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P0555 IN-HOSPITAL OUTPATIENT CLINICS: A SOLUTION TO OUR OVERCROWDED INTERNAL MEDICINE WARDS
Abstracts from 8th Congress of the European Federation of Internal Medicine / European Journal of Internal Medicine 20S (2009), S1–S283 of metformin. Its incidence was estimated in 2 to 9 cases per 100,000 patients treated with metformin each year, with an associated mortality rate as high as 50%. Because reports of dosages in overdose are often unreliable, it is unclear what minimum dose of metformin leads to toxicity. Recognition of MALA requires a high index of suspicion as its presentation can be very subtle. It should be considered in anyone who presents with intentional overdose, and in diabetic patients with comorbidities such as renal insufficiency, liver disease, or heart failure. There are no antidotes for metformin poisoning but haemodialysis is appealing as it can buffer acidosis and theoretically extract metformin from blood. The authors present a case of a 77 year old woman, relevant past history of diabetes mellitus, coronary bypass in 2006, acute pancreatitis in 2008, usually medicated with metformin (1000mg/day), who was referred to our emergency department with hypoglycemia (20 mg/dL). A few days before she had been medicated with amoxicilin+clavulanic acid for a respiratory infection but developed a clinical picture with vomiting, abdominal pain and diarrhea. She was instructed by her family doctor to change the antibiotic to levofloxacin. On presentation she was awake and oriented, polipneic, icteric sclera, glicemia – 84 mg/dL, hypotensive, t°C – 35.4, abdomen slightly tender diffusely, with no other changes. The blood gas analysis revealed a severe metabolic acidosis, lactate > 15 mmol/L and high anion gap (27,2 mmol/L) that could not be reversed with bicarbonate. Because her condition began to worsen, with altered mental status, and poor response to fluid therapy she was admitted in our ICU (SAPS II – 100, SOFA – 12, APACHE – 11). At this time she had septic shock criteria, bilateral otorrhagia and rapidly developed multiorgan failure (neurological, respiratory, cardiovascular, hemathological, renal and liver failure). It was attempted haemodialysis to reverse acidemia and hyperlactacidemia but the patient died during the session. The definite diagnosis of MALA was not achieved in this patient because it’s not possible in our country to measure serum levels of metformin. However it seems a highly probable diagnosis since it is one of the causes of high anion gap acidosis (type B) in a diabetic patient and tipically does not respond to bicarbonate therapy. We defend that vomiting and diarrhea precipited the poisoning. We decided to choose haemodialysis over continuous venovenous hemofiltration since the patient was critically ill, hemodinamically unstable and had a severe acidosis (pH< 7.1). The authors mean with this case to alert the physicians to this rare, and many times forgotten, entity that could easily arise in the context of dehydration or renal failure in a diabetic patient.
