Masked Polycythemia Vera and Iron Deficiency in a Fertile-Age Woman.

Polycythemia vera (PV) is a myeloproliferative disorder that leads to increased red blood cell (RBC) mass. The V617F activating mutation for Janus kinase 2 (JAK2) is a classic finding in PV, but it is not exclusive to this condition. The radionuclide assay is an accurate method for accessing RBC, but hemoglobin (Hb) and hematocrit (Htc) values are frequently the first abnormal markers reported in a routine blood count and the basis for further investigation. Diagnostic criteria for PV were recently updated to include lower thresholds for Hb and Htc, increasing diagnostic sensitivity. However, it has been reported that a subset of patients does not meet these thresholds, besides having an active masked disease. We are presenting a case of a fertile-age woman with menometrorrhagia, whose blood loss and consequent iron depletion worked as a limiting factor for Hb and Htc increase, delaying the proper diagnosis. Splenomegaly, iron deficiency markers, and low erythropoietin supported PV investigation. The correction of iron depletion led to the unveiling of covert erythrocytosis. Concomitant hemoglobinopathies and secondary causes for erythrocytosis were excluded. The diagnosis was confirmed with polymerase chain reaction (PCR) for V617F-JAK2 mutation and bone marrow biopsy. As this case highlights, despite not meeting diagnostic criteria at presentation, masked PV exhibited clinical, laboratory, and imaging features of active symptomatic disease. For that, a higher level of suspicion must be held for fertile-age women who present with normal Hb and Htc levels and significant iron depletion, in the presence of low serum erythropoietin or splenomegaly.

Prescription Pattern of Proton Pump Inhibitors at Hospital Admission and Discharge.

BACKGROUND: Proton pump inhibitors (PPI) have reportedly been used in inappropriate clinical settings, often leading to an increased risk of adverse effects, drug interactions, and costs. AIM: The aim of this study was to evaluate the adequacy of PPI prescription in an internal medicine ward. METHODS: The discharged home inpatients of a segment in the medicine department of a central hospital in the first trimester of 2017 were evaluated; those who died or were transferred to another unit were excluded. Data on gender, age, admission, and discharge therapy and diagnoses which could support PPI use were collected from clinical records. Statistical analysis was performed using Microsoft Excel 2013® and IBM SPSS Statistics 20®. RESULTS: A total of 318 hospitalizations were included, corresponding to 301 patients; 171 (56.8%) were female and the average age was 75.4 ± 14.6 years. Among the 318 hospitalizations, 148 patients (46.5%) were on PPI at admission and 175 (55%) at discharge, the majority of them without indication (n = 91, 61.5% vs. n = 109, 62.3%). The main inappropriate indication was anticoagulation alone (n = 33, 36.3% vs. n = 43, 39.4%). There was indication for PPI therapy in 93 (29.2%) of the cases at admission and 111 (34.9%) at discharge, mostly for prophylaxis of gastrointestinal bleeding in high-risk patients (n = 82, 88.2% vs. n = 96, 86.5%). Among those with indication, 57 (61.3%) were medicated at admission versus 66 (59%) at discharge. The association between PPI therapy and an indication for its prescription was lost by the time of discharge (p = 0.245). CONCLUSIONS: PPI prescription is not in agreement with existing recommendations, which is why it should be revised at hospital discharge. The primary indication for PPI therapy is the prophylaxis of gastrointestinal bleeding in high-risk patients and the main inappropriate indication is prophylaxis in low-risk patients. A large proportion of the patients indicated for PPI use were discharged without prescription.

INTRODUÇÃO: Os inibidores da bomba de protões (IBP) têm sido utilizados em situações sem indicação, com aumento do risco de efeitos adversos, interações medicamentosas e custos. OBJETIVO: Avaliar a pertinência da prescrição dos IBP numa enfermaria de Medicina Interna. MÉTODOS: Foram avaliados os internamentos de uma Enfermaria de Medicina de um Hospital Central, cuja alta ocorreu para o domicílio no 1° trimestre de 2017; foram excluídos aqueles que morreram ou foram transferidos. Foram recolhidos os seguintes dados do processo clínico: género, idade, terapêutica á admissão e á alta; antecedentes pessoais ou diagnósticos que pudessem sustentar a toma de IBP. A análise estatística foi realizada através do Microsoft Excel 2013® e IBM SPSS Statistics 20®. RESULTADOS: Foram incluídos 318 internamentos, correspondentes a 301 doentes, 171 (56.8%) do género feminino, com uma idade média de 75.4 ± 14.6 anos. Nos 318 internamentos, 148 doentes (46.5%) estavam sob IBP á admissão e 175 (55%) á alta, a maioria (n = 91, 61.5% vs. n = 109, 62.3%) sem indicação. A principal indicação inapropriada foi a anticoagulação isolada (n = 33, 36.3% vs. n = 43, 39.4%). Houve indicação para uso de IBP em 93 (29.2%) casos á admissão e 111 (34.9%) á alta, na maioria (n = 82, 88,2% vs. n = 96, 86.5%) para profilaxia de hemorragia gastrointestinal em doentes de alto risco. Dos doentes com indicação, apenas 57 (61.3%) estavam medicados á admissão versus 66 (59%) á alta. Houve uma perda de associação entre a terapêutica com IBP e a existência de indicação para a sua prescrição no momento da alta (p = 0.245). CONCLUSÕES: A prescrição de IBP é incongruente com as recomendações, pelo que esta deve ser revista no momento da alta. A principal indicação para IBP é a profilaxia de hemorragia gastrointestinal em doentes de alto risco e a principal indicação inapropriada é a sua profilaxia em doentes de baixo risco. Uma proporção significativa de doentes com indicação para IBP teve alta sem a sua prescrição.

CT-Proven Ischaemic Stroke as the First Manifestation of Occult Lung Cancer.

Cancer is associated with a higher risk of stroke, and in rare cases stroke can be the first manifestation of occult neoplasia. We present the case of a 74-year-old woman hospitalized for ischaemic stroke with multiple cerebral infarctions in several vascular territories. The exclusion of other aetiologies and the simultaneous presence of thromboembolic events in other organs raised the suspicion of a hypercoagulable state, which upon investigation revealed occult neoplasia of the lung. There was rapid deterioration, with recurrent thrombotic events despite anticoagulation, which eventually led to the patient's death. LEARNING POINTS: Stroke can be the first manifestation of occult neoplasia.In the presence of cryptogenic stroke, high D-dimers, multiple brain infarctions in different vascular territories and thromboembolic events in other organs, the possibility of hidden neoplasia should be considered.Anticoagulation in disseminated intravascular coagulation is insufficient if the primary disease is not treated.

Intramural hematoma of the esophagus after thrombolysis for ischemic stroke.

Intramural dissecting hematoma is an unusual esophageal condition with a threatening presentation but excellent prognosis when managed conservatively.We report the case of an 88-year-old woman who developed an intramural hematoma of the esophagus after intravenous thrombolysis for an acute ischemic stroke. Before thrombolysis, nasogastric intubation was attempted unsuccessfully. She was kept on nil by mouth, intravenous hydration, proton pump inhibitor, antiemetics,and an antibiotic initiated 2 days before for periodontal disease. The esophageal hematoma regressed, and she resumed oral diet asymptomatically.To our knowledge, this is the first report of this type of lesion after thrombolysis for an ischemic stroke. A brief discussion and literature review are presented.