Anterior ischemic optic neuropathy and hematologic malignancy: a systematic review of case reports and case series.

OBJECTIVE: Demographic and clinical characteristics associated with nonarteritic anterior ischemic optic neuropathy (NAION) are well described. Patients with hematologic neoplasms may share some of these characteristics, and it may be useful clinically to better understand this set of patients. Our objective is to review systematically the characteristics of patients with both hematologic malignancies and NAION. DESIGN: Systematic review. PARTICIPANTS: Patients with NAION diagnosis related in time to a hematologic neoplasm. METHODS: Data sources for the study included MEDLINE, Web of Science, LILACS, SciELO, and OpenGrey. The study eligibility criteria included case reports and case series. RESULTS: We found 261 records, with 15 studies included plus our case report. A total of 19 patients (8 female) with mean age of 54.6 years (range, 12-87) were analyzed: 37% (7) non-Hodgkin lymphoma; 26% (5) myeloproliferative neoplasms; 21% (4) myelodysplasia; 16% (3) leukemias. The limitations included verification bias, inability to test statistical association between NAION and hematologic neoplasms, the small number of cases, and confounding factors related to medical history and specific interventions in each case limited the robustness of our conclusions. CONCLUSIONS: Our results identified the characteristics of patients with NAION and hematologic neoplasms related in time. Additional observational studies may enlighten the importance of looking for evidence of an occult neoplastic disorder in patients presenting with NAION. A prompt diagnosis would be of invaluable significance for the best management, in terms of follow-up and therapeutics.

Classification systems for lower extremity amputation prediction in subjects with active diabetic foot ulcer: a systematic review and meta-analysis.

AIM: We systematically review the available systems used to classify diabetic foot ulcers in order to synthesize their methodological qualitative issues and accuracy to predict lower extremity amputation, as this may represent a critical point in these patients' care. MATERIAL AND METHODS: Two investigators searched, in EBSCO, ISI, PubMed and SCOPUS databases, and independently selected studies published until May 2013 and reporting prognostic accuracy and/or reliability of specific systems for patients with diabetic foot ulcer in order to predict lower extremity amputation. RESULTS: We included 25 studies reporting a prevalence of lower extremity amputation between 6% and 78%. Eight different diabetic foot ulcer descriptions and seven prognostic stratification classification systems were addressed with a variable (1-9) number of factors included, specially peripheral arterial disease (n = 12) or infection at the ulcer site (n = 10) or ulcer depth (n = 10). The Meggitt-Wagner, S(AD)SAD and Texas University Classification systems were the most extensively validated, whereas ten classifications were derived or validated only once. Reliability was reported in a single study, and accuracy measures were reported in five studies with another eight allowing their calculation. Pooled accuracy ranged from 0.65 (for gangrene) to 0.74 (for infection). CONCLUSION: There are numerous classification systems for diabetic foot ulcer outcome prediction, but only few studies evaluated their reliability or external validity. Studies rarely validated several systems simultaneously and only a few reported accuracy measures. Further studies assessing reliability and accuracy of the available systems and their composing variables are needed.

Validation and comparison of currently available stratification systems for patients with diabetes by risk of foot ulcer development.

AIMS/HYPOTHESIS: There are five systems to stratify the risk for the development of a diabetic foot ulcer (DFU). This study aimed to prospectively validate all of them in the same cohort of participants to allow their direct comparison. METHODS: A retrospective cohort study was conducted on all patients with diabetes but without an active DFU attending our podiatry section (n=364) from January 2008 to December 2010. Participants' characteristics and all variables composing the stratification systems were assessed at baseline. Follow-up was performed for 1 year or until DFU occurred. RESULTS: Participants had a mean age of 64 years; 99.7% had type 2 diabetes and 48.6% were male. Median follow-up was 12 months (1-12) during which 33 subjects (9.1%) developed a DFU. Age, diabetes duration, foot deformity, peripheral vascular disease, diabetic peripheral neuropathy, previous DFU, and previous lower extremity amputation were associated with DFU occurrence. All systems presented greater DFU occurrence frequency as the risk group was higher (χ(2), P<0.001) and showed good diagnostic accuracy values, especially negative predictive value (≥ 95%) and area under the receiver operating curve (≥ 0.73). The lowest performance concerned positive predictive value (≤ 29.5%). CONCLUSIONS/INTERPRETATION: All the currently available stratification systems show high accuracy to detect which patients will develop a DFU with no significant differences among them. Therefore, for diabetic foot screening and resource allocation, it would be desirable to have a single unified system, combining the available systems, prospectively validated in a multicenter context and testing the inclusion of novel predictive variables' pertinence.

[Cardiac effects of acute poisoning with tricyclic antidepressants: systematic review of the literature. Part I]. / Os efeitos cardíacos da intoxicação aguda por antidepressivos tricíclicos: revisão sistemática da literatura. Parte I.

Tricyclic antidepressant overdose is a frequent diagnosis in the emergency room. It is responsible for a significant percentage of hospital admissions for observation and treatment. This is due to its cardiac (as well as neurologic) toxicity, and the difficulty in predicting its clinical gravity. The authors present the paper with two objectives in mind: 1) information about a common and significant cardiological emergency; 2) presentation of the methodology concerning systematic reviews of the literature. In this first (of four) articles, the epidemiology tricyclic antidepressant overdose is presented. In the remaining three papers we will present its clinical presentation, diagnosis, treatment, prognosis and prevention. Note: this is the first of a series of four articles on the cardiac toxicity of tricyclic antidepressant overdose; the next three articles will be presented in the July, August and September issues of the RPC.

[Thrombolytic therapy in acute myocardial infarct--is it being used to the fullest?]. / Terapêutica trombolítica no enfarte agudo do miocárdio--estará a ser utilizada em pleno?

OBJECTIVE: To evaluate the experience with thrombolytic therapy (TT) in the treatment of patients with the discharge diagnosis of acute myocardial infarction (AMI). DESIGN: Retrospective analysis of the clinical records of patients with the discharge diagnosis of AMI, between May 1988 and December 1995. SETTING: Intensive Cardiac Care Unit (UCIM-Medicina IV) of Santa Maria University Hospital, Lisbon, Portugal. PATIENTS: 1319 patients, 958 men (73%) and 361 women, mean age 64 +/- 12 years. MAIN RESULTS: Thrombolytic therapy was administered in 391 patients (30%). Female patients received less thrombolytic therapy compared with male (17% vs. 34%; p < 0.001). Anterior wall infarction was more frequent (38%). Patients in Killip class I-II (77%) received more thrombolytic therapy than class III-IV (33% vs. 17%). The utilization rate of thrombolytic therapy increased from 25% in 1988 to 34% in 1995. Two major categories of patients were not treated with thrombolysis: 1) patients presented more than 12 hours after pain onset (38%); 2) patients without ST segment elevation or LBBB on the ECG presented (37%). Overall hospital mortality was 15.6%. The mortality in patients receiving thrombolytic therapy was significantly lower than in those excluded (9.4% vs. 18.2%; p < 0.001). CONCLUSION: Only 30% of patients with AMI receive TT. Of those excluded from this important therapeutic intervention, 75% had no ECG criteria or were outside the standard therapeutic "window". This significant group of patients need new diagnostic and intervention strategies.

Reduced glomerular filtration rate can maintain a rise in plasma bicarbonate concentration in humans.

In humans, deficiency of chloride and potassium were found to perpetuate the hyperbicarbonatemia that attends metabolic alkalosis induced by gastric aspiration partly by increasing renal bicarbonate reabsorption, commensurate with the attendant increase in filtered bicarbonate load, and partly by decreasing glomerular filtration rate (GFR), which minimizes the degree of which the filtered bicarbonate load increases and thereby minimizes the requisite increase in bicarbonate reabsorption. The relative contribution of stimulated renal bicarbonate reabsorption might increase, however, if the supply of extrarenal bicarbonate is increased, in which case a greater degree of hyperbicarbonatemia would be sustained. To investigate that possibility, we reexamined the mechanism of perpetuation of gastric alkalosis in normal subjects eating a low NaCl diet supplemented with bicarbonate salts. Prior to gastric aspiration, plasma bicarbonate concentration ([HCO3]p) and pH were higher than in similarly studied subjects not receiving bicarbonate: 29.9 +/- 0.6 vs. 25.3 +/- 0.1 and 7.43 +/- 0.008 vs. 7.41 +/- 0.002 mEq/l, respectively. With continued bicarbonate supplementation, gastric aspiration induced a further significant increase (p less than 0.05) in [HCO3]p of 10.8%, to values not significantly different from those in nonbicarbonate-loaded subjects with gastric alkalosis: 33.2 +/- 1.2 mEq/l. GFR decreased significantly by 8.4% (from 98 +/- 4 to 90 +/- 3 ml/min, p less than 0.025), offsetting nearly commensurately the increase in [HCO3]p so that total bicarbonate reabsorption was not significantly increased (2.90 +/- 0.12 vs. 2.97 +/- 0.19 mEq/min, p = NS).(ABSTRACT TRUNCATED AT 250 WORDS)