IgG4-mediated disease and potential risk of malignancy
IgG4-related disease (IgG4-RD) is considered a systemic, chronic and inflammatory disorder that is characterized by the enlargement of involved organs, elevated levels of IgG4 and abundant infiltration of plasmacytes with IgG4 and fibrosis in involved organs. The involved organs share a number of core pathologic features and striking clinical and serologic similarities, including tumour-like swelling of involved organs, a lymphoplasmacytic infiltrate enriched in IgG4-positive plasma cells, and a variable degree of fibrosis. We welcome the review from Dr Poo and colleagues from Imperial College, London in which they retrosp...
Source: QJM - October 8, 2019 Category: Internal Medicine Source Type: research

Report of the 113th Annual Meeting of the Association of Physicians of Great Britain and Ireland
(Source: QJM)
Source: QJM - September 5, 2019 Category: Internal Medicine Source Type: research

Scientific Business Abstracts of the 113th Annual Meeting of the Association of Physicians of Great Britain and Ireland
(Source: QJM)
Source: QJM - September 5, 2019 Category: Internal Medicine Source Type: research

Treating chronic cough —the definitive review
TheQJM has provided a platform for publishing outstanding ‘State-of-the-Art’ clinical reviews1 –4 and we continue this tradition in the current issue of the Journal with a clinical update by Dr Mathur and colleagues from the Aberdeen Royal Infirmary on the common and often difficult to treat —chronic cough. (Source: QJM)
Source: QJM - September 5, 2019 Category: Internal Medicine Source Type: research

Group B streptococcus bacteraemia and purulent pericarditis in an immunocompetent adult
Learning point for cliniciansGroup B streptococcus bacteraemia is rarely associated with purulent pericarditis, and even less so in immunocompetent patients. However, it can lead to significant morbidity and mortality especially when caused by the novel emerging strain ST 283. (Source: QJM)
Source: QJM - August 6, 2019 Category: Internal Medicine Source Type: research

Direct oral anticoagulants in cirrhosis —safe and effective alternative to traditional anticoagulants
TheQJM has highlighted in recent articles the complications of end-stage liver disease.1 –3 Now, we address the clinically relevant question of whether direct oral anticoagulants (DOACs) are safe and effective in patients with cirrhosis. These patients are at significantly enhanced risk of thrombosis, be it a deep venous thrombosis or pulmonary embolism. Historically these patients were treated with vitamin K antagonists such as warfarin or low molecular weight heparin. These therapeutic modalities are associated with the requirement for monitoring, interactions with food or drugs and narrow therapeutic window. (Source: QJM)
Source: QJM - August 5, 2019 Category: Internal Medicine Source Type: research

Fibrosing mediastinitis mimicking a lung carcinoma
Learning points for cliniciansFibrosing mediastinitis (FM) is characterized by a proliferation of a dense fibrous tissue within the mediastinum.FM symptoms are nonspecific including cough, dyspnea, pulmonary infection and hemoptysis.Diagnosis of FM is generally easy on the chest computed tomography scan.In not calcified FM, it ’s necessary to exclude malignant disease such as lung carcinoma. (Source: QJM)
Source: QJM - August 1, 2019 Category: Internal Medicine Source Type: research

A case of renal tuberculosis following BCG therapy for bladder cancer
Learning point for cliniciansA 49-year-old patient came to the hospital with pyelonephritis and high fever. He was treated for non-muscle-invasive bladder cancer with Bacillus Calmette –Guérin instillations. An abdominal contrast-enhanced computed tomography was obtained, revealing rounded masses of low-density in the left kidney. Several tests were performed, confirming mycobacterial infection. The patient was successfully treated. (Source: QJM)
Source: QJM - July 25, 2019 Category: Internal Medicine Source Type: research

Rituximab depletion of intrahepatic B cells to control refractory hepatic autoimmune overlap syndrome
Learning points for cliniciansHepatic autoimmune overlap syndromes should be considered in patients with evidence of more than one autoimmune hepatic disease.Disease resistant to standard immunosuppression and treatment of cholestasis can progress rapidly to cirrhosis and associated complications.Specialist input and treatment with novel therapies, such as B-cell depleting agents, present an opportunity to achieve disease remission in refractory cases. (Source: QJM)
Source: QJM - June 27, 2019 Category: Internal Medicine Source Type: research

