Gastric perforation by fish bone with hepatic abscess formation presenting as prolonged fever.

A 70-year-old woman presented to the emergency department with a 3-week history of prolonged fever, asthenia and anorexia, denying other symptoms. Physical examination was unremarkable and the patient admitted for further investigation. Initial laboratory testing showed leucocytosis, elevated C-reactive protein and cholestasis, without hyperbilirubinemia or cytolysis. Abdominal ultrasonography found no abnormalities. Viral serologies, autoimmune tests and blood cultures were collected for further investigation of causes of prolonged fever with hepatic involvement. After two days, Citrobacter koseri was isolated in blood cultures and intravenous (IV) piperacillin-tazobactam initiated. Computed tomography (CT) scan of the abdomen showed a left lobe hepatic abscess with gas and a linear hyperdense image, possibly a foreign body, piercing through the gastric antrum into the abscess. Surgical exploration was done for source control. The abscess was drained and the foreign body, a 3.5 cm long fishbone, was removed. The patient's condition rapidly improved. Gastrointestinal perforation due to the ingestion of sharp and elongated foreign bodies usually occur in ileal loops, where the intestinal wall is thinner, causing extravasation of fluids and air into the peritoneum and typically presents with an acute abdomen. The uncommon location of perforation masked these symptoms leading to the unusual presentation with prolonged fever.

Statin-induced low cholesterol is not associated with poor outcome in chronic heart failure.

BACKGROUND: Low cholesterol levels are associated with a worse outcome in patients with heart failure (HF). Use of statins in HF remains controversial. We aimed to assess whether the prognosis of patients with intrinsically low cholesterol levels differed from that of those with pharmacologically induced low cholesterol. MATERIALS AND METHODS: We conducted a retrospective cohort study on 464 ambulatory patients attending a specialized HF clinic. Patients were cross-classified according to statin therapy and admission total cholesterol level (low cholesterol <150 mg/dL and cholesterol ≥150 mg/dL): (1) low total cholesterol level on statin therapy; (2) low total cholesterol level not taking statins; (3) cholesterol ≥150 mg/dL on statin therapy; and (4) cholesterol ≥150 mg/dL not on statin therapy. Patients were followed up to 5 years and the outcome was all-cause death. A Cox regression analysis was used in prognosis assessment. RESULTS: Almost two thirds of the patients were men and the median population age was 69 years; 22.8% of the patients had preserved ejection fraction and 43.5% severe systolic dysfunction. The patients with an intrinsically low cholesterol had a hazard ratio of all-cause death up to 5 years of 2.38 (1.08-7.14) compared to those with low cholesterol induced by statin use. This association was independent of other variables associated with outcome. CONCLUSIONS: Patients with HF with instrisically low cholesterol levels have a double risk of death up to 5 years compared to patients with pharmacologically induced low cholesterol. Clinicians should not limit the use of statins by fear of lowering the cholesterol levels.

Population-based study on the prevalence of spirometric obstructive pattern in Porto, Portugal.

BACKGROUND: The diagnosis of obstructive lung disease (OLD) based on clinical grounds is challenging. There have been no population-based COPD studies that collected pulmonary function data in Portugal, a country in transition between phases 2 and 3 of the smoking epidemic. OBJECTIVE: To estimate the prevalence of obstructive pattern on spirometry in a representative sample of adults from Porto, Portugal. METHODS: We conducted a health survey between 2001 and 2003, and 758 participants ≥ 40 years old had reliable spirometry. We used a structured questionnaire to collect demographic, clinical, social, and behavioral data. Obstructive pattern was defined as FEV(1)/FVC < 70%. Logistic regression was performed to quantify the association between socio-demographic and clinical factors and outcome. RESULTS: The participants' mean ± SD age was 58.5 ± 11.5 years, and 62% were women. The prevalence of spirometric obstructive pattern was 10.7%, 95% CI 8.6-13.1%; 13.4% in men, and 9.1% in women (P = .08). The age-adjusted odds ratios for cumulative smoking exposure of less than and more than 20 pack years, in comparison with never smokers, were 3.49 (95% CI 1.02-11.92) and 3.91 (95% CI 1.29-11.89) among men, and 1.47 (95% CI 0.53-4.08) and 2.68 (95% CI 1.07-6.68) among women, respectively. Previously diagnosed OLD was reported by 30.9% (95% CI 21.1-42.1%) of the participants with spirometric obstructive pattern. Spirometry confirmed the OLD diagnosis in 20.5% (95% CI 13.7-28.7%) of subjects who self-reported OLD (kappa = 0.14, 95% CI 0.07-0.20). CONCLUSIONS: The prevalence of spirometric obstructive pattern was high. Considering Portugal's position in the smoking epidemic, together with the aging of the population, we can expect an increase in the prevalence of OLD in older people and in women. Our results confirm the limited validity of self-reported OLD in epidemiological studies.

