Paediatric Cogan´s syndrome - review of literature, case report and practical approach to diagnosis and management.

BACKGROUND: Cogan´s syndrome is a rare, presumed autoimmune vasculitis of various vessels characterized by interstitial keratitis and vestibular impairment accompanied by sensorineural hearing loss. Due to the rarity of Cogan´s syndrome in children, therapeutic decision making may be challenging. Therefore, a literature search was performed to collect all published paediatric Cogan´s syndrome cases with their clinical characteristics, disease course, treatment modalities used and their outcome. The cohort was supplemented with our own patient. MAIN TEXT: Altogether, 55 paediatric Cogan´s syndrome patients aged median 12 years have been reported so far. These were identified in PubMed with the keywords "Cogan´s syndrome" and "children" or "childhood". All patients suffered from inflammatory ocular and vestibulo-auditory symptoms. In addition, 32/55 (58%) manifested systemic symptoms with musculoskeletal involvement being the most common with a prevalence of 45%, followed by neurological and skin manifestations. Aortitis was detected in 9/55 (16%). Regarding prognosis, remission in ocular symptoms was attained in 69%, whereas only 32% achieved a significant improvement in auditory function. Mortality was 2/55. Our patient was an 8 year old girl who presented with bilateral uveitis and a history of long standing hearing deficit. She also complained of intermittent vertigo, subfebrile temperatures, abdominal pain with diarrhoea, fatigue and recurrent epistaxis. The diagnosis was supported by bilateral labyrinthitis seen on contrast-enhanced magnetic resonance imaging. Treatment with topical and systemic steroids was started immediately. As the effect on auditory function was only transient, infliximab was added early in the disease course. This led to a remission of ocular and systemic symptoms and a normalization of hearing in the right ear. Her left ear remained deaf and the girl is currently evaluated for a unilateral cochlear implantation. CONCLUSIONS: This study presents an analysis of the largest cohort of paediatric Cogan´s syndrome patients. Based on the collected data, the first practical guide to a diagnostic work-up and treatment in children with Cogan´s syndrome is provided.

A practical approach to chronic kidney disease in primary care.

Chronic kidney disease (CKD), a common clinical problem in primary care, can be defined as any abnormality of the kidney structure and/or function that has been present for at least 3 months. Over the past 20 years, the incidence and prevalence of CKD have been increasing in Malaysia in line with the rising number of non-communicable diseases. At present, CKD has no cure. The treatment of CKD is very much dependent on early diagnosis and prevention of CKD progression. In this article, we aim to illustrate a practical approach to CKD in primary care, including diagnosis, evaluation, and management of CKD.

Therapeutical Targets in Allergic Inflammation.

From the discovery of IgE to the in-depth characterization of Th2 cells and ILC2, allergic inflammation has been extensively addressed to find potential therapeutical targets. To date, omalizumab, an anti-IgE monoclonal antibody, and dupilumab, an anti-IL-4 receptor α monoclonal antibody, represent two pillars of biologic therapy of allergic inflammation. Their increasing indications and long-term follow-up studies are shaping the many different faces of allergy. At the same time, their limitations are showing the intricate pathogenesis of allergic diseases.

Diabetes-Related Microvascular Complications - A Practical Approach.

Diabetes-related microvascular complications include diabetic neuropathy (eg, diabetic symmetric polyneuropathy (DSPN), cardiac autonomic neuropathy, gastroparesis, enteropathy, erectile dysfunction, female sexual dysfunction, and hypoglycemia unawareness), diabetic kidney disease (DKD), and diabetes-related eye disease (eg, diabetic retinopathy (DR) and cataract). Both diabetes duration and degree of glycemic control strongly correlate with the development of microvascular complications. The development of diabetes-related microvascular complications interferes with the patient's quality of life and poses higher health system costs. This article will discuss a practical approach to effectively minimize/delay and manage the most common diabetes-related microvascular (DSPN, DKD, and DR).

Colonoscopic Evaluation of Lower Gastrointestinal Bleeding (LGIB): Practical Approach.

