Medicina Interna

Semiology of Cardiac Tamponade: Jugular Vein Distention

Pedro Fernandes Moura — 2024-12-19

Dermatomyositis: The Importance of the Clinical Eye

Joana Gomes da Cunha — 2024-12-19

Direct Costs of Heart Failure in the Autonomous Region of Madeira

Luís Ramos dos Santos — 2024-12-19

Introduction: Heart failure (HF) is a global public health
issue. Its economic impact in the Autonomous Region of
Madeira (ARM) is unknown. Thus, profiling HF prevalence,
healthcare utilization and related costs in the ARM is fundamental.

We aimed to estimate the direct costs of HF in the ARM.

Methods: Prevalence-based, cost-of-illness study based
on 2014, from the health system perspective. Hospitalization and emergency department (ED) episodes were identified by the International Classification of Diseases 9th edition – Clinical Modification (ICD-9-CM). Patterns of visits, tests and medication consumption were derived from previous reported research. Costs were based on Disease Related Groups and from the official regional health system tariffs.

Results: There was a 4.93% prevalence above the age
of 25 (9201 patients). Out of these, 4140 were symptomatic
and hence healthcare consumers. We identified 426 admissions with a primary diagnosis of HF, 17 305 primary
care medical visits, 857 ED visits and 6707 medical hospital
visits. Total direct costs were €4 089 540.10. Hospital-related
care was responsible for the majority of costs (56%), followed by primary care costs (23%), medication (20%) and
long-term care (2%). The average annual cost per patient
was €987.81.

Conclusion: Total annual direct costs amounted to 0.1%
of the gross domestic product of the ARM and 1.2% of the
healthcare budget of the ARM for 2014. This research adds
information about the disease that was until now unknown
and should lead to better disease management programs.

Treatment Challenge of Complex Aortic Atherosclerosis in Acute Ischemic Stroke Context: A Retrospective Study

Daniela Cruz — 2024-12-19

Introduction: Complex aortic atherosclerosis is an important cause of stroke. However, the lack of scientific evidence makes its treatment controversial, which highlights the need for further research. This study aims to evaluate the efficacy and safety of the therapeutic strategies used in complex aortic atherosclerosis.

Material and Methods: A retrospective analysis was carried out on patients hospitalized with ischemic stroke and complex aortic atherosclerosis diagnosed by transesophageal echocardiography, between January 1, 2010 and December 31, 2022.

Results: Of the 82 patients included, 23.2% had ischemic
stroke recurrence, of which 47.4% were treated with clopidogrel monotherapy. Patients taking clopidogrel had a higher ischemic stroke recurrence rate (p <0.001), while patients taking dual antiplatelet therapy had a lower recurrence rate (p = 0.035). There was no recurrence in patients receiving direct oral anticoagulants. Regarding the patients treated with warfarin, five had recurrence with an infra-therapeutic INR and two had hemorrhagic events.

Conclusion: In our population, dual antiplatelet therapy
with acetylsalicylic acid and clopidogrel for 3 to 6 months
followed by single antiplatelet therapy with acetylsalicylic acid seems to be the safest and most effective strategy for the treatment of ischemic stroke associated with complex aortic atherosclerosis, while clopidogrel monotherapy was associated with a higher recurrence rate. Direct oral anticoagulants appeared to be effective and safer than warfarin for patients receiving anticoagulant therapy.

Population Study of the Green and Blue Priorities in an Emergency Department

David Prescott — 2024-12-19

Introduction: The management of the Emergency Department (ED) is complex and multifactorial, and with a growing influx of patients, it is burdened with hospital overcrowding, longer wait times, professional burnout, and lower quality of care. Approximately 43% of cases in Portugal are classified as low-priority emergencies.

Methods: This retrospective observational study was conducted in the ED of a district hospital in Portugal from October 2018 to May 2019. It included adults with green and blue priority
in triage. Discharge destination and number of ED admissions were analysed, with associations examined in relation to age, mode of arrival, activation of the "via azul" (fast-track system), and access to primary healthcare services.

Results: We included 41 066 episodes, with the majority being of green priority (99.9%). The majority of patients, 98.8%, were discharged to outpatient care. Frequent flyers (≥ 4 admissions) made up 3.3% of the group and 0.3% were high users (≥ 10 admissions). Analysis showed significant associations of discharge destination with age, mode of arrival, and activation of the "via azul" (p <0.001). There was also a significant association between number of admissions and age (p <0.001) and the number of admissions and
access to primary healthcare services (p <0.001).

Conclusion: The study highlights the importance of different factors in the patient’s destination, showing a strong association between age and hospital admission. Furthermore, the mode of arrival to the ED and the activation of the "via azul" are also associated with the patient's discharge destination. However, further studies are needed to understand the systematic issues within the ED.

