Patient safety initiatives from around the world.

PubMed

Tingle, John

2017-05-25

John Tingle, Reader in Health Law at Nottingham Trent University, and Jen Minford, Junior Doctor Co-ordinator, Nottingham University Hospitals NHS Trust, discuss initiatives presented at a global summit on patient safety.

Acute-onset chronic inflammatory demyelinating polyneuropathy: An electrodiagnostic study.

PubMed

Anadani, Mohammad; Katirji, Bashar

2015-11-01

Acute-onset chronic inflammatory demyelinating polyneuropathy (A-CIDP) is an increasingly recognized CIDP subtype. Differentiating A-CIDP from Guillain-Barré syndrome (GBS) is challenging but important, because there are different treatment outcomes. We report 3 patients with A-CIDP who were initially diagnosed with severe GBS but were later confirmed to have CIDP based on their clinical course and electrodiagnostic (EDx) studies. We also report on the long-term treatment of these patients and review the literature on EDx studies in this syndrome. Three patients were initially diagnosed with GBS and responded to treatment. However, all 3 had arrest in improvement or deterioration during their rehabilitation phases. EDx studies showed prominent demyelinating changes many months after the initial presentation. All responded very well to immunotherapy. Although several features may suggest the diagnosis of A-CIDP at initial presentation, close follow-up of GBS patients during the recovery phase is also needed for accurate diagnosis. EDx studies may distinguish patients with A-CIDP from GBS patients. © 2015 Wiley Periodicals, Inc.

Clinical Subtypes of Dementia with Lewy Bodies Based on the Initial Clinical Presentation.

PubMed

Morenas-Rodríguez, Estrella; Sala, Isabel; Subirana, Andrea; Pascual-Goñi, Elba; Sánchez-Saudinós, MaBelén; Alcolea, Daniel; Illán-Gala, Ignacio; Carmona-Iragui, María; Ribosa-Nogué, Roser; Camacho, Valle; Blesa, Rafael; Fortea, Juan; Lleó, Alberto

2018-06-04

Dementia with Lewy bodies (DLB) is a heterogeneous disease in which clinical presentation, symptoms, and evolution widely varies between patients. To investigate the existence of clinical subtypes in DLB based on the initial clinical presentation. 81 patients with a clinical diagnosis of probable DLB were consecutively included. All patients underwent a neurological evaluation including a structured questionnaire about neuropsychiatric symptoms and sleep, an assessment of motor impairment (Unified Parkinson Disease Rating Scale subscale III), and a formal neuropsychological evaluation. Onset of core symptoms (hallucinations, parkinsonism, and fluctuations) and dementia were systematically reviewed from medical records. We applied a K-means clustering method based on the initial clinical presentation. Cluster analysis yielded three different groups. Patients in cluster I (cognitive-predominant, n = 46) presented more frequently with cognitive symptoms (95.7%, n = 44, p < 0.001), and showed a longer duration from onset to DLB diagnosis (p < 0.001) than the other clusters. Patients in cluster II (neuropsychiatric-predominant, n = 22) were older at disease onset (78.1±5 versus 73.6±6.1 and 73.6±4.2 in clusters I and III, respectively, both p < 0.01), presented more frequently with psychotic symptoms (77.3%, n = 17), and had a shorter duration until the onset of hallucinations (p < 0.001). Patients in cluster III (parkinsonism-predominant, n = 13) showed a shorter time from onset to presence of parkinsonism (p < 0.001) and dementia (0.008). Three subtypes of clinical DLB can be defined when considering the differential initial presentations. The proposed subtypes have distinct clinical profiles and progression patterns.

Clinicopathological correlates in HIV seropositive tuberculosis cases presenting with jaundice after initiating antiretroviral therapy with a structured review of the literature.

PubMed

Barr, David A; Ramdial, Pravistadevi K

2012-10-14

The development of jaundice after initiation of HAART in HIV-TB co-infected patients is a challenging presentation in resource constrained settings, and is often attributed to drug induced liver injury (DILI).Some investigators have described hepatic tuberculosis Immune Reconstitution Inflammatory Syndrome (TB-IRIS) as a cause of liver disease in patients initiating HAART, which could also cause jaundice. We report the clinical and histopathological features of five HIV-TB co-infected patients presenting with a syndrome of jaundice, tender hepatomegaly, bile canalicular enzyme rise and return of constitutional symptoms within 8 weeks of initiation of highly active antiretroviral therapy (HAART) for advanced HIV infection at a rural clinic in KwaZulu Natal, South Africa.All five patients had been diagnosed with tuberculosis infection prior to HAART initiation and were on antituberculous medication at time of developing jaundice. There was evidence of multiple aetiologies of liver injury in all patients. However, based on clinical course and pathological findings, predominant hepatic injury was thought to be drug induced in one case and hepatic tuberculosis associated immune reconstitution inflammatory syndrome (TB-IRIS) in the other four.In these later 4 patients, liver biopsy findings included necrotising and non-necrotising granulomatous inflammation in the lobules and portal tracts. The granulomas demonstrated - in addition to epithelioid histiocytes and Langhans giant cells - neutrophils, plasma cells and large numbers of lymphocytes, which are not features of a conventional untreated tuberculous response. In this high TB prevalent, low resource setting, TB-IRIS may be an important cause of jaundice post-HAART initiation. Clinicopathological correlation is essential for optimal diagnosis. Further multi-organ based histopathological studies in the context of immune reconstitution would be useful to clinicians in low resource settings dealing with this challenging presentation.

Catastrophic antiphospholipid antibody syndrome presenting as acute vascular occlusion in a young female patient.

PubMed

Alonso, Joaquín Valle; Del Pozo, Francisco Javier Fonseca; Álvarez, Manuel Vaquero; Pedraza, Jorge; Aguayo, Miguel Angel; Sanchez, Almudena

Acquired thrombotic and thromboembolic disorders may be presented initially with symptoms and signs of acute ischaemia or organ dysfunction that will lead many of these patients to seek care in the emergency department. We report a case of a 19-year-old female patient who developed catastrophic antiphospholipid syndrome (CAPS syndrome or Asherson syndrome) 6 weeks post stillbirth with an initial presentation of acute vascular occlusion. The patient was immediately operated and anticoagulated with significant improvement. Copyright © 2016 Elsevier España, S.L.U. and Sociedad Española de Reumatología y Colegio Mexicano de Reumatología. All rights reserved.

Investigating the anticipatory postural adjustment phase of gait initiation in different directions in chronic ankle instability patients.

PubMed

Ebrahimabadi, Zahra; Naimi, Sedigheh Sadat; Rahimi, Abbas; Sadeghi, Heydar; Hosseini, Seyed Majid; Baghban, Alireza Akbarzadeh; Arslan, Syed Asadullah

2018-01-01

The main objective of the present study was to analyze how supra spinal motor control mechanisms are altered in different directions during anticipatory postural phase of gait initiation in chronic ankle instability patients. It seems that supra spinal pathways modulate anticipatory postural adjustment phase of gait initiation. Yet, there is a dearth of research on the effect of chronic ankle instability on the anticipatory postural adjustment phase of gait initiation in different directions. A total of 20 chronic ankle instability participants and 20 healthy individuals initiated gait on a force plate in forward, 30° lateral, and 30° medial directions. According to the results of the present study, the peak lateral center of pressure shift decreased in forward direction compared to that in other directions in both groups. Also, it was found that the peak lateral center of pressure shift and the vertical center of mass velocity decreased significantly in chronic ankle instability patients, as compared with those of the healthy individuals. According to the results of the present study, it seems that chronic ankle instability patients modulate the anticipatory postural adjustment phase of gait initiation, compared with healthy control group, in order to maintain postural stability. These changes were observed in different directions, too. Copyright © 2017 Elsevier Ltd. All rights reserved.

Clinicopathological correlates in HIV seropositive tuberculosis cases presenting with jaundice after initiating antiretroviral therapy with a structured review of the literature

PubMed Central

2012-01-01

Background The development of jaundice after initiation of HAART in HIV-TB co-infected patients is a challenging presentation in resource constrained settings, and is often attributed to drug induced liver injury (DILI).Some investigators have described hepatic tuberculosis Immune Reconstitution Inflammatory Syndrome (TB-IRIS) as a cause of liver disease in patients initiating HAART, which could also cause jaundice. Case presentations We report the clinical and histopathological features of five HIV-TB co-infected patients presenting with a syndrome of jaundice, tender hepatomegaly, bile canalicular enzyme rise and return of constitutional symptoms within 8 weeks of initiation of highly active antiretroviral therapy (HAART) for advanced HIV infection at a rural clinic in KwaZulu Natal, South Africa. All five patients had been diagnosed with tuberculosis infection prior to HAART initiation and were on antituberculous medication at time of developing jaundice. There was evidence of multiple aetiologies of liver injury in all patients. However, based on clinical course and pathological findings, predominant hepatic injury was thought to be drug induced in one case and hepatic tuberculosis associated immune reconstitution inflammatory syndrome (TB-IRIS) in the other four. In these later 4 patients, liver biopsy findings included necrotising and non-necrotising granulomatous inflammation in the lobules and portal tracts. The granulomas demonstrated – in addition to epithelioid histiocytes and Langhans giant cells – neutrophils, plasma cells and large numbers of lymphocytes, which are not features of a conventional untreated tuberculous response. Conclusion In this high TB prevalent, low resource setting, TB-IRIS may be an important cause of jaundice post-HAART initiation. Clinicopathological correlation is essential for optimal diagnosis. Further multi-organ based histopathological studies in the context of immune reconstitution would be useful to clinicians in low resource settings dealing with this challenging presentation. PMID:23061403

A Case of Myxedema Coma Presenting as a Brain Stem Infarct in a 74-Year-Old Korean Woman

PubMed Central

Ahn, Ji Yun; Kwon, Hyuk-Sool; Ahn, Hee Chol

2010-01-01

Myxedema coma is the extreme form of untreated hypothyroidism. In reality, few patients present comatose with severe myxedema. We describe a patient with myxedema coma which was initially misdiagnosed as a brain stem infarct. She presented to the hospital with alteration of the mental status, generalized edema, hypothermia, hypoventilation, and hypotension. Initially her brain stem reflexes were absent. After respiratory and circulatory support, her neurologic status was not improved soon. The diagnosis of myxedema coma was often missed or delayed due to various clinical findings and concomitant medical condition and precipitating factors. It is more difficult to diagnose when a patient has no medical history of hypothyroidism. A high index of clinical suspicion can make a timely diagnosis and initiate appropriate treatment. We report this case to alert clinicians considering diagnosis of myxedema coma in patients with severe decompensated metabolic state including mental change. PMID:20808690

A case of myxedema coma presenting as a brain stem infarct in a 74-year-old Korean woman.

PubMed

Ahn, Ji Yun; Kwon, Hyuk-Sool; Ahn, Hee Chol; Sohn, You Dong

2010-09-01

Myxedema coma is the extreme form of untreated hypothyroidism. In reality, few patients present comatose with severe myxedema. We describe a patient with myxedema coma which was initially misdiagnosed as a brain stem infarct. She presented to the hospital with alteration of the mental status, generalized edema, hypothermia, hypoventilation, and hypotension. Initially her brain stem reflexes were absent. After respiratory and circulatory support, her neurologic status was not improved soon. The diagnosis of myxedema coma was often missed or delayed due to various clinical findings and concomitant medical condition and precipitating factors. It is more difficult to diagnose when a patient has no medical history of hypothyroidism. A high index of clinical suspicion can make a timely diagnosis and initiate appropriate treatment. We report this case to alert clinicians considering diagnosis of myxedema coma in patients with severe decompensated metabolic state including mental change.

ED presentations of acute renal infarction.

PubMed

Huang, Chien-Cheng; Lo, Hong-Chang; Huang, Hsien-Hao; Kao, Wei-Fong; Yen, David Hung-Tsang; Wang, Lee-Min; Huang, Chun-I; Lee, Chen-Hsen

2007-02-01

The objective of the study was to investigate initial clinical characteristics that can suggest an early diagnosis of patients with acute renal infarction presenting with flank and/or abdominal pain in the emergency department (ED). From January 1, 1996, through December 31, 2005, 20 adult patients with renal infarction diagnosed by contrast-enhanced computed tomography in the ED were enrolled. Medical records, including demographic data, risk factors for thromboembolism, initial clinical presentations, laboratory data, treatment programs and outcomes, were retrospectively reviewed and analyzed. Mean patient age was 60.3 years (range, 21-80). The estimated incidence of renal infarction was 0.004% (20 of 481,540) among the ED census. The median time of onset of symptoms before the ED visit was 31 hours (range, 1-285). Eighteen patients (90%) had a history of more than 1 risk factor for thromboembolic events. In clinical presentations, all the patients had either abdominal or flank pain and tenderness. Nineteen patients (95%) had an elevated serum lactate dehydrogenase level with a mean +/- SD of 812.1 +/- 569.4 U/L. Sixteen patients (80%) presented with the triad--persisting flank or abdominal pain/tenderness, elevated serum lactate dehydrogenase level, and proteinuria. Among all 20 patients, 10 patients (50%) were diagnosed as having renal infarction at the initial ED visit. No specific clinical characteristics could be identified to distinguish those patients diagnosed early and those with delayed diagnosis. All 20 patients received medical treatment with coumadin, which was given in combination with heparin treatment in 11, peripheral intravenous and/or local intra-arterial thrombolytics with urokinase in 5, and mitral valve replacement in 1. No patient died. Although 4 patients had a mildly elevated serum creatinine level (>1.5 mg/dL) during hospitalization, none of them needs dialysis after more than 1 year of follow-up. In this study, we delineated specifically clinical features for emergency physicians to raise their suspicion index for an early diagnosis of patients with renal infarction, a disease which is uncommon and is usually delayed or missed at initial ED presentation.

The effect of vertebral fracture on the early neurologic recovery in patients with central cord syndrome.

PubMed

Schroeder, Gregory D; Kepler, Christopher K; Hjelm, Nik; Vaccaro, Alexander R; Weinstein, Michael S

2015-05-01

To compare early changes in the ASIA Motor Score (AMS) between patients with central cord syndrome (CCS) from an acute fracture to patients without a fracture. Patients with CCS were identified and stratified based on the presence of a fracture. The AMS through the first week of the patients' hospitalization was obtained. Initial injury severity as well as early neurologic recovery was measured using the AMS. Analysis of variance was performed to determine if age, gender, rectal tone at presentation, congenital stenosis, or surgery within 24 h significantly effected the change in AMS. A strong trend (p = 0.0504) towards a more severe initial neurologic injury in patients with a fracture (AMS 59.7) than in patients without a fracture (AMS 70.2) was identified. However, in the week after injury, patients with a fracture had an improvement in their neurologic function (ΔAMS +4.8) while patients without a fracture demonstrated neurologic decline (ΔAMS -5.9). The change in AMS between patients with and without a fracture was nearly significant (p = 0.06). Patients with central cord syndrome present with similar symptoms, but injuries with and without a fracture may be associated with a different early neurologic recovery. Patients with a fracture have a more severe injury at initial presentation, but tend to have neurologic improvement in the first week; conversely patients without a fracture have a less severe initial neurologic injury, but tend to have a slight decline in neurologic function over the first week.

Initial varus displacement of proximal humerus fractures results in similar function but higher complication rates.

PubMed

Capriccioso, Christina E; Zuckerman, Joseph D; Egol, Kenneth A

2016-04-01

To investigate the effect of initial varus or valgus surgical neck alignment on outcomes of patients who sustained proximal humerus fractures treated with open reduction and internal fixation (ORIF). An institutional review board approved database of proximal humerus fractures treated with locked plates was reviewed. Of 185 fractures in the database, 101 fractures were identified and met inclusion criteria. Initial varus displacement was seen in 47 fractures (OTA types 11.A2.2, A3.1, A3.3, B1.2, B2.2, C1.2, C2.2, or C2.3) and initial valgus displacement was observed in 54 fractures (OTA types 11.A2.3, B1.1, C1.1, or C2.1). All patients were treated in a similar manner and examined by the treating physician at standard intervals. Functional outcomes were quantified via the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and physical examination data at 12 months. Radiographs were reviewed for complications of healing. Additionally, complication rate and reoperation rate were investigated. Patients who presented with initial varus displacement had an average age of 59.3 years, while patients in the valgus group had an average age of 62.4 years. Overall, there was no statistically significant difference in age, sex distribution, BMI, fracture parts, screws used, or implant plate type between the two groups. At a minimum 12 months follow up, there was no significant difference in DASH scores between those presenting with varus versus valgus fracture patterns. In addition, no significant differences were seen in final shoulder range of motion in any plane. Overall, 30 patients included in this study developed a complication. A significantly greater number of patients in the initial varus cohort developed complications (40.4%), as compared to 20.3% of patients in the initial valgus cohort (P=0.03). Fourteen patients in this study underwent reoperation. Nine of these patients were in the varus cohort, while 5 were in the valgus cohort (P=0.15). In this study, initial surgical neck displacement in varus or valgus was found to not significantly affect functional outcome. Based upon our findings, patients with varus displaced proximal humerus fractures are at a greater risk of developing postoperative complications than those who present with initial valgus displaced fracture patterns. Copyright © 2016 Elsevier Ltd. All rights reserved.

Risk factors for tuberculosis treatment failure, default, or relapse and outcomes of retreatment in Morocco

PubMed Central

2011-01-01

Background Patients with tuberculosis require retreatment if they fail or default from initial treatment or if they relapse following initial treatment success. Outcomes among patients receiving a standard World Health Organization Category II retreatment regimen are suboptimal, resulting in increased risk of morbidity, drug resistance, and transmission.. In this study, we evaluated the risk factors for initial treatment failure, default, or early relapse leading to the need for tuberculosis retreatment in Morocco. We also assessed retreatment outcomes and drug susceptibility testing use for retreatment patients in urban centers in Morocco, where tuberculosis incidence is stubbornly high. Methods Patients with smear- or culture-positive pulmonary tuberculosis presenting for retreatment were identified using clinic registries in nine urban public clinics in Morocco. Demographic and outcomes data were collected from clinical charts and reference laboratories. To identify factors that had put these individuals at risk for failure, default, or early relapse in the first place, initial treatment records were also abstracted (if retreatment began within two years of initial treatment), and patient characteristics were compared with controls who successfully completed initial treatment without early relapse. Results 291 patients presenting for retreatment were included; 93% received a standard Category II regimen. Retreatment was successful in 74% of relapse patients, 48% of failure patients, and 41% of default patients. 25% of retreatment patients defaulted, higher than previous estimates. Retreatment failure was most common among patients who had failed initial treatment (24%), and default from retreatment was most frequent among patients with initial treatment default (57%). Drug susceptibility testing was performed in only 10% of retreatment patients. Independent risk factors for failure, default, or early relapse after initial treatment included male gender (aOR = 2.29, 95% CI 1.10-4.77), positive sputum smear after 3 months of treatment (OR 7.14, 95% CI 4.04-13.2), and hospitalization (OR 2.09, 95% CI 1.01-4.34). Higher weight at treatment initiation was protective. Male sex, substance use, missed doses, and hospitalization appeared to be risk factors for default, but subgroup analyses were limited by small numbers. Conclusions Outcomes of retreatment with a Category II regimen are suboptimal and vary by subgroup. Default among patients receiving tuberculosis retreatment is unacceptably high in urban areas in Morocco, and patients who fail initial tuberculosis treatment are at especially high risk of retreatment failure. Strategies to address risk factors for initial treatment default and to identify patients at risk for failure (including expanded use of drug susceptibility testing) are important given suboptimal retreatment outcomes in these groups. PMID:21356062

Risk factors for tuberculosis treatment failure, default, or relapse and outcomes of retreatment in Morocco.

PubMed

Dooley, Kelly E; Lahlou, Ouafae; Ghali, Iraqi; Knudsen, Janine; Elmessaoudi, My Driss; Cherkaoui, Imad; El Aouad, Rajae

2011-02-28

Patients with tuberculosis require retreatment if they fail or default from initial treatment or if they relapse following initial treatment success. Outcomes among patients receiving a standard World Health Organization Category II retreatment regimen are suboptimal, resulting in increased risk of morbidity, drug resistance, and transmission.. In this study, we evaluated the risk factors for initial treatment failure, default, or early relapse leading to the need for tuberculosis retreatment in Morocco. We also assessed retreatment outcomes and drug susceptibility testing use for retreatment patients in urban centers in Morocco, where tuberculosis incidence is stubbornly high. Patients with smear- or culture-positive pulmonary tuberculosis presenting for retreatment were identified using clinic registries in nine urban public clinics in Morocco. Demographic and outcomes data were collected from clinical charts and reference laboratories. To identify factors that had put these individuals at risk for failure, default, or early relapse in the first place, initial treatment records were also abstracted (if retreatment began within two years of initial treatment), and patient characteristics were compared with controls who successfully completed initial treatment without early relapse. 291 patients presenting for retreatment were included; 93% received a standard Category II regimen. Retreatment was successful in 74% of relapse patients, 48% of failure patients, and 41% of default patients. 25% of retreatment patients defaulted, higher than previous estimates. Retreatment failure was most common among patients who had failed initial treatment (24%), and default from retreatment was most frequent among patients with initial treatment default (57%). Drug susceptibility testing was performed in only 10% of retreatment patients. Independent risk factors for failure, default, or early relapse after initial treatment included male gender (aOR = 2.29, 95% CI 1.10-4.77), positive sputum smear after 3 months of treatment (OR 7.14, 95% CI 4.04-13.2), and hospitalization (OR 2.09, 95% CI 1.01-4.34). Higher weight at treatment initiation was protective. Male sex, substance use, missed doses, and hospitalization appeared to be risk factors for default, but subgroup analyses were limited by small numbers. Outcomes of retreatment with a Category II regimen are suboptimal and vary by subgroup. Default among patients receiving tuberculosis retreatment is unacceptably high in urban areas in Morocco, and patients who fail initial tuberculosis treatment are at especially high risk of retreatment failure. Strategies to address risk factors for initial treatment default and to identify patients at risk for failure (including expanded use of drug susceptibility testing) are important given suboptimal retreatment outcomes in these groups.

Pretreatment costs of care and time to initial treatment for patients with cancer of unknown primary.

PubMed

Walker, Mark S; Weinstein, Laura; Luo, Roger; Marino, Ingrid

2018-06-01

Time to treatment and pretreatment costs may be affected by unknown primary tumor site. This retrospective study used electronic medical record data from patients in ten US community oncology practices. Eligible patients were ≥18 years, diagnosed with cancer of unknown primary (CUP) or known metastatic solid tumor, and presented between 1 January 2012 and 30 June 2014. Patients with CUP (n = 294) had a longer interval than non-CUP patients (n = 92) from presentation to treatment initiation (1.18 vs 0.49 months, p < 0.0001), and had higher pretreatment costs (US$27,882 vs US$20,449, p = 0.0075). When analyzed as monthly cost, the difference between groups in log-cost per month was nonsignificant. Higher pretreatment costs in CUP patients appeared attributable to significantly longer time to initiation of therapy.

An unusual pathogen in ambulatory care: two cases of Scedosporium soft tissue infections presenting as "unresponsive cellulitis".

PubMed

Misselbrook, Gary Peter; Lillie, Patrick; Thomas, Claire P

2016-01-01

Soft tissue infections with Scedosporium spp. are an uncommon but serious and emerging cause of infection in immunocompromised patients. Acute Medical Units (AMUs) in the UK are increasingly managing patients with cellulitis in an outpatient setting, therefore acute physicians should be aware of some of the more uncommon causes of soft tissue infection, particularly in patients not responding to initial antibiotic therapy. We present two cases of Scedosporium presenting to the AMU as cellulitis not responding to initial antibiotic therapy and outline the assessment and management of this important condition.

Progressive Posterior Lenticonus in a Patient with Alport Syndrome

PubMed Central

Al-Mahmood, Ammar M.; Al-Swailem, Samar A.; Al-Khalaf, Abdulrahman; Al-Binali, Ghada Y.

2010-01-01

We report a rare case of Alport syndrome with progressive posterior lenticonus. A 24-year-old male presented to our tertiary eye care center with history of poor vision. At initial presentation, the patient had bilateral anterior lenticonus, posterior subcapsular cataract, and renal failure. The patient was diagnosed with Alport syndrome based on a positive family history of the disease and clinical findings. Further examination revealed progressive posterior lenticonus that was not present initially. The presence of such finding is important because it influences the surgical approach to avoid complications during cataract surgery. PMID:21180444

Time-trends in the prescribing of gastroprotective agents to primary care patients initiating low-dose aspirin or non-steroidal anti-inflammatory drugs: a population-based cohort study.