P0555 IN-HOSPITAL OUTPATIENT CLINICS: A SOLUTION TO OUR OVERCROWDED INTERNAL MEDICINE WARDS
Inês Araújo, Pedro Sarmento, Filipa Marques, Filipa Gândara, Beissan Beseisso, Isabel Arroja, Catarina Bastos, Susana Quintão, Ana Leitão, Cândida Fonseca. Serviço De Medicina Iii, Hospital S. Francisco Xavier - Centro Hospitalar De Lisboa Ocidental Patients (pts) admitted in Internal Medicine Wards (IM) are older and older and have various chronic comorbidities. Chronic pts represent at least 25% of discharges, contribute to overcrowd our IM wards and consume most of health care resources. Of the 10% of the so-called high users of the Emergency Department, 70% also are chronic medical pts. Therefore, new in-hospital cost-saving strategies to improve care of pts with chronic medical diseases are needed. Outpatient Clinics are specialized units competent to assist and treat chronic pts. Specially developped for oncology and AIDS, outpatient Clinics for other medical Specialities have only exceptionaly been implemented in Portuguese Health Care system. Aim: To point out to the importance of in hospital Outpatient Clinics design to manage pts soffring from chronic medical disease. Methods: In 2006 we have put into practice an Outpatient Clinic in a Central University Hospital, based on a multidisciplinary nurse/physician team, open to and shared by all Medical Specialities. We assist to chronic medical pts, with a special investment in pts and care providers education and early treatment of disease decompensation. Functioning rules and activity of a 24-month period (September 2006 – August 2008) are reported. Results: Outpatient Clinic has a therapy room with five non invasively monitored chairs where intravenous drug therapy can be delivered, in a day-hospital regimen, to decompensated pts, for a maximum of 8 hours per daily, without hospitalization. From Set 06 to Aug 08 we performed 8159 medical sessions: 13171 INR controls (anticoagulation clinic) and 4988 therapeutic procedures/clinical evaluations/educational sessions. In 2007, 497 chronic pts were attended in the Outpatient Clinic (290 females and 207
S185
males) and 1771 sessions were done (± 3.56 sessions/pt). In 41% of these sessions drug treatments were carried out. Of these, 66.8% were prolonged intravenous therapies (frusemide, iron, amiodarone, pentoxifiline ...). For the first 50 pts with chronic heart failure attended, It has been possible to save 44 hospitalizations and their respective costs. An increasing search for this outpatient unit by health care professionals and pts has been noted. Conclusions: The AA discuss in-hospital Medical Outpatient Clinics relevance for chronic disease management and to ensure transition of care between Hospital and Primary Care. We strongly believe that this kind of units will be, in the future, more and more important in hospitals, and for national health care systems.
P0556 AN UNUSUAL CASE OF POLYMYOSITIS
Filipe Perneta, Mónica Velosa, Mónica Caldeira, Susana Chaves, Gonçalo Silva, Rubina Miranda, António Caldeira Ferreira. Hospital Central Do Funchal Introduction: Polymyositis (PM) is a distinct form of inflammatory myopathy, along with Dermatomyositis (DM). The hallmark of both these disorders is symmetric muscle weakness. However, a variety of other disease manifestations are also characteristic, like skin findings such as Gottron’s sign and heliotrope rash (DM only), Interstitial Lung Disease, Raynaud phenomenon, inflammatory arthritis and elevated serum autoantibodies. In addition, both entities are associated with malignancies in a significant minority of cases revealing a close relationship between inflammatory myopathy and cancer. Hepatocellular Carcinoma (HCC) is one of the most common malignancies worldwide with unique geographic, sex, and age distributions. Important risk factors for the development of HCC include the Hepatitis B carrier state, Chronic Hepatitis C virus (HCV) infection, Hereditary Hemochromatosis, and Cirrhosis of almost any cause. Most paraneoplastic syndromes (PS) in HCC are biochemical abnormalities without associated clinical consequence. This include hypoglycaemia, erythrocytosis, hypercalcemia, hypercholesterolemia, dysfibrinogenemia, carcinoid syndrome and cutaneous and muscle manifestations like PM e DM. Aims: Review of recent data about PM and HCC. Methods: Consult of medical file of the patient. Results: The authors present the clinical case of a 74 year-old male brought to the Emergency Department because of a sudden onset of a confusional state, tremors and overall weakness, without significant motor impairment or lateralization. Past medical history of type II Diabetes Mellitus and Hepatitis B, with a twelve year evolution. Laboratory work-up showed rhabdomyolysis (Creatine Kinase [CK]=3020 U/L). Normal Brain Computed Tomography (CT). The patient was admitted to the Internal Medicine Department to be studied. The patient became cooperative, oriented, but maintained complaints of proximal muscle fatigue. By the 7th day of admission we verified an analytical worsening of CK levels to 11961 U/L. The malignancy markers showed an elevated Alpha-fetoprotein (>3000 μg/L), an increase in liver function tests and abnormal coagulation, with elevated INR and prolonged prothrombin time. Electromyographical study showed proximal muscle lesion on upper and lower limbs. An Abdominal CT revealed a 5 cm nodule of HCC with adjacent intra-hepatic metastasis, corroborated by Ultrasonography (US). A progressive liver failure, with elevation of liver markers and persistent altered coagulation tests deterred the possibility of an US guided biopsy, albeit support therapy with vitamin K. The patient died of Upper Gastro-Intestinal bleeding and multi-organ failure approximately 1.5 months of the initial approach. Conclusions: The authors present this clinical case as a rare manifestation of a PS by HCC through the form of PM. We alert to the fact that, although classically DM is associated with malignancies, their first manifestation might be a PM.
