurysm
– – – – – – – – – – ND Colelithiasis N ND 12
– – – – ND ND ND – – – – N N LCA aneurysm 68
– = negative, + = positive, ND = not done, N = normal, italics = diagnostic criteria of KD, NSTEMI = non-ST elevation MI, LCA = left coronary artery.
A 45 year old lady presented with sudden onset rapid involuntary movements of limbs and torso for 5 hours. There were no obvious triggering factors. She had a past medical history of depression and was on sertraline. She was not on any other medications in the past. She was a chronic alcoholic and admitted to drinking 35 units of alcohol per week. She drank 5 units of alcohol 24 hours before admission. She was a non smoker. There was no positive family history of abnormal movements. On initial assessment, she was found to have bilateral extensive choreiform movements. Her vital observations were stable. Her respiratory, cardiac and abdominal examinations were normal. On neurological examination, her GCS was 15/15, her pupils were equal and reacting to light. There was no nystagmus. There were no signs of meningismus and her motor and sensory examinations were normal. She was treated with benzodiazepines and haloperidol intravenously and was given vitamin B infusions. She was extensively investigated for identifying the cause of these continuous choreiform movements. All her blood tests including renal functions, liver functions, thyroid function tests, calcium levels and ceruloplasmin levels came back normal. Her autoantibody screen was normal. Her urine examination was normal too. She went on to have MRI Brain and it showed atrophy of frontal and parietal white matter, parietal and temporal gray matter, and thalami, accompanied by widespread sulcal but no ventricular enlargements. She was started on chlordiazepoxide for detoxification and 2 days after the start of librium, these abnormal involuntary movements started to settle. She responded well to chlordiazepoxide and she remained symptom free on follow up. Alcohol withdrawal can very occasionally present as choreiform movements, which respond to chlordiazepoxide dramatically.
P0129 AUDIT OF THROMBOPROPHYLAXIS IN HOSPITAL ACQUIRED VENOUS THROMBOEMBOLISM
Alexander Rawlinson. Salford Royal NHS Foundation Trust
Figure 1 (left). Strawberry tongue in Kawasaki disease. Figure 2 (right). Desquamation from finger tips in Kawasaki disease
Figure 3. Coronary artery aneurysm in Kawasaki disease
Background: Venous thromboembolism (VTE) is a significant but preventable cause of morbidity and mortality in hospitalised medical patients. Extensive evidence supports the efficacy and cost-effectiveness of thromboprophylaxis, using low molecular weight heparin but its use remains variable. For this reason consensus guidelines have been developed to help individual institutions form protocols for prescribing thromboprophylaxis to medical patients. The aim of our audit was to assess concordance with a protocol in cases of hospital-acquired VTE. Method: We carried out an audit of thromboprophylaxis in all patients diagnosed with hospital-acquired VTE in 2008. Results: We identified 33 cases of hospital-acquired VTE and were able to assess thromboprophylaxis in 28 of these. We found that only 18% of medical patients who had an indication for thromboprophylaxis received low molecular weight heparin. None of the patients given prophylaxis were clearly prescribed a dose based on their weight and overall weights were recorded in only 21% of cases. In 6 deaths due to pulmonary embolism only 2 had received low molecular weight heparin despite all 6 having an indication for thromboprophylaxis. Discussion: Despite the introduction of a protocol prescribing of thromboprophylaxis in medical patients with hospital-acquired VTE remains poor. We postulate the reasons for this are lack of awareness of the extent of VTE in medical patients, ignorance of the protocol and difficulty in applying the protocol, particularly weighing patients.
S47
and about 60% of our patients with a CHADS2 score of 2 or superior were discharged with warfarin. Physical and/or mental deterioration were important reasons not to start oral anticoagulation.