PubMed

Warlé-van Herwaarden, Margaretha F; Koffeman, Aafke R; Valkhoff, Vera E; 't Jong, Geert W; Kramers, Cornelis; Sturkenboom, Miriam C; De Smet, Peter A G M

2015-09-01

Low-dose aspirin (LDA) and non-steroidal-anti-inflammatory drugs (NSAIDs) both increase the risk of upper gastrointestinal events (UGIEs). In the Netherlands, recommendations regarding the prescription of gastroprotective agents (GPAs) in LDA users were first issued in 2009 in the HARM-Wrestling consensus. National guidelines on gastroprotective strategies (GPSs) in NSAID users were issued in the first part of the preceding. The aim of the present study was to examine time-trends in GPSs in patients initiating LDA and those initiating NSAIDs between 2000 and 2012. Within a large electronic primary healthcare database, two cohorts were selected: (i) patients newly prescribed LDA and (ii) patients newly prescribed NSAIDs between 2000 and 2012. Patients who had been prescribed a GPA in the previous six months were excluded. For both cohorts, patients' risk of a UGIE was classified as low, moderate or high, based on the HARM-Wrestling consensus, and the presence of an adequate GPSwas determined. A total of 37 578 patients were included in the LDA cohort and 352 025 patients in the NSAID cohort. In both cohorts, an increase in GPSs was observed over time, but prescription of GPAs was lower in the LDA cohort. By 2012, an adequate GPS was present in 31.8% of high-risk LDA initiators, vs. 48.0% of high-risk NSAID initiators. Despite a comparable risk of UGIEs, GPSs are prescribed less in high-risk LDA initiators than in high-risk NSAID initiators. For both groups of patients, there is still room for improvement in guideline adherence. © 2015 The British Pharmacological Society.

Gastrointestinal Bleeding Due to Gastrointestinal Tract Malignancy: Natural History, Management, and Outcomes.

PubMed

Schatz, Richard A; Rockey, Don C

2017-02-01

Gastrointestinal (GI) tumor bleeding can vary from occult bleeding to massive hemorrhage and can be the presenting sign of malignancy. Our primary aims were to: (1) characterize the natural history, treatment, and outcomes in patients with GI tumor bleeding and (2) compare and contrast bleeding in upper GI (UGI)/small bowel (SB) and lower GI malignancies. Patients with endoscopically confirmed tumor bleeding were identified through search of consecutive electronic medical records: Bleeding was determined by the presence of melena, hematochezia, hematemesis, or fecal occult blood. Comprehensive clinical and management data were abstracted. A total of 354 patients with GI tumors were identified: 71 had tumor bleeding (42 UGI/SB and 29 colonic). GI bleeding was the initial presenting symptom of malignancy in 55/71 (77%) of patients; 26/71 patients had widely metastatic disease at presentation. Further, 15 of 26 patients with metastatic disease presented with GI bleeding. Visible bleeding was present in 14/42 (33%) and 4/29 (14%) of UGI/SB and colonic tumors, respectively. Endoscopic hemostasis was attempted in 10 patients, and although initial control was successful in all, bleeding recurred in all of these patients. The most common endoscopic lesion was clean-based tumor ulceration. Overall mortality at 1 year was 57% for esophageal/gastric, 14% for SB, and 33% for colonic tumors. When patients with GI malignancy present with GI bleeding, it is often the index symptom. Initial endoscopic hemostasis is often successful, but rebleeding is typical. Esophageal and gastric tumors carry the poorest prognosis, with a high 1-year mortality rate.

Ethnicity and the first diagnosis of a wide range of cardiovascular diseases: Associations in a linked electronic health record cohort of 1 million patients.

PubMed

George, Julie; Mathur, Rohini; Shah, Anoop Dinesh; Pujades-Rodriguez, Mar; Denaxas, Spiros; Smeeth, Liam; Timmis, Adam; Hemingway, Harry

2017-01-01

While the association of ethnic group with individual cardiovascular diseases has been studied, little is known about ethnic differences in the initial lifetime presentation of clinical cardiovascular disease in contemporary populations. We studied 1,068,318 people, aged ≥30 years and free from diagnosed CVD at baseline (90.9% White, 3.6% South Asian and 2.9% Black), using English linked electronic health records covering primary care, hospital admissions, acute coronary syndrome registry and mortality registry (CALIBER platform). During 5.7 years median follow-up between 1997-2010, 95,224 people experienced an incident cardiovascular diagnosis. 69.9% (67.2%-72.4%) of initial presentation in South Asian <60 yrs were coronary heart disease presentations compared to 47.8% (47.3%-48.3%) in White and 40.1% (36.3%-43.9%) in Black patients. Compared to White patients, Black patients had significantly lower age-sex adjusted hazard ratios (HRs) for initial lifetime presentation of all the coronary disease diagnoses (stable angina HR 0.80 (95% CI 0.68-0.93); unstable angina- 0.75 (0.59-0.97); myocardial infarction 0.49 (0.40-0.62)) while South Asian patients had significantly higher HRs (stable angina- 1.67 (1.52-1.84); unstable angina 1.82 (1.56-2.13); myocardial infarction- 1.67 (1.49-1.87). We found no ethnic differences in initial presentation with heart failure (Black 0.97 (0.79-1.20); S Asian 1.04(0.87-1.26)). Compared to White patients, Black patients were more likely to present with ischaemic stroke (1.24 (0.97-1.58)) and intracerebral haemorrhage (1.44 (0.97-2.12)). Presentation with peripheral arterial disease was less likely for Black (0.63 (0.50-0.80)) and South Asian patients (0.70 (0.57-0.86)) compared with White patients. While we found the anticipated substantial predominance of coronary heart disease presentations in South Asian and predominance of stroke presentations in Black patients, we found no ethnic differences in presentation with heart failure. We consider the public health and research implications of our findings. NCT02176174, www.clinicaltrials.gov.

Initial body temperature in ischemic stroke: nonpotentiation of tissue-type plasminogen activator benefit and inverse association with severity.

PubMed

Kim, Seo Hyun; Saver, Jeffrey L

2015-01-01

Body temperature (BT) is an important physiological factor in acute ischemic stroke. However, the relationship of initial BT to stroke severity and degree of benefit from thrombolytic therapy has been delineated incompletely. We analyzed the public data set of the 2 National Institute of Neurological Disorders and Stroke Tissue-Type Plasminogen Activator (tPA) stroke trials, comparing patients with lower (<37.0°C) and higher (≥37.0°C) presenting BT. Among 595 patients (297 placebo and 298 tPA treated) with documented initial BT, 77.1% had initial BT <37.0°C and 22.9% ≥37.0°C. Patients with higher initial BT had lower baseline stroke severity in both tPA-treated patients (the National Institute of Health Stroke Scale median, 11 versus 15; P=0.05) and placebo-treated patients (median, 13 versus 16; P<0.01). Patients with higher initial BT also had lower infarction volume on computed tomography at 3 months in both tPA-treated patients (median, 9.6 versus 16.7 cm(3); P=0.08) and placebo-treated patients (median, 13.1 versus 28.1 cm(3); P=0.02), but no clinical outcome differences. Analysis of lytic treatment effect found no heterogeneity in the degree of tPA benefit in both higher and lower BT groups (≥37.0°C: odds ratio for the modified Rankin Scale 0-1 outcome, 2.55; 95% confidence interval, 1.05-6.21 and <37.0°C: odds ratio, 2.30; 95% confidence interval, 1.38-3.84; heterogeneity P=0.83). In patients with hyperacute stroke, higher presenting temperatures are associated with less severe neurological deficits and reduced final infarct volumes. Presenting temperature does not modify the benefit of tPA on 3-month favorable outcome. © 2014 American Heart Association, Inc.

CD4+ cell count recovery in naïve patients initiating cART, who achieved and maintained plasma HIV-RNA suppression.

PubMed

Costagliola, Dominique; Lacombe, Jean-Marc; Ghosn, Jade; Delaugerre, Constance; Pialoux, Gilles; Cuzin, Lise; Launay, Odile; Ménard, Amélie; de Truchis, Pierre; Mary-Krause, Murielle; Weiss, Laurence; Delfraissy, Jean-François

2014-01-01

A key objective of combined antiretroviral therapy (cART) is to reach and maintain high CD4 cell counts to provide long-term protection against AIDS-defining opportunistic infections and malignancies, as well as other comorbidities. However, a high proportion of patients present late for care. Our objective was to assess CD4 cell count recovery up to seven years in naïve patients initiating cART with at least three drugs in usual clinical care. From the French Hospital Database on HIV, we selected naïve individuals initiating cART from 2000 with at least two years of follow-up. Participants were further required to have achieved viral load suppression by six months after initiating cART and were censored in case of virological failure. We calculated the proportion of patients (Kaplan-Meier estimates) who achieved CD4 recovery to >500/mm(3) according to baseline CD4 cell count. A total of 15,025 patients were analyzed with a median follow-up on ART of 65.5 months (IQR: 42.3-96.0). At cART initiation, the median age was 38.6 years (IQR: 32.2-46.0), 9734 (64.8%) were men, median CD4 cell count was 239 (IQR: 130-336) and 2668 (17.8%) had a prior AIDS event. RESULTS are presented in the Table 1. This study shows that CD4 cell counts continue to increase seven years after cART initiation, whatever the baseline CD4 cell count. Failing to achieve CD4 recovery with continuous viral load suppression is rare for naïve patients initiating cART in routine clinical practice, but takes substantially longer in patients who initiate antiretroviral therapy at low CD4 cell counts.

Muscle paralysis in thyrotoxicosis.

PubMed

Siddiqui, Fraz Anwar; Sheikh, Aisha

2015-05-29

Thyrotoxic periodic paralysis (TPP) is a condition characterised by muscle paralysis due to hypokalaemia usually secondary to thyrotoxicosis. We report a case of a 31-year-old man with no known comorbidities who presented to a tertiary healthcare unit with a 1-month history of difficulty in breathing, palpitations, weight loss and hoarseness of voice. On examination, his thyroid gland was palpable and fine hand tremors were present. An initial provisional diagnosis of hyperthyroidism was made. Three months after initial presentation, the patient presented in emergency with severe muscle pain and inability to stand. Laboratory results revealed hypokalaemia. All the symptoms reverted over the next few hours on administration of intravenous potassium. A diagnosis of TTP was established. After initial presentation, the patient was treated with carbimazole and propranolol. Once he was euthyroid, radioactive iodine ablation therapy (15 mCi) was carried out as definitive therapy, after which the patient's symptoms resolved; he is currently doing fine on levothyroxine replacement and there has been no recurrence of muscle paralysis. 2015 BMJ Publishing Group Ltd.

Atypical Initial Presentation of Painful Muscle Cramps in a Patient with Amyotrophic Lateral Sclerosis: A Case Report and Brief Review of the Literature.

PubMed

Kuzel, Aaron R; Lodhi, Muhammad Uzair; Syed, Intekhab Askari; Rahim, Mustafa

2017-11-10

Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disorder characterized clinically by progressive muscle weakness that can occur proximally or distally in either the upper or lower extremities. It includes both upper motor neuron signs (spasticity, hyperreflexia, clonus, and Babinski sign) and lower motor neuron signs (atrophy, weakness, and muscle fasciculation). Initial presentation of progressively painful muscle cramps should lead the physician to screen for other signs of amyotrophic lateral sclerosis. We report the case of a 51-year-old male, who presented with dull muscle cramps in the right upper shoulder and arm. After a careful history and physical exam, it was found that patient had both upper and lower motor neuron signs; therefore, a diagnosis of amyotrophic lateral sclerosis was made. Amyotrophic lateral sclerosis should strongly be considered in the differential diagnosis of patients presenting with an atypical initial presentation of progressively painful muscle cramps.

Churg-Strauss syndrome presenting with eosinophilic myocarditis: a diagnostic challenge.

PubMed

Correia, Ana Sofia; Gonçalves, Alexandra; Araújo, Vítor; Almeida e Silva, João; Pereira, José Manuel; Rodrigues Pereira, Pedro; Pizarro, Manuel; Silva, João Carlos; Maciel, Maria Júlia

2013-09-01

Churg-Strauss syndrome (CSS) is an unusual disease that presents as systemic vasculitis and peripheral eosinophilia in patients with an atopic constitution. Cardiac involvement is unusual and often not prominent on initial presentation, but is an important cause of morbidity and mortality in patients with CSS. We report the case of a young woman with severe acute myocarditis. Coronary arteriography demonstrated extensive focal vasculopathy, consistent with coronary vasculitis, and myocardial biopsy showed eosinophilic myocarditis. This presentation led to an initial diagnosis of CSS in this patient and appropriate therapy resulted in a spectacular remission of disease activity. Copyright © 2012 Sociedade Portuguesa de Cardiologia. Published by Elsevier España. All rights reserved.

Fatal thalamic abscess secondary to dental infection.

PubMed

Basyuni, Shadi; Sharma, Valmiki; Santhanam, Vijay; Ferro, Ashley

2015-12-17

We present the case of poor neurological recovery and subsequent death secondary to a thalamic abscess in a 53-year-old man. This patient initially presented with sudden dysarthria and left hemiparesis while driving. Neuroimaging showed a multilobular abscess involving the right thalamus with oedema extending to the basal ganglionic region and brainstem. The source of the abscess was initially unknown and it required draining multiple times while the different causes were being explored. The patient's neurological state along with intubation made for a difficult and inconclusive oral examination. It was only after neuroimaging included tooth-bearing areas that it became evident that this patient had extensive periodontal disease with multiple areas of periapical radiolucencies. The patient underwent complete dental clearance alongside repeated drainage of the abscess. Despite initial postoperative improvement, the patient never recovered from the neurological damage and died 3 weeks later. 2015 BMJ Publishing Group Ltd.

Utility of screening ultrasound after first febrile UTI among patients with clinically significant vesicoureteral reflux.

PubMed

Massanyi, Eric Z; Preece, Janae; Gupta, Angela; Lin, Susan M; Wang, Ming-Hsien

2013-10-01

To assess the sensitivity and negative predictive value (NPV) of screening renal and bladder ultrasound (RBUS) after initial febrile urinary tract infection (UTI) among patients with clinically significant vesicoureteral reflux (VUR). A retrospective review was performed of all children <2 years of age who presented with a febrile UTI between 2004 and 2011. The sensitivity and NPV of initial RBUS was calculated among patients who were found to have high-grade (IV-V) VUR. Additionally, initial RBUS among patients with evidence of photopenia on dimercaptosuccinic acid (DMSA) scan or who underwent surgical intervention were reviewed. One hundred forty-four patients with febrile UTI were identified; available RBUS, voiding cystourethrogram (VCUG), and DMSA results for each kidney were reviewed. One hundred fifty-eight kidneys had evidence of VUR on VCUG, and initial RBUS demonstrated abnormality in 25 (sensitivity 0.17). Forty-five kidneys had high-grade VUR and RBUS revealed abnormality in 16 (sensitivity 0.36). One hundred seventy-eight kidneys had no evidence of abnormality on initial RBUS, and 136 (76%) were found to have VUR (NPV 0.24), of which 31 had high-grade VUR (NPV 0.83). Seven kidneys had scarring on DMSA and initial RBUS was normal in 4 (57%). Twelve of 19 patients (63%) who eventually underwent surgical intervention had a normal initial RBUS. RBUS has poor sensitivity and NPV for detecting high-grade VUR in patients <2 years who present with a febrile UTI. A significant number of patients who were diagnosed with high-grade VUR, renal scarring, or underwent surgical correction of VUR had a negative screening RBUS. Copyright © 2013 Elsevier Inc. All rights reserved.

Time-trends in the prescribing of gastroprotective agents to primary care patients initiating low-dose aspirin or non-steroidal anti-inflammatory drugs: a population-based cohort study

PubMed Central

Warlé-van Herwaarden, Margaretha F; Koffeman, Aafke R; Valkhoff, Vera E; ’t Jong, Geert W; Kramers, Cornelis; Sturkenboom, Miriam C; De Smet, Peter A G M

2015-01-01

Aims Low-dose aspirin (LDA) and non-steroidal-anti-inflammatory drugs (NSAIDs) both increase the risk of upper gastrointestinal events (UGIEs). In the Netherlands, recommendations regarding the prescription of gastroprotective agents (GPAs) in LDA users were first issued in 2009 in the HARM-Wrestling consensus. National guidelines on gastroprotective strategies (GPSs) in NSAID users were issued in the first part of the preceding. The aim of the present study was to examine time-trends in GPSs in patients initiating LDA and those initiating NSAIDs between 2000 and 2012. Methods Within a large electronic primary healthcare database, two cohorts were selected: (i) patients newly prescribed LDA and (ii) patients newly prescribed NSAIDs between 2000 and 2012. Patients who had been prescribed a GPA in the previous six months were excluded. For both cohorts, patients’ risk of a UGIE was classified as low, moderate or high, based on the HARM-Wrestling consensus, and the presence of an adequate GPSwas determined. Results A total of 37 578 patients were included in the LDA cohort and 352 025 patients in the NSAID cohort. In both cohorts, an increase in GPSs was observed over time, but prescription of GPAs was lower in the LDA cohort. By 2012, an adequate GPS was present in 31.8% of high-risk LDA initiators, vs. 48.0% of high-risk NSAID initiators. Conclusions Despite a comparable risk of UGIEs, GPSs are prescribed less in high-risk LDA initiators than in high-risk NSAID initiators. For both groups of patients, there is still room for improvement in guideline adherence. PMID:25777983

Fever as an initial manifestation of spondyloarthritis: A retrospective study.

PubMed

Byun, Se Jin; Bae, William Han; Jung, Seung Min; Lee, Sang-Won; Park, Yong-Beom; Song, Jason Jungsik

2017-01-01

We aimed to evaluate a wide spectrum of clinical features of adult patients with spondyloarthritis (SpA) whose initial manifestation was fever, using the Assessment of SpondyloArthritis international Society (ASAS) classification criteria. We retrospectively collected the electronic medical records of hospitalized SpA patients who initially presented to the Severance Hospital (Seoul, Korea) with fever from January 2010 to May 2016. As a control group, we also recruited one-hundred consecutive patients who were diagnosed with SpA in our outpatient clinic. Clinical features and laboratory findings were compared in two patient groups. There were 26 patients who had fever as initial presentation of SpA (reactive arthritis 50%, undifferentiated SpA 26.9%, ankylosing spondylitis 15.4%, enteropathic arthritis 3.8%, psoriatic arthritis 3.8%). Peripheral SpA was more common in febrile SpA patients than in control SpA patients (65.4% vs 24.0%, p<0.001). Febrile SpA patients were less frequently HLA-B27 positive than control SpA patients (52.2% vs 77.0%, p<0.05). At baseline, systemic inflammatory markers were significantly higher in the febrile SpA patients (white blood cell count, 11.57 vs 7.81 cells/μL, p<0.001; erythrocyte sedimentation rate, 69.2 vs 41.0 mm/h, p<0.001; C-reactive protein, 109.6 vs 15.3 mg/L, p<0.001). The proportion of patients treated with systemic steroids was significantly higher in febrile SpA patients (57.7% vs. 11.0%, p<0.001). The proportion of patients who visited rheumatology specialty was significantly lower in febrile SpA patients than in control SpA patients (7.7% vs 59.0%, p<0.001). Various subgroups of SpA can be presented with fever as an initial manifestation. Febrile SpA patients demonstrated higher systemic inflammation and a lower chance to visit rheumatology in early stage. When evaluating febrile patients with any clinical features of SpA, clinicians are advised to consider performing SpA-focused evaluation including HLA-B27 or a simple sacroiliac joint radiograph.

Primary Sjögren syndrome that initially presented with repeated hypergammaglobulinemic purpura after prolonged sitting

PubMed Central

Zhou, Zhihua; Jiang, Weiqiang; Wang, Ming; Liu, Yongyuan; Zhang, Wei; Huang, Manping; Liang, Donghui

2017-01-01

Abstract Rationale: Purpura is a common dermatologic manifestation in Sjögren syndrome (SS). When a patient presents with sicca symptoms, the diagnosis of SS is not difficult. Patient concerns: Here, we reported a case of a 52-year-old Chinese woman who initially presented with nonpalpable purpura on both lower extremities, and these lesions had developed soon after prolonged sitting. In the past 2 years, she had repeated cutaneous nonpalpable purpura 4 times. She had no sicca symptoms, dry eyes, or dry mouth. Diagnoses: Combining the laboratory findings, Schirmer test, and labial gland biopsy, primary SS was confirmed. Interventions: The patient was placed on a trial of hydroxychloroquine (200 mg once daily). Outcomes: The purpura on both lower extremities had faded at the sixth day after onset and at the third day after hydroxychloroquine treatment. Lessons: These case was not easy to diagnosis primary SS because she had no sicca symptoms. A patient with primary SS who initially presented with recurrent purpura associated with prolonged sitting. Prolonged sitting had been a possible aggravating factor for the cutaneous purpura of this patient with primary SS. PMID:29390329

Gastric peritoneal carcinomatosis - a retrospective review

PubMed Central

Tan, Hwee Leong; Chia, Claramae Shulyn; Tan, Grace Hwei Ching; Choo, Su Pin; Tai, David Wai-Meng; Chua, Clarinda Wei Ling; Ng, Matthew Chau Hsien; Soo, Khee Chee; Teo, Melissa Ching Ching

2017-01-01

AIM To characterize patients with gastric peritoneal carcinomatosis (PC) and their typical clinical and treatment course with palliative systemic chemotherapy as the current standard of care. METHODS We performed a retrospective electronic chart review of all patients with gastric adenocarcinoma with PC diagnosed at initial metastatic presentation between January 2010 and December 2014 in a single tertiary referral centre. RESULTS We studied a total of 271 patients with a median age of 63.8 years and median follow-up duration of 5.1 mo. The majority (n = 217, 80.1%) had the peritoneum as the only site of metastasis at initial presentation. Palliative systemic chemotherapy was eventually planned for 175 (64.6%) of our patients at initial presentation, of which 171 were initiated on it. Choice of first-line regime was in accordance with the National Comprehensive Cancer Network Guidelines for Gastric Cancer Treatment. These patients underwent a median of one line of chemotherapy, completing a median of six cycles in total. Chemotherapy disruption due to unplanned hospitalizations occurred in 114 (66.7%), while cessation of chemotherapy occurred in 157 (91.8%), with 42 cessations primarily attributable to PC-related complications. Patients who had initiation of systemic chemotherapy had a significantly better median overall survival than those who did not (10.9 mo vs 1.6 mo, P < 0.001). Of patients who had initiation of systemic chemotherapy, those who experienced any disruptions to chemotherapy due to unplanned hospitalizations had a significantly worse median overall survival compared to those who did not (8.7 mo vs 14.6 mo, P < 0.001). CONCLUSION Gastric PC carries a grim prognosis with a clinical course fraught with disease-related complications which may attenuate any survival benefit which palliative systemic chemotherapy may have to offer. As such, investigational use of regional therapies is warranted and required validation in patients with isolated PC to maximize their survival outcomes in the long run. PMID:28344747

Selective Transcatheter Arterial Embolization for Treatment of Bleeding Complications or Reduction of Tumor Mass of Hepatocellular Adenomas

DOE Office of Scientific and Technical Information (OSTI.GOV)

Erdogan, Deha; Delden, Otto M. van; Busch, Olivier R. C.

2007-11-15

Hepatocellular adenomas (HCAs) are benign liver lesions which may be complicated by spontaneous intratumoral bleeding, with or without rupture into the abdominal cavity, or malignant degeneration. Recent advances in radiological interventional techniques now offer selective transcatheter arterial embolization (TAE) as an alternative approach to surgery as the initial treatment to stop the bleeding or as an elective treatment to reduce the tumor mass of the HCA. Herein, we report our initial experience using TAE in the management of HCA. Five female patients and one male patient presented with spontaneous hemorrhage of HCA. Four patients were initially treated with selective TAEmore » to stop the bleeding. In two patients in whom the bleeding stopped spontaneously, TAE was electively undertaken 1 year after presentation to reduce the tumor mass of HCAs >5 cm. Selective TAE as initial treatment in patients with spontaneous bleeding of HCA with or without rupture is effective and will change the need for urgent laparotomy to control bleeding. Selective TAE may also be used as an elective treatment to reduce the tumor mass of larger HCAs.« less

Initial resuscitation for Australasian Triage Scale 2 patients in a Nepalese emergency department.

PubMed

Basnet, Bibhusan; Bhandari, Rabin; Moore, Malcolm

2012-08-01

Triage is recognized as important in providing timely care to emergency patients. However, systematic triage is only practised in two EDs in Nepal. The first objective of this study was to assess the performance of one of these departments in seeing triaged patients in a timely fashion. Second, an epidemiological survey of patients presenting to the ED was performed to describe the conditions seen and initial resuscitation undertaken. We performed a descriptive cross-sectional study in the ED of B.P. Koirala Institute of Health Sciences, eastern Nepal where the Australasian Triage Scale (ATS) is used. One hundred and sixty patients triaged as ATS 2 were recruited. The time taken for the duty doctor to see the patient was noted. The presenting problems, vital signs and level of consciousness were measured at presentation. The resuscitation measures were recorded. The mean waiting time was 2.1 ± 1.7 min with a range of 1-10 min, which meets the benchmark for ATS 2. At triage, the most common presenting problems were circulatory shock (23.1%), altered consciousness (21%), respiratory difficulty (16.9%) and poisoning (15%). Oxygen, i.v. fluids and antibiotics were the most common therapies used in the initial resuscitation of patients. Patients triaged as ATS 2 were seen in a timely fashion. Seriously ill patients requiring resuscitation present commonly to this ED. This is a big challenge for junior doctors. Improved training, treatment protocols and equipment are needed to help manage this burden. © 2012 The Authors. EMA © 2012 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

Very long-term sequelae of craniopharyngioma.

