Herbert French (1875–1951) and his differential diagnosis a “work of reference unique in medical literature”

In 1912, the Guy’s Hospital Assistant Physician, Dr Herbert French FRCP, published a magnum opus, An Index of Differential Diagnosis of Main Symptoms by Various Authors. This pioneering work was to formalise the paradigm of a six-chain sequence which underpins best-practice clinical medicine today. That chain comprises: taking a history, examination, compiling a differential diagnosis, tests and investigations, and formulating a diagnosis. Herbert French coined the term “differential diagnosis”; and formalised the earlier developments of Thomas Sydenham (1624 – 1689), Hermann Boerhaave (1668 – 1738) and later(1892), those of Sir William Osler in his The Principles and Practice of Medicine. French placed differential diagnosis formally as the pivot of the sequence of Oslerian medicine which distinguishes modern Western medicine from other healthcare systems. Herbert French was the Goulstonian Lecturer of the Royal College of Physicians (1907), a doctor-soldier in World War I and one of the Royal Physicians to H. M. Household. A prolific writer in the medical press, French updated and personally edited the first six editions of his Differential Diagnosis. The thirteenth edition (1996) was described as a work which “had no parallel” .This work, today in its sixteenth edition, remains “a reference unique in medical literature”.

Proton pump inhibitor indications in a Brazilian tertiary hospital

SUMMARY OBJECTIVES To evaluate the frequency of prescription of proton pump inhibitors (PPIs) and their indications in patients hospitalized at the Hospital de Clínicas of the Federal University of Uberlândia (HC-UFU). METHODS This is a quantitative cross-sectional observational study that analyzes data obtained from patient records on prescriptions of PPIs for patients hospitalized at the HC-UFU and from a questionnaire applied to assistant physicians on the indications of the drug in each case and evaluates the indication based on literature data. RESULTS On a pre-determined day, of a total of 462 inpatients, there was a prescription of PPI for 183 (39.3%), with a higher frequency (73.5%) in the Intensive Care Unit (ICU), followed by the infirmaries and the Emergency Room. The assistant physician was located in 116 cases, and the main motivation referred to prescription was prophylaxis of digestive hemorrhage (77%). However, after reviewing medical records, it was noticed that in 50.8% of the cases, the prescription was not supported by the literature. CONCLUSION The frequency of PPI prescriptions for inpatients in the HC-UFU is among the lowest described in the literature, but there are still unnecessary prescriptions. Instruction and awareness of the assisting team can minimize these numbers.

Population-based assessment of patient and provider characteristics influencing pediatric outpatient antibiotic use in a high antibiotic-prescribing state

Objective:To identify patient and provider characteristics associated with high-volume antibiotic prescribing for children in Tennessee, a state with high antibiotic utilization.Design:Cross-sectional, retrospective analysis of pediatric (aged <20 years) outpatient antibiotic prescriptions in Tennessee using the 2016 IQVIA Xponent (formerly QuintilesIMS) database.Methods:Patient and provider characteristics, including county of prescription fill, rural versus urban county classification, patient age group, provider type (nurse practitioner, physician assistant, physician, or dentist), physician specialty, and physician years of practice were analyzed.Results:Tennessee providers wrote 1,940,011 pediatric outpatient antibiotic prescriptions yielding an antibiotic prescribing rate of 1,165 per 1,000 population, 50% higher than the national pediatric antibiotic prescribing rate. Mean antibiotic prescribing rates varied greatly by county (range, 39–2,482 prescriptions per 1,000 population). Physicians wrote the greatest number of antibiotic prescriptions (1,043,030 prescriptions, 54%) of which 56% were written by general pediatricians. Pediatricians graduating from medical school prior to 2000 were significantly more likely than those graduating after 2000 to be high antibiotic prescribers. Overall, 360 providers (1.7% of the 21,798 total providers in this dataset) were responsible for nearly 25% of both overall and broad-spectrum antibiotic prescriptions; 20% of these providers practiced in a single county.Conclusions:Fewer than 2% of providers account for 25% of pediatric antibiotic prescriptions. High antibiotic prescribing for children in Tennessee is associated with specific patient and provider characteristics that can be used to design stewardship interventions targeted to the highest prescribing providers in specific counties and specialties.

Gerhard Henrik Armauer Hansen – A legend

Gerhard Henrik Armauer Hansen radicalized the views on leprosy when he discovered the leprosy bacilli in 1873. He was a man born in a humble background but with perseverance finished medicine at the University of Christiania and later joined as assistant physician under another stalwart Danielssen at St. Jogren’s Hospital, Bergen. It was here that he made the greatest discovery of his time, but it would be years before, he was truly acknowledged for his work. His theory of contagion helped in the measures to control leprosy in the form of leprosy acts. Hansen passed away in 1912, and his name remains engraved in the pages of the history of leprosy.