P0126 RECURRENCE IN MAJOR BLEEDING DURING ANTICOAGULANT TREATMENT IN PATIENTS WITH PULMONARY EMBOLISM. EXPERIENCES TO COMPARISON: "MAJBLEEDR-VTE" STUDY VERSUS “RIETE” DATABASE
Maurizio Maria Ciammaichella, Rosa Maida, Carla Patrizi, Giannantonio Cerqua. St. John Hospital, Emergency Medicine, Rome, Italy Contraindications to anticoagulation
stockings (TEDs). TED stocking was mainly used in stroke patients. No thromboprophylaxis was prescribed to 68 (48%) patients at risk of VTE. Discussion & conclusion: We have shown that nearly half of all hospitalised internal medicine patients at high risk of VTE did not receive thromboprophylaxis, a finding comparable to previous studies. VTE is a major public health issue and is easily preventable. We have incorporated a VTE risk assessment tool into our medical admissions proforma to ensure thromboprophylaxis is appropriately prescribed. We recommend that all hospitals admitting acutely ill patients in internal medicine should implement similar strategies. Keywords: venous thromboembolism, thromboprophylaxis
P0125 ATRIAL FIBRILLATION: A COMMON ARRHYTHMIA IN INTERNAL MEDICINE
José Tiago Sequeira Lopes Da Silva, Nicolas Bureo Gutierrez, Veronica Fernandez Auzmendi, Olga Gonzalez Casas, Fermin Olgado Ferrero, Dolores Magro Ledesma. Internal Medicine Department, Hospital Infanta Cristina, Badajoz, Spain Background: Atrial Fibrillation (A. Fib.) is the most common arrhythmia and one very important cause of admittance in Internal Medicine. It consumes many important resources and is a cause of serious complications. Aims: To study the characteristics of patients diagnosed of A. Fib. and the reason of their admittance in a Department of Internal Medicine, type of A. Fib. commonly seen, studies requested during their stay, treatment chosen, CHADS2 score and if anticoagulation was prescribed, and if not, why not. Methods: We performed a descriptive retrospective study of all patients discharged of our Department during February of 2.005 and August of 2.008 in which A. Fib. was considered one of the principal diagnosis. Results: During this 3 and half years, 158 patients with diagnosis of A. Fib. were admitted. 39 patients died, thus making that 119 were discharged during this period of time. 45 of them were men and 65 were women, with a mean age of 76 years. First detected A. Fib. (54 cases) and Permanent A. Fib. (46 cases) were more commonly diagnosed. Persistent and Paroxysmal A. Fib. corresponded to 10 and 9 cases, respectively. Studying their medical background, we noticed that 82 patients had been previously diagnosed of Hypertension, 45 were Diabetic, 18 had had Strokes and 23 suffered from Ischemic Heart Disease. Pulmonary Diseases (Chronic Obstructive Pulmonary Disease, Pulmonary Hypertension and Obstructive Sleep Apnea Syndrome) were also frequent in our patients. The primary reason of admittance was Congestive Heart Failure (61 patients), followed by Respiratory Infections (16 cases) and Stroke (15 admittances). All performed a thoracic radiography and an electrocardiogram. To 72 patients an echocardiogram was also requested, and 64 had their thyroid hormone levels studied. In 86 patients a rate control therapy was chosen with digoxin, beta-blockers or calcium channel blockers, while in 11 patients an antiarrhythmic drug, especially amiodarone, was prescribed. According to the CHADS2 score, in 105 patients anticoagulation was obliged, since the score was 2 or superior, but of these only 63 patients were discharged with warfarin. The primary reason not to use anticoagulants was old age/physical deterioration (16 patients) and dementia (8 patients). Anemia and current alcoholism were also important reasons. Antiplatelet therapy was decided in 31 patients. Summary: Patients admitted in Internal Medicine with A. Fib. are usually people of old age, frequently women, with a background of Hypertension, Diabetes, Cardiac Ischemia or Pulmonary Disease. Most of them were admitted due to Heart Failure secondary to A. Fib. not previously diagnosed. Digoxin and beta-blockers were more frequently prescribed than antiarrhytmic drugs
Background: The Authors have introduced the study "MAJBLEEDrVTE",from name "MAJOR BLEEDING recurrence-VENOUS THROMBOEMBOLISM" turned to 140 patients admitted to the unit “Degenza Breve/Sub-Intensiva C" in the period January 2005-December 2008 with pulmonary embolism and subjected to treatment with anticoagulant drugs: unfractionated heparin (UFH)+antivitamin K (AVK). Aims: Aims of the study are following:to verify the cases of recurrence in major bleeding in the 140 patients enlisted and treated with anticoagulant drugs (UFH+AVK); to confront study "MAJBLEEDr-VTE" with RIETE data on patients treated with anticoagulant drugs (UFH+AVK). Methods: The study "MAJBLEEDr-VTE" has enlisted 140 patients with pulmonary embolism who have been subordinated to anticoagulant treatment with UFH+AVK. Therefore,we have brought back in Table 1 the data extrapolated from the RIETE