BACKGROUND: Haematochesia (Lower Gastrointestinal Bleeding (LGIB) is the most common reason for endoscopic examination. Generaly it is caused by hemorrhoids and diverticular disease, but other anorectal conditions can also lead to LGIB. Recurrent bleeding may result in secondary iron deficiency anemia. Colonoscopy is the primary diagnostic option for establishing a diagnosis of colonic bleeding. OBJECTIVE: This study aimed to analyze symptoms and endoscopic finding (specialy hemorrhoids) who may be sources of LGIB.Second goal of this study is to estimate time from onset of symptoms to performance of a colonoscopy. METHODS: A retrospective study included 603 adult patients who underwent colonoscopy in General Hospital "Sv. Apostol Luka", Doboj, Bosnia and Herzegovina, between 1.1.2020 and 31.12.2020. RESULTS: Average age of the examined population was 62±13,3years. According to the gender they were mostly men. To be exact,by percentage it was 53.7% of men and 46,3% of women, or by number: 324 men and 279 women. The most common indications for colonoscopy were LGIB (48,8%), abdominal pain and irregular stool. Most frequent endoscopic findings were hemorrhoids 42%. Normal findings had almost one third of all examinated patients. Combined findings-presence of more clinical entities in one patient were presented in 95 cases. In the group with hemorrhoids were almost two thirds of males, but there was no gender difference noted in between group with LGIB and without LGIB. More than half patients were older than 61 years. Anemia was presented in almost 20% of cases. Significantly it is higher frequency of abdominal pain, irregular stool and weight loss observed on the group without LGIB. Also, significantly more frequently patients with LGIB underwent colonoscopy in 0-30 days when compared with patients without LGIB (p=0,016). CONCLUSION: In patients with haematochezia, taking a careful medical history is mandatory. Hemorrhoids, diverticular disease and colorectal cancers are the most common causes of bleeding. Patients with LGIB and abdominal pain were previously examined with colonoscopy. Completely colonoscopy is advocated to detect probable proximal lesions.

Intravitreal Injections with Vascular Endothelial Growth Factor Inhibitors: A Practical Approach.

Intravitreal injections with vascular endothelial growth factor inhibitors constitute the most prevalent ophthalmic procedure in developed countries. Historically, there has been steady growth in the number of treatments performed of this kind, and projection studies estimate further growth in such treatments in the future. We provide a practical approach to intravitreal injections and discuss important aspects relating to the setting, the patient, the procedure, and the information given to the patient.

Lung Health Care pilot project trims patient pill load and antibiotic prescription in primary health care settings in Kerala, India.

INTRODUCTION: Kerala, the southern Indian state piloted Lung Health Care Project (LHCP) which is a locally adopted version of WHO recommended Practical Approach to Lung health (PAL). The current study assessed the impact of the project on the prescribing practices of doctors and consumption of antibiotics and other drugs. METHODS: This study compared performance of primary health care institutions with regard to drug prescriptions and consumptions before and after the implementation of the project. Chronic respiratory disease (CRD) patients in institutions implemented the project were interviewed in the OPD at exit and their prescriptions were documented at baseline and after six months. Focus group discussions were conducted with doctors to explore the reasons behind changes in drug consumption pattern. RESULTS: In the project implementing institutions, mean number of drugs prescribed for CRDs was 3.88 (SD 1.50) and 2.73 (SD 1.18) at baseline and after six months respectively (p < 0.001). Adjusted odds ratio for prescribing an antibiotic and injection to a CRD patient during impact assessment at institutions implementing project was 0.34 (95% CI 0.15-0.75 p 0.008) and 0.39 (95% CI 0.20-0.74 p 0.004) respectively, as compared to baseline. The factors which helped in reducing antibiotic and injection use as felt by the doctors were presence of a protocol, good quality trainings, supportive supervision and monitoring, availability of alternate drugs and good participation of staff nurses especially in-patient education. CONCLUSION: Strict adherence to diagnostic and management algorithms of Lung health care project in a primary health care setting in India helped in reducing pill burden to patients and prescription of antibiotics and injections.

Ophthalmology Practice During the Coronavirus Disease 2019 Pandemic: The University of Pittsburgh Experience in Promoting Clinic Safety and Embracing Video Visits.