Helicobacter pylori infection and the risk of colorectal cancer: a nationwide population-based cohort study
This study examined the association betweenH. pylori infection and colorectal cancer (CRC) in a nationwide population-based Chinese cohort study.MethodsA total of approximately 3936 individuals with newly diagnosedH. pylori infection (theH. pylori-infected cohort) and 15  744 age- and sex-matched patients with diagnoses absence ofH. pylori infection (the comparison cohort) from 2000 to 2005 were identified from Taiwan ’s National Health Insurance Research Database. The Kaplan–Meier method was used for measuring the cumulative incidence of CRC in each cohort. Cox proportional hazards models were used to com...
Source: QJM - June 26, 2019 Category: Internal Medicine Source Type: research

A combined panel of circulating microRNA as a diagnostic tool for detection of the non-small cell lung cancer
ConclusionIn summary, our data suggested the diagnostic importance of combined-miR-panel including miR-21, miR-638, miR148 and miR-152 for effective discrimination of NSCLC from non-cancerous subjects. (Source: QJM)
Source: QJM - June 25, 2019 Category: Internal Medicine Source Type: research

Central venous catheter use increases ischemic stroke risk: a nationwide population-based study
This study investigated the association between CVC placement and ischemic stroke risk in an Asian population.DesignPopulation-based retrospective study.MethodsWe enrolled 37  623 patients who ever-received CVC placement over 2000–10 and propensity score-matched individuals without CVC placement as the comparison cohort from the Taiwan National Health Insurance Research Database. We determined the cumulative incidence rates and adjusted hazard ratios (aHRs) for ischem ic stroke.ResultsWe finally identified and enrolled 34  164 propensity score-matched pairs of individuals. Compared with the comparison group...
Source: QJM - June 21, 2019 Category: Internal Medicine Source Type: research

IgG4-related disease in a multi-ethnic community: clinical characteristics and association with malignancy
ConclusionsWe report a large UK-based cohort of IgG4-RD that shows no clear ethnic predisposition and a wide range of affected organs. We discuss the use of serum IgG4 concentrations as a disease marker in IgG4-RD, the association with malignant disease and outcomes according to differing treatment regimens. (Source: QJM)
Source: QJM - June 21, 2019 Category: Internal Medicine Source Type: research

Neurosarcoidosis and infliximab therapy monitored by 18FDG PET/CT
Learning points for cliniciansNeurosarcoidosis is a severe disease affecting young adults with a mortality rate of 5%.Cranial nerve palsy, spinal cord disease, seizures or headaches are the main symptoms.18FDG PET/CT is useful in diagnosing neurosarcoidosis involving cranial nerves and in monitoring treatment response under tumor necrosis factor-alpha inhibitors, such as infliximab. (Source: QJM)
Source: QJM - June 21, 2019 Category: Internal Medicine Source Type: research

Hydroxychloroquine was associated with reduced risk of new-onset diabetes mellitus in patients with Sj ögren syndrome
AbstractObjectivesTo determine whether taking hydroxychloroquine (HCQ) could prevent the development of new-onset diabetes mellitus (DM) among patients with Sj ögren syndrome (SS).MethodsThis is a nationwide, population-based, retrospective cohort study utilizing the Taiwan National Health Insurance Research Database (NHIRD). Data were collected from 1 January 1999, through 31 December 2013, using theInternational Classification of Diseases,Ninth Revision,Clinical Modification codes. In total, 7774 patients newly diagnosed with SS by at least three outpatient visits or one inpatient admission were selected from the NH...
Source: QJM - June 20, 2019 Category: Internal Medicine Source Type: research

Hepatocellular carcinoma in cystic fibrosis liver disease: a cautionary tale
Learning point for cliniciansThis case illustrates the limitations of using non-invasive criteria for the diagnosis of hepatocellular carcinoma. The criteria may not be valid in rarer cause of cirrhosis such as cystic fibrosis. If the diagnosis precludes life-saving treatment such as liver transplantation a confirmatory liver biopsy may be wise. (Source: QJM)
Source: QJM - June 19, 2019 Category: Internal Medicine Source Type: research