database inherent 24932 patients,updated to November 2008.In the database we have searched the following analytical profile:Treatment prior to Major Bleeding: UFH + Anti-vitamin K drugs, Symptoms:Any symptoms,Treatment Phase in which bleeding occurred:Any treatment,Severity:Any,Site:Any.In Table 2 we have brought back,instead,the coming from data from MAJBLEEDr-VTE Study on 140 patients enlisted.We have searched the same analytical profile of RIETE database. Results: The coming from data from Registry RIETE and the MAJBLEEDrVTE Study have documented,according to the following analytical profile "treatment prior to bleeding:UFH+AVK drugs",0 cases of recurrence in major bleeding during associated treatment with unfractionated heparin to antivitamin K drugs.In the RIETE Registry five cases with Good Outcome have been analyzed: in one patient the therapy has been transiently suspended for 2 days,in two patients has been maintained the same therapy with 26450 IU to the dose of 434 IU/kg,in one patient the therapy has been switched to UFH (dose 24000 IU/die,414 IU/kg),in one patient the therapy has been switched to AVK drugs.The coming from data from the MAJBLEEDr-VTE Study have documented as in no case it has been necessary definitely to suspend the therapy with UFH+AVK,in two cases the therapy with UFH+AVK has been transiently suspended for 2 days,in two cases it has been switched to LMWH (dose 12000 IU/die,100 IU/kg), in two cases has been chosen the strategy with LMWH (dose 12000 IU/die,100 IU/kg) and caval filter system,in one case the therapy has been switched to AVK.Five patients with major bleeding have been afflicted with digestive haemorrhage (4 cases), haemoptysis (1 case).As for the data of the RIETE Registry also ours five patients have had a Good Outcome. Conclusions: The comparative analysis of the coming from data from the database of the RIETE Registry and from the MAJBLEEDr-VTE Study demonstrated as it has not been evidence of recurrence in major bleeding in no case as a result of treatment with UFH+AVK.
P0127 KAWASAKI DISEASE AND ITS IMPACT IN THE ADULT: REPORT OF 2 CASES AND LITERATURE REVIEW
Sebastian Schröder, Marta Garcia Vidal, Enrique Saiz Hervas, Julio De Miguel Prieto. Department of Internal Medicine, Hospital Universitario Príncipe De Asturias, Alcalá De Henares, Spain Background: Kawasaki disease (KD) first described in 1967 is an acute multisystem vasculitis with still unknown etiology although both clinical and epidemiological features strongly support an infectious cause. Diagnosis is based on clinical criteria. KD is primarily affecting young children however occasionally cases in adults were described. Objectives: To describe 2 cases of adult KD and to review the medical literature to better define the epidemiological, clinical and therapeutic aspects of adult KD. Methods: Report of two cases and review of the literature using a Medline search from 1967 to October 2008.
S48
Abstracts from 8th Congress of the European Federation of Internal Medicine / European Journal of Internal Medicine 20S (2009), S1–S283
Table 1. Diagnostic Guidelines for Kawasaki Disease Fever of 5 days or more without other explanation and at least 4 of the 5 following criteria*: 1. Polymorphic exanthema 2. Changes in peripheral extremities: Acute phase: erythema and/or indurative edema of the palms and soles Convalescent phase: desquamation from finger tips 3. Bilateral non-exudative conjunctival injection 4. Changes in the oropharynx: injected or fissured lips; strawberry tongue; injected pharynx 5. Acute nonsuppurative cervical lymphadenopathy (>1.5 cm in diameter) *Patients with fewer than 4 of these signs can be diagnosed as atypical Kawasaki disease if coronary artery abnormalities are pesent.
Results: We describe a 28 year old woman who fulfilled clinical criteria and a second case (36 year woman) with incomplete KD which was diagnosed after presenting myocardial infarction leading to detection of a coronary aneurysm.
Also coronary aneurysm is a rare complication in adult KD (5%) comparing to children (20-25%) echocardiography has its limitations detecting coronary abnormalities in adults and new non-invasive methods of coronary imaging (MRI and fast CT) and stress testing should complete the investigations. Including our two cases there are 84 reports of adult-onset KD. Interestingly 20 cases are associated to HIV infection occurring preferentially when immunosuppression is severe and HIV viral load is high. This suggests a role of immune status and/or the HI virus in the pathophysiology of KD. Treatment with intravenous immunoglobulin and Aspirin is effective in adult KD. Conclusions: The association of prolonged fever and clinical criteria should, after exclusion of the differential diagnoses, suggest a diagnosis of Kawasaki disease in the adult leading to diagnostic and therapeutic managements to prevent, even though extremely rare, formation of coronary disease. Keywords: Kawasaki disease, Coronary aneurysm.