The coronavirus disease 2019 pandemic has led to widespread change as public health strategies for containment have emphasized social distancing and remaining at home. These policies have led to downscaled clinic volumes, cancellation of elective procedures, enhanced personal protective strategies in the clinic, and adoption of telemedicine encounters. We describe the evidence-based practical approach taken in our ophthalmology department to continue delivering eye care during the pandemic by rescheduling visits, enhancing clinic safety, and adopting virtual video encounters.

Molecular Genetics of Renal Cell Tumors: A Practical Diagnostic Approach.

Renal epithelial cell tumors are composed of a heterogeneous group of tumors with variable morphologic, immunohistochemical, and molecular features. A "histo-molecular" approach is now an integral part of defining renal tumors, aiming to be clinically and therapeutically pertinent. Most renal epithelial tumors including the new and emerging entities have distinct molecular and genetic features which can be detected using various methods. Most renal epithelial tumors can be diagnosed easily based on pure histologic findings with or without immunohistochemical examination. Furthermore, molecular-genetic testing can be utilized to assist in arriving at an accurate diagnosis. In this review, we presented the most current knowledge concerning molecular-genetic aspects of renal epithelial neoplasms, which potentially can be used in daily diagnostic practice.

Antiarrhythmic Drugs: Risks and Benefits.

The narrow therapeutic window of antiarrhythmic drugs makes their use clinically challenging. A solid understanding of the mechanisms of arrhythmias and how antiarrhythmics affect these mechanisms is only a preliminary step in their appropriate selection. Clinical factors, side-effect profiles, and proarrhythmic risks are more important than the cellular mechanisms of actions in drug selection and monitoring. This article provides a simplified approach to understanding cellular mechanisms and provides a practical approach to the selection and use of this important class of medications.

Health benefits of Practical Approach to Lung health (PAL) experienced by patients with chronic respiratory diseases - Results from PAL pilot project in primary health care setting in Kerala, India.

Government of Kerala state had implemented a pilot project of the World Health Organisation recommended Practical Approach to Lung health (PAL) strategy, with an intention to improve the quality of diagnosis, treatment and management of common chronic respiratory diseases (CRD) in primary health care settings. The current study was done as a part of implementation of PAL pilot project and was intended to assess the benefits of PAL for the individual patients with CRDs accessing services from primary health institutions. Exit interviews were conducted at the baseline and for impact assessment after six months of pilot project by interviewing patients with CRD attending primary health institutions implementing PAL and control institutions. A total of 94 and 100 CRD patients were interviewed at baseline and after six months in the PAL implementing institutions, and 88 and 96 CRD patients were interviewed at the control institutions. Reduction in number of medical consultation, hospital admissions and exacerbations among CRD patients were 5.03, 3.20 and 2.24 times higher in PAL implementing institutions as compared to the control institutions. PAL pilot project in India implemented in an area with a reasonably sound primary health care system has proved that it might be beneficial for the patients with CRD as it reduces frequency of exacerbations, hospital visits and frequency of medical consultations.

Practical Approach to Lung Health - Experience from the Republic of Macedonia.