Usability of donor corneas harvested from the deceased having septicaemia or malignancy
ConclusionsCorneal tissues harvested from septicaemia donors showed significantly higher incidence of corneal contamination, confirming their unsuitability for usage. However, there was no incidence of tumour transmission in corneal tissues of the patients with malignancies, suggesting that they can be considered for ophthalmic purpose. (Source: QJM)
Source: QJM - June 14, 2019 Category: Internal Medicine Source Type: research

A negative D-dimer identifies patients at low risk of death within 30 days: a prospective observational emergency department cohort study
AbstractObjectiveTo determine the ability of a normal D-dimer level (
Source: QJM - June 10, 2019 Category: Internal Medicine Source Type: research

Absence of a cerebral hemisphere
Learning point for cliniciansDDMS is a rare disease of childhood. One needs to have a high index of suspicion to make the diagnosis, especially in an adult who presents with a long history of hemiparesis, seizures and intellectual disability. A thorough history and clinical examination followed by CT brain can establish this diagnosis. (Source: QJM)
Source: QJM - June 10, 2019 Category: Internal Medicine Source Type: research

Pulmonary embolism: an often forgotten differential diagnosis for abdominal pain
Learning point for cliniciansPulmonary embolism (PE) accounts for a significant cause of morbidity and mortality. A missed diagnosis is a recipe for catastrophe. Abdominal pain is an unusual presentation for this condition and can be the only clinical symptom as in the case discussed. It is imperative to maintain a systemic approach as physicians and to consider this potentially fatal diagnosis in cases with unexplained abdominal pain. (Source: QJM)
Source: QJM - June 7, 2019 Category: Internal Medicine Source Type: research

Forced sterilization during post-war era in Japan
The forced sterilization (FS) was regally performed in Japan until 1996 after a now-defunct Eugenic Protection Law was effective in 1948. An estimated 25  000 operations in total underwent for 48 years while eugenic concept has been regarded as a taboo after the World War II.1,2 Little has been known regarding how medical professionals were involved in the decision making of FS before we, a survey team of physicians, nurses and investigational journalists, launched a series of reports on FS recently since February 2018.3 The nationwide newspapers in Japan published over 160 FS-related articles monthly between t...
Source: QJM - June 5, 2019 Category: Internal Medicine Source Type: research

Tongue infection caused by Dirofilaria repens
Learning points for cliniciansThe most common insect-borne tissue parasitoses in the countries with temperate climate are dirofilariases. Most often, larvae develop in the subcutaneous tissue of exposed body surfaces, in the conjunctiva and even in the submucosa of the oral cavity.Usually, the patient has no subjective symptoms, and accidentally finds tissue swelling.Definitive diagnosis is made after removal of the larva and macroscopic or histological assessment. In most cases, removal of the larva is sufficient and further treatment is not necessary. (Source: QJM)
Source: QJM - June 5, 2019 Category: Internal Medicine Source Type: research

Cardiovascular and renal outcomes following percutaneous coronary intervention in a population with renal disease: a case-control study
ConclusionCases undergoing PCI had lower mortality, and PCI was not associated with accelerated CKD progression. On this data, PCI should not be deferred as a treatment option in patients with CKD. Serum creatinine and calcium-phosphate product predict mortality following PCI in this cohort, and may be useful in risk-stratifying patients with CKD being considered for PCI. (Source: QJM)
Source: QJM - June 4, 2019 Category: Internal Medicine Source Type: research

Infective endocarditis: a retrospective cohort study
ConclusionsThis Irish cohort exhibited first-world demographic patterns comparable to those published in contemporary international literature. PVE required surgery more often and was associated with higher rates of mortality than NVE. Embolic complications were relatively common and represent important sequelae, especially in the intravenous drug user population. It is also pertinent to aggressively treat older cohorts as they were associated with increased mortality. (Source: QJM)
Source: QJM - May 31, 2019 Category: Internal Medicine Source Type: research

Gender differences in cardiovascular risk of patients with rheumatoid arthritis
ConclusionsWomen with RA have significantly better endothelial function than men with RA. It means that even though RA is 3-fold more prevalent in women, women are more protected from atherosclerotic coronary artery disease and cardiac events. (Source: QJM)
Source: QJM - May 31, 2019 Category: Internal Medicine Source Type: research