PubMed

Wijnen, Mark; van den Heuvel-Eibrink, Marry M; Janssen, Joseph A M J L; Catsman-Berrevoets, Coriene E; Michiels, Erna M C; van Veelen-Vincent, Marie-Lise C; Dallenga, Alof H G; van den Berge, J Herbert; van Rij, Carolien M; van der Lely, Aart-Jan; Neggers, Sebastian J C M M

2017-06-01

Studies investigating long-term health conditions in patients with craniopharyngioma are limited by short follow-up durations and generally do not compare long-term health effects according to initial craniopharyngioma treatment approach. In addition, studies comparing long-term health conditions between patients with childhood- and adult-onset craniopharyngioma report conflicting results. The objective of this study was to analyse a full spectrum of long-term health effects in patients with craniopharyngioma according to initial treatment approach and age group at craniopharyngioma presentation. Cross-sectional study based on retrospective data. We studied a single-centre cohort of 128 patients with craniopharyngioma treated from 1980 onwards (63 patients with childhood-onset disease). Median follow-up since craniopharyngioma presentation was 13 years (interquartile range: 5-23 years). Initial craniopharyngioma treatment approaches included gross total resection ( n  = 25), subtotal resection without radiotherapy ( n  = 44), subtotal resection with radiotherapy ( n  = 25), cyst aspiration without radiotherapy ( n  = 8), and 90 Yttrium brachytherapy ( n  = 21). Pituitary hormone deficiencies (98%), visual disturbances (75%) and obesity (56%) were the most common long-term health conditions observed. Different initial craniopharyngioma treatment approaches resulted in similar long-term health effects. Patients with childhood-onset craniopharyngioma experienced significantly more growth hormone deficiency, diabetes insipidus, panhypopituitarism, morbid obesity, epilepsy and psychiatric conditions compared with patients with adult-onset disease. Recurrence-/progression-free survival was significantly lower after initial craniopharyngioma treatment with cyst aspiration compared with other therapeutic approaches. Survival was similar between patients with childhood- and adult-onset craniopharyngioma. Long-term health conditions were comparable after different initial craniopharyngioma treatment approaches and were generally more frequent in patients with childhood- compared with adult-onset disease. © 2017 European Society of Endocrinology.

Post-operative re-bleeding in patients with hypertensive ICH is closely associated with the CT blend sign.

PubMed

Wu, Guofeng; Shen, Zhengkui; Wang, Likun; Sun, Shujie; Luo, Jinbiao; Mao, Yuanhong

2017-07-06

Intracranial post-operative re-haemorrhage is an important complication in patients with hypertensive intracerebral haemorrhage (ICH). The purpose of the present study was to determine the value of the computed tomography (CT) blend sign in predicting post-operative re-haemorrhage in patients with ICH. A total of 126 patients with ICH were included in the present study. All the patients underwent standard stereotactic minimally invasive surgery(MIS) to remove the ICH within 24 h following admission. There were 41 patients with a blend sign on initial CT and 85 patients without a blend sign on the initial CT. Multivariable logistic regression analyses were performed to assess the relationship between the presence of the blend sign on the non-enhanced admission CT scan and post-operative re-haemorrhage. Post-operative re-haemorrhage occurred in 24 of the 41 patients with the blend sign, and in 9 of the 85 patients without the blend sign. The incidence of re-haemorrhage was significantly different between the groups. The multivariate logistic regression analysis demonstrated that the initial Glasgow coma scale score (p = 0.002) and blend sign (P < 0.00) on the initial CT scan are independent predictors of post-operative re-haemorrhage. The sensitivity, specificity, and positive and negative predictive values of the blend sign for predicting post-operative re-haemorrhage were 72.7, 81.7, 58.5 and 89.4%, respectively. The presence of the blend sign on the initial CT scan is closely associated with post-operative re-haemorrhage in patients with ICH who undergo stereotactic MIS.

Characteristics of Cytomegalovirus Uveitis in Immunocompetent Patients.

PubMed

Woo, Jyh Haur; Lim, Wee K; Ho, Su L; Teoh, Stephen C

2015-01-01

To present the clinical characteristics of patients with anterior uveitis who had evidence of cytomegalovirus (CMV) infection on polymerase chain reaction PCR-based assays for viral DNA in aqueous samples. This was a retrospective observational case series of 16 patients with CMV infection on qualitative polymerase chain reaction PCR-based assays for viral DNA in aqueous samples. Case records of 16 patients were reviewed and relevant clinical information was collected using a standardized data sheet. There were 10 male and 6 female patients, with 16 eyes included. The median age at the first attack was 52 years (range 27-77 years). Thirteen patients (81.3%) presented with an initial BCVA of 20/40 or better. Eleven eyes (68.8%) had anterior chamber inflammation of 1+ cells or less. Eight eyes (50.0%) had concomitant sectoral iris atrophy, while 2 eyes were noted to have heterochromic irides. Eleven patients (68.8%) presented with an elevated intraocular pressure. Seven patients (43.8%) had clinical features that led to a presumptive diagnosis of Posner-Schlossman syndrome, while 3 patients (18.8%) were initially diagnosed with Fuchs heterochromic iridocyclitis. Six patients were initially treated for uveitic glaucoma or anterior uveitis of unknown cause. There is a spectrum of clinical manifestations of CMV anterior uveitis. A high index of suspicion of a possible viral etiology, especially CMV, and subsequent accurate identification of the virus involved are fundamental to the overall therapeutic approach.

Risk Score to Predict Need for Intensive Care in Initially Hemodynamically Stable Adults With Non-ST-Segment-Elevation Myocardial Infarction.

PubMed

Fanaroff, Alexander C; Chen, Anita Y; Thomas, Laine E; Pieper, Karen S; Garratt, Kirk N; Peterson, Eric D; Newby, L Kristin; de Lemos, James A; Kosiborod, Mikhail N; Amsterdam, Ezra A; Wang, Tracy Y

2018-05-25

Intensive care unit (ICU) use for initially stable patients presenting with non-ST-segment-elevation myocardial infarction (NSTEMI) varies widely across hospitals and minimally correlates with severity of illness. We aimed to develop a bedside risk score to assist in identifying high-risk patients with NSTEMI for ICU admission. Using the Acute Coronary Treatment and Intervention Outcomes Network (ACTION) Registry linked to Medicare data, we identified patients with NSTEMI aged ≥65 years without cardiogenic shock or cardiac arrest on presentation. Complications requiring ICU care were defined as subsequent development of cardiac arrest, shock, high-grade atrioventricular block, respiratory failure, stroke, or death during the index hospitalization. We developed and validated a model and integer risk score (Acute Coronary Treatment and Intervention Outcomes Network (ACTION) ICU risk score) that uses variables present at hospital admission to predict requirement for ICU care. Of 29 973 patients with NSTEMI, 4282 (14%) developed a complication requiring ICU-level care, yet 12 879 (43%) received care in an ICU. Signs or symptoms of heart failure, initial heart rate, initial systolic blood pressure, initial troponin, initial serum creatinine, prior revascularization, chronic lung disease, ST-segment depression, and age had statistically significant associations with requirement for ICU care after adjusting for other risk factors. The ACTION ICU risk score had a C-statistic of 0.72. It identified 11% of patients as having very high risk (>30%) of developing complications requiring ICU care and 49% as having low likelihood (<10%) of requiring an ICU. The ACTION ICU risk score quantifies the risk of initially stable patients with NSTEMI developing a complication requiring ICU care, and could be used to more effectively allocate limited ICU resources. © 2018 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.

Metastatic prostate cancer in the modern era of PSA screening

PubMed Central

Fontenot, Philip A.; Nehra, Avinash; Parker, William; Wyre, Hadley; Mirza, Moben; Duchene, David A.; Holzbeierlein, Jeffrey; Thrasher, James Brantley; Veldhuizen, Peter Van; Lee, Eugene K.

2017-01-01

ABSTRACT Introduction To characterize initial presentation and PSA screening status in a contemporary cohort of men treated for metastatic prostate cancer at our institution. Materials and methods We reviewed records of 160 men treated for metastatic prostate cancer between 2008-2014 and assessed initial presentation, categorizing patients into four groups. Groups 1 and 2 presented with localized disease and received treatment. These men suffered biochemical recurrence late (>1 year) or earlier (<1 year), respectively, and developed metastases. Groups 3 and 4 had asymptomatic and symptomatic metastases at the outset of their diagnosis. Patients with a first PSA at age 55 or younger were considered to have guideline-directed screening. Results Complete records were available on 157 men for initial presentation and 155 men for PSA screening. Groups 1, 2, 3 and 4 included 27 (17%), 7 (5%), 69 (44%) and 54 (34%) patients, respectively. Twenty (13%) patients received guideline-directed PSA screening, 5/155 (3%) patients presented with metastases prior to age 55 with their first PSA, and 130/155 (84%) had their first PSA after age 55, of which 122/130 (94%) had metastasis at the time of diagnosis. Conclusion Despite widespread screening, most men treated for metastatic prostate cancer at our institution presented with metastases rather than progressed after definitive treatment. Furthermore, 25 (16%) patients received guideline-directed PSA screening at or before age 55. These data highlight that, despite mass screening efforts, patients treated for incurable disease at our institution may not have been a result of a failed screening test, but a failure to be screened. PMID:28338310

Efficacy and tolerability of lacosamide for secondary epileptic seizures in patients with brain tumor: A multicenter, observational retrospective study

PubMed Central

Sepúlveda-Sánchez, Juan Manuel; Conde-Moreno, Antonio; Barón, Manuel; Pardo, Javier; Reynés, Gaspar; Belenguer, Antonio

2017-01-01

The present observational, multicenter, retrospective study investigated the efficacy and tolerability of lacosamide in controlling secondary epileptic seizures in patients with brain tumors in Spain. Data from the medical records of patients ≥18 years of age with brain tumors, who had received at least one dose of lacosamide for seizure management between July 2013 and November 2013, were collected. The primary and secondary objectives of the present study were to assess the effectiveness and tolerability of lacosamide. Data from 39 patients (mean age, 54.1 years; 66.7% male) were collected, where the two main reasons for initiation of lacosamide treatment were the lack of efficacy of other antiepileptic drugs (in 76.9% of patients) and the presence of adverse events (12.8%) associated with other antiepileptic drugs. At the initiation of treatment, patients received a mean lacosamide dose of 138.5±68.3 mg/day. At 6 months, lacosamide had significantly reduced the mean number of seizures from 26.4 (standard deviation [SD], 50.4) seizures for the 6 months prior to lacosamide initiation to a mean of 9.4 (SD, 22.8) seizures during the 6 months subsequent to lacosamide initiation; P<0.001. Lacosamide was generally well tolerated; of the 25 patients who had complete safety data available at a 6-month follow-up, 3 patients (12%) reported an adverse event, including dizziness, asthenia, instability and irritability. The present retrospective analysis suggested that lacosamide is an effective and well-tolerated treatment in patients experiencing seizures due to brain tumors. Additional prospective studies with a larger patient population and randomized trial design are warranted. PMID:28599411

Efficacy and tolerability of lacosamide for secondary epileptic seizures in patients with brain tumor: A multicenter, observational retrospective study.

PubMed

Sepúlveda-Sánchez, Juan Manuel; Conde-Moreno, Antonio; Barón, Manuel; Pardo, Javier; Reynés, Gaspar; Belenguer, Antonio

2017-06-01

The present observational, multicenter, retrospective study investigated the efficacy and tolerability of lacosamide in controlling secondary epileptic seizures in patients with brain tumors in Spain. Data from the medical records of patients ≥18 years of age with brain tumors, who had received at least one dose of lacosamide for seizure management between July 2013 and November 2013, were collected. The primary and secondary objectives of the present study were to assess the effectiveness and tolerability of lacosamide. Data from 39 patients (mean age, 54.1 years; 66.7% male) were collected, where the two main reasons for initiation of lacosamide treatment were the lack of efficacy of other antiepileptic drugs (in 76.9% of patients) and the presence of adverse events (12.8%) associated with other antiepileptic drugs. At the initiation of treatment, patients received a mean lacosamide dose of 138.5±68.3 mg/day. At 6 months, lacosamide had significantly reduced the mean number of seizures from 26.4 (standard deviation [SD], 50.4) seizures for the 6 months prior to lacosamide initiation to a mean of 9.4 (SD, 22.8) seizures during the 6 months subsequent to lacosamide initiation; P<0.001. Lacosamide was generally well tolerated; of the 25 patients who had complete safety data available at a 6-month follow-up, 3 patients (12%) reported an adverse event, including dizziness, asthenia, instability and irritability. The present retrospective analysis suggested that lacosamide is an effective and well-tolerated treatment in patients experiencing seizures due to brain tumors. Additional prospective studies with a larger patient population and randomized trial design are warranted.

Assessing health seeking behaviour among tuberculosis patients in rural South Africa.

PubMed

Pronyk, R M; Makhubele, M B; Hargreaves, J R; Tollman, S M; Hausler, H P

2001-07-01

South Africa's rural Northern Province. To examine patterns of health seeking behaviour among hospitalised tuberculosis patients. Information on personal characteristics, health seeking behaviour and delays to presentation and hospitalisation was collected from hospitalised TB patients. Analysis of rates was used to investigate factors associated with delay. Among 298 patients, median total delay to hospitalisation was 10 weeks, with patient delay contributing a greater proportion than service provider delay. Patients more often presented initially to public hospitals (41%) or clinics (31 %) than to spiritual/traditional healers (15%) or private GPs (13%). Total delay was shorter amongst those presenting to hospitals than those presenting to clinics (rate ratio 1.33, 95%CI 1.13-1.85), with a significantly smaller proportion of the total delay attributable to the health service provider (18% vs. 42%). Those exhibiting a conventional risk profile for TB (migrants, alcohol drinkers, history of TB) were diagnosed most quickly by health services, while women remained undiagnosed for longer. Considerable delay exists between symptom onset and treatment initiation among pulmonary tuberculosis patients. While a substantial delay was attributable to late patient presentation, an important, preventable period of infectiousness was caused by the failure of recognised clinical services to diagnose tuberculosis among symptomatic individuals.

A trauma outreach program provided by a level I trauma center is an effective way to initiate peer review at referring hospitals and foster process improvements.

PubMed

Byrnes, Matthew C; Irwin, Eric; Becker, Leslie; Thorson, Melissa; Beilman, Greg; Horst, Patrick; Croston, Kevin

2010-04-01

The initial care of critically injured patients has profound effects on ultimate outcomes. The "golden hour" of trauma care is often provided by rural hospitals before definitive transfer. There are, however, no standardized methods for providing educational feedback to these hospitals for the purposes of performance improvement. We hypothesized that an outreach program would stimulate peer review and identify systematic deficiencies in the care of patients with injuries. We developed a quality improvement program aimed at providing educational feedback to hospitals that referred patients to our American College of Surgeons-verified level I trauma center. We traveled to each referral center to provide feedback on the initial treatment and ultimate outcome of patients that were transferred to us. These feedback sessions were presented in the format of case presentations and case discussions. The outreach program was presented at each hospital every 3 months to 6 months. Nine hospitals were included in our program. We received 334 patients in transfer from these hospitals during the study period. Formal peer review that focused on trauma patients increased from 14% of hospitals to 100% of hospitals after institution of the program. Eighty-five percent of hospitals thought that the care of patients with injuries was improved as a result of the program. Eighty-five percent of hospitals developed process improvement initiatives as a result of the program. A formal outreach program can stimulate peer review at rural hospitals, provide continuing education in the care of patients with injuries, and foster process improvements at referring hospitals.

Symptomatic Patients without Epidemiological Indicators of HIV Have a High Risk of Missed Diagnosis: A Multi-Centre Cross Sectional Study.

PubMed

Brännström, Johanna; Svedhem, Veronica; Marrone, Gaetano; Andersson, Örjan; Azimi, Farshad; Blaxhult, Anders; Sönnerborg, Anders

2016-01-01

One quarter of HIV-1 positive individuals in Sweden present for care with HIV or AIDS associated conditions without an HIV test (missed presentations) and 16% report neglect of such symptoms. The objective of this study was to identify risk factors for these missed opportunities of HIV-1 diagnosis. A national study, recruiting 409 newly diagnosed HIV-1 infected adults over a 2.5-year period, was performed. Logistic regression models tested the relationship between missed presentation and patient's neglect versus socio-demographic and behavioural risk factors. Additionally the initiator of the HIV test was assessed. The odds for a missed presentation was lower for migrants (from East Europe, Asia, and Pacific (East): OR 0.4 (0.2-0.8); Sub-Saharan Africa (SSA): 0.3 (0.2-0.6); other: 0.5 (0.2-1.0)), compared to patients born in Sweden, just as symptoms neglected by the patient (East (0.3 (0.1-1.0); SSA (0.4 (0.2-0.8)). The latter was also lower for men who have sex with men (0.5 (0.2-1.0)), compared to patients infected heterosexually. Patients infected in the East, with present/previous substance use or a previous negative HIV test were more likely to take the initiative to test on their own, whereas those >50 years and with a previously missed presentation had significantly reduced odds, p<0.05. Individuals without epidemiological indicators of HIV are more likely to have a history of missed presentations, to neglect symptoms and are less prone to take an initiative to test for HIV themselves. It is important to further implement testing to include all patients with symptoms and conditions indicative of HIV.

Initial presentations and final outcomes of primary pyogenic liver abscess: a cross-sectional study

PubMed Central

2014-01-01

Background Although pyogenic liver abscess (PPLA) fatalities are decreasing owing to early diagnosis and effective treatments, PPLA-associated complications still exist. The purpose of this study was to analyze the characteristic features of initial presentations and final outcomes of PPLA caused by different pathogens. Methods This retrospective study collected and analyzed information regarding initial presentations and final outcomes in patients diagnosed with PPLA at admitted at Changhua Christian Hospital from January 1 to December 31, 2010. Results During the study period, we analyzed the records of a total of 134 patients with documented PPLA. There were no significant causative pathogen-related differences in symptoms at initial presentation. Compared with the survivor group, patients in the mortality group were characterized by male gender (p < 0.001), malignancy (p < 0.001), respiratory distress (p =0.007), low blood pressure (p = 0.024), jaundice (p = < 0.001), rupture of liver abscess (p < 0.001), endophthalmitis (p = 0.003), and multiple organ failure (p < 0.001). No patients received liver transplantation or were diagnosed with HIV during the study period. According to univariate logistic regression analysis, gender (OR = 1.185, 95% CI: 0.284–11.130, p = 0.006), malignancy (OR = 2.067, 95% CI: 1.174–13.130, p = 0.004), respiratory distress (OR = 1.667, 95% CI: 1.164–14.210, p = 0.006), low blood pressure (OR = 2.167, 95% CI: 2.104–13.150, p = 0.003), jaundice (OR = 1.9, 95% CI: 1.246–3.297, p = 0.008), rupture of liver abscess (OR = 5.167, 95% CI: 2.194–23.150, p = 0.003), endophthalmitis (OR = 2.167, 95% CI: 1.234–13.140, p = 0.005), and multiple organ failure (OR = 3.067, 95% CI: 1.184–15.150, p = 0.001) differed significantly between the mortality and survivor groups. Conclusion Although the initial presentations of PPLA caused by different pathogens were similar, there were significant differences in mortality in cases involving: (1) male patients, (2) malignancy, (3) initial respiratory distress, (4) initial low blood pressure, (5) jaundice, (6) rupture of liver abscess, (7) endophthalmitis, , and (8) multiple organ failure. We strongly recommend using a severity score of the disease to determine the risk of mortality for each patient with PPLA. In order to prevent complications and reduce mortality, more attention must be paid to high-risk PPLA patients. PMID:25066384

The utility of repeat sestamibi scans in patients with primary hyperparathyroidism after an initial negative scan.

PubMed

Krishnamurthy, Vikram D; Sound, Sara; Okoh, Alexis K; Yazici, Pinar; Yigitbas, Hakan; Neumann, Donald; Doshi, Krupa; Berber, Eren

2017-06-01

We analyzed the utility of repeated sestambi scans in patients with primary hyperparathyroidism and its effects on operative referral. We carried out a retrospective review of patients with primary hyperparathyroidism who underwent repeated sestambi scans exclusively within our health system between 1996-2015. Patient demographic, presentation, laboratory, imaging, operative, and pathologic data were reviewed. Univariate analysis with JMP Pro v12 was used to identify factors associated with conversion from an initial negative to a subsequent positive scan. After exclusion criteria (including reoperations), we identified 49 patients in whom 59% (n = 29) of subsequent scans remained negative and 41% (n = 20) converted to positive. Factors associated with an initial negative to a subsequent positive scan included classic presentation and second scans with iodine subtraction (P = .04). Nonsurgeons were less likely to order an iodine-subtraction scan (P < .05). Fewer patients with negative imaging were referred to surgery (33% vs 100%, P = .005), and median time to operation after the first negative scan was 25 months (range 1.4-119). Surgeon-performed ultrasonography had greater sensitivity and positive predictive value than repeated sestamibi scans. Negative sestambi scans decreased and delayed operative referral. Consequently, we identified several process improvement initiatives, including education regarding superior institutional imaging. Combining all findings, we created an algorithm for evaluating patients with primary hyperparathyroidism after initially negative sestamibi scans, which incorporates surgeon-performed ultrasonography. Copyright © 2016 Elsevier Inc. All rights reserved.

Emotional state affects gait initiation in individuals with Parkinson’s disease

PubMed Central

Hass, Chris J.; Bowers, Dawn; Janelle, Christopher M.

2013-01-01

The purpose of the present study was to determine the impact of manipulating emotional state on gait initiation in persons with Parkinson’s disease (PD) and healthy older adults. Following the presentation of pictures that are known to elicit specific emotional responses, participants initiated gait and continued to walk for several steps at their normal pace. Reaction time, the displacement and velocity of the center of pressure (COP) trajectory during the preparatory postural adjustments, and length and velocity of the first two steps were measured. Analysis of the gait initiation measures revealed that exposure to (1) threatening pictures, relative to all other pictures, speeded the initiation of gait for PD patients and healthy older adults; (2) approach-oriented emotional pictures (erotic and happy people), relative to withdrawal-oriented pictures, facilitated the anticipatory postural adjustments of gait initiation for PD patients and healthy older adults, as evidenced by greater displacement and velocity of the COP movement; and (3) emotional pictures modulated gait initiation parameters in PD patients to the same degree as in healthy older adults. Collectively, these findings hold significant implications for understanding the circuitry underlying the manner by which emotions modulate movement and for the development of emotion-based interventions designed to maximize improvements in gait initiation for individuals with PD. PMID:22194236

Initial heart rate and cardiovascular outcomes in patients presenting with acute coronary syndrome.

PubMed

Asaad, Nidal; El-Menyar, Ayman; AlHabib, Khalid F; Shabana, Adel; Alsheikh-Ali, Alawi A; Almahmeed, Wael; Al Faleh, Hussam; Hersi, Ahmad; Al Saif, Shukri; Al-Motarreb, Ahmed; Sulaiman, Kadhim; Al Nemer, Khalid; Amin, Haitham; Al Suwaidi, Jassim

2014-06-01

To assess the impact of on-admission heart rate (HR) in patients presenting with acute coronary syndrome (ACS). Data were collected retrospectively from the second Gulf Registry of Acute Coronary Events. Patients were divided according to their initial HR into: (I: < 60, II: 60-69, III: 70-79, IV: 80-89 and V: ≥ 90 bpm). Patients' characteristics and hospital and one- and 12-month outcomes were analyzed and compared. Among 7939 consecutive ACS patients, groups I to V represented 7%, 13%, 20%, 23.5%, and 37%, respectively. Mean age was higher in groups I and V. Group V were more likely males, diabetic and hypertensive. ST-elevation myocardial infarction was the main presentation in groups I and V. Reperfusion therapies were less likely given to group V. Beta blockers were more frequently prescribed to group III in comparison to groups with higher HR. Groups I and V were associated with worse hospital outcomes. Multivariate analysis showed initial tachycardia as an independent predictor for heart failure (OR 2.2; 95%CI: 1.39-3.32), while bradycardia was independently associated with higher one-month mortality (OR 2.0; 95%CI: 1.04-3.85) CONCLUSION: The majority of ACS patients present with tachycardia. However, low or high HR is a marker of high risk that needs more attention and management.