P0128 AN INTERESTING CASE OF ALCOHOL WITHDRAWAL
Poonam Batra, Munish Batra. Aintree University Hospital
Table 2. Clinical and diagnostic findings
Clinical presentation Age (years)/Sex Fever > 5 days Rush Adenopathy Conjunctival Effusion Oropharynx Changes Extremity Changes Complications Diagnostics Hepatitis viruses Blood cultures EBV CMV Parvovirus B19 Herpes simplex Virus Varicella Zoster Virus HIV Anti–streptolysin O ANA ANCA Abdominal echography Echocardiography Coronariography Diagnosis delay (days)
Patient 1
Patient 2
28/F + + – + + + –
36/F + + – + – + NSTEMI, coronary aneurysm
– – – – – – – – – – ND Colelithiasis N ND 12
– – – – ND ND ND – – – – N N LCA aneurysm 68
– = negative, + = positive, ND = not done, N = normal, italics = diagnostic criteria of KD, NSTEMI = non-ST elevation MI, LCA = left coronary artery.
A 45 year old lady presented with sudden onset rapid involuntary movements of limbs and torso for 5 hours. There were no obvious triggering factors. She had a past medical history of depression and was on sertraline. She was not on any other medications in the past. She was a chronic alcoholic and admitted to drinking 35 units of alcohol per week. She drank 5 units of alcohol 24 hours before admission. She was a non smoker. There was no positive family history of abnormal movements. On initial assessment, she was found to have bilateral extensive choreiform movements. Her vital observations were stable. Her respiratory, cardiac and abdominal examinations were normal. On neurological examination, her GCS was 15/15, her pupils were equal and reacting to light. There was no nystagmus. There were no signs of meningismus and her motor and sensory examinations were normal. She was treated with benzodiazepines and haloperidol intravenously and was given vitamin B infusions. She was extensively investigated for identifying the cause of these continuous choreiform movements. All her blood tests including renal functions, liver functions, thyroid function tests, calcium levels and ceruloplasmin levels came back normal. Her autoantibody screen was normal. Her urine examination was normal too. She went on to have MRI Brain and it showed atrophy of frontal and parietal white matter, parietal and temporal gray matter, and thalami, accompanied by widespread sulcal but no ventricular enlargements. She was started on chlordiazepoxide for detoxification and 2 days after the start of librium, these abnormal involuntary movements started to settle. She responded well to chlordiazepoxide and she remained symptom free on follow up. Alcohol withdrawal can very occasionally present as choreiform movements, which respond to chlordiazepoxide dramatically.
P0129 AUDIT OF THROMBOPROPHYLAXIS IN HOSPITAL ACQUIRED VENOUS THROMBOEMBOLISM
Alexander Rawlinson. Salford Royal NHS Foundation Trust
Figure 1 (left). Strawberry tongue in Kawasaki disease. Figure 2 (right). Desquamation from finger tips in Kawasaki disease
Figure 3. Coronary artery aneurysm in Kawasaki disease
Background: Venous thromboembolism (VTE) is a significant but preventable cause of morbidity and mortality in hospitalised medical patients. Extensive evidence supports the efficacy and cost-effectiveness of thromboprophylaxis, using low molecular weight heparin but its use remains variable. For this reason consensus guidelines have been developed to help individual institutions form protocols for prescribing thromboprophylaxis to medical patients. The aim of our audit was to assess concordance with a protocol in cases of hospital-acquired VTE. Method: We carried out an audit of thromboprophylaxis in all patients diagnosed with hospital-acquired VTE in 2008. Results: We identified 33 cases of hospital-acquired VTE and were able to assess thromboprophylaxis in 28 of these. We found that only 18% of medical patients who had an indication for thromboprophylaxis received low molecular weight heparin. None of the patients given prophylaxis were clearly prescribed a dose based on their weight and overall weights were recorded in only 21% of cases. In 6 deaths due to pulmonary embolism only 2 had received low molecular weight heparin despite all 6 having an indication for thromboprophylaxis. Discussion: Despite the introduction of a protocol prescribing of thromboprophylaxis in medical patients with hospital-acquired VTE remains poor. We postulate the reasons for this are lack of awareness of the extent of VTE in medical patients, ignorance of the protocol and difficulty in applying the protocol, particularly weighing patients.