Prevalence and characteristics of sleep apnoea in patients with stable heart failure: Results from a heart failure clinic.

BACKGROUND: Heart failure (HF) and sleep apnoea (SA) association has been recognized but whether it results from confounding factors (hypertension, ischaemia, obesity) remains unclear.We aimed to determine the prevalence of SA in HF and to identify potential risk factors for SA in HF population. METHODS: We prospectively evaluated 103 patients with stable HF on optimized therapy. In-laboratory polysomnography was performed. Type and severity of SA were defined according international criteria. Demographic, anthropometric and clinical characteristics were collected. Continuous data are expressed as median and interquartile range. RESULTS: SA was found in 72.8%, moderate to severe in a significant proportion (apnoea-hypopnoea index > or = 15- 44.7% of all patients) and predominantly obstructive (60.0% of patients with SA). Most patients were non-sleepy (Epworth < 10- 66%). SA patients were predominantly men (85.3 vs 60.7%, p-0.015), had larger neck (38.0 (35.0-42.0) vs 35.0 (33.2-38.0) cm, p-0.003), severe systolic dysfunction, (63.9 vs 33.3%, p-0.018), left ventricle (LV) hypertrophy (16.2 vs 0.0%, p-0.03), LV and left atria (LA) dilatation (49.0 (44.0-52.0) vs 42.0 (38.0-48.0) mm, p < 0.001; 60.0 (54.0-65.0) vs 56.0 (52.0-59.0) mm, p-0.01). However, only LA diameter was an independent predictor of SA. Higher body-mass index (BMI) was associated with moderate to severe SA. Patients with obstructive SA had larger neck and a trend for higher BMI, snoring and sleepiness. Hypocapnia was not associated with central SA. CONCLUSIONS: In our HF population, SA was prevalent, frequently asymptomatic and without characteristic risk factors. Unlike previously reported, obstructive SA was the predominant type. These results suggest that SA is underdiagnosed in HF and there is a possible correlation between them, independent of confounding factors. Recent advances in HF therapy might influence prevalence and type of SA in this population.

Left ventricular systolic function in the prognosis of patients hospitalized due to worsening heart failure.

INTRODUCTION: Preserved left ventricular systolic function (LVSF) is observed in up to 50% of patients with heart failure (HF). We aimed to determine the prognostic value of LVSF and identify prognostic indices in patients hospitalized due to HF with preserved and depressed LVSF. METHODS: We evaluated clinical records of 304 patients admitted due to decompensated HF, with ECG, echocardiogram and plasma NT-proBNP determination. The endpoint was death or hospital readmission within 6 months. RESULTS: Patients with preserved LVSF were more frequently women (72.9% vs. 45.0%, p < 0.001) and were more frequently in atrial fibrillation (56.3% vs. 35.6%, p < 0.001). NT-proBNP values at discharge were higher in patients with depressed LVSF (median 5291 [2050-10306] vs. 2146 [1048-4052] pg/ml, p < 0.001). Among patients with preserved LVSF, predictors of adverse events were male ender, hemoglobin, serum creatinine and serum sodium levels at discharge. Among patients with depressed LVSF, predictors of adverse events were male gender, atrial fibrillation, non-prescription of ACE inhibitors at discharge and NT-proBNP levels at discharge. Death or hospital readmission occurred in 40 patients with preserved LVSF and 95 with depressed LVSF (HR = 1.20 [95% CI: 0.83-1.73]). CONCLUSIONS: Our results show an ominous prognosis of acute HF, regardless of LVSF, in an elderly HF population. Patients with preserved LVSF presented weaker neurohumoral activation, These results reinforce the need for closer follow-up and aggressive strategies irrespective of systolic function in HF patients.