High-velocity facial gunshot wounds: multidisciplinary care from prehospital to discharge

PubMed Central

Sinnott, J D; Morris, G; Medland, P J; Porter, K

2016-01-01

A case is presented in which a high velocity rifle (shotgun) was fired into the inferior part of a patient's face in an attempted suicide causing widespread trauma to the inferior and left side of the patient's face. He presented to his general practitioner where an ambulance was called. The patient is followed from prehospital care (air ambulance) to resuscitation in accident and emergency and through the first stages of reconstructive surgery. The article focuses on the multidisciplinary approach to the patient's prehospital care and initial resuscitation at a major trauma centre. CT reconstruction images of the patient's skull allow visualisation of the extent of bone damage at presentation. Medical photography allows visualisation of the extent of the initial damage and shows how reconstructive surgery was undertaken early and in progressive stages. A literature review was performed allowing discussion of the current evidence and best practice in the management of facial gunshot wounds. PMID:26823355

Primary Sjögren syndrome that initially presented with repeated hypergammaglobulinemic purpura after prolonged sitting: A case report.

PubMed

Zhou, Zhihua; Jiang, Weiqiang; Wang, Ming; Liu, Yongyuan; Zhang, Wei; Huang, Manping; Liang, Donghui

2017-12-01

Purpura is a common dermatologic manifestation in Sjögren syndrome (SS). When a patient presents with sicca symptoms, the diagnosis of SS is not difficult. Here, we reported a case of a 52-year-old Chinese woman who initially presented with nonpalpable purpura on both lower extremities, and these lesions had developed soon after prolonged sitting. In the past 2 years, she had repeated cutaneous nonpalpable purpura 4 times. She had no sicca symptoms, dry eyes, or dry mouth. Combining the laboratory findings, Schirmer test, and labial gland biopsy, primary SS was confirmed. The patient was placed on a trial of hydroxychloroquine (200 mg once daily). The purpura on both lower extremities had faded at the sixth day after onset and at the third day after hydroxychloroquine treatment. These case was not easy to diagnosis primary SS because she had no sicca symptoms. A patient with primary SS who initially presented with recurrent purpura associated with prolonged sitting. Prolonged sitting had been a possible aggravating factor for the cutaneous purpura of this patient with primary SS. Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.

Effect of Immunotherapy on Seizure Outcome in Patients with Autoimmune Encephalitis: A Prospective Observational Registry Study

PubMed Central

Jung, Keun-Hwa; Sunwoo, Jun-Sang; Moon, Jangsup; Lim, Jung-Ah; Lee, Doo Young; Shin, Yong-Won; Kim, Tae-Joon; Lee, Keon-Joo; Lee, Woo-Jin; Lee, Han-Sang; Jun, Jinsun; Kim, Dong-Yub; Kim, Man-Young; Kim, Hyunjin; Kim, Hyeon Jin; Suh, Hong Il; Lee, Yoojin; Kim, Dong Wook; Jeong, Jin Ho; Choi, Woo Chan; Bae, Dae Woong; Shin, Jung-Won; Jeon, Daejong; Park, Kyung-Il; Jung, Ki-Young; Chu, Kon; Lee, Sang Kun

2016-01-01

Objective To evaluate the seizure characteristics and outcome after immunotherapy in adult patients with autoimmune encephalitis (AE) and new-onset seizure. Methods Adult (age ≥18 years) patients with AE and new-onset seizure who underwent immunotherapy and were followed-up for at least 6 months were included. Seizure frequency was evaluated at 2–4 weeks and 6 months after the onset of the initial immunotherapy and was categorized as “seizure remission”, “> 50% seizure reduction”, or “no change” based on the degree of its decrease. Results Forty-one AE patients who presented with new-onset seizure were analysed. At 2–4 weeks after the initial immunotherapy, 51.2% of the patients were seizure free, and 24.4% had significant seizure reduction. At 6 months, seizure remission was observed in 73.2% of the patients, although four patients died during hospitalization. Rituximab was used as a second-line immunotherapy in 12 patients who continued to have seizures despite the initial immunotherapy, and additional seizure remission was achieved in 66.6% of them. In particular, those who exhibited partial response to the initial immunotherapy had a better seizure outcome after rituximab, with low adverse events. Conclusion AE frequently presented as seizure, but only 18.9% of the living patients suffered from seizure at 6 months after immunotherapy. Aggressive immunotherapy can improve seizure outcome in patients with AE. PMID:26771547

Involuntary psychiatric attendances at an Australasian emergency department: A comparison of police and health-care worker initiated presentations.

PubMed

Llewellin, Peter; Arendts, Glenn; Weeden, Jacqueline; Pethebridge, Andrew

2011-10-01

To identify any significant differences in the population of patients brought in to a hospital ED under involuntary mental health orders, based on whether the orders are initiated by police or health professionals. A retrospective analysis of consecutive presentations to a tertiary hospital ED with a co-located psychiatric emergency care centre over a 12 month period, with univariate and multivariate statistical comparisons. Two hundred and eighty-two patients (making 378 ED presentations) met the case definition and were analysed. Compared with patients on medical orders, patients on police orders had significantly more presentations related to violence, longer stays in ED and lower rates of admission to an inpatient bed, but were no more likely to require restraint or security intervention within the ED. Patients on police and medical orders differ considerably, but the impact of these differences on ED workload is small. © 2011 The Authors. EMA © 2011 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

Predictive capabilities of preoperative and postoperative pulmonary function tests in delayed repair of congenital diaphragmatic hernia.

PubMed

Tracy, T F; Bailey, P V; Sadiq, F; Noguchi, A; Silen, M L; Weber, T R

1994-02-01

To improve the survival of newborns with congenital diaphragmatic hernia (CHD), preoperative stabilization with conventional ventilatory therapy and extracorporeal membrane oxygenation (ECMO) have been used. Measurements that quantify pulmonary function may allow an accurate assessment of lethal pulmonary hypoplasia and predict outcome. Pulmonary function tests (PFTs) were obtained in 20 infants preoperatively and postoperatively; these included measurements of compliance, dynamic compliance, and tidal volume. Overall survival was 75%. Six surviving infants were initially managed with ventilator therapy alone, followed by repair (group 1). The remaining 14 patients, who were moribund at presentation or whose initial ventilator therapy failed, were placed on ECMO and received repair during bypass; nine survived (group 2), and five died (group 3). Compliance, dynamic compliance, and tidal volume obtained at initial presentation and immediately preoperatively were significantly higher for group 1 as compared with groups 2 and 3. Infants whose initial compliance was greater than 0.25 mL/cm H2O/kg and initial tidal volume was greater than 3.5 mL/kg did not require ECMO. Ultimate improvement in compliance was noted in 5 of 6 patients in group 1, 8 of 8 patients in group 2, and 5 of 5 in group 3. This improvement followed an initial decline in compliance in 9 of 14 survivors, from 15% to 76%. All six patients in group 1 had tidal volumes of more than 4 mL/kg, as did 7 of 9 patients in group 2. Only one patient among the ECMO nonsurvivors (group 3) had a postoperative tidal volume of this magnitude. These data suggest that initial PFTs may predict which infants will require ECMO.(ABSTRACT TRUNCATED AT 250 WORDS)

Foudroyant Course of an Extensive Clostridium septicum Gas Gangrene in a Diabetic Patient with Occult Carcinoma of the Colon

PubMed Central

Kutup, Asad; Gehl, Axel; Zustin, Jozef; Grossterlinden, Lars G.; Rueger, Johannes M.; Lehmann, Wolfgang

2013-01-01

Background. Spontaneous gas gangrene is a rare disease in which Clostridium septicum frequently can be detected. After an incubation period of 5–48 hours, a very painful swelling is accompanied by a rapidly spreading toxic-infectious clinical picture ultimately leading to septic shock and multiple organ failure. We present a case of a completely documented rare infectious disease with triage findings including initial vital signs, initial medical findings, and the emergency lab., radiological, intraoperative, histopathological, microbiological, and postmortem results. After initial diagnosis of the underlying disease, the patient has been immediately transferred to the operating theatre. The laboratory findings reflect the devastating effect of toxin α which is a toxin typically produced by C. septicum. The patient presented both an anaemia and a manifest coagulopathy as well as an onset of multiple organ failure. Despite the aggressive medical and surgical measures that have been taken, this patient could not be saved. Discussion. The case presented vividly emphasises the difficulty to identify these cases early enough to save a patient. This documentation may help health care providers to identify this life threatening disease as early as possible in future cases. PMID:23864974

Goodpasture’s Disease: An Uncommon Disease With an Atypical Clinical Course

PubMed Central

Shiferaw, Bethel; Miro, Viktor; Smith, Carroll; Akella, Jagadish; Chua, Walter; Kim, Zae

2016-01-01

Goodpasture’s disease is an uncommon composite of features including renal failure with pulmonary hemorrhage secondary to an autoimmune response that specifically targets these organ systems. We present a case of particular interest in regards to atypical presentation, and the uncommon treatment that the patient underwent. A 65-year-old Afghani female arrived with complaints of nausea, vomiting, loss of appetite, malaise, decreased urine output, exertional dyspnea, and cough. The patient presented initially with renal failure and unexpectedly developed respiratory failure after hemodialysis. Initial CT of thorax revealed diffuse bilateral pulmonary edema. Subsequently, the patient received a bronchoscopy demonstrating alveolar hemorrhage, which highlights a clinician’s need to maintain a differential and reassess patients. Anti-GBM antibody in the serum was detected and the renal biopsy revealed evidence of the antibody on immunofluorescence. In regards to management, the patient could only be treated with plasmapheresis as she had contraindication to initiation of immunosuppression, after which she showed significant clinical improvement. We would like to highlight the benefit of plasmapheresis without concomitant immunosuppression and recommend such an approach to be considered in similar clinical scenarios, where contraindication for immunosuppressant therapy exists. PMID:26668684

In real life, one-quarter of patients with hormone receptor-positive metastatic breast cancer receive chemotherapy as initial palliative therapy: a study of the Southeast Netherlands Breast Cancer Consortium.

PubMed

Lobbezoo, D J A; van Kampen, R J W; Voogd, A C; Dercksen, M W; van den Berkmortel, F; Smilde, T J; van de Wouw, A J; Peters, F P J; van Riel, J M G H; Peters, N A J B; de Boer, M; Peer, P G M; Tjan-Heijnen, V C G

2016-02-01

The objective of this study was to present initial systemic treatment choices and the outcome of hormone receptor-positive (HR+) metastatic breast cancer. All the 815 consecutive patients diagnosed with metastatic breast cancer in 2007-2009 in eight participating hospitals were identified. From the 611 patients with HR+ disease, a total of 520 patients with HER2-negative (HER2-) breast cancer were included. Initial palliative systemic treatment was registered. Progression-free survival (PFS) and overall survival (OS) per initial palliative systemic therapy were obtained using the Kaplan-Meier method and compared using the log-rank test. From the total of 520 patients with HR+/HER2- metastatic breast cancer, 482 patients (93%) received any palliative systemic therapy. Patients that received initial chemotherapy (n = 116) were significantly younger, had less comorbidity, had received more prior adjuvant systemic therapy and were less likely to have bone metastasis only compared with patients that received initial endocrine therapy (n = 366). Median PFS of initial palliative chemotherapy was 5.3 months [95% confidence interval (CI) 4.2-6.2] and of initial endocrine therapy 13.3 months (95% CI 11.3-15.5), with a median OS of 16.1 and 36.9 months, respectively. Initial chemotherapy was also associated with worse outcome in terms of PFS and OS after adjustment for prognostic factors. A high percentage of patients with HR+ disease received initial palliative chemotherapy, which was associated with worse outcome, even after adjustment of relevant prognostic factors. © The Author 2015. Published by Oxford University Press on behalf of the European Society for Medical Oncology. All rights reserved. For permissions, please email: journals.permissions@oup.com.

Bone metastases as initial presentation of hepatocellular carcinoma.

PubMed

Monteserin, Luzdivina; Mesa, Alicia; Fernandez-Garcia, Maria Soledad; Gadanon-Garcia, Arantza; Rodriguez, Manuel; Varela, María

2017-10-18

Extra-hepatic spread is present in 5% to 15% of patients with hepatocellular carcinoma (HCC) at the time of diagnosis. The most frequent sites are lung and regional lymph nodes. Here, we report 3 cases of unsuspected HCC with symptoms due to bone lesions as initial presentation. Morphological characteristics and immunohistochemistry from the examined bone were the key data for diagnosis. None of the patients had an already known chronic liver disease. Differential diagnoses with HCC upon ectopic liver disease or hepatoid adenocarcinoma were shown. Therapy with the orally active multikinase inhibitor sorafenib plus symptomatic treatment was indicated.

Complementary and alternative medicine use in patients presenting to a head and neck oncology clinic.

PubMed

Vyas, Tarren; Hart, Robert D; Trites, Jonathan R; Philips, Timothy J; Archibald, Kathleen E M; Phillips, Judith E; Taylor, S Mark

2010-06-01

The aim of this study was to determine the prevalence of complementary and alternative medicine (CAM) use among patients presenting to a head and neck oncology clinic prior to a diagnosis. The study was conducted by administering questionnaires to 102 patients after being seen in the Head and Neck Oncology clinic for their initial consultation. The questionnaire assessed the extent of CAM use, types of CAMs used, and their reasons for use. A total of 132 CAMs were currently being used among 56 patients. The most common CAMs in use were multivitamins (26/132) and vitamin D (21/132). Meditation and yoga were associated with the greatest perceived benefit. The majority of patients obtained their information from family and friends. Most patients were using CAMs for physical health and well-being. As CAM use among the population is widespread, it is important for clinicians to specifically address their use on initial presentation. (c) 2009 Wiley Periodicals, Inc. Head Neck, 2010.

HYPOPHOSPHATEMIC RICKETS: CASE REPORT.

PubMed

Maia, Marta Liliane de Almeida; Abreu, Ana Lucia Santos; Nogueira, Paulo Cesar Koch; Val, Maria Luiza Dautro Moreira do; Carvalhaes, João Tomas de Abreu; Andrade, Maria Cristina de

2018-03-29

Early diagnosis and immediate treatment of hypophosphatemic rickets is of utmost importance as it may prevent subsequent sequelae. This report aims at warning pediatricians to consider the presence of the disease. Description of the metabolic profile, creatinine clearance, nutritional status, weight and body structure of a patient who presented the clinical-laboratorial characteristics of hypophosphatemic rickets and was followed in an outpatient clinic for tubulopathies over the period of 12 months. The patient had been bedridden for some time, was dependent on mechanical ventilation and presented an altered metabolic bone condition. Treatment was phosphate (initial: 65 mg/kg/day and final: 24,2 mg/kg/day), calcium (initial: 127 mg/kg/day, final: 48,4 mg/kg/day) and calcitriol (initial: 0.06 mcg/kg/day, final: 0.03 mcg/kg/day). The patient improved, evolving into spontaneous breathing and walking unaided. Laboratory results: calcium (mg/dL) initial 7.1, final 10.1; phosphate (mg/dL) initial 1.7 final 3.2; magnesium (mg/dL) initial 1.5 final 2.1, parathyroid hormone (pg/l) initial 85.8, final 52.7, alkaline phosphatase (UI/l) initial 12660, final 938; there was also improvement in weight/structural development (Z score: H/A initial: -6.05, final -3.64; W/A: initial -2.92, final -1.57) with presence of transitory gallstones. Creatinine clearance (mL/min/1.73m2bsa) was constant. The medication improved his laboratory results and nutritional status, but the patient did not return for two years for follow-up and, during this period, his condition has noticeably deteriorated. Early diagnosis and follow-up are essential in dealing with this pathology.

Nonspecific abdominal pain is a safe diagnosis.

PubMed

Pennel, David John Laurie; Goergen, Nina; Driver, Chris P

2014-11-01

The aim of this study is to assess if a clinical diagnosis of nonspecific abdominal pain (NSAP) is safe and if patients with this initial diagnosis are likely to require further investigation or surgical intervention. 3323 patients admitted with NSAP from July 1990 to September 2012 utilizing a prospective database of all surgical admissions were included. Readmission over the period of the study and specifically within 30 days of their initial presentation was identified together with any invasive investigation or surgical intervention. 319 children (9.6%) were subsequently readmitted with abdominal pain at some point during the study period. Of these, 78 (2.3%) were readmitted within 30 days. 118 (3.5%) children subsequently had an operation or invasive investigation some point following their initial admission. Of these 33 (0.6%) had the procedure within 3 months of the initial admission. 13 patients had an appendicectomy within 3 months of the initial presentation. Of these histology confirmed appendicitis in 8 patients. This gives an overall incidence of "missed" appendicitis of 0.2 % (8/3323). This study confirms that a clinical diagnosis of nonspecific abdominal pain (NSAP) is safe in a pediatric population and the risk of "missing" appendicitis is only 0.2%. Patients and/or parents can be confidently reassured that the risk of missing organic pathology is very low. Copyright © 2014 Elsevier Inc. All rights reserved.

Editor's Choice-The role of the emergency department in the management of acute heart failure: An international perspective on education and research.

PubMed

Pang, Peter S; Collins, Sean P; Miró, Òscar; Bueno, Hector; Diercks, Deborah B; Di Somma, Salvatore; Gray, Alasdair; Harjola, Veli-Pekka; Hollander, Judd E; Lambrinou, Ekaterini; Levy, Phillip D; Papa, AnnMarie; Möckel, Martin

2017-08-01

Emergency departments are a major entry point for the initial management of acute heart failure (AHF) patients throughout the world. The initial diagnosis, management and disposition - the decision to admit or discharge - of AHF patients in the emergency department has significant downstream implications. Misdiagnosis, under or overtreatment, or inappropriate admission may place patients at increased risk for adverse events, and add costs to the healthcare system. Despite the critical importance of initial management, data are sparse regarding the impact of early AHF treatment delivered in the emergency department compared to inpatient or chronic heart failure management. Unfortunately, outcomes remain poor, with nearly a third of patients dying or re-hospitalised within 3 months post-discharge. In the absence of robust research evidence, consensus is an important source of guidance for AHF care. Thus, we convened an international group of practising emergency physicians, cardiologists and advanced practice nurses with the following goals to improve outcomes for AHF patients who present to the emergency department or other acute care setting through: (a) a better understanding of the pathophysiology, presentation and management of the initial phase of AHF care; (b) improving initial management by addressing knowledge gaps between best practices and current practice through education and research; and (c) to establish a framework for future emergency department-based international education and research.

Iron Deficiency Anemia in Adolescents Who Present with Heavy Menstrual Bleeding.

PubMed

Cooke, Amanda G; McCavit, Timothy L; Buchanan, George R; Powers, Jacquelyn M

2017-04-01

To assess the clinical severity and initial treatment of iron deficiency anemia (IDA) in female adolescents with heavy menstrual bleeding (HMB) in our center. Retrospective cohort study of electronic medical records via search of administrative records using International Classification of Diseases Ninth Revision codes for IDA or unspecified anemia and disorders of menstruation. Children's Medical Center in Dallas, Texas. One hundred seven patients with HMB and concomitant IDA (median age, 14.4 years) who presented to the outpatient, emergency department, and/or inpatient settings. The median initial hemoglobin concentration for all patients (n = 107) was 7.4 g/dL, and most (74%, n = 79) presented to the emergency department or via inpatient transfer. Symptomatic IDA was treated with blood transfusion in 46 (43%, n = 46). Ferrous sulfate was the most commonly prescribed oral iron therapy. Seven patients received intravenous iron therapy either initially or after oral iron treatment failure. Combined oral contraceptives were commonly prescribed for abnormal uterine bleeding, yet 10% of patients (n = 11) received no hormonal therapy during their initial management. Evaluation for underlying bleeding disorders was inconsistent. Severe anemia because of IDA and HMB resulting in urgent medical care, including hospitalization and blood transfusion, is a common but underemphasized problem in adolescent girls. In addition to prevention and early diagnosis, meaningful efforts to improve initial management of adolescents with severe HMB and IDA are necessary. Copyright © 2016 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.

Chronic inflammatory demyelinating polyneuropathy in children: a report of four patients with variable relapsing courses

PubMed Central

Chang, Soo Jin; Lee, Ji Hyun; Kim, Shin Hye; Lee, Joon Soo; Kim, Heung Dong; Kang, Joon Won; Lee, Young Mock

2015-01-01

Chronic inflammatory demyelinating polyneuropathy (CIDP) is a chronically progressive or relapsing symmetric sensorimotor disorder presumed to occur because of immunologic antibody-mediated reactions. To understand the clinical courses of CIDP, we report variable CIDP courses in children with respect to initial presentation, responsiveness to medical treatment, and recurrence interval. Four patients who were diagnosed with acute-onset and relapsing CIDP courses at Severance Children's Hospital, Seoul, Korea, were enrolled in this retrospective study. We diagnosed each patient on the basis of the CIDP diagnostic criteria developed in 2010 by the European Federation of Neurological Societies/Peripheral Nerve Society Guidelines. We present the cases of four pediatric patients diagnosed with CIDP to understand the variable clinical course of the disease in children. Our four patients were all between 8 and 12 years of age. Patients 1 and 2 were diagnosed with acute cerebellar ataxia or Guillain-Barré syndrome as initial symptoms. While patients 1 and 4 were given only intravenous dexamethasone (0.3 mg/kg/day) for 5 days at the first episode, Patients 2 and 3 were given a combination of intravenous immunoglobulin (2 g/kg) and dexamethasone (0.3 mg/kg/day). All patients were maintained with oral prednisolone at 30 mg/day, but their clinical courses were variable in both relapse intervals and severity. We experienced variable clinical courses of CIDP in children with respect to initial presentation, responsiveness to medical treatment, and recurrence interval. PMID:26124851

Chronic inflammatory demyelinating polyneuropathy in children: a report of four patients with variable relapsing courses.

PubMed

Chang, Soo Jin; Lee, Ji Hyun; Kim, Shin Hye; Lee, Joon Soo; Kim, Heung Dong; Kang, Joon Won; Lee, Young Mock; Kang, Hoon-Chul

2015-05-01

Chronic inflammatory demyelinating polyneuropathy (CIDP) is a chronically progressive or relapsing symmetric sensorimotor disorder presumed to occur because of immunologic antibody-mediated reactions. To understand the clinical courses of CIDP, we report variable CIDP courses in children with respect to initial presentation, responsiveness to medical treatment, and recurrence interval. Four patients who were diagnosed with acute-onset and relapsing CIDP courses at Severance Children's Hospital, Seoul, Korea, were enrolled in this retrospective study. We diagnosed each patient on the basis of the CIDP diagnostic criteria developed in 2010 by the European Federation of Neurological Societies/Peripheral Nerve Society Guidelines. We present the cases of four pediatric patients diagnosed with CIDP to understand the variable clinical course of the disease in children. Our four patients were all between 8 and 12 years of age. Patients 1 and 2 were diagnosed with acute cerebellar ataxia or Guillain-Barré syndrome as initial symptoms. While patients 1 and 4 were given only intravenous dexamethasone (0.3 mg/kg/day) for 5 days at the first episode, Patients 2 and 3 were given a combination of intravenous immunoglobulin (2 g/kg) and dexamethasone (0.3 mg/kg/day). All patients were maintained with oral prednisolone at 30 mg/day, but their clinical courses were variable in both relapse intervals and severity. We experienced variable clinical courses of CIDP in children with respect to initial presentation, responsiveness to medical treatment, and recurrence interval.

Prevalence and Prognosis of Cerebrovascular Accidents and its Subtypes Among Patients with Systemic Lupus Erythematosus in Isfahan, Iran: A Hospital Clinic-based Study.

PubMed

Saadatnia, Mohammad; Sayed-Bonakdar, Zahra; Mohammad-Sharifi, Ghasem; Sarrami, Amir Hossein

2014-01-01

The aim of the present study was to determine the prevalence and prognosis of cerebrovascular accident (CVA) and its subtypes among Iranian patients with systemic lupus erythematosus (SLE). In a cross-sectional study, medical records of 575 SLE patients were reviewed. The patients developing CVA in their course of disease were extracted. In these patients, data about demographic features, lupus anti bodies, duration of the disease until CVA, CVA manifestation(s) and follow-up duration were gathered. In the next step, patients with any kinds of CVA were summoned to Neurology clinic to identify the grade of disability in each patient with CVA. We identified 38 patients with CVA of which 6 (15.8%) were men and 32 (84.2%) were women. The most common subtype of CVA was small vessels thrombosis (21.05%) among the study patients and hemi paresis was the most prevalent initial presentation (39.47%). In 11 (28.9%) patients, SLE was initiated with CVA and in 3 (7.9%) patients CVA had happened in the 1(st) year of SLE. Anti-phospholipid antibodies (APLA) were positive in 29 (76.3%) patients. Mean modified Rankin Scale in patient with positive and negative serology for APLA was 0.93 ± 1.11 and 0.22 ± 0.66 respectively (P = 0.006). Our study shows that 6.6% of Iranian SLE patients have CVA during their course of the disease. Small vessels thrombosis is the most common CVA subtype and hemi paresis is the most prevalent initial presentation. Moreover, we showed that the prognosis of CVA in Iranian SLE patients is not unfavorable.