Lung-limited granulomatosis with polyangiitis: managed without immunosuppression
Learning point for cliniciansLimited granulomatosis with polyangiitis presenting as a lung nodule, with the diagnosis made on excision, with no systemic features and negative ANCA, may be treated conservatively (without immunosuppression) if closely monitored but it Is suggested that patients are fully informed of the possibility of relapse. (Source: QJM)
Source: QJM - May 31, 2019 Category: Internal Medicine Source Type: research

Wellens syndrome: Differential and outcome
We read with great pleasure the article ‘T’ twist: Wellens syndrome, published by Ramanathanet al. in the month of May in your esteemed journal quarterly of medicine. Authors have described the presence of biphasic T waves, in the presence of critical stenosis of left anterior descending (LAD) artery suggestive of Wellens syndrome excellently.1 (Source: QJM)
Source: QJM - May 28, 2019 Category: Internal Medicine Source Type: research

Controversies in Wellens syndrome
We thank Dr Mishra and his colleagues for reading our article ‘“T” twist: Wellens syndrome’ and sharing their recent experiences in relation to it.1 (Source: QJM)
Source: QJM - May 28, 2019 Category: Internal Medicine Source Type: research

Safety of direct oral anticoagulants in patients with cirrhosis: a systematic review and meta-analysis
ConclusionsOur study demonstrates that, compared to those who were treated with traditional anticoagulants, cirrhotic patients who were treated with DOACs had no significant increase risk of all-cause bleeding and major bleeding. (Source: QJM)
Source: QJM - May 28, 2019 Category: Internal Medicine Source Type: research

Posterior reversible encephalopathy syndrome induced by red blood cell transfusion
Learning point for cliniciansPhysicians should be aware of posterior reversible encephalopathy syndrome as a rare but serious complication if a patient with chronic severe anaemia develops neurological symptoms after red blood cell transfusion. Rapid correction of chronic anaemia without haemodynamic instability should be avoided. (Source: QJM)
Source: QJM - May 25, 2019 Category: Internal Medicine Source Type: research

Mandibular hemangio-ameloblastoma
Learning point for cliniciansDue to the scarcity of literature for hemangio-ameloblastoma (HA), the pathological knowledge about this tumor is superficial and limited. Further, HA due to its extreme vascular component may cause surgical complications. Therefore, it is important to diagnose this entity as it will help the clinicians to be wary during the planning of management and avoid any complications during surgery. This case will add the valuable insights for the clinicians to know about biological behavior and prognosis of this entity. (Source: QJM)
Source: QJM - May 23, 2019 Category: Internal Medicine Source Type: research

Indwelling pleural catheters: an overview and real-life experience
ConclusionsIPC insertion is a safe procedure and represents an exciting and expanding field in the management of pleural disease. Further longitudinal studies are required to fully delineate their place in the management of both malignant and benign effusions. (Source: QJM)
Source: QJM - May 23, 2019 Category: Internal Medicine Source Type: research

Pyroglutamic acidosis
Learning points for cliniciansClinicians should be alerted to the complication of pyroglutamic acidosis in patients undergoing prolonged treatment with flucloxacillin, who are using paracetamol regularly for analgesia. Development of hospital acquired infection can unmask this phenomenon leading to greater morbidity in compromised individuals. (Source: QJM)
Source: QJM - May 14, 2019 Category: Internal Medicine Source Type: research

Head to head comparison between neurology residents and a mobile medical application for diagnostic accuracy in cognitive neurology
AbstractBackgroundA novel Mobile Medical Application (App) App was created on iOS platform (Neurology Dx®) to deduce Differential Diagnoses (DDx) from a set of user selected Symptoms, Signs, Imaging data and Lab findings. The DDx generated by the App was compared for diagnostic accuracy with differentials reasoned by participating neurology residents when presented with same clinical vignettes.MethodsHundred neurology residents in seven leading Neurology centers across India participated in this study. A panel of experts created 60 clinical vignettes of varying levels of difficulty related to Cognitive neurology. Each ...
Source: QJM - May 14, 2019 Category: Internal Medicine Source Type: research