P0557 IDIOPATHIC GRANULOMATOUS MASTITIS – A DIAGNOSIS OF EXCLUSION
Maria Filipa Seabra Pereira 1 , Lèlita Santos 1 , Cristina Furtuoso 2 , Carlos Oliveira 2 , M Helena Saldanha 1 . 1 Serviço De Medicina – Hospitais Da Universidade De Coimbra; 2 Serviço De Ginecologia – Hospitais Da Universidade De Coimbra Introduction: Idiopathic granulomatous mastitis (IGM) is a rare benign disease of unknown etiology, which often mimics infection or malignancy. As a result, histopathological confirmation of idiopathic granulomatous mastitis is mandatory, combined with exclusion of infection (as tuberculous, syphilitic,
P0555 IN-HOSPITAL OUTPATIENT CLINICS: A SOLUTION TO OUR OVERCROWDED INTERNAL MEDICINE WARDS
Inês Araújo, Pedro Sarmento, Filipa Marques, Filipa Gândara, Beissan Beseisso, Isabel Arroja, Catarina Bastos, Susana Quintão, Ana Leitão, Cândida Fonseca. Serviço De Medicina Iii, Hospital S. Francisco Xavier - Centro Hospitalar De Lisboa Ocidental Patients (pts) admitted in Internal Medicine Wards (IM) are older and older and have various chronic comorbidities. Chronic pts represent at least 25% of discharges, contribute to overcrowd our IM wards and consume most of health care resources. Of the 10% of the so-called high users of the Emergency Department, 70% also are chronic medical pts. Therefore, new in-hospital cost-saving strategies to improve care of pts with chronic medical diseases are needed. Outpatient Clinics are specialized units competent to assist and treat chronic pts. Specially developped for oncology and AIDS, outpatient Clinics for other medical Specialities have only exceptionaly been implemented in Portuguese Health Care system. Aim: To point out to the importance of in hospital Outpatient Clinics design to manage pts soffring from chronic medical disease. Methods: In 2006 we have put into practice an Outpatient Clinic in a Central University Hospital, based on a multidisciplinary nurse/physician team, open to and shared by all Medical Specialities. We assist to chronic medical pts, with a special investment in pts and care providers education and early treatment of disease decompensation. Functioning rules and activity of a 24-month period (September 2006 – August 2008) are reported. Results: Outpatient Clinic has a therapy room with five non invasively monitored chairs where intravenous drug therapy can be delivered, in a day-hospital regimen, to decompensated pts, for a maximum of 8 hours per daily, without hospitalization. From Set 06 to Aug 08 we performed 8159 medical sessions: 13171 INR controls (anticoagulation clinic) and 4988 therapeutic procedures/clinical evaluations/educational sessions. In 2007, 497 chronic pts were attended in the Outpatient Clinic (290 females and 207
S185
males) and 1771 sessions were done (± 3.56 sessions/pt). In 41% of these sessions drug treatments were carried out. Of these, 66.8% were prolonged intravenous therapies (frusemide, iron, amiodarone, pentoxifiline ...). For the first 50 pts with chronic heart failure attended, It has been possible to save 44 hospitalizations and their respective costs. An increasing search for this outpatient unit by health care professionals and pts has been noted. Conclusions: The AA discuss in-hospital Medical Outpatient Clinics relevance for chronic disease management and to ensure transition of care between Hospital and Primary Care. We strongly believe that this kind of units will be, in the future, more and more important in hospitals, and for national health care systems.
P0556 AN UNUSUAL CASE OF POLYMYOSITIS
Filipe Perneta, Mónica Velosa, Mónica Caldeira, Susana Chaves, Gonçalo Silva, Rubina Miranda, António Caldeira Ferreira. Hospital Central Do Funchal Introduction: Polymyositis (PM) is a distinct form of inflammatory myopathy, along with Dermatomyositis (DM). The hallmark of both these disorders is symmetric muscle weakness. However, a variety of other disease manifestations are also characteristic, like skin findings such as Gottron’s sign and heliotrope rash (DM only), Interstitial Lung Disease, Raynaud phenomenon, inflammatory arthritis and elevated serum autoantibodies. In addition, both entities are associated with malignancies in a significant minority of cases revealing a close relationship between inflammatory myopathy and cancer. Hepatocellular Carcinoma (HCC) is one of the most common malignancies worldwide with unique geographic, sex, and age distributions. Important risk factors for the development of HCC include the Hepatitis B carrier state, Chronic Hepatitis C virus (HCV) infection, Hereditary Hemochromatosis, and Cirrhosis of almost any cause. Most paraneoplastic syndromes (PS) in HCC are biochemical abnormalities without associated clinical consequence. This include hypoglycaemia, erythrocytosis, hypercalcemia, hypercholesterolemia, dysfibrinogenemia, carcinoid syndrome and cutaneous and muscle manifestations like PM e DM. Aims: Review of recent data about PM and HCC. Methods: Consult of medical file of the patient. Results: The authors present the clinical case of a 74 year-old male brought to the Emergency Department because of a sudden onset of a confusional state, tremors and overall weakness, without significant motor impairment or lateralization. Past medical history of type II Diabetes Mellitus and Hepatitis B, with a twelve year evolution. Laboratory work-up showed rhabdomyolysis (Creatine Kinase [CK]=3020 U/L). Normal Brain Computed Tomography (CT). The patient was admitted to the Internal Medicine Department to be studied. The patient became cooperative, oriented, but maintained complaints of proximal muscle fatigue. By the 7th day of admission we verified an analytical worsening of CK levels to 11961 U/L. The malignancy markers showed an elevated Alpha-fetoprotein (>3000 μg/L), an increase in liver function tests and abnormal coagulation, with elevated INR and prolonged prothrombin time. Electromyographical study showed proximal muscle lesion on upper and lower limbs. An Abdominal CT revealed a 5 cm nodule of HCC with adjacent intra-hepatic metastasis, corroborated by Ultrasonography (US). A progressive liver failure, with elevation of liver markers and persistent altered coagulation tests deterred the possibility of an US guided biopsy, albeit support therapy with vitamin K. The patient died of Upper Gastro-Intestinal bleeding and multi-organ failure approximately 1.5 months of the initial approach. Conclusions: The authors present this clinical case as a rare manifestation of a PS by HCC through the form of PM. We alert to the fact that, although classically DM is associated with malignancies, their first manifestation might be a PM.
P0557 IDIOPATHIC GRANULOMATOUS MASTITIS – A DIAGNOSIS OF EXCLUSION
Maria Filipa Seabra Pereira 1 , Lèlita Santos 1 , Cristina Furtuoso 2 , Carlos Oliveira 2 , M Helena Saldanha 1 . 1 Serviço De Medicina – Hospitais Da Universidade De Coimbra; 2 Serviço De Ginecologia – Hospitais Da Universidade De Coimbra Introduction: Idiopathic granulomatous mastitis (IGM) is a rare benign disease of unknown etiology, which often mimics infection or malignancy. As a result, histopathological confirmation of idiopathic granulomatous mastitis is mandatory, combined with exclusion of infection (as tuberculous, syphilitic,