Treatment of carcinoma of the penis by iridium 192 wire implant

DOE Office of Scientific and Technical Information (OSTI.GOV)

Daly, N.J.; Douchez, J.; Combes, P.F.

1982-07-01

Since 1971, a group of 22 adult patients with squamous cell carcinoma of the penis have been treated by iridium 192 wire implants. There were 6 T1 tumors, 14 T2 tumors and 2 T3; only one patient (T3) presented with local failure after implant. Local necrosis occurred in 2 patients without local tumoral recurrence, but was sufficient enough to warrant amputation. Thus 19/22 (86%) patients were locally cured with penile conservation. In these patients the most frequent posttherapeutic complication is chronic urethral stenosis (9/19 patients, 47%) requiring repeated instrumental dilations. Four patients presented with initial inguinal mestastatic nodes; only onemore » was cured by radiosurgical treatment. Among patients without metastatic nodes at the time of diagnosis, none had delayed metastatic nodes. Three patients died of nodal evolution, 5 patients died of intercurrent disease without evidence of disease and 14 are now alive and NED. It appears that iridium 192 wire implant is the most effective conservative treatment of invasive squamous cell carcinoma of the penis; however, these results confirm that no particular treatment is required for inguinal nodal areas for patients who initially present with no disease.« less

Erythema Nodosum as the Initial Presentation of Nivolumab-Induced Sarcoidosis-Like Reaction.

PubMed

Laroche, Alexandre; Alarcon Chinchilla, Evelyn; Bourgeault, Emilie; Doré, Marc-André

2018-05-01

We report a case of nivolumab-related sarcoidosis-like syndrome that initially presented with erythema nodosum. Sarcoidosis development has been described in single and combination immunotherapy. A 68-year-old white woman with metastatic ocular amelanotic choroid melanoma was treated with nivolumab. The patient developed histologically confirmed erythema nodosum lesions and pulmonary granuloma sarcoidosis. Nivolumab was discontinued and the patient started ipilimumab therapy. Sarcoidosis-like syndrome with lymphadenopathy is a rare adverse event that is important to recognize since it can be mistaken for metastatic disease progression. Tissue biopsy of new lesions during immunotherapy is an important step in patient evaluation.

Use of Recombinant Factor VIIa in a Pediatric Patient With Initial Presentation of Refractory Acute Immune Thrombocytopenic Purpura and Severe Bleeding

PubMed Central

Gurion, Reut; Siu, Anita; Weiss, Aaron R.; Masterson, Margaret

2012-01-01

Severe bleeding in acute immune thrombocytopenic purpura (ITP) is rare but can cause significant complications to the patient. Here we report the case of a pediatric patient with acute ITP and hematuria refractory to anti-D immune globulin, high dose intravenous immunoglobulin G, and high dose steroids. Her hematuria was successfully treated with recombinant factor VIIa (rFVIIa). While further investigation on the use of rFVIIa in ITP is warranted, this case report contributes to the pediatric literature for its use during the course of an initial presentation of ITP with hemorrhagic complications. PMID:23258971

Unilateral proptosis as the initial manifestation of malignancy.

PubMed

Rakul Nambiar, K; Ajith, P S; Arjunan, Asha

2017-09-01

Proptosis, a common sign with a broad differential diagnosis, is defined as anterior displacement and protrusion of one or both orbital globes. Patients can present with varying degrees of chronicity, visual loss and associated symptoms. The etiology of acquired unilateral proptosis is diverse, ranging from benign to life-threatening. The causes of unilateral proptosis include traumatic, vascular, endocrine, inflammatory, infective and malignant. Breast carcinoma is the most common metastatic cause of proptosis; however, proptosis has never been reported as the initial manifestation of breast carcinoma. Our patient presented with unilateral proptosis secondary to an intraorbital lesion and histopathology of orbital lesion was suggestive of metastatic breast adenocarcinoma. She was later diagnosed to have primary breast carcinoma. We present this unusual case of a 56-year-old woman who presented with proptosis as the initial manifestation of a metastatic breast malignancy. Copyright © 2017 National Cancer Institute, Cairo University. Production and hosting by Elsevier B.V. All rights reserved.

Delayed treatment of ruptured brain AVMs: is it ok to wait?

PubMed

Beecher, Jeffrey S; Lyon, Kristopher; Ban, Vin Shen; Vance, Awais; McDougall, Cameron M; Whitworth, Louis A; White, Jonathan A; Samson, Duke; Batjer, H Hunt; Welch, Babu G

2018-04-01

OBJECTIVE Despite a hemorrhagic presentation, many patients with arteriovenous malformations (AVMs) do not require emergency resection. The timing of definitive management is not standardized in the cerebrovascular community. This study was designed to evaluate the safety of delaying AVM treatment in clinically stable patients with a new hemorrhagic presentation. The authors examined the rate of rehemorrhage or neurological decline in a cohort of patients with ruptured brain AVMs during a period of time posthemorrhage. METHODS Patients presenting to the authors' institution from January 2000 to December 2015 with ruptured brain AVMs treated at least 4 weeks posthemorrhage were included in this analysis. Exclusion criteria were ruptured AVMs that required emergency surgery involving resection of the AVM, prior treatment of AVM at another institution, or treatment of lesions within 4 weeks for other reasons (subacute surgery). The primary outcome measure was time from initial hemorrhage to treatment failure (defined as rehemorrhage or neurological decline as a direct result of the AVM). Patient-days were calculated from the day of initial rupture until the day AVM treatment was initiated or treatment failed. RESULTS Of 102 ruptured AVMs in 102 patients meeting inclusion criteria, 7 (6.9%) failed the treatment paradigm. Six patients (5.8%) had a new hemorrhage within a median of 248 days (interquartile range 33-1364 days). The total "at risk" period was 18,740 patient-days, yielding a rehemorrhage rate of 11.5% per patient-year, or 0.96% per patient-month. Twelve (11.8%) of 102 patients were found to have an associated aneurysm. In this group there was a single (8.3%) new hemorrhage during a total at-risk period of 263 patient-days until the aneurysm was secured, yielding a rehemorrhage risk of 11.4% per patient-month. CONCLUSIONS It is the authors' practice to rehabilitate patients after brain AVM rupture with a plan for elective treatment of the AVM. The present data are useful in that the findings quantify the risk of the authors' treatment strategy. These findings indicate that delaying intervention for at least 4 weeks after the initial hemorrhage subjects the patient to a low (< 1%) risk of rehemorrhage. The authors modified the treatment paradigm when a high-risk feature, such as an associated intracranial aneurysm, was identified.

Reasons Associated with Total Thyroidectomy as Initial Surgical Management of an Indeterminate Thyroid Nodule.

PubMed

Angell, Trevor E; Vyas, Chirag M; Barletta, Justine A; Cibas, Edmund S; Cho, Nancy L; Doherty, Gerard M; Gawande, Atul A; Howitt, Brooke E; Krane, Jeffrey F; Marqusee, Ellen; Strickland, Kyle C; Alexander, Erik K; Moore, Francis D; Nehs, Matthew A

2018-05-01

Diagnostic hemithyroidectomy (HT) is the most widely recommended surgical procedure for a nodule with indeterminate cytology; however, additional details may make initial total thyroidectomy (TT) preferable. We sought to identify patient-specific factors (PSFs) associated with initial TT in patients with indeterminate thyroid nodules. Retrospective analysis of all patients with a thyroid nodule ≥ 1 cm and initial cytology of atypia of undetermined significance or suspicious for follicular neoplasm between 2012 and 2015 who underwent thyroidectomy. Medical records were reviewed for patient demographics, neck symptoms, nodule size, cytology, molecular test results, final histopathology, and additional PSFs influencing surgical management. Variables were analyzed to determine associations with the use of initial TT. Logistic regression analyses were performed to identify independent associations. Of 325 included patients, 182/325 (56.0%) had HT and 143/325 (44.0%) had TT. While patient age and sex, nodule size, and cytology result were not associated with initial treatment, five PSFs were associated with initial TT (p < 0.0001). These included contralateral nodules, hypothyroidism, fluorodeoxyglucose avidity on positron emission tomography scan, family history of thyroid cancer, and increased surgical risk. At least one PSF was present in 126/143 (88.1%) TT patients versus 47/182 (25.8%) HT patients (p < 0.0001). Multivariate logistic regression analysis demonstrated that these variables were the strongest independent predictor of TT (odds ratio 45.93, 95% confidence interval 18.80-112.23, p < 0.001). When surgical management of an indeterminate cytology thyroid nodule was performed, several PSFs were associated with a preference by surgeons and patients for initial TT, which may be useful to consider in making decisions on initial operative extent.

The Value of Serum CA125 in the Diagnosis of Borderline Tumors of the Ovary: A Subanalysis of the Prospective Multicenter ROBOT Study.

PubMed

Fotopoulou, Christina; Sehouli, Jalid; Ewald-Riegler, Nina; de Gregorio, Nikolaus; Reuss, Alexander; Richter, Rolf; Mahner, Sven; Kommoss, Friedrich; Schmalfeldt, Barbara; Fehm, Tanja; Hanker, Lars; Wimberger, Pauline; Canzler, Ulrich; Pfisterer, Jacobus; Kommoss, Stefan; Hauptmann, Steffen; du Bois, Andreas

2015-09-01

The value of the serum tumor marker CA125 in borderline tumors of the ovary (BOTs) is not well defined, with unclear benefit in both diagnosis and follow-up. The aim of the present project was to identify the predictive value of CA125 for stage and relapse. CA125 data were extracted from the ROBOT multicenter study of patients with BOT treated between 1998 and 2008 in 24 German centers. While patients' data were retrieved retrospectively from hospital records and clinical tumor registries, follow-up and independent central pathology review were performed prospectively. We identified 127 patients from the ROBOT database fulfilling the eligibility criterion of available CA125 at initial diagnosis. Eighty-three (65.3%) patients had increased CA125 levels (>35 U/L). Of the patients, 85.0% presented with serous and 13.4% with mucinous BOT histology, whereas 29.9% had stage I disease. Fifteen (11.8%) patients experienced a relapse. Multivariate analysis identified raised CA125, young age, and serous histology as independent predictors of peritoneal implants of any type at initial presentation. Raised CA125 at initial diagnosis was, however, not an independent predictor of future relapse. Elevated CA125 seems to be associated with the presence of peritoneal implants of any type at initial diagnosis of serous BOT, but failed to have any independent predictive value on future relapse. Prospective multicenter studies are warranted to evaluate CA125 measurements in the follow-up management of BOT.

Clinical outcomes of radiotherapy as initial local therapy for Graves' ophthalmopathy and predictors of the need for post-radiotherapy decompressive surgery.

PubMed

Prabhu, Roshan S; Liebman, Lang; Wojno, Ted; Hayek, Brent; Hall, William A; Crocker, Ian

2012-06-19

The optimal initial local treatment for patients with Graves' ophthalmopathy (GO) is not fully characterized. The purpose of this retrospective study is to describe the clinical outcomes of RT as initial local therapy for GO and define predictors of the need for post-RT salvage bony decompressive surgery. 91 patients with active GO and without prior surgery were treated with RT as initial local therapy between 01/1999 and 12/2010, with a median follow-up period of 18.3 months (range 3.7 - 142 months). RT dose was 24 Gy in 12 fractions. 44 patients (48.4%) had prior use of steroids, with 31 (34.1%) being on steroids at the initiation of RT. The most common presenting symptoms were diplopia (79%), proptosis (71%) and soft tissue signs (62%). 84 patients (92.3%) experienced stabilization or improvement of GO symptoms. 58 patients (64%) experienced improvement in their symptoms. 19 patients (20.9%) underwent salvage post-RT bony decompressive surgery. Smoking status and total symptom score at 4 months were independent predictors of post-RT bony decompression with odds ratios of 3.23 (95% CI 1.03 - 10.2) and 1.59 (95% CI 1.06 - 2.4), respectively. Persistent objective vision loss at 4 months post-RT was the most important symptom type in predicting salvage decompression. Chronic dry eye occurred in 9 patients (9.9%) and cataracts developed in 4 patients (4.4%). RT is effective and well tolerated as initial local therapy for active GO, with only 21% of patients requiring decompressive surgery post RT. Most patients experience stabilization or improvement of GO symptoms, but moderate to significant response occurs in the minority of patients. Smoking status and total symptom severity at 4 months, primarily persistent objective vision loss, are the primary determinants of the need for post-RT salvage bony decompression. Patients who smoke or present with predominantly vision loss symptoms should be advised as to their lower likelihood of symptomatic response to RT and their increased likelihood of requiring post-RT decompressive surgery.

Recurrent coagulopathy and thrombocytopenia in children treated with crotalidae polyvalent immune fab: a case series.

PubMed

Miller, Alexander D; Young, Michael C; DeMott, Megan C; Ly, Binh T; Clark, Richard F

2010-08-01

Recurrent signs and symptoms after initial treatment and control of coagulopathy and thrombocytopenia after American pit viper (crotaline) envenomations have been previously described in patients treated with Crotalidae polyvalent immune Fab antivenom (FabAV). The significance and necessity of treatment of these recurrent abnormalities are uncertain. Our goal was to further characterize recurrent coagulopathy or thrombocytopenia in pediatric patients. All cases presenting to our Toxicology Consult Service, which covers 6 hospitals in a metropolitan area, from May 2007 to April 2008 with recurrent coagulopathy after initial control with FabAV were included and retrospectively reviewed. Four cases of pediatric patients are presented who presented with recurrent coagulopathy and/or thrombocytopenia after initial control with FabAV. The patients were all treated with delayed administration of FabAV with variable results. Blood products administered without concurrent FabAV were of limited use. The laboratory abnormalities took up to 18 days to resolve in one case. One patient developed hemodynamically significant spontaneous bleeding. The cases presented here suggest administration of FabAV may correct delayed coagulopathy associated with crotaline envenomations. The first 3 cases illustrate that in the face of severe derangements in laboratory values, most envenomated patients treated with FabAV do not develop significant bleeding. These cases may respond to additional antivenom alone. However, case 4 illustrates that hemodynamically significant spontaneous bleeding can occur. Until more data are available, readministration of FabAV is a reasonable first-line therapy for delayed coagulopathy associated with crotaline envenomations.

Evaluation of Emergency Department Management of Opioid-Tolerant Cancer Patients With Acute Pain.

PubMed

Patel, Pina M; Goodman, Lauren F; Knepel, Sheri A; Miller, Charles C; Azimi, Asma; Phillips, Gary; Gustin, Jillian L; Hartman, Amber

2017-10-01

There are no previously published studies examining opioid doses administered to opioid-tolerant cancer patients during emergency department (ED) encounters. To determine if opioid-tolerant cancer patients presenting with acute pain exacerbations receive adequate initial doses of as needed (PRN) opioids during ED encounters based on home oral morphine equivalent (OME) use. We performed a retrospective cohort study of opioid-tolerant cancer patients who received opioids in our ED over a two-year period. The percentage of patients who received an adequate initial dose of PRN opioid (defined as ≥10% of total 24-hour ambulatory OME) was evaluated. Logistic regression was used to establish the relationship between 24-hour ambulatory OME and initial ED OME to assess whether higher home usage was associated with higher likelihood of being undertreated. Out of 216 patients, 61.1% of patients received an adequate initial PRN dose of opioids in the ED. Of patients taking <200 OMEs per day at home, 77.4% received an adequate initial dose; however, only 3.2% of patients taking >400 OMEs per day at home received an adequate dose. Patients with ambulatory 24-hour OME greater than 400 had 99% lower odds of receiving an adequate initial dose of PRN opioid in the ED compared to patients with ambulatory 24-hour OME less than 100 (OR <0.01, CI 0.00-0.02, P < 0.001). Patients with daily home use less than 200 OMEs generally received adequate initial PRN opioid doses during their ED visit. However, patients with higher home opioid usage were at increased likelihood of being undertreated. Copyright © 2017 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.

[Reasons for not initating HCV treatment in prison: a subanalysis of the EPIBAND study].

PubMed

de Juan, J; Faraco, I; Saiz de la Hoya, P; Marco, A; Yllobre, C; Da Silva, A; del Pozo, E; Veiras, F M

2011-01-01

This sub-analysis was designed within the framework of the EPIBAND study to establish the reasons why prison patients do not initiate HCV treatment. Epidemiological, prospective, multicentre study conducted in 26 centres. We present the results from those patients included in the EPIBAND study who did not initiate HCV treatment for different reasons. A total of 195 patients were evaluated (average age 39 ± 6.6 years, 86.7% male and 96.9% Spanish nationality). The reasons why this population did not initiate HCV treatment were secondary ones relating to the patient (41%), medical reasons (30.8%), and the prison environment (3.6%). 47.5% of patients reported lack of awareness and motivation, and 18.8% did not initiate treatment as a result of adverse events. Immunological status (35%). as well as psychiatric and neurological disorders (28.3%) were the main medical reasons for contraindication. Aspects associated to prison environment such as impending release or change of prison (64.4%) were among the various reasons that influenced treatment initiation. Lack of motivation and awareness in patients as well as adverse events were the main reasons for not initiating therapy. These factors are subjective, modifiable aspects that depend on patient education and adequate medical care.

A Multilevel Analysis of Real-World Variations in Oral Anticoagulation Initiation for Atrial Fibrillation in Valencia, a European Region.

PubMed

García-Sempere, Aníbal; Bejarano-Quisoboni, Daniel; Librero, Julián; Rodríguez-Bernal, Clara L; Peiró, Salvador; Sanfélix-Gimeno, Gabriel

2017-01-01

Introduction: Beyond clinical trials, clinical practice guidelines, and administrative regulation, treatment decision-making can be influenced by individual and contextual factors. Our goal was to describe variations in the patterns of initiation of anticoagulation therapy in patients with atrial fibrillation by Health Areas (HA) in the region of Valencia in Spain and to quantify the influence of the HAs on variations in treatment choice. Methods: We conducted a population-based retrospective cohort study of all atrial fibrillation patients who started treatment with oral anticoagulants between November 2011 and February 2014 in each of the region's 24 HAs. We described patient and utilization characteristics per HA and initiation patterns over time, and we identified contextual and individual factors associated with differences in initiation patterns. Results: 21,879 patients initiated treatment with an oral anticoagulant in the 24 HAs. Initiation with direct oral anticoagulants (DOAC) in the first year was 14.6%. In November 2013 the ratio was 25.4%, with HA ratios ranging from 3.8 to 57.1%. DOAC-initiating patients had less comorbidity but were more likely to present episodes of previous ischemic stroke, hemorrhagic stroke, or TIA when compared with patients initiating with VKA treatment. Variability among HAs was statistically significant, with the majority of HAs ranking above or below the regional initiation average (ICC ≈ 8%). Conclusion: There was high variability in the percentage of DOAC initiation and in the choice of DOAC among HAs. Interventions aimed to improve DOAC initiation decision-making and to reduce variations should take into account the Health Area component.

A Multilevel Analysis of Real-World Variations in Oral Anticoagulation Initiation for Atrial Fibrillation in Valencia, a European Region

PubMed Central

García-Sempere, Aníbal; Bejarano-Quisoboni, Daniel; Librero, Julián; Rodríguez-Bernal, Clara L.; Peiró, Salvador; Sanfélix-Gimeno, Gabriel

2017-01-01

Introduction: Beyond clinical trials, clinical practice guidelines, and administrative regulation, treatment decision-making can be influenced by individual and contextual factors. Our goal was to describe variations in the patterns of initiation of anticoagulation therapy in patients with atrial fibrillation by Health Areas (HA) in the region of Valencia in Spain and to quantify the influence of the HAs on variations in treatment choice. Methods: We conducted a population-based retrospective cohort study of all atrial fibrillation patients who started treatment with oral anticoagulants between November 2011 and February 2014 in each of the region's 24 HAs. We described patient and utilization characteristics per HA and initiation patterns over time, and we identified contextual and individual factors associated with differences in initiation patterns. Results: 21,879 patients initiated treatment with an oral anticoagulant in the 24 HAs. Initiation with direct oral anticoagulants (DOAC) in the first year was 14.6%. In November 2013 the ratio was 25.4%, with HA ratios ranging from 3.8 to 57.1%. DOAC-initiating patients had less comorbidity but were more likely to present episodes of previous ischemic stroke, hemorrhagic stroke, or TIA when compared with patients initiating with VKA treatment. Variability among HAs was statistically significant, with the majority of HAs ranking above or below the regional initiation average (ICC ≈ 8%). Conclusion: There was high variability in the percentage of DOAC initiation and in the choice of DOAC among HAs. Interventions aimed to improve DOAC initiation decision-making and to reduce variations should take into account the Health Area component. PMID:28883793

How the probability of presentation to a primary care clinician correlates with cancer survival rates: a European survey using vignettes.

PubMed

Harris, Michael; Frey, Peter; Esteva, Magdalena; Gašparović Babić, Svjetlana; Marzo-Castillejo, Mercè; Petek, Davorina; Petek Ster, Marija; Thulesius, Hans

2017-03-01

European cancer survival rates vary widely. System factors, including whether or not primary care physicians (PCPs) are gatekeepers, may account for some of these differences. This study explores where patients who may have cancer are likely to present for medical care in different European countries, and how probability of presentation to a primary care clinician correlates with cancer survival rates. Seventy-eight PCPs in a range of European countries assessed four vignettes representing patients who might have cancer, and consensus groups agreed how likely those patients were to present to different clinicians in their own countries. These data were compared with national cancer survival rates. A total of 14 countries. Consensus groups of PCPs. Probability of initial presentation to a PCP for four clinical vignettes. There was no significant correlation between overall national 1-year relative cancer survival rates and the probability of initial presentation to a PCP (r  = -0.16, 95% CI -0.39 to 0.08). Within that there was large variation depending on the type of cancer, with a significantly poorer lung cancer survival in countries where patients were more likely to initially consult a PCP (lung r = -0.57, 95% CI -0.83 to -0.12; ovary: r = -0.13, 95% CI -0.57 to 0.38; breast r = 0.14, 95% CI -0.36 to 0.58; bowel: r = 0.20, 95% CI -0.31 to 0.62). There were wide variations in the degree of gatekeeping between countries, with no simple binary model as to whether or not a country has a "PCP-as-gatekeeper" system. While there was case-by-case variation, there was no overall evidence of a link between a higher probability of initial consultation with a PCP and poorer cancer survival. KEY POINTS European cancer survival rates vary widely, and health system factors may account for some of these differences. The data from 14 European countries show a wide variation in the probability of initial presentation to a PCP. The degree to which PCPs act as gatekeepers varies considerably from country to country. There is no overall evidence of a link between a higher probability of initial presentation to a PCP and poorer cancer survival.

Evaluation of the AHRQ Patient Safety Initiative: Synthesis of Findings

PubMed Central

Farley, Donna O; Damberg, Cheryl L

2009-01-01

Objective To present overall findings from the 4-year evaluation of the national patient safety initiative operated by the Agency for Healthcare Research and Quality (AHRQ). Data Sources Interviews with AHRQ staff, grantees, and other patient safety stakeholders; published materials; and internal AHRQ documents. Study Design The evaluation was structured to address a system framework of five components involved in improving safety. The initiative's contributions to improving each system component were assessed qualitatively, comparing results from three separate analyses—AHRQ's achievement of its patient safety goals, our own assessment of the initiative's activities, and independent stakeholder ratings of AHRQ's contributions. Findings and Conclusions AHRQ has faced a daunting challenge for improving patient safety, given the complex problems of the U.S. health care system and the limited resources AHRQ has had to address them. The patient safety initiative achieved strongest progress for its contributions to knowledge of patient safety epidemiology and effective practices, where AHRQ has considerable experience, and to strengthening infrastructure to support adoption of safe practices. Progress was slower in establishing a national monitoring capability and dissemination of safe practices for adoption. AHRQ needs to expand efforts to apply new knowledge for stimulating use of safe practices in the field. PMID:21456115

The Relationship Between Guideline-Recommended Initiation of Therapy, Outcomes, and Cost for Patients with Metastatic Non-Small Cell Lung Cancer.