Reply to: Effects of aspirin and non-steroidal anti-inflammatory drugs on the risk of cholangiocarcinoma: a meta-analysis
Dear editor, (Source: QJM)
Source: QJM - May 9, 2019 Category: Internal Medicine Source Type: research

Effects of aspirin and non-steroidal anti-inflammatory drugs on the risk of cholangiocarcinoma: a meta-analysis
To the Editor, (Source: QJM)
Source: QJM - May 9, 2019 Category: Internal Medicine Source Type: research

Reversible hydrocephalus from ventriculoperitoneal shunt dysfunction secondary to MRI exposure —a rare cause of functional decline in elderly
Learning points for cliniciansReversible hydrocephalus from ventriculoperitoneal shunt dysfunction should be kept in mind when an elderly patient presents with acute functional decline, as it is easily treatable. Recent magnetic resonance imaging (MRI) exposure causing shunt interference should be considered, especially with the widespread use of MRI and aging population of shunted patients. (Source: QJM)
Source: QJM - May 9, 2019 Category: Internal Medicine Source Type: research

Snail1-dependent cancer-associated fibroblasts induce epithelial-mesenchymal transition in lung cancer cells via exosomes
ConclusionsThe molecular mechanism underlying how CAFs induce EMT in cancer cells may be that CAFs deliver SNAI1 to recipient cancer cells via exosomes. (Source: QJM)
Source: QJM - April 27, 2019 Category: Internal Medicine Source Type: research

Validating the effects of correcting vitamin D deficiency; time for reappraisal of clinical trial design
Goreyet al.1 report many reasons for vitamin D [VitD] supplementation trials producing disparate results. Additionally, investigating causality for the inverse associations consistently seen between VitD status and health risks,2 and suggested by many specific mechanistic effects, requires randomized controlled trial (RCT) designs suitable for nutrients, not pharmaceuticals. Rises in serum 25 hydroxyvitamin D3 (25(OH)D) concentrations and in the biological effectiveness of VitD when supplementing deficiency are both ‘S-shaped’. This means that failure to increase deficient 25(OH)D values up onto the steep part ...
Source: QJM - April 24, 2019 Category: Internal Medicine Source Type: research

Prolonged PR interval in a patient with acute rheumatic fever
A previously healthy, 11-year-old boy presented to the emergency department with fever and polyarthritis of 7-days duration. His vital signs were body temperature 39.5 °, heart rate 90/min, blood pressure 108/53 mmHg, respiratory rate 22/min and oxygen saturation 98% on room air. Physical examination revealed polyarthritis in the bilateral knees, left elbow and right ankle. Subcutaneous nodules, heart murmur and chorea were denied. Electrocardiography showed a p rolonged PR interval (Figure  1a), and echocardiography revealed trivial aortic valve regurgitation. Laboratory data demonstrated elevated inflammato...
Source: QJM - April 9, 2019 Category: Internal Medicine Source Type: research

Rheumatoid arthritis-associated interstitial lung disease
A 34-year-old undocumented woman from Mexico, past medical history of asthma and rheumatoid arthritis (RA) presents to the ED with fever, myalgia, fatigue, cough, and difficulty taking deep breaths for the past 3 days requiring albuterol inhaler three to four times a day. Her symptoms worsened 1 h prior to arrival. (Source: QJM)
Source: QJM - April 1, 2019 Category: Internal Medicine Source Type: research

Double doughnut sign in dengue encephalitis
(Source: QJM)
Source: QJM - March 27, 2019 Category: Internal Medicine Source Type: research

Snake envenomation: is the 20  min whole blood clotting test (WBCT20) the optimum test for management?
ConclusionsWBCT20 is a highly sensitive test with excellent reliability for detecting envenomation. However, the false positive rate in this study was 24%. Asymptomatic snake bite patients with a positive WBCT20 but no corresponding clinical signs of envenomation should be tested using PT/INR before receiving ASV to prevent unnecessary waste of anti-venom. (Source: QJM)
Source: QJM - March 27, 2019 Category: Internal Medicine Source Type: research

Sheehan ’s like syndrome in a man
An 84-year-old physician self-diagnosed that he had a pituitary tumour when he was found to have a bilateral upper quadrantanopia on routine eye testing. Magnetic resonance imaging (MRI) confirmed a large non-functioning pituitary macroadenoma associated with chiasmal compression. Investigation showed partial hypopituitarism with disconnection hyperprolactinaemia [prolactin 1095 mU/L (60 –300)]. He was treated with hormonal replacement consisting of thyroxin 100 µg and prednisolone 3 mg and was offered transphenoidal hypophysectomy, but chose a conservative approach. Two years later, his visual fi...
Source: QJM - March 26, 2019 Category: Internal Medicine Source Type: research

Dumb-bell shaped cervical neurofibroma
A 45-year-old lady presented with complaints of neck pain, progressive weakness of all four limbs, numbness over the trunk and limbs for 6  months and inability to walk without support since 2 months. She was noted to have multiple cutaneous neurofibromas over the face, trunk and limbs, café-au-lait spots (Figure  1a), axillary freckling and Lisch nodules of the irises in both eyes. She had grade 4/5 muscle power in upper and lower limbs, hyperreflexia and reduced sensations below neck level. A diagnosis of neurofibromatosis type 1 (NF1), with spastic quadriparesis resulting from cervical cord com...
Source: QJM - March 25, 2019 Category: Internal Medicine Source Type: research

Reply to: ‘Effects of aspirin and non-steroidal anti-inflammatory drugs on the risk of cholangiocarcinoma: a meta-analysis’
Dear editor, (Source: QJM)
Source: QJM - March 25, 2019 Category: Internal Medicine Source Type: research

Aspirin use and the risk of cholangiocarcinoma
One meta-analysis conducted by Lapumnuaypolet al. published in QJM reported the association between aspirin use and the risk of cholangiocarcinoma, and the finding indicates that aspirin use might be a protective factor against cholangiocarcinoma.1 Some of my ideas are shared with the readers. First, odds ratio means the odds of exposure among persons with disease of interest vs. the odds of exposure among persons without disease of interest in a case-control study. In Lapumnuaypolet al.’s meta-analysis, the odds of aspirin exposure was lower among persons with cholangiocarcinoma than the odds of aspirin exposure amo...
Source: QJM - March 25, 2019 Category: Internal Medicine Source Type: research

Endobronchial mucosa-associated lymphoid tissue (MALT) lymphoma
An 86-year-old woman presented with a chief complaint of productive cough for 1  month. She had never smoked and had no particular personal and family medical history. Chest radiography and computed tomography (CT) were performed, and wall thickening extending from the left main to upper bronchus (Figure  1A, arrow) and atelectasis of the left upper lobe were detected. Sputum culture and cytology did not reveal any remarkable findings, and serum tumor marker levels were within normal ranges. She subsequently underwent bronchoscopy, and multiple nodular protruding lesions were detected in the entire endobronchia...
Source: QJM - March 21, 2019 Category: Internal Medicine Source Type: research

IgG4-related periarteritis of the carotid artery
A 74-year-old woman presented with the swelling of the right upper eyelid. Fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) showed abnormal uptake in the left anterior neck as well as in the swelling right lacrimal gland. The cervical uptake was fusiform-shaped (Figure  1a, arrow) and contiguous to the left carotid artery (Figure  1a, arrowhead). No abnormal uptake was found in the other major arteries. Ultrasonography revealed that the cervical lesion corresponded to a homogeneously thickened wall without luminal stenosis/dilatation (Figure  1b, upper). These ultrasonograph...
Source: QJM - March 21, 2019 Category: Internal Medicine Source Type: research

Juvenile diabetes and visual impairment: Wolfram syndrome
The presence of diabetes and visual impairment in a young individual is a good diagnostic criterion to suspect Wolfram syndrome (WS) or Diabetes insipidus, Diabetes mellitus, optic atrophy and deafness.1,2 WS is a rare autosomal recessive disease due to mutations in the Wolframin (WFS1) gene. These mutations lead to endoplasmic reticulum stress-related decline of pancreatic beta-cell number and a decrease in endogenous insulin secretion. Affected individuals are therefore usually insulin-dependent, with a few rare exceptions reported.3 –5 Here we describe a 9-year-old boy who presented with visual impairment and diab...
Source: QJM - March 19, 2019 Category: Internal Medicine Source Type: research