Palliative care need in patients with advanced heart failure hospitalized in a tertiary hospital

ABSTRACT Objective: To evaluate the need for palliative care in patients with advanced Congestive Heart Failure (CHF) hospitalized in a cardiology ward. Method: Application of the World Health Organization Palliative Needs tool (NECPAL) with the assistant physician, patient and/or caregiver for evaluation of indication of Palliative Care (PC). Results: 82 patients with a diagnosis of class III/IV Heart Failure or ejection fraction less than or equal to 40% in echocardiography of the last 12 months were included: Mean age 68 ± 20 years, 51 male patients and 31 female patients. Forty-three patients (52.4%) were married or in consensual union and ten (12%) lived alone. The death of 46 patients (56.1%) in the subsequent 12 months would not surprise their physician, and forty-five patients (55%) had palliative care indication according to the NECPAL. Conclusion: About half of patients hospitalized for class III/IV Heart Failure would have an indication of Palliative Care for the relief of suffering caused by the disease.

BULLOUS ERYTHEMA NODOSUM AS INITIAL MANIFESTATION OF LEPROSY

Introduction: Leprosy is a chronic granulomatous infectious disease caused by Mycobacterium leprae with protean manifestations, particularly prone to affect skin and peripheral nerves. The natural course of the disease may be associated with the development of type 1 or type 2 immunologic reactions. These immunologic reactions are reported to be caused by increased activity of the immune system, particularly a cell-mediated immune response against live leprosy bacillus or remnants of dead bacilli. Leprosy is one of the oldest diseases of mankind. Its clinical diagnosis can be challenging due to the varied manifestations. The first description of bullous erythema nodosum was made 1898 and since then there are few recorded reports. Case Report: Here we present a case of bullous erythema nodosum as leprosy first manifestation. A 35 year-woman presented with 1-year history of disseminated blisters on trunk, forearms and thighs, and multiple painful ulcerated nodules on her face. She reported that the lesions in her face became eroded and ulcerated spontaneously. There were no thickened nerves. Blood and Histopathological investigations were made. The treatment instituted was prednisone 1mg/kg without thalidomide. After two weeks with excellent response, specific therapy for Mycobacterium leprae was initiated by the infectious diseases assistant physician with a satisfactory response.

Deaths by tuberculosis in a priority city for disease control in the Brazilian Northeast: sociodemographic-operational characteristics and vulnerable territories.

Introduction: Incorporating spatial approaches into epidemiological research is a challenge in public health research. The goal in this study was to analyze the spatial distribution of cases of deaths by tuberculosis in Imperatriz – MA (Brazil) and to characterize these events according to sociodemographic and operational characteristics. Methods: In this ecological study, all deaths from tuberculosis as the primary cause registered in the Mortality Information System from 2005 to 2014 were considered. The research variables were subject to descriptive analysis, point density analysis (Kernel Intensity Estimation) and area analysis. Results: Fifty cases of deaths by TB were identified, particularly the pulmonary clinical form. Male patients were predominant, with a median age of 59 years, mulatto race/color, single, who had finished secondary education. Most deaths happened at the hospital, with medical care before death and without autopsy. Most events happened at the hospital, with medical care delivery by an assistant physician and without autopsy. The point density revealed heterogeneity in the spatial distribution of the deaths, with rates of up to 2.33 deaths/km2. The area analysis by census sector presented age standardized mortality rates of 0.00 to 4.00 deaths/100,000 inhabitants-year. Conclusion: The results contributed to the knowledge on the spatial distribution of cases of deaths by Tuberculosis and their characteristics in the research scenario. The importance of space is highlighted as a methodological alternative to support the planning, monitoring and assessment of health actions, targeting interventions to the control of the disease in vulnerable territories. Keywords: Tuberculosis; Health Information Systems; Mortality; Spatial analysis.

Lumbar puncture in patients using anticoagulants and antiplatelet agents

ABSTRACT The use of anticoagulants and antiplatelet agents has largely increased. Diagnostic lumbar puncture in patients taking these drugs represents a challenge considering the opposing risks of bleeding and thrombotic complications. To date there are no controlled trials, specific guidelines, nor clear recommendations in this area. In the present review we make some recommendations about lumbar puncture in patients using these drugs. Our recommendations take into consideration the pharmacology of these drugs, the thrombotic risk according to the underlying disease, and the urgency in cerebrospinal fluid analysis. Evaluating such information and a rigorous monitoring of neurological symptoms after lumbar puncture are crucial to minimize the risk of hemorrhage associated neurological deficits. An individualized patient decision-making and an effective communication between the assistant physician and the responsible for conducting the lumbar puncture are essential to minimize potential risks.