PubMed

Casebeer, Adrianne; Antol, Dana Drzayich; DeClue, Richard W; Hopson, Sari; Li, Yong; Khoury, Raya; Michael, Todd; Sehman, Marina; Parikh, Aparna; Stemkowski, Stephen; Bunce, Mikele

2018-06-01

Guideline-recommended therapy for metastatic non-small cell lung cancer (mNSCLC) encourages evidence-based treatment; however, there is a knowledge gap regarding the influence of guideline-recommended initiation of therapy on outcomes and cost. To investigate if lack of guideline-recommended initiation of first-line systemic therapy was associated with worse patient outcomes and increased costs for patients with mNSCLC. In this retrospective analysis, 1,344 Medicare patients with mNSCLC were identified from Humana data. Performance status (PS) was imputed using procedure, diagnosis, and durable medical equipment codes pre-index. Guideline-recommended initiation of therapy was defined as ≥1 cycle of National Comprehensive Cancer Network-recommended first-line therapy based on age and PS or targeted therapies regardless of age and PS. Demographics and clinical characteristics were compared by guideline-recommended initiation of therapy. A Cox model assessed factors associated with 6-month mortality. End-of-life quality of care indicators included hospital admission and oncology infusions 30 days preceding death and were evaluated using logistic regression models. A generalized linear model assessed the relationship between guideline-recommended initiation of therapy and total health care costs in the 6 months post-index controlling for clinical, demographic, and treatment characteristics. Logistic models for inpatient stays and emergency department visits were also evaluated. Guideline-recommended therapy initiation was observed in 75.5% of patients. Patients not initiating guideline-recommended therapy were older, with a mean (SD) age of 72.5 (6.7) versus 71.2 (6.2) years (P = 0.001), and more frequently identified as having a low-income subsidy (30.0% vs. 16.4%; P < 0.001). Among the 24.6% of patients who died ≤ 6 months post-index, a greater percentage had not initiated guideline-recommended therapy (28.8% vs. 23.2%; P = 0.040). In adjusted models, PS (not initiation of guideline-recommended therapy) was predictive of mortality (patients with poor PS had an 84% higher probability of death [P = 0.014]). Among decedents, 64.2% were hospitalized, and 33.9% had an oncology-related infusion within 30 days of death, with no differences by guideline-recommended initiation of therapy. These end-of-life quality indicators were not associated with guideline-recommended initiation of therapy in adjusted models. Overall, 47.5% of patients who initiated guideline-recommended therapy were hospitalized compared with 55.0% of patients who did not (P = 0.026). Patients initiating guideline-recommended therapy had higher post-index total and oncology-related health care costs and fewer hospitalizations. In models, these differences in costs and hospitalizations were not associated with initiation of guideline-recommended therapy. Most patients initiated guideline-recommended therapy, with no differences in mortality and quality of care at the end of life by guideline-recommended initiation of therapy, though adherence beyond treatment initiation was not assessed. Unadjusted hospitalization rates were lower and costs were higher for patients who initiated guideline-recommended therapy. These differences were no longer observed after risk adjustment, suggesting that they may have been influenced by patient characteristics, disease progression, and subsequent treatment decisions. This study was sponsored by Genentech. Khoury, Michael, Parikh, and Bunce are employed by Genentech. Casebeer, Drzayich Antol, DeClue, Hopson, Li, and Stemkowski are employed by Comprehensive Health Insights, Humana, which was contracted by Genentech to conduct this study. Sehman is employed by Humana. Based on this research, 2 posters were presented at the Academy of Managed Care Pharmacy Nexus 2017 on October 16-19, 2017, in Dallas, Texas. Another poster was also presented at the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) Annual European Congress on October 29-November 2, 2016, in Vienna, Austria.

Breast mass as the initial presentation of esophageal carcinoma: a case report

PubMed Central

Norooz, Mohammad Tayefeh; Ahmadi, Hamed; Zavarei, Mansour Jamali; Daryaei, Parviz

2009-01-01

Introduction Esophageal cancer is considered as a fatal malignancy. It mostly metastasizes to lung, liver, and bone while breast metastasis has been rarely reported. This is the fifth report of metastatic breast cancer from esophageal cancer, which differs from previous reported cases in terms of initial presentation with metastatic breast mass and no metastatic involvement of other organs. Case presentation We present a 35-year-old Caucasian woman who initially complained of a painful breast mass. Squamous pearls on cytologic evaluation suggested a metastatic lesion. Two months history of dysphagia was extracted through detailed interview with patient and further investigation revealed a stage IV esophageal squamous cell carcinoma. Conclusion In this case, breast lesion as an unusual presentation of esophageal carcinoma emphasizes the great role of thorough medical history taking and cytologic study in evaluating an accidentally detected breast mass. The increasing reports of breast metastasis in patients with esophageal carcinoma necessitate the careful breast examination in visits after treatment of the primary tumor. PMID:19829901

Racial Variation In Timing Of Pyeloplasty: Prenatal Versus Postnatal Diagnosis

PubMed Central

Routh, Jonathan C.; Pennison, Melanie; Rosoklija, Ilina; Dobbins, Sarah; Kokorowski, Paul J.; Hubert, Katherine C.; Huang, Lin; Nelson, Caleb P.

2013-01-01

Purpose We have previously shown that non-white patients with UPJ obstruction undergo pyeloplasty at a younger age than do whites. The mechanisms behind this are unclear, as there is no known racial variation in the natural history of UPJ obstruction. We sought to use a detailed clinical database to explain this phenomenon. Methods We performed a retrospective review of all patients undergoing primary pyeloplasty at our institution between 1992 and 2008. Over 360 data points were abstracted for each patient, including self-reported patient race, socioeconomic status, symptom duration, and presentation. Results Of 847 patients undergoing pyeloplasty during the study period, 741 met inclusion criteria. Non-white patients underwent surgery younger than did whites (non-white 0.6 v. white 2.6 years, p<0.0001). When stratified by timing of clinical presentation (prenatal versus postnatal), there was no significant difference by race among patients presenting prenatally (0.37 v. 0.36 years, p=0.22). Non-white patients presenting postnatally were significantly younger than white patients (6.3 v. 8.2 years, p=0.03). This appeared to be due to differences in both the age at initial clinical presentation (5.4 v. 7.0 years, p=0.03) and in time from initial clinical presentation to urology evaluation (0.6 v. 3.2 months, p=0.03). These differences persisted after correcting for other factors, including markers of socioeconomic status. Conclusions Consistent with previous studies, we found that non-white patients underwent primary pyeloplasty at a younger age than whites. This difference is limited to patients presenting after birth. Prenatally diagnosed patients underwent surgery at similar ages regardless of race. PMID:22014821

High-velocity facial gunshot wounds: multidisciplinary care from prehospital to discharge.

PubMed

Sinnott, J D; Morris, G; Medland, P J; Porter, K

2016-01-28

A case is presented in which a high velocity rifle (shotgun) was fired into the inferior part of a patient's face in an attempted suicide causing widespread trauma to the inferior and left side of the patient's face. He presented to his general practitioner where an ambulance was called. The patient is followed from prehospital care (air ambulance) to resuscitation in accident and emergency and through the first stages of reconstructive surgery. The article focuses on the multidisciplinary approach to the patient's prehospital care and initial resuscitation at a major trauma centre. CT reconstruction images of the patient's skull allow visualisation of the extent of bone damage at presentation. Medical photography allows visualisation of the extent of the initial damage and shows how reconstructive surgery was undertaken early and in progressive stages. A literature review was performed allowing discussion of the current evidence and best practice in the management of facial gunshot wounds. 2016 BMJ Publishing Group Ltd.

The evaluation of anxiety and panic agarophobia scores in patients with benign paroxysmal positional vertigo on initial presentation and at the follow-up visit.

PubMed

Kahraman, Serif Samil; Arli, Cengiz; Copoglu, Umit Sertan; Kokacya, Mehmet Hanifi; Colak, Sait

2017-05-01

Patients with BPPV experienced short but intense anxiety and/or panic disorder, especially at the initial visit, but most patients recovered without medication with successful treatment. Recent studies have shown that people with dizziness report some psychological problems such as panic and agoraphobia and anxiety. The aim of this study was to evaluate anxiety and panic agorophobia levels in patients with benign paroxysmal positional vertigo on initial presentation and at the follow-up visit and compare the scores with the control group. All the 32 patients in the study had a diagnosis of BPPV confirmed by their history, typical subjective symptom reports, and characteristic positional nystagmus during the Dix-Hallpike test and/or Roll test. The patients were instructed to complete the standard forms of Beck anxiety inventory and panic agoraphobia scale questionnaire before and at 7 and 14 days after the canalith repositioning treatment. The validity scores of panic agoraphobia were statistically significantly higher in patients with BPPV than in the control group in each period (p < .001) and the validity scores of the Beck anxiety inventory were statistically significantly higher in patients with BPPV than in the control group at the first and second evaluation (p < .001).

Biventricular hypertrophy and heart failure as initial presentation of Cushing's disease

PubMed Central

Hey, Thomas Morris; Dahl, Jordi Sanchez; Brix, Thomas Heiberg; Søndergaard, Eva Vad

2013-01-01

We present a unique case of a 32-year-old woman with severe biventricular hypertrophy and acute heart failure with reduced left ventricular ejection fraction of 25–30% due to Cushing's disease. The patient was admitted to a specialised cardiac unit and treated with conventional therapy against heart failure. The department of endocrinology was consulted because of clinical suspicion of Cushing's syndrome. Initial biochemistry indicated the presence of adrenocorticotropic hormone (ACTH) dependent Cushing's syndrome and a dexamethasone suppression test confirmed the diagnosis. A cerebral MRI scan revealed a pituitary adenoma and a sinus petrosus inferior catheterisation confirmed increased production of ACTH from the pituitary. The patient was referred to the neurosurgical department and the adenoma was successfully removed by transsphenoidalic catheterisation and ablation. Five months following the initial hospitalisation the patient was nearly in full recovery with respect to her cardiac function and biochemically there were no signs of Cushing's syndrome. PMID:24186856

A 90-year-old man with factious disorder: Separating fact from fiction.

PubMed

Amladi, Anjani K; DePry, Dwayne R

2018-07-01

Objective Factitious disorders are known to exist in the medical community but are not commonly diagnosed in clinical practice. The majority of the literature on factitious disorder comes from case reports or case series. This particular case is unusual because it describes a patient who initially presented with purely physical complaints, but over time, the symptoms transitioned into predominantly psychiatric concerns. This case describes the patient's unique presentation and is followed by a discussion of the management of factitious disorder. Methods The patient was seen during the course of an inpatient psychiatric hospitalization. Electronic chart review was conducted, and information from each prior hospitalization was gathered between the dates of first initial documented presentation available in the electronic record in 1995 to most recent hospitalization in 2017. Results The patient still continues to present to the emergency department. Upon each presentation, staff work to objectively assess his complaints to be sure that there is no true underlying medical emergency. There is also a focus on providing non-judgmental, supportive, and compassionate care. Conclusion This case highlights the importance of corroborating objective findings with the patient's subjective reports gathered during a history and physical, and to recognize that patients with this disorder can present to any specialty. Thus, the collaboration between specialties is critical in the care of these patients to minimize unnecessary, costly, and sometimes dangerous interventions.

Periodic Paralysis and Encephalopathy as Initial Manifestations of Graves' Disease: Case Report and Review of the Literature.

PubMed

Tsironis, Theocharis; Tychalas, Athanasios; Kiourtidis, Dimitrios; Kountouras, Jannis; Xiromerisiou, Georgia; Rudolf, Jobst; Deretzi, Georgia

2017-07-01

Thyrotoxic periodic paralysis (TPP) is an uncommon complication of Graves' disease, characterized by the triad of acute hypokalemia without total body potassium deficit, episodic muscle paralysis, and thyrotoxicosis. Graves' encephalopathy is an extremely rare form of encephalopathy associated with autoimmune thyroid disease (EAATD), characterized by neuropsychiatric symptoms, increased antithyroid antibodies and cerebrospinal fluid protein concentration, nonspecific electroencephalogram abnormalities, and cortico-responsiveness. Coexistence of both these complications in the same patient has not been reported before. We herein present a 48-year-old white male patient with TPP and encephalopathy as initial presentations of Graves' disease. Flaccid tetraparesis was reversed a few hours after potassium level correction and the patient did not suffer any relapse with the successful pharmaceutical management of the thyroid function. One month later, the patient presented with dizziness and behavioral symptoms, such as inappropriate laughter and anger. Brain magnetic resonance imaging revealed meningeal enhancement and cerebrospinal fluid analysis showed a mild protein increase, with a blood-brain barrier disruption. With the suspicion of EAATD, the patient was treated with high doses of corticosteroids and improved dramatically. To our knowledge this is the first reported coexistence of potentially treatable TPP and EAATD as initial neurological manifestations of Graves' disease, thereby underscoring the necessity of suspicion of possible underlying Graves' disease in patients with acute paralysis and encephalopathy of unclear origin.

Cognitive Behavioral Treatment of Panic Disorder and Agoraphobia in a Multiethnic Urban Outpatient Clinic: Initial Presentation and Treatment Outcome

ERIC Educational Resources Information Center

Friedman, Steven; Braunstein, Jeffrey W.; Halpern, Beth

2006-01-01

Few studies examine the effectiveness of panic control treatment across diverse ethnic groups. In this paper we present data on 40 patients (African American, n = 24; Caucasian, n = 16) with panic disorder and comorbid agoraphobia who presented at an anxiety disorder clinic in an inner-city area. On initial assessment both groups were similar on…

Avoiding misdiagnosing neuroblastoma as Wilms tumor.

PubMed

Dickson, Paxton V; Sims, Thomas L; Streck, Christian J; McCarville, M Beth; Santana, Victor M; McGregor, Lisa M; Furman, Wayne L; Davidoff, Andrew M

2008-06-01

Although occasionally difficult, distinguishing abdominal neuroblastoma (NBL) from Wilms tumor (WT) at presentation is important, as surgical management differs significantly. We reviewed our 20-year experience (1987-2006) treating patients with NBL, focusing on those with an initial diagnosis of WT, to determine presenting features that would have suggested the correct preoperative diagnosis. Retrospective case cohort study reviewing charts and imaging of patients with NBL initially diagnosed clinically with WT. Preoperative symptoms, laboratory studies, and imaging were evaluated. Similar variables were assessed in the 20 patients with WT most recently treated at our institution. Nine patients with NBL were identified as those who had an exploratory laparotomy with a preoperative diagnosis of WT; 8 underwent nephrectomy at exploration. Children with NBL had symptoms such as fever and weight loss at presentation (67%) more often than patients with WT (20%). Preoperative computed tomography demonstrated intratumoral calcifications, vascular encasement, or both in 78% of patients with NBL but were never seen in WT patients. Of interest, preoperative urinary catecholamines were elevated in 5 patients ultimately diagnosed with NBL. Although NBL can be mistaken for WT at presentation, the presence of constitutional symptoms, or intratumoral calcification or vascular encasement on preoperative imaging should heighten suspicion for NBL. In addition, laboratory evaluation, including urinary catecholamines, should be completed before surgery when the etiology of an abdominal tumor is uncertain.

Delays in initiation of acyclovir therapy in herpes simplex encephalitis.

PubMed

Hughes, Peter S; Jackson, Alan C

2012-09-01

Diagnosis of herpes simplex encephalitis (HSE) is based on clinical findings, MRI, and detection of herpes simplex virus (HSV) DNA in cerebrospinal fluid (CSF) using polymerase chain reaction amplification. Delays in starting treatment are associated with poorer clinical outcomes. We assessed the timing of initiation of acyclovir therapy in HSE. Inpatient databases from seven hospitals in Winnipeg, Manitoba were used to identify individuals diagnosed with encephalitis and HSE from 2004 to 2009. The time taken to initiate therapy with acyclovir and the reasons for delays were determined. Seventy-seven patients were identified; 69 (90%) received acyclovir; in the others a non-HSV infection was strongly suspected. Thirteen patients were subsequently confirmed to have HSE. Acyclovir was initiated a median of 21 hours (3-407) after presentation in encephalitis cases, and a median of 11 hours (3-118) in HSE. The most common reason for delay was a failure to consider HSE in the differential diagnosis, despite suggestive clinical features. Where therapy was delayed in HSE patients, the decision to begin acyclovir was prompted by transfer of the patient to a different service (55%), recommendations by consultants (18%), imaging results (18%), and CSF pleocytosis (9%). Delays in initiating acyclovir for HSE are common, and are most often due to a failure to consider HSE in a timely fashion on presentation. In order to improve patient outcomes, physicians should be more vigilant for HSE, and begin acyclovir therapy expeditiously on the basis of clinical suspicion rather than waiting for confirmatory tests.

Subacute Sclerosing Panencephalitis Presenting with Isolated Positive Psychotic and Catatonic Symptoms

PubMed Central

Parmar, Arpit; Ranjan, Rajeev; Sagar, Rajesh

2017-01-01

Subacute sclerosing panencephalitis (SSPE) is a rare slowly progressing neurological illness. Although patients with SSPE initially present with symptoms such as myoclonic jerks, cognitive decline, and personality/behavioral changes usually, rarely pure psychiatric symptoms (e.g., mania, psychosis, and catatonia) have also been reported during the initial course of the illness. We report an unusual case of an adolescent with SSPE presenting with prominent positive psychotic and catatonic symptoms with the absence of classical symptoms of SSPE in initial course of illness and further discussed the relevant literature. PMID:28852257

Subacute Sclerosing Panencephalitis Presenting with Isolated Positive Psychotic and Catatonic Symptoms.

PubMed

Parmar, Arpit; Ranjan, Rajeev; Sagar, Rajesh

2017-01-01

Subacute sclerosing panencephalitis (SSPE) is a rare slowly progressing neurological illness. Although patients with SSPE initially present with symptoms such as myoclonic jerks, cognitive decline, and personality/behavioral changes usually, rarely pure psychiatric symptoms (e.g., mania, psychosis, and catatonia) have also been reported during the initial course of the illness. We report an unusual case of an adolescent with SSPE presenting with prominent positive psychotic and catatonic symptoms with the absence of classical symptoms of SSPE in initial course of illness and further discussed the relevant literature.

Frequent development of combined pituitary hormone deficiency in patients initially diagnosed as isolated growth hormone deficiency: a long term follow-up of patients from a single center.

PubMed

Otto, Aline P; França, Marcela M; Correa, Fernanda A; Costalonga, Everlayny F; Leite, Claudia C; Mendonca, Berenice B; Arnhold, Ivo J P; Carvalho, Luciani R S; Jorge, Alexander A L

2015-08-01

Children initially diagnosed with isolated GH deficiency (IGHD) have a variable rate to progress to combined pituitary hormone deficiency (CPHD) during follow-up. To evaluate the development of CPHD in a group of childhood-onset IGHD followed at a single tertiary center over a long period of time. We retrospectively analyzed data from 83 patients initially diagnosed as IGHD with a mean follow-up of 15.2 years. The Kaplan-Meier method and Cox regression analysis was used to estimate the temporal progression and to identify risk factors to development of CPHD over time. From 83 patients initially with IGHD, 37 (45%) developed CPHD after a median time of follow up of 5.4 years (range from 1.2 to 21 years). LH and FSH deficiencies were the most common pituitary hormone (38%) deficiencies developed followed by TSH (31%), ACTH (12%) and ADH deficiency (5%). ADH deficiency (3.1 ± 1 years from GHD diagnosis) presented earlier and ACTH deficiency (9.3 ± 3.5 years) presented later during follow up compared to LH/FSH (8.3 ± 4 years) and TSH (7.5 ± 5.6 years) deficiencies. In a Cox regression model, pituitary stalk abnormalities was the strongest risk factor for the development of CPHD (hazard ratio of 3.28; p = 0.002). Our study indicated a high frequency of development of CPHD in patients initially diagnosed as IGHD at childhood. Half of our patients with IGHD developed the second hormone deficiency after 5 years of diagnosis, reinforcing the need for lifelong monitoring of pituitary function in these patients.

Progression of initially mild hepatic fibrosis in patients with chronic hepatitis C infection.

PubMed

Williams, M J; Lang-Lenton, M

2011-01-01

A significant number of patients with chronic hepatitis C infection have minimal fibrosis at presentation. Although the short-term outlook for such patients is good, there are limited data available on long-term progression. We assessed the risk of fibrosis progression in 282 patients with chronic hepatitis C with Ishak stage 0 or 1 fibrosis on initial liver biopsy. Progression of fibrosis stage occurred in 118 patients (42%) over a median interval of 52.5 months. Thirteen (5%) progressed to severe (Ishak stage 4 or more) fibrosis. Progression was significantly associated with both age at initial biopsy [odds ratio (OR) for progression of 1.31 per 10 year increase in age] and median alanine transaminase (ALT) levels during follow-up (OR of 1.06 per 10 IU/L increase). There was no significant association with gender, histological inflammatory grade, hepatic steatosis or body mass index. We conclude that hepatitis C with initially mild fibrosis does progress in a substantial proportion of patients and should not be viewed as a benign disease. Early antiviral therapy should be considered in older patients and those with high ALT levels.

Hospitalization, frequency of interventions, and quality of life after endoscopic, surgical, or conservative treatment in patients with chronic pancreatitis.

PubMed

Rutter, Karoline; Ferlitsch, A; Sautner, T; Püspök, A; Götzinger, P; Gangl, A; Schindl, M

2010-11-01

Patients with chronic pancreatitis usually have a long and debilitating history of disease with frequent hospital admissions, episodes of intractable pain and multiple interventions. The sequences of treatment at initial presentation, endoscopy, surgery, or conservative treatment may affect the time course and admissions needed for disease control, thereby determining quality of life and overall outcome. A total of 292 patients with initial endoscopic, surgical, or conservative pharmacological treatment were retrospectively analyzed regarding frequency of interventions, days in hospital, symptom-free intervals, morbidity, and mortality. Quality of life (QoL) at the latest follow-up was measured by two standardized quality of life questionnaires (EORTC C30 and PAN26). Endoscopic treatment was initially performed in 150 (51.4%) patients, whereas 99 (33.9%) underwent surgery and 43 (14.7%) patients were treated conservatively at their initial presentation. Patients who underwent surgery had a significantly shorter time in the hospital (25.3 ± 24.6, 34.4 ± 35.1, 61.1 ± 37.9; P < 0.001), fewer subsequent therapies (0.43 ± 1.0, 2.1 ± 2.4, 3.1 ± 3.0; P ≤ 0.001), and a longer relapse-free interval (P = 0.004) compared with endoscopically treated patients. The overall complication rate was 32% both after surgery and endoscopy. Infectious-related complications occurred more often after surgical treatment (P ≤ 0.001), whereas patients after endoscopic intervention developed acute or chronic pancreatitis or pseudocyst formation (P = 0.023). Patients who undergo surgery as their initial treatment for chronic pancreatitis require less consecutive interventions, a shorter hospital stay, and have a better quality of life compared with any other treatment. Surgery should therefore be considered early for the treatment of chronic pancreatitis, when endoscopic or conservative treatment fails and patients require further intervention.

Critical care considerations in the management of the trauma patient following initial resuscitation

PubMed Central

2012-01-01

Background Care of the polytrauma patient does not end in the operating room or resuscitation bay. The patient presenting to the intensive care unit following initial resuscitation and damage control surgery may be far from stable with ongoing hemorrhage, resuscitation needs, and injuries still requiring definitive repair. The intensive care physician must understand the respiratory, cardiovascular, metabolic, and immunologic consequences of trauma resuscitation and massive transfusion in order to evaluate and adjust the ongoing resuscitative needs of the patient and address potential complications. In this review, we address ongoing resuscitation in the intensive care unit along with potential complications in the trauma patient after initial resuscitation. Complications such as abdominal compartment syndrome, transfusion related patterns of acute lung injury and metabolic consequences subsequent to post-trauma resuscitation are presented. Methods A non-systematic literature search was conducted using PubMed and the Cochrane Database of Systematic Reviews up to May 2012. Results and conclusion Polytrauma patients with severe shock from hemorrhage and massive tissue injury present major challenges for management and resuscitation in the intensive care setting. Many of the current recommendations for “damage control resuscitation” including the use of fixed ratios in the treatment of trauma induced coagulopathy remain controversial. A lack of large, randomized, controlled trials leaves most recommendations at the level of consensus, expert opinion. Ongoing trials and improvements in monitoring and resuscitation technologies will further influence how we manage these complex and challenging patients. PMID:22989116

Syncope Best Practices: A Syncope Clinical Practice Guideline to Improve Quality.

PubMed

Phelps, Heather M; Sachdeva, Ritu; Mahle, William T; McCracken, Courtney E; Kelleman, Michael; McConnell, Michael; Fischbach, Peter S; Cardis, Brian M; Campbell, Robert M; Oster, Matthew E

2016-05-01

To determine whether implementation of a standardized clinical practice guideline (CPG) for the evaluation of syncope would decrease practice variability and resource utilization. A retrospective review of medical records of patients presenting to our practice for outpatient evaluation of syncope before and after implementation of the CPG. The guideline included elements of history, physical exam, electrocardiogram, and "red flags" for further testing. Outpatient pediatric cardiology offices of a large pediatric cardiology practice. All new patients between 3 and 21 years old, who presented to cardiology clinic with a chief complaint of syncope. The CPG for the evaluation of pediatric syncope was presented to the providers. Resource utilization was determined by the tests ordered by individual physicians before and after initiation of the CPG. Patient final diagnoses were recorded and the medical records were subsequently reviewed to determine if any patients, who presented again to the system, were ultimately diagnosed with cardiac disease. Of the 1496 patients with an initial visit for syncope, there was no significant difference in the diagnosis of cardiac disease before or after initiation of the CPG: (0.6% vs. 0.4%, P = .55). Electrocardiography provides the highest yield in the evaluation of pediatric syncope. Despite high compliance (86.9%), there were no overall changes in costs ($346.31 vs. $348.53, P = .85) or in resource utilization. There was, however, a decrease in the variability of ordering of echocardiograms among physicians, particularly among those at the extremes of utilization. Although the CPG did not decrease already low costs, it did decrease the wide variability in echo utilization. Evaluation beyond detailed history, physical exam, and electrocardiography provides no additional benefit in the evaluations of pediatric patients presenting with syncope. © 2015 Wiley Periodicals, Inc.