Factors Associated with Return to Conventional Hospitalization During Hospital at Home

Daniela Meireles — 2024-12-19

Introduction: Return to conventional hospitalization is defined as “the return of a patient to the conventional ward from the hospital at home (HaH), and is one of the criteria used to
measure the quality of health care provided.

Methods: A two-year retrospective observational study collected sociodemographic and clinical data, as well as indicators related to the clinical management process and the reason for return to the conventional ward. Statistical analyses included a comparison between “patients without return” versus “patients with return” and multiple correspondence analysis.

Results: A total of 562 patients were included. Thirty (5.3%) patients returned to the conventional ward. None of the variables was associated with returning to hospital. The multiple correspondence analysis found a relationship between the “destination” at the end of the hospitalization and
the “age group”.

Conclusion: Comparing return rates is challenging, given the heterogeneity of the services provided. However, in this analysis, the return rate was low and it was not possible to find any variables that are associated with the risk of return to conventional hospitalization.

Seronegative Autoimmune Hepatitis / Primary Biliary Cholangitis Overlap Syndrome

Andreia Coutinho — 2024-12-19

It remains unclear whether overlap syndrome is a variant of primary biliary cholangitis, autoimmune hepatitis or an individual entity unto itself. Here we present the clinical case, diagnostic workup and management of a patient with this condition. It is the case of a Caucasian female, 64 years old, that presented with clinical features of both diseases, a
biochemical pattern resembling autoimmune hepatitis and a histology favouring primary biliary cholangitis, but no autoimmune antibodies were detected.

Wilson’s Disease: A Family History

Maria Teresa Brito — 2024-12-19

Wilson's disease (WD) is a rare monogenic, autosomal recessive disorder of copper accumulation. Clinical features include liver disease, hemolytic anemia, neuropsychiatric disorders, and cooper´s deposits in the cornea - Kayser-Fleischer rings, a characteristic feature of WD. Lifelong treatment is required to prevent disease progression, highlighting the importance of accurate diagnosis.

We report the cases of two young siblings with WD with liver disease and Kayser-Fleischer rings - both were asymptomatic, and the family history was positive for liver disease of unknown etiology. The eldest brother had elevated aminotransferases and gamma-glutamyltransferase - transient elastography fibrosis staging was F4, abdominal magnetic resonance imaging (MRI) showed hepatic steatosis, ceruloplasmin was undetectable with markedly elevated 24 hours urinary copper.
The diagnosis of WD was confirmed by Kayser-Fleischer rings. The younger sibling also presented with elevated ALT and GGT, extremely low ceruloplasmin, high 24 hours urinary copper and
Kayser-Fleischer rings. Both patients were started on chelation and are being actively followed.

Hemochromatosis

Margarida Araújo — 2024-12-19

Hemochromatosis is a hereditary disease of iron metabolism resulting from genetic defects in the hepcidin-ferroportin axis, exhibiting variable penetrance and, therefore, clinical heterogeneity. This condition leads to uncontrolled iron absorption, posing a risk of overload in vital organs such as the liver, heart, pancreas, joints, and endocrine organs. Patients face an increased risk of cirrhosis and hepatocellular carcinoma. Suspect hemochromatosis in the presence of symptoms, a family history, or elevated serum iron markers, especially transferrin saturation. Diagnosis is challenging due to the non-specificity of clinical manifestations and serum iron markers. There are several genes implicated, but HFE is the most frequently affected; C282Y homozygosity associated with iron overload makes the diagnosis; other genetic variants may require additional study with magnetic resonance imaging or liver biopsy The preferred treatment
includes phlebotomy; alternatively, erythrocytapheresis or
iron chelation can be considered. Early initiation of treatment
is crucial to reduce the high morbidity and mortality
associated with the disease.

Leadership in General Internal Medicine: Are We Leading or Managing?

Flávia Borges — 2024-12-19

Multidisciplinary Discharge Planning Team: A Project of the Medicine 2 Service of the Amadora/Sintra Local Health Unit

João Tiago Serra — 2024-12-19

The challenge of finding a balance between the inpatient
capacity of the Internal Medicine wards and the growing social needs of the inpatients is a variable in constant tension. The high number of social admissions is a well-known problem and limits the appropriate response to acute admissions. Discharge Planning Teams are multidisciplinary teams of doctors, nurses and social workers who work with all professionals involved in the clinical pathway and discharge planning. The team's working model is based on the early and systematic assessment of all users, using three scales as instruments that constitute the team's initial assessment of the user. The monitoring of several indicators in real-time makes it possible to adjust and improve the assessment process, as well as to monitor gains in terms of care indicators.