BACKGROUND: Among the adults and children aged 5 yrs who attend PHC settings, 20-30% seeks to care for respiratory symptoms. Over 80-90% of the respiratory patients suffer from acute respiratory infections (ARI), followed by chronic obstructive pulmonary diseases (COPD), asthma, and less frequently with pneumonia and tuberculosis (TB). To improve the quality of care in patients who seek assistance for respiratory symptoms in PHC settings and the efficiency of respiratory service delivery within healthcare systems, WHO has designated several initiatives among which one is PAL (Practical Approach to Lung Health). PAL is an integrated and symptom-based approach focused on all priority respiratory illnesses encountered in PHC, including TB. Its patient-centred syndromic approach aims to improve the quality of diagnosis and treatment of respiratory illnesses in a PHC setting. AIM: To evaluate the short-term impact of PAL approach in improving the management of patients with the most frequent respiratory diseases by the GPs from PHC settings in the Republic of Macedonia. MATERIAL AND METHODS: A total of 588 GPs were educated for the most frequent respiratory diseases during the PAL training from 2013-2016. To evaluate the efficiency of GPs education from PHC settings, GPs fill in a form out of 69 questions for the patients enrolled before (baseline survey) and after PAL training (impact survey), and the results of the two surveys were compared. This analysis aimed to assess if the theoretical and practical skills obtained during the PAL training have been used in the routine practice of the GPs who attended the training and to what degree. RESULTS: Our results showed that in the impact study more patients with ARI (P < 0.000001) and more patients with COPD exacerbations were treated in the PHC settings (P < 0.000008). More patients suspected of asthma were referred to upper health level for diagnosis (P < 0.037). The comparison of the findings between the baseline and impact surveys suggest that training on PAL had an impact in decreasing drug prescription through a reduction in a prescription for antibiotics for ARI, COPD and asthma. Our study indicates that training on PAL is likely to increase the prescription of inhaled corticosteroids and tends to decrease the prescription of other formulation of these drugs (P < 0.0000001). The impact surveys showed that the patients with COPD and pneumonia in the PHC settings were better managed due to the more frequent use of CAT questionnaires and CURB test. And regarding TB cases, our study indicates that the GPs were more aware of this disease and were more willing to take part in the patient treatment follow-up (P < 0.000001). CONCLUSION: The results from this study showed that implementation of PAL approach for GPs from the PHC setting in our country have positive results (effect) in the management of patients with respiratory symptoms: it is likely to reduce prescribing for antibiotics, to increase the use of inhalation medication which is highly recommended in the management of asthma and COPD, and to decrease the referral of patients with chronic diseases to the upper health level. However, more experience is needed for long-term influence on the effects over the cost-effectiveness of respiratory care services and on strengthening the health care system.

Pernicious Anemia: Fundamental and Practical Aspects in Diagnosis.

BACKGROUND: Pernicious Anemia (PA), the most common cause of cobalamin deficiency anemia worldwide, is an autoimmune disease of multifactorial etiologies involving complex environmental and immunological factors. Although it was first reported by Addison in 1849 with subsequent advances in understanding of pathogenesis and molecular biology, diagnosis of PA is still challenging for clinicians because of its complexity and diverse clinical presentations. CONCLUSION: Herein, we provide an overview of PA, mainly focusing on its scientific and practical aspects in diagnosis. We also discuss the limitations of currently available diagnostic tools for the evaluation of cobalamin deficiency and PA.

Abordaje práctico de la espondiloartritis / Practical approach to spondyloarthritis

Introducción: la espondiloartritis, es una forma de artritis inflamatoria que, generalmente comienza entre los 17 y los 45 años. La inflamación sistémica es una característica clave que ayuda a distinguirla de otros tipos de artritis, incluida la artritis por desgaste y desgarro, como la osteoartritis. Objetivo: brindar información sobre el abordaje práctico de la espondiloartritis para contribuir a esclarecer puntos que, a juicio de los autores de este trabajo, son importantes para el manejo de la misma. Desarrollo: en poco tiempo han tenido lugar inusitados avances que abarcan todos los aspectos de su manejo, incluidos el diagnóstico y el seguimiento, pero sobre todo en su tratamiento. Algunas presentaciones engañosas son propias del comienzo retardado, como la espondiloartritis periférica de inicio tardío (LOPS), que se caracteriza por una oligoartritis inflamatoria que contrasta con los signos generales, un importante síndrome inflamatorio y, a veces, edema asimétrico de las extremidades inferiores. Conclusiones: el papel de los reumatólogos es esencial en el manejo de esta enfermedad, pues son los especialistas mejor calificados para tener a su cargo a estos pacientes, mientras que los generalistas participan más en la detección de la misma(AU)

Introduction: spondyloarthritis, or SpA, is a form of inflammatory arthritis that usually begins between 17 and 45 years. Systemic inflammation is a key feature that helps distinguish it from other types of arthritis, including arthritis by tearing and tearing, such as osteoarthritis. Objective: to provide information on the practical approach of spondyloarthritis to help clarify points that, in the opinion of the authors of this work, are important for the management of it. Development: in a short time, there have been unusual advances that cover all aspects of its management, including diagnosis and monitoring, but especially in its treatment. Some deceptive presentations are typical of delayed onset, such as late-onset peripheral spondyloarthritis (LOPS), which is characterized by an inflammatory oligoarthritis that contrasts with the general signs, an important inflammatory syndrome and, sometimes, asymmetric edema of the lower extremities. Conclusions: the role of rheumatologists is essential in the management of this disease, as they are the best qualified specialists to be in charge of these patients, while the generalists participate more in the detection of it(AU)

Atrial fibrillation in the elderly: a review.

Atrial fibrillation (AF) is common in the elderly population. Elderly patients with AF are often asymptomatic, may have atypical presentation or may present with heart failure or thromboembolic complications. The optimal management strategy of AF in the elderly population is challenging. We present an overview of AF in elderly patients, in particular addressing the pros and cons of various management strategies, and provide a practical approach within the guidelines.

Montelukast for the high impact of asthma exacerbations in Venezuela: a practical and valid approach for Latin America?

BACKGROUND: Asthma affects mainly Venezuela's urban and poor majority. Exacerbations bring about a high demand in health services, thus becoming a significant public health problem. In general, asthma control programs (GINA) with use of inhaled steroid medications have proven effective, although their implementation in real life remains cumbersome. Montelukast could be a useful and practical tool for these deprived socioeconomic sectors. METHODS: This real-life pilot study was conducted in a prospective, double blinded, placebo-controlled manner with randomized and parallel groups. Asthmatics that had never used leukotriene modifiers were recruited and followed-up every three months. The main outcome was the number of exacerbations meriting use of nebulized bronchodilators administered by the health care system. RESULTS: Eighty-eight asthmatic patients were enrolled, between children and adults. Groups were comparable in: demographic data, previous use of other medications, ACT scores, pulmonary functions (Wright Peak Flow meter), allergy status (Skin Prick Test) as well as adherence to the prescribed Montelukast treatment. By an intention to treat (ITT), a total of 64 patients were included for analysis. For the three and six months time points the difference between placebo and Montelukast was found to be significant (p < 0.03 and p < 0.04, respectively). Such trends continued for the rest of the year, but without statistical significance, due to patient attrition. CONCLUSIONS: This real-life pilot study shows that a simplified strategy with oral Montelukast was practical and effective in controlling exacerbations in an asthmatic population of a vulnerable community from Caracas. Such an approach reinforces the role of primary care in asthma treatment.

Court room exposure to medical students: a practical approach to legal procedures in Indian scenario.

BACKGROUND: Education of law and bioethics has been recognized as an integral part of medical education. Medical professionals are required to contribute to the jurisprudence in various roles including the role of an 'Expert Medical Witness'. Practical knowledge of legal procedures enables the medical professional to facilitate the judiciary in delivering justice in its right spirit. Unfortunately medical students lack this practical empowerment and thus may not be able to contribute to the justice system to the fullest potential during their professional life. We offered exposure to real life courtroom procedures to medical students to enhance their knowledge and confidence. MATERIALS AND METHODS: Ninety seven medical students were exposed to real courtroom visits in batches of 20. They attended the legal proceeding of a medical witness examination in real case scenario and also interacted with the judge, public prosecutor and defense lawyer. All the relevant issues were discussed thoroughly before and after the court visits. A consensually validated questionnaire was used to determine the enhancement in their knowledge whereas their experience was assessed through a semi structured questionnaire. RESULTS: The average knowledge level improved significantly from 34.4 (SD = 5.59) to 40.74 (SD = 5.35) [p < 0.001, 95% CI of the difference: (-7.455, -5.225)]. Only 7 students reported that they require more such visits to attain desired confidence level. The average rating for the whole process was 8.08(SD = 1.35) out of 10, with only 5 students rating the process below 5 points. CONCLUSION: The process served as an ice breaker for the doubts and fear about the court and legal procedures. This module may be refined and replicated to develop a medical professional who is confident and empowered about the legal system which will benefit the judiciary and in turn the common man of the society.