Uremic pericarditis in patients with End Stage Renal Disease: Prevalence, symptoms and outcome in 2017.

PubMed

Bentata, Yassamine; Hamdi, F; Chemlal, A; Haddiya, I; Ismaili, N; El Ouafi, N

2018-03-01

The prevalence of uremic pericarditis (UP) used to range from 3% to 41%. More recently, it has decreased to about 5%-20% and to <5% in the last decades, as hemodialysis techniques have become widely used and dialysis quality improved. The objective of this work is to determine the initial clinical picture and the prognosis of patients presenting End Stage Renal Disease (ESRD) with UP. This is a retrospective study (May 2015-September 2017). Inclusion criteria targeted patients who had uremic pericarditis defined as pericarditis occurring in a patient with ESRD before initiation of renal replacement therapy, or within eight weeks of its initiation. 16 patients met the inclusion criteria. The median age of patients was 54 [24, 71] years and 56.2% were male. Pericardial effusion was small, moderate and large in 31.2%, 37.6% and 31.2% of cases respectively. One pericardiocentesis was performed in view of a clinical picture of impending cardiac tamponade and three pericardial drainages were performed given presentation of tamponade. Hemodialysis was initiated for all the patients and continued for 2 to 3weeks until complete regression of the pericardial effusion. The mean number of dialysis sessions was 11±3.5. One patient died of septic shock that developed three weeks after diagnosis of uremic pericarditis. UP is considered a rare but fatal complication of ESRD because of the risk of tamponade and its prognosis remains dependent on early diagnosis and adequate treatment of ESRD. Copyright © 2017 Elsevier Inc. All rights reserved.

A British Ophthalmological Surveillance Unit (BOSU) study into dysthyroid optic neuropathy in the United Kingdom.

PubMed

Wong, Yun; Dickinson, Jane; Perros, Petros; Dayan, Colin; Veeramani, Pratibha; Morris, Daniel; Foot, Barny; Clarke, Lucy

2018-06-18

This prospective British Ophthalmological Surveillance Unit (BOSU) study on dysthyroid optic neuropathy (DON) determines the incidence, presenting features and management throughout the UK. New cases were identified through the BOSU yellow card and an initial questionnaire and a subsequent 9-month follow-up questionnaire were posted out. From August 2015 to August 2016 DON was reported in 49 patients with 71 eyes affected, 22 patients had bilateral DON. The most common presenting symptom was blurred vision (83%) and the most common examination finding was upgaze restriction (85%). 85% of patients were initially treated with 3 days of either 1 g or 500 mg intravenous methyl prednisolone. We received 25 follow-up questionnaires (51% of the initial cohort) with 38 eyes treated for DON and 13 bilateral cases. The average steroid dose over 9 months was 4.5 g and 47% of patients had a surgical orbital decompression. The mean visual acuity gain after 9 months of follow-up for all patients was 0.25 LogMAR. The mean visual acuity gain after just medical therapy was 0.25 LogMAR and after both medical therapy and orbital decompression it was 0.24 LogMAR. In conclusion, the incidence of DON in the UK from this study is 0.75 per million population per annum. The majority of patients are treated with initial medical therapy and almost half of all patients subsequently went on to have an orbital decompression. With either medical therapy or medical and surgical therapy, vision can improve in patients with DON.

Periorbital edema as an initial presentation of rosacea.

PubMed

Chen, D M; Crosby, D L

1997-08-01

Rosacea is a common dermatosis with a variety of clinical manifestations. The eyes are often affected. The most frequent ocular findings are blepharitis and conjunctivitis. We describe three patients with rosacea in whom periorbital edema was the initial presentation. This symptom may be confused with other dermatoses and may be refractory to conventional treatments for rosacea.

Various Manifestations of Hyperthyroidism in an Ambulatory Clinic: Case Studies

PubMed Central

Tripp, Warren; Rao, Vijaya; Creary, Ludlow B.

1987-01-01

This study reviews five cases of women with hyperthyroidism, three black women and two Hispanic women. Initially, two patients presented with voice changes, weight loss, and increased appetite. Only two patients presented with classical symptoms of hyperthyroidism. Examination showed all patients had diffusely enlarged thyroids and exaggerated reflexes. Two patients showed Graves' opthalmopathy. These cases document the variety of presentations of hyperthyroidism. Hence, a high index of suspicion must exist for this disease, even in the absence of a number of the classical manifestations of hyperthyroidism. When patients present to primary care centers with a constellation of symptoms, an examination of the thyroid gland is essential. PMID:3694696

Length of Recovery From Sports-Related Concussions in Pediatric Patients Treated at Concussion Clinics.

PubMed

Thomas, Donald J; Coxe, Kathryn; Li, Hongmei; Pommering, Thomas L; Young, Julie A; Smith, Gary A; Yang, Jingzhen

2018-01-01

We quantified the length of recovery time by week in a cohort of pediatric sports-related concussion patients treated at concussion clinics, and examined patient and injury characteristics associated with prolonged recovery. A retrospective, cohort design. Seven concussion clinics at a Midwest children's hospital. Patients aged 10 to 17 years with a diagnosed sports-related concussion presenting to the clinic within 30 days of injury. Length of recovery by week. Unadjusted and adjusted multinomial logistic regression analyses were used to model the effect of patient and injury characteristics on length of recovery by week. Median length of recovery was 17 days. Only 16.3% (299/1840) of patients recovered within one week, whereas 26.4% took longer than four weeks to recover. By 2 months postinjury, 6.7% of patients were still experiencing symptoms. Higher symptom scores at injury and initial visit were significantly associated with prolonged symptoms by week. Patients who presented to the clinic more than 2 weeks postinjury or who had 2 or more previous concussions showed increased risk for prolonged recovery. Females were at greater risk for prolonged recovery than males (odds ratio = 2.08, 95% confidence interval = 1.49-2.89). Age was not significantly associated with recovery length. High symptom scores at injury and initial visit, time to initial clinical presentation, presence of 2 or more previous concussions, and female sex are associated with prolonged concussion recovery. Further research should aim to establish objective measures of recovery, accounting for treatment received during the recovery. The median length of recovery is 17 days among pediatric sports-related concussion patients treated at concussion clinics. Only 16.3% of patients recovered within one week, whereas 26.4% took longer than 4 weeks to recover.

Characteristics of cerebrovascular accidents at time of diagnosis in a series of 98 patients with giant cell arteritis.

PubMed

Zenone, Thierry; Puget, Marie

2013-12-01

The objective of this study was to determine the characteristics of cerebrovascular accidents at time of diagnosis in patients with giant cell arteritis. Retrospective data were collected from 98 patients at a single hospital with giant cell arteritis (according to the American College of Rheumatology classification criteria) diagnosed between October 1999 and January 2012. Cerebrovascular accident was found at initial presentation in 6 patients (6.1 %, 95 % CIs 2.3-12.9). Most of them had other symptoms of giant cell arteritis when the disease began. Signs reflecting the involvement of vertebro-basilar territory were present in 3 cases. No other case of cerebrovascular accident was described during the follow-up of patient; particularly no case of cerebrovascular accident occurred once corticosteroid therapy for the treatment of giant cell arteritis had been initiated. No differences in the epidemiologic, clinical and laboratory features at the time of diagnosis between patients who had cerebrovascular accidents and the rest of the giant cell arteritis patients were observed. Prognosis was good in our survey. However, there was no case of bilateral vertebral artery occlusion, a condition associated with poor prognosis. The present study confirms that cerebrovascular accidents may be the initial manifestation of giant cell arteritis, an argument in favor of a direct effect of the vasculitis in the development of cerebrovascular accidents rather than a complication of the corticosteroid therapy. The diagnosis of giant cell arteritis should always be considered in an elderly patient with stroke and an unexplained elevation of inflammatory biomarkers.

Pyogenic liver abscess: An audit of 10 years’ experience

PubMed Central

Pang, Tony CY; Fung, Thomas; Samra, Jaswinder; Hugh, Thomas J; Smith, Ross C

2011-01-01

AIM: To describe our own experience with pyogenic liver abscesses over the past 10 years and investigate the risk factors associated with failure of initial percutaneous therapy. METHODS: A retrospective study of records of 63 PLA patients presenting between 1998 and 2008 to Australian tertiary referral centre, were reviewed. Amoebic and hydatid abscesses were excluded. Demographic, clinical, radiological, and microbiological characteristics, as well as surgical/radiological interventions, were recorded. RESULTS: Sixty-three patients (42 males, 21 females) aged 65 (± 14) years [mean ± (SD)] had prodromal symptoms for a median (interquartile range; IQR) of 7 (5-14) d. Only 59% of patients were febrile at presentation; however, the serum C-reactive protein was elevated in all 47 in whom it was measured. Liver function tests were non-specifically abnormal. 67% of patients had a solitary abscess, while 32% had > 3 abscesses with a median (IQR) diameter of 6.3 (4-9) cm. Causative organisms were: Streptococcus milleri 25%, Klebsiella pneumoniae 21%, and Escherichia coli 16%. A presumptive cryptogenic cause was most common (34%). Four patients died in this series: one from sepsis, two from advanced cancer, and one from acute myocardial infarction. The initial procedure was radiological aspiration ± drainage in 54 and surgery in two patients. 17% underwent surgical management during their hospitalization. Serum hypoalbuminaemia [mean (95% CI): 32 (29-35) g/L vs 28 (25-31) g/L, P = 0.045] on presentation was found to be the only factor related to failure of initial percutaneous therapy on univariate analysis. CONCLUSION: PLA is a diagnostic challenge, because the presentation of this condition is non-specific. Intravenous antibiotics and radiological drainage in the first instance allows resolution of most PLAs; However, a small proportion of patients still require surgical drainage. PMID:21472130

[Central nervous tuberculosis in patients non-VIH: seven case reports].

PubMed

Mazodier, K; Bernit, E; Faure, V; Rovery, C; Gayet, S; Seux, V; Donnet, A; Brouqui, P; Disdier, P; Schleinitz, N; Kaplanski, G; Veit, V; Harlé, J-R

2003-02-01

Tuberculosis involving the central nervous system (CNS) is rarely observed in non immuno-compromised hosts. We report herin the various clinical, biological and radiological manifestations observed in 7 patients with CNS tuberculosis. Clinical and biological records of 7 patients with CNS tuberculosis were retrospectively studied. All patients had encephalic CT-scan and MRI in the course of the disease. 5 women and 2 men with a mean age of 38.4 years initially initially presented with headache (n = 6), fever (n = 5), meningeal irritation (n = 3), localizing neurological signs (n = 1). Lumbar punction revealed lymphocytic meningitis (n = 6/7). Mycobacterium tuberculosis or bovis was isolated in 3 patients only. Cerebral tomodensitography or magnetic resonance imaging were initially normal in most of cases (n = 4/7), but discovered in the course of disease basilar meningitis (n = 6), hydrocephalus (n = 6), abcess or tuberculoma (n = 4). In all the patients, initiation of the treatment was complicated by clinical and/or biological deterioration, called paradoxal reaction, leading in all cases to glucocorticoid adjunction, with various final results. Indeed, 4 patients developed neurological sequelae. No patient died. CNS tuberculosis is a rare disease in non immunocompromised patients whose diagnostic may be difficult due to the absence of specific clinical symptoms, negative initial radiological examination, as well as delayed and often negative bacterial isolation. Paradoxal reaction appeared to be frequent despite specific antibiotherapy and underlines the beneficial effects of addictive corticosteroids.

Delayed splenic rupture presenting 70 days following blunt abdominal trauma.

PubMed

Resteghini, Nancy; Nielsen, Jonpaul; Hoimes, Matthew L; Karam, Adib R

2014-01-01

Delayed splenic rupture following conservative management of splenic injury is an extremely rare complication. We report a case of an adult patient who presented with delayed splenic rupture necessitating splenectomy, 2 months following blunt abdominal trauma. Imaging at the initial presentation demonstrated only minimal splenic contusion and the patient was discharge following 24 hours of observation. © 2014.

How the manner of presentation of data influences older patients in determining their treatment preferences.

PubMed

Mazur, D J; Merz, J F

1993-03-01

To assess how the manner of presentation of graphic data to older patients influences their treatment preferences. Cross-sectional structured interviews with patients. A university-based Department of Veterans Affairs Medical Center. One hundred sixty-six consecutive patients (mean age = 64.8 years, range of ages 29-82) seen in a Department of Veterans Affairs general medicine clinic. Five pairs of 5-year survival curves were presented to patients. Each pair was composed of two survival curves for alternative unidentified treatments for an unidentified medical condition. Curve A (LT = better long-term, worse short-term survival) was fixed throughout all curve pairs. Curve B (ST = better short-term, worse long-term survival) changed in each curve pair, showing incrementally better chances of short-term survival across the five curve pairs. Patients were randomly assigned to view the curve pairs in forward (increasing short-term survival) or backward (decreasing short-term survival) order. Order is a significant predictor of patients' initial preferences for the short-term survival curve (P = 0.0004) as well as their willingness to shift preferences during presentation of the five curve pairs. Patients > or = 65 were more likely to initially choose the ST curve in forward order presentation than patients < 65. More educated patients generally were less likely to prefer the ST curve under both elicitation orders. The data indicate that the method of eliciting patients' preferences strongly influenced their expressed preferences, and that these preferences may have predictable relationships with demographic characteristics such as age.

Currently used dosage regimens of vancomycin fail to achieve therapeutic levels in approximately 40% of intensive care unit patients.

PubMed

Obara, Vitor Yuzo; Zacas, Carolina Petrus; Carrilho, Claudia Maria Dantas de Maio; Delfino, Vinicius Daher Alvares

2016-01-01

This study aimed to assess whether currently used dosages of vancomycin for treatment of serious gram-positive bacterial infections in intensive care unit patients provided initial therapeutic vancomycin trough levels and to examine possible factors associated with the presence of adequate initial vancomycin trough levels in these patients. A prospective descriptive study with convenience sampling was performed. Nursing note and medical record data were collected from September 2013 to July 2014 for patients who met inclusion criteria. Eighty-three patients were included. Initial vancomycin trough levels were obtained immediately before vancomycin fourth dose. Acute kidney injury was defined as an increase of at least 0.3mg/dL in serum creatinine within 48 hours. Considering vancomycin trough levels recommended for serious gram-positive infection treatment (15 - 20µg/mL), patients were categorized as presenting with low, adequate, and high vancomycin trough levels (35 [42.2%], 18 [21.7%], and 30 [36.1%] patients, respectively). Acute kidney injury patients had significantly greater vancomycin trough levels (p = 0.0055, with significance for a trend, p = 0.0023). Surprisingly, more than 40% of the patients did not reach an effective initial vancomycin trough level. Studies on pharmacokinetic and dosage regimens of vancomycin in intensive care unit patients are necessary to circumvent this high proportion of failures to obtain adequate initial vancomycin trough levels. Vancomycin use without trough serum level monitoring in critically ill patients should be discouraged.

"RAPID" team triage: one hospital's approach to patient-centered team triage.

PubMed

Shea, Sheila Sanning; Hoyt, K Sue

2012-01-01

Patients who present to the emergency department want definitive care by a health care provider who can perform an initial assessment, initiate treatment, and implement a disposition plan. The traditional "nurse triage" model often creates barriers to the process of rapidly evaluating patients. Therefore, innovative strategies must be explored to improve the time of patient arrival to the time seen by a qualified provider in order to complete a thorough medical screening examination. One such approach is a rapid team triage system that provides a patient-centered process. This article describes the implementation of a rapid team triage model in an urban community hospital.

Contrast-enhanced [18F] fluorodeoxyglucose-positron emission tomography-computed tomography as an initial imaging modality in patients presenting with metastatic malignancy of undefined primary origin.

PubMed

Jain, Avani; Srivastava, Madhur Kumar; Pawaskar, Alok Suresh; Shelley, Simon; Elangovan, Indirani; Jain, Hasmukh; Pandey, Somnath; Kalal, Shilpa; Amalachandran, Jaykanth

2015-01-01

To evaluate the advantages of contrast enhanced F-18-fluorodeoxyglucose (FDG) positron emission tomography-computed tomography (PET-contrast enhanced CT [CECT]) when used as an initial imaging modality in patients presenting with metastatic malignancy of undefined primary origin (MUO). A total of 243 patients with fine needle aspiration cytology/biopsy proven MUO were included in this prospective study. Patients who were thoroughly evaluated for primary or primary tumor was detected by any other investigation were excluded from the analysis. Totally, 163 patients with pathological diagnosis of malignancy but no apparent sites of the primary tumor were finally selected for analysis. The site of probable primary malignancy suggested by PET-CECT was confirmed by biopsy/follow-up. PET-CECT suggested probable site of primary in 128/163 (78.52%) patients. In 30/35 remaining patients, primary tumor was not detected even after extensive work-up. In 5 patients, where PET-CECT was negative, primary was found on further extensive investigations or follow-up. The sensitivity, specificity, positive predictive value and negative predictive value of the study were 95.76%, 66.67%, 88.28% and 85.71% respectively. F-18 FDG PET-CECT aptly serves the purpose of initial imaging modality owing to high sensitivity, negative and positive predictive value. PET-CECT not only surveys the whole body for the primary malignancy but also stages the disease accurately. Use of contrast improves the diagnostic utility of modality as well as help in staging of the primary tumor. Although benefits of using PET-CECT as initial diagnostic modality are obvious from this study, there is a need for a larger study comparing conventional methods for diagnosing primary in patients with MUO versus PET-CECT.

Complete atrioventricular block as initial manifestation of systemic lupus erythematosus.

PubMed

Arce-Salinas, C A; Carmona-Escamilla, M A; Rodríguez-García, F

2009-01-01

Only a few cases of complete atrioventricular block (AVB) in adult lupus patients have been previously described, but only one as the initial manifestation. A 19-year-old woman who presented with seizures and loss of consciousness, was diagnosed with complete ABV and underwent pacemaker placement. Over the next weeks she developed serositis, joint, cutaneous, and renal involvement; positive antinuclear antibodies and high anti-SSA/Ro titers. This is the second case with AVB as a feature of SLE at onset. A review of previous complete AVB cases of adult SLE patients is presented.

Aerophagia in adults: a comparison with functional dyspepsia.

PubMed

Chitkara, D K; Bredenoord, A J; Rucker, M J; Talley, N J

2005-11-01

Aerophagia is a functional upper gastrointestinal disorder that has not previously been well described in a large patient group. To describe the initial evaluation of patients who presented with symptoms of aerophagia at a tertiary medical centre. A computerized search was used to identify all patients who were diagnosed with aerophagia at the Mayo Clinic, Rochester between 1996 and 2003 (n = 79). Individual medical charts were abstracted for information on the demographics, clinical features, co-morbid diagnoses, diagnostic workup and treatment. Information on presenting symptoms was also collected for a group of patients who were classified as having functional dyspepsia for comparison (n = 121). The median duration of symptoms in patients with aerophagia was 24 months. The most common symptoms were belching (56%), abdominal pain (19%), bloating (27%) and abdominal distension (19%). Patients with functional dyspepsia had a higher prevalence of reporting nausea, vomiting, early satiety, weight loss and abdominal pain (all P < 0.01, adjusting for age, gender and body mass index). Significantly more patients with aerophagia had anxiety (19%) than those with functional dyspepsia (6%, P < 0.01). Individuals with aerophagia experience prolonged upper gastrointestinal symptoms. Initial presenting symptoms appear to be distinctly different from those who have functional dyspepsia.

Prognostic factors in pemphigus vulgaris and pemphigus foliaceus.

PubMed

Saha, M; Bhogal, B; Black, M M; Cooper, D; Vaughan, R W; Groves, R W

2014-01-01

Pemphigus typically has a chronic course, although there is great variability in disease duration (DD) and time taken to disease remission (DR) between individuals with the disease. The reasons for this are unclear. To explore the prognostic influence of epidemiological, clinical, immunological and genetic factors on disease course and remission in pemphigus vulgaris (PV) and pemphigus foliaceus (PF). This was a retrospective study of patients with PV and PF, recruited from a single UK centre. Direct and indirect immunofluorescence and enzyme-linked immunosorbent assay studies for antidesmoglein (Dsg) antibodies were used to assess immunological factors. Polymerase chain reaction with sequence specific primers (PCR-SSP) was used to assess the Class II human leukocyte antigen status of patients. Prognostic endpoints investigated were time to initial first DR and total DD. Ninety-five patients were recruited (79 PV and 16 PF). Patients of Indo-Asian origin were significantly associated with longer DD than White-British patients (P = 0.029). In addition, younger age at onset was associated with a worse prognosis in terms of DD: the mean age at presentation of patients with DD of < 5 years was 49 years (SEM = 3.4) compared with 40 years (SEM = 1.9) in those with DD > 5 years (P = 0.039). A higher initial intercellular antibody titre on normal human skin substrate was associated with a greater time to initial DR (P = 0.007) and high anti-Dsg 3 levels at baseline were associated with a longer total DD (P = 0.03). Ethnic group, age at presentation, initial intercellular antibody titre and initial Dsg 3 antibody levels all had a significant impact on prognosis of pemphigus. © 2013 British Association of Dermatologists.

Helminthic infections mimicking malignancy: a review of published case reports.

PubMed

Pilsczek, Florian H

2010-08-04

Infectious diseases, including infections with helminths, can initially present similarly to malignancies. The goal of the article is to review reports of helminthic infections that are initially diagnosed as malignancy. The database PubMed was searched for English language references published as of July 2009. The following published case reports and case series, mainly from Asia and Africa, were identified: Nematodes: 8 publications (1 patient with Angiostrongylus cantonensis, 2 Stronglyloides stercoralis, 1 Toxocara species, 1 Dioctophyma renale, 1 Ascaris species, 1 Gnathostoma spinigerum, 1 Dirofilaria repens); Trematodes: 7 publications (46 patients with Schistosoma species, 2 Fasciola hepatica, 1 Paragonimus westermani); Cestodes: 6 publications (10 patients with Echinococcus species, 1 Sparganum mansoni). To avoid unnecessary investigations and treatment, physicians should be aware when diagnosing patients from Asia or Africa that a large number of helminthic infections can present similar to malignancies.

Etiologies of altered mental status in patients with presumed ethanol intoxication.

PubMed

Martel, Marc L; Klein, Lauren R; Lichtenheld, Andrew J; Kerandi, Allan M; Driver, Brian E; Cole, Jon B

2018-06-01

Altered mental status is a commonly evaluated problem in the ED. Ethanol intoxication is common, and prehospital history may bias emergency physicians to suspect this as the cause of altered mental status. Quantitative ethanol measurement can rapidly confirm the diagnosis, or if negative, prompt further evaluation. Our objective was to identify the etiologies of altered mental status in ED patients initially presumed to be intoxicated with ethanol but found to have negative quantitative ethanol levels. This was a 5-year (2012-2016) electronic medical record review of ED patients presenting with altered mental status. Patients were included if they presented with presumed ethanol intoxication and had an initial ethanol concentration of zero. Etiologies of altered mental status were categorized into medical, traumatic, psychiatric, and drug-related causes. 29,322 patients presented during the study period with presumed alcohol intoxication, 1875 patients had negative ethanol levels. The etiology of altered mental status was due to illicit substances in 1337 patients (71%), psychiatric causes in 354 patients (19%), medical causes in 166 patients (9%) and trauma in 18 patients (1%). A total of 179 patients (10%) were admitted to the hospital; 19 patients (1%) to the ICU. The presumptive diagnosis of ethanol intoxication in patients presenting to the ED with altered mental status was inaccurate in 5% of patients. The etiology of altered mental status was serious and required hospitalization in 10% of the cohort. Rapid assessment of quantitative ethanol levels should be performed, breathalyzers may be preferred over serum testing. Copyright © 2018 Elsevier Inc. All rights reserved.

Psychotherapy of Bereavement After Homicide

PubMed Central

RYNEARSON, TED

1994-01-01

The author presents guidelines for the assessment and initial treatment of bereavement after a homicide. Early interventions include nonverbal techniques applied in individual and group therapy. Because patients are over-whelmed and reactive, initial treatment strategy is supportive and focuses on reestablishing resiliency rather than on preexisting vulnerabilities (ambivalence, guilt, repression, denial). Adjustment to homicidal dying is lifelong, and therapist and patient should acknowledge that change may be limited. PMID:22700202

Clinical course and quality of care in ART-naïve patients newly presenting in a HIV outpatient clinic.

PubMed

Platten, M; Linnemann, R; Kümmerle, T; Jung, N; Wyen, C; Ehren, K; Gravemann, S; Gillor, D; Cornely, O A; Fischer, J; Lehmann, C; Rockstroh, J K; Fätkenheuer, G; Vehreschild, J J

2014-10-01

Little data exist about the quality of care for HIV-infected subjects in Germany. We investigated the clinical course of HIV-infected subjects newly presenting in our HIV outpatient clinic. Antiretroviral therapy (ART)-naïve HIV-infected subjects presenting between 2007 and 2008 were followed until June 2012. Clinical data and laboratory parameters were collected prospectively and analysed retrospectively. From 281 subjects included, 34 patients (12%) were lost to follow-up. 247 subjects remained, and 171 patients were followed for 1,497 days [1,121/1,726] (all data: median [interquartile range]). ART was started in 199 patients (81%) 182 days [44/849] after HIV diagnosis, and all patients were treated according to European guidelines or within clinical trials. The CD4 cell count at first presentation was 320/µL [160/500] and declined to 210/µL [100/300] at ART start. 12 months thereafter, the CD4 cell count increased to 410/µL [230/545]. The HIV RNA was suppressed below 50 copies/mL after 108 days [63/173] in 182 patients (91%). Initial ART was changed in 71 patients (36%) after 281 days [99/718], in five patients (7%) due to virological failure, in 66 patients (93%) due to other reasons, e.g. side effects or patient's request. Two-thirds of the included patients were followed for more than 3 years, and ART was initiated in 81% of the patients leading to complete virological suppression in most patients. Compliance of physicians with treatment guidelines was high. Late presentation with a severely compromised immune function remains a problem and impairs the otherwise good prognosis of HIV infection.

Circulating endothelial cells and their progenitors in acute myeloid leukemia

PubMed Central

Zahran, Asmaa Mohammed; Aly, Sanaa Shaker; Altayeb, Hanan Ahmed; Ali, Arwa Mohammed

2016-01-01

Acute myeloid leukemia (AML) is an aggressive hematological malignancy characterized by the accumulation of immature myeloid progenitor cells in the bone marrow. Studies are required to investigate the prognostic and predictive value of surrogate biomarkers. Given the importance of angiogenesis in oncology in terms of pathogenesis as well as being a target for treatment, circulating endothelial cells (CECs) and endothelial progenitor cells (EPCs) are promising candidates to serve as such markers. The aim of the present study was to quantify CECs and EPCs in patients with AML at initial diagnosis and following induction chemotherapy, and to correlate these findings with the response to treatment in AML patients. The present study included 40 patients with de novo AML and 20 age- and gender-matched healthy controls. CECs and EPCs were evaluated by flow cytometry at initial diagnosis and after induction chemotherapy (3+7 protocol for AML other than M3 and all-trans-retinoic acid plus anthracycline for M3 disease). CECs and EPCs were significantly higher in AML patients at diagnosis and after induction chemotherapy than in controls. After induction chemotherapy, CECs and EPCs were significantly decreased compared with the levels at initial diagnosis. Patients who achieved complete response (n=28) had lower initial CEC and EPC levels compared with patients who did not respond to treatment. These results suggest that CEC levels are higher in AML patients and may correlate with disease status and treatment response. Further investigations are required to better determine the predictive value and implication of these cells in AML management. PMID:27602121

Pediatric Emergency Research Canada (PERC): Patient/Family-Informed Research Priorities for Pediatric Emergency Medicine.

PubMed

Bialy, Liza; Plint, Amy C; Freedman, Stephen B; Johnson, David W; Curran, Janet A; Stang, Antonia S

2018-06-06

A growing body of literature supports patient and public involvement in the design, prioritization and dissemination of research and evidence based medicine. The objectives of this project were to engage patients and families in developing a prioritized list of research topics for Pediatric Emergency Medicine (PEM) and to compare results with prior research prioritization initiatives in the ED (emergency department) setting. We utilized a systematic process to combine administrative data on frequency of patient presentations to the ED with multiple stakeholder input including an initial stakeholder survey followed by a modified Delphi consensus methodology consisting of two web-based surveys and a face-to-face meeting. The prioritization process resulted in a ranked list of 15 research priorities. The top five priorities were mental health presentations, pain and sedation, practice tools, quality of care delivery and resource utilization. Mental health, pain and sedation, clinical prediction rules, respiratory illnesses /wheeze, patient safety/medication error and sepsis were identified as shared priorities with prior initiatives. Topics identified in our process that were not identified in prior work included resource utilization, ED communication, antibiotic stewardship and patient/family adherence with recommendations. This work identifies key priorities for research in PEM. Comparing our results with prior initiatives in the ED setting identified shared research priorities and opportunities for collaboration among PEM research networks. This work in particular makes an important contribution to the existing literature by including the patient/family perspective missing from prior work. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

Churg-Strauss syndrome: a new endotype of severe asthma? Results of 14 Turkish patients.

PubMed

Yılmaz, İnsu; Çelik, Gülfem; Aydın, Ömür; Özdemir, Seçil Kepil; Soyyiğit, Şadan; Sözener, Zeynep; Özgüçlü, Selcan; Atasoy, Çetin; Düzgün, Nurşen; Mungan, Dilşad; Sin, Betül; Demirel, Yavuz Selim; Mısırlıgil, Zeynep

2015-07-01

Churg-Strauss syndrome (CSS) is a rare multisystem vasculitis. Considering the variation of autoimmune diseases in different races, it is of interest to determine whether any outstanding features exist for Turkish patients with CSS. The aim of this study was to evaluate the clinical and serological features of the disease, the treatment, and long-term follow-up details, and to investigate possible etiological factors of Turkish CSS patients. The study included 14 patients who were diagnosed with CSS, and followed by our department between 2004 and 2012. Possible etiological factors, initial symptoms, clinical presentations, treatment, as well as outcomes were documented. The study was approved by the local ethics. All patients fulfilled the American College of Rheumatology criteria. Initial symptoms were worsening asthma (n = 14; 100%) and skin lesions (n = 6; 43%). All patients had a diagnosis of asthma and nasal polyps, whereas 57.1% had aspirin hypersensitivity at the time of diagnosis. The lungs (100%) and skin (43%) were most commonly involved. Peripheral eosinophilia dominated on initial presentations of all patients. Initial treatments included oral methyl prednisolone in all cases, whereas cyclophosphamide and azathioprine were used in three cases. Relapses were detected in five cases. None of the cases were able to stop the oral corticosteroid treatment. No fatalities were observed. We herein describe a new severe asthma endotype in connection with CSS. We suggest that physicians who deal with uncontrolled severe asthma cases should consider CSS in the presence of nasal polyps, aspirin hypersensitivity, and especially peripheral blood eosinophilia over 10%. © 2014 John Wiley & Sons Ltd.

Temporal trends of time to antiretroviral treatment initiation, interruption and modification: examination of patients diagnosed with advanced HIV in Australia.

PubMed

Wright, Stephen T; Law, Matthew G; Cooper, David A; Keen, Phillip; McDonald, Ann; Middleton, Melanie; Woolley, Ian; Kelly, Mark; Petoumenos, Kathy

2015-01-01

HIV prevention strategies are moving towards reducing plasma HIV RNA viral load in all HIV-positive persons, including those undiagnosed, treatment naïve, on or off antiretroviral therapy. A proxy population for those undiagnosed are patients that present late to care with advanced HIV. The objectives of this analysis are to examine factors associated with patients presenting with advanced HIV, and establish rates of treatment interruption and modification after initiating ART. We deterministically linked records from the Australian HIV Observational Database to the Australian National HIV Registry to obtain information related to HIV diagnosis. Logistic regression was used to identify factors associated with advanced HIV diagnosis. We used survival methods to evaluate rates of ART initiation by diagnosis CD4 count strata and by calendar year of HIV diagnosis. Cox models were used to determine hazard of first ART treatment interruption (duration >30 days) and time to first major ART modification. Factors associated (p<0.05) with increased odds of advanced HIV diagnosis were sex, older age, heterosexual mode of HIV exposure, born overseas and rural-regional care setting. Earlier initiation of ART occurred at higher rates in later periods (2007-2012) in all diagnosis CD4 count groups. We found an 83% (69, 91%) reduction in the hazard of first treatment interruption comparing 2007-2012 versus 1996-2001 (p<0.001), and no difference in ART modification for patients diagnosed with advanced HIV. Recent HIV diagnoses are initiating therapy earlier in all diagnosis CD4 cell count groups, potentially lowering community viral load compared to earlier time periods. We found a marked reduction in the hazard of first treatment interruption, and found no difference in rates of major modification to ART by HIV presentation status in recent periods.

Measurement of serum antibodies against NY-ESO-1 by ELISA: A guide for the treatment of specific immunotherapy for patients with advanced colorectal cancer.

PubMed

Long, Yan-Yan; Wang, Yu; Huang, Qian-Rong; Zheng, Guang-Shun; Jiao, Shun-Chang

2014-10-01

NY-ESO-1 has been identified as one of the most immunogenic antigens; thus, is a highly attractive target for cancer immunotherapy. The present study analyzed the expression of serum antibodies (Abs) against NY-ESO-1 in patients with advanced colorectal cancer (CRC), with the aim of guiding the treatment of NY-ESO-1-based specific-immunotherapy for these patients. Furthermore, the present study was the first to evaluate the kinetic expression of anti-NY-ESO-1 Abs and investigate the possible influencing factors. A total of 239 serum samples from 155 pathologically confirmed patients with advanced CRC (stages III and IV) were collected. The presence of spontaneous Abs against NY-ESO-1 was analyzed using an enzyme-linked immunosorbent assay (ELISA). The results demonstrated that 24.5% (38/155) of the investigated patients were positive for NY-ESO-1-specific Abs. No statistically significant correlations were identified between the expression of anti-NY-ESO-1 Abs and clinicopathological parameters, including age and gender, location, grading, local infiltration, lymph node status, metastatic status and K-ras mutation status (P>0.05). In 59 patients, the kinetic expression of anti-NY-ESO-1 Abs was analyzed, of which 14 patients were initially positive and 45 patients were initially negative. Notably, 16/59 (27.1%) patients changed their expression status during the study period, and the initially positive patients were more likely to change compared with the initially negative patients (85.7 vs. 8.8%; P<0.001). Therefore, monitoring serum Abs against NY-ESO-1 by ELISA is an easy and feasible method. The high expression rate of NY-ESO-1-specific Abs in CRC patients indicates that measuring the levels of serum Abs against NY-ESO-1 may guide the treatment of NY-ESO-1-based specific immunotherapy for patients with advanced CRC.

Measurement of serum antibodies against NY-ESO-1 by ELISA: A guide for the treatment of specific immunotherapy for patients with advanced colorectal cancer

PubMed Central

LONG, YAN-YAN; WANG, YU; HUANG, QIAN-RONG; ZHENG, GUANG-SHUN; JIAO, SHUN-CHANG

2014-01-01

NY-ESO-1 has been identified as one of the most immunogenic antigens; thus, is a highly attractive target for cancer immunotherapy. The present study analyzed the expression of serum antibodies (Abs) against NY-ESO-1 in patients with advanced colorectal cancer (CRC), with the aim of guiding the treatment of NY-ESO-1-based specific-immunotherapy for these patients. Furthermore, the present study was the first to evaluate the kinetic expression of anti-NY-ESO-1 Abs and investigate the possible influencing factors. A total of 239 serum samples from 155 pathologically confirmed patients with advanced CRC (stages III and IV) were collected. The presence of spontaneous Abs against NY-ESO-1 was analyzed using an enzyme-linked immunosorbent assay (ELISA). The results demonstrated that 24.5% (38/155) of the investigated patients were positive for NY-ESO-1-specific Abs. No statistically significant correlations were identified between the expression of anti-NY-ESO-1 Abs and clinicopathological parameters, including age and gender, location, grading, local infiltration, lymph node status, metastatic status and K-ras mutation status (P>0.05). In 59 patients, the kinetic expression of anti-NY-ESO-1 Abs was analyzed, of which 14 patients were initially positive and 45 patients were initially negative. Notably, 16/59 (27.1%) patients changed their expression status during the study period, and the initially positive patients were more likely to change compared with the initially negative patients (85.7 vs. 8.8%; P<0.001). Therefore, monitoring serum Abs against NY-ESO-1 by ELISA is an easy and feasible method. The high expression rate of NY-ESO-1-specific Abs in CRC patients indicates that measuring the levels of serum Abs against NY-ESO-1 may guide the treatment of NY-ESO-1-based specific immunotherapy for patients with advanced CRC. PMID:25187840

How the probability of presentation to a primary care clinician correlates with cancer survival rates: a European survey using vignettes

PubMed Central

Harris, Michael; Frey, Peter; Esteva, Magdalena; Gašparović Babić, Svjetlana; Marzo-Castillejo, Mercè; Petek, Davorina; Petek Ster, Marija; Thulesius, Hans

2017-01-01

Objective European cancer survival rates vary widely. System factors, including whether or not primary care physicians (PCPs) are gatekeepers, may account for some of these differences. This study explores where patients who may have cancer are likely to present for medical care in different European countries, and how probability of presentation to a primary care clinician correlates with cancer survival rates. Design Seventy-eight PCPs in a range of European countries assessed four vignettes representing patients who might have cancer, and consensus groups agreed how likely those patients were to present to different clinicians in their own countries. These data were compared with national cancer survival rates. Setting A total of 14 countries. Subjects Consensus groups of PCPs. Main outcome measures Probability of initial presentation to a PCP for four clinical vignettes. Results There was no significant correlation between overall national 1-year relative cancer survival rates and the probability of initial presentation to a PCP (r  = −0.16, 95% CI −0.39 to 0.08). Within that there was large variation depending on the type of cancer, with a significantly poorer lung cancer survival in countries where patients were more likely to initially consult a PCP (lung r = −0.57, 95% CI −0.83 to −0.12; ovary: r = −0.13, 95% CI −0.57 to 0.38; breast r = 0.14, 95% CI −0.36 to 0.58; bowel: r = 0.20, 95% CI −0.31 to 0.62). Conclusions There were wide variations in the degree of gatekeeping between countries, with no simple binary model as to whether or not a country has a “PCP-as-gatekeeper” system. While there was case-by-case variation, there was no overall evidence of a link between a higher probability of initial consultation with a PCP and poorer cancer survival. Key points European cancer survival rates vary widely, and health system factors may account for some of these differences. The data from 14 European countries show a wide variation in the probability of initial presentation to a PCP. The degree to which PCPs act as gatekeepers varies considerably from country to country. There is no overall evidence of a link between a higher probability of initial presentation to a PCP and poorer cancer survival. PMID:28277044

Impact of colour blindness on recognition of haematuria in bladder cancer patients.

PubMed

Katmawi-Sabbagh, Samer; Haq, Ahsanul; Jain, Sunila; Subhas, Gokul; Turnham, Helen

2009-01-01

Colour blindness might lead to failure in recognizing frank haematuria. Our aim is to investigate as to whether colour-blind males who develop bladder cancer present later with less favourable histology. Two hundred male patients with bladder cancer were assessed using Ishihara plate test for colour deficiency. Degree of haematuria, method of presentation and initial histologic findings were also determined. Colour-blind patients who develop bladder cancer present with less favourable histology compared with non-colour-blind (p = 0.01). Colour blindness was associated with presentation with more advanced bladder tumours.

Risk Factor Analysis for the Outcomes of Indirect Traumatic Optic Neuropathy with No Light Perception at Initial Visual Acuity Testing.

PubMed

Lai, I-Li; Liao, Han-Tsung

2018-04-26

The optimal management of indirect traumatic optic neuropathy (TON) is controversial. We aimed to compare the differences in visual improvement by treatment option in patients presenting with TON and no light perception (NLP). We also wanted to identify any patient-related factors that might favor the use of steroid pulse therapy or optic nerve decompression (OND). We retrospectively identified 46 consecutive patients with indirect TON treated at Chang Gung Memorial Hospital between 2007 and 2015. The outcome was the improvement in visual acuity by improvement rate and degree of improvement. Females had a better improvement rate than did males. Compared with delayed treatment, patients receiving steroid pulse therapy within 14 hours or receiving OND within 26 hours had a better improvement rate/degree. In patients with an initial intraocular pressure (IOP) of 17-23 mm Hg, the improvement rate/degree was significantly better than for patients with an IOP outside this range. For patients treated by OND, an initially normal IOP (11-21 mm Hg) suggested a significantly better prognosis in the improvement rate/degree. For patients with indirect TON, initial NLP implies a poor prognosis, but steroid pulse therapy or OND are both feasible treatment options. These results emphasize the importance of timely treatment for patients with indirect TON and NLP. Females and patients with an initial IOP of 17-23 mm Hg were more likely to recover. The results of our study indicate that normal initial IOP (11-21 mm Hg) is good prognostic factor for patients with indirect TON treated with OND. Copyright © 2018 Elsevier Inc. All rights reserved.

[18F]-Fluoro-Deoxy-Glucose Positron Emission Tomography Scan Should Be Obtained Early in Cases of Autoimmune Encephalitis

PubMed Central

Sarwal, A.; Hantus, S.

2016-01-01

Introduction. Autoimmune encephalitis (AE) is a clinically challenging diagnosis with nonspecific neurological symptoms. Prompt diagnosis is important and often relies on neuroimaging. We present a case series of AE highlighting the importance of an early [18F]-fluoro-deoxy-glucose positron emission tomography (FDG-PET) scan. Methods. Retrospective review of seven consecutive cases of autoimmune encephalitis. Results. All patients had both magnetic resonance imaging (MRI) and FDG-PET scans. Initial clinical presentations included altered mental status and/or new onset seizures. Six cases had serum voltage-gated potassium channel (VGKC) antibody and one had serum N-methyl-D-aspartate (NMDA) antibody. MRI of brain showed mesial temporal lobe hyperintensity in five cases of VGKC. The other two patients with VGKC or NMDA AE had restiform body hyperintensity on MRI brain or a normal MRI, respectively. Mesial temporal lobe hypermetabolism was noted in three cases on FDG-PET, despite initial unremarkable MRI. Malignancy workup was negative in all patients. Conclusion. A high index of suspicion for AE should be maintained in patients presenting with cognitive symptoms, seizures, and limbic changes on neuroimaging. In cases with normal initial brain MRI, FDG-PET can be positive. Additionally, extralimbic hyperintensity on MRI may also be observed. PMID:27559482

Patient-Focused Drug Development: A New Direction for Collaboration.

PubMed

Perfetto, Eleanor M; Burke, Laurie; Oehrlein, Elisabeth M; Epstein, Robert S

2015-01-01

Patient-Focused Drug Development (PFDD) is a new initiative from the Food and Drug Administration (FDA) intended to bring patient perspectives into an earlier stage of product development. The goal is that patients will be able to provide context for benefit-risk assessments and input to review divisions, and also aid in the development of new assessment tools, study endpoints, and risk communications. This paper provides a summary on what is known to date about FDA's PFDD initiative and describes implications for patients, researchers, payers, and the biopharmaceutical industry. It also provides a roadmap for stakeholders to consider in defining their role in and in shaping PFDD's direction, and for expanding PFDD principles to conditions beyond the current 20 under FDA consideration. A search was conducted of the peer-reviewed and gray literature using PubMed and Google. This included laws, FDA guidance documents, the peer-reviewed literature, and FDA presentations for content relevant to the search term "patient-focused drug development." Currently, FDA activities within PFDD are limited to gaining patient insights through 20 disease-specific meetings. However, many stakeholders see the initiative much more generally as representing a broad shift toward patient centeredness in biopharmaceutical product development. Depending upon the trajectory taken and whether or not all PFDD aims are eventually addressed, the initiative has the potential to change product development in fundamental ways. Further research should explore how patient input on disease manifestation and treatment options is best ascertained from patients and documented before initiating and during drug development.

Human Trafficking, Sexual Assault, or Something Else? A Complicated Case With an Unexpected Outcome.

PubMed

Scott-Tilley, Donna; Crites, Heather

This case report presents a patient who presented multiple times with vaginal injuries and bleeding, reporting sexual assault with a foreign object. Findings from her history and physical examination were consistent with sexual assault and human trafficking. The outcome of this case was not what we initially expected when the patient first presented for care. However, the patient ultimately received the care she needed. This case illuminates the need for excellent continuing education, interdisciplinary communication, and continuity of care.

Trends in CD4 cell count response to first-line antiretroviral treatment in HIV-positive patients from Asia, 2003-2013: TREAT Asia HIV Observational Database Low Intensity Transfer.

PubMed

De La Mata, Nicole L; Ly, Penh S; Ng, Oon T; Nguyen, Kinh V; Merati, Tuti P; Pham, Thuy T; Lee, Man P; Choi, Jun Y; Sohn, Annette H; Law, Matthew G; Kumarasamy, Nagalingeswaran

2017-11-01

Antiretroviral treatment (ART) guidelines have changed over the past decade, recommending earlier initiation and more tolerable regimens. The study objective was to examine the CD4 response to ART, depending on the year of ART initiation, in HIV-positive patients in the Asia-Pacific. We included HIV-positive adult patients who initiated ART between 2003 and 2013 in our regional cohort from eight urban referral centres in seven countries within Asia. We used mixed-effects linear regression models to evaluate differences in CD4 response by year of ART initiation during 36 months of follow-up, adjusted a priori for other covariates. Overall, 16,962 patients were included. Patients initiating in 2006-9 and 2010-13 had an estimated mean CD4 cell count increase of 8 and 15 cells/µl, respectively, at any given time during the 36-month follow-up, compared to those in 2003-5. The median CD4 cell count at ART initiation also increased from 96 cells/µl in 2003-5 to 173 cells/µl in 2010-13. Our results suggest that the CD4 response to ART is modestly higher for those initiating ART in more recent years. Moreover, fewer patients are presenting with lower absolute CD4 cell counts over time. This is likely to reduce their risk of opportunistic infections and future non-AIDS defining cancers.

[The application of impulse magnetic therapy for the treatment of the patients presenting with lymphedema of the lower extremities].

PubMed

Kulchitskaya, D B; Gerasimenko, M Yu; Aphanova, T V; Konchugova, T V

The principal objective of the present work was to evaluate the influence of impulse magnetic therapy on the state of the microcirculatory system in the patients presenting with lymphedema of the lower extremities. The study included 59 patients with stage of 1 and 2 lymphedema who were divided into two groups. Those comprising the first group had impulse magnetic therapy applied to their lower extremities while the patients making up the second group served as controls. All the patients were examined with the use of the laser Doppler flowmetry (LDF) that revealed the initially present pathological changes in the microcirculatory system of their lower extremities. The study has demonstrated that the application of impulse magnetic therapy produced a positive effect on all the constituent components of the microcirculatory blood stream of the patients suffering from lymphedema of the lower extremities. Specifically, the initially increased arteriolar tonus was decreased, the blood flow in the capillary vessels was improved, and congestive phenomena in the venular segments of the microcirculation blood stream were markedly reduced. The results of the LDF examination in the control group gave no evidence of significant changes in the patients' microcirculatory system. The results of the LDF examination of the patients of the control group suggested the absence of any appreciable changes in the microcirculatory system. The present study has demonstrated the advisability of the application of impulse magnetic therapy for the treatment of the patients presenting with lymphedema of the lower extremities as a minimally invasive technique for the evaluation of the condition of the microcirculatory system and the objective assessment of the effectiveness of the outcomes of physiotherapy in the patients with vascular pathology.

Ewings Sarcoma: A Case of Respiratory Distress and Opacification That Was not Pneumonia.

PubMed

Wells, Jordee M; Spencer, Sandra P

2018-05-01

The Ewing sarcoma family of tumors typically appears in the second decade of life with regional pain and swelling of a long bone. The following case presents a pediatric patient, aged 4 years, given a diagnosis of Ewing sarcoma of the rib with the initial presentation of respiratory distress, hypoxia, and pleural effusion. Respiratory distress accounts for a large majority of emergency department visits annually, so it is the distinct responsibility of the emergency department physician to avoid premature closure in attributing the most common diagnoses to account for the presenting symptoms. In this case, the careful study of the initial radiographic findings led to further identification and characterization of the mass through thoracic computed tomography to suggest Ewing sarcoma, despite the patient's unlikely demographics and presentation.

Serial Sampling of High-Sensitivity Cardiac Troponin T May Not Be Required for Prediction of Acute Myocardial Infarction Diagnosis in Chest Pain Patients with Highly Abnormal Concentrations at Presentation.

PubMed

Mueller-Hennessen, Matthias; Mueller, Christian; Giannitsis, Evangelos; Biener, Moritz; Vafaie, Mehrshad; deFilippi, Christopher R; Christ, Michael; Ordóñez-Llanos, Jorge; Panteghini, Mauro; Plebani, Mario; Verschuren, Franck; Melki, Dina; French, John K; Christenson, Robert H; Body, Richard; McCord, James; Dinkel, Carina; Katus, Hugo A; Lindahl, Bertil

2017-02-01

Guidelines for diagnosing acute myocardial infarction (AMI) recommend adding kinetic changes to the initial cardiac troponin (cTn) blood concentration to improve AMI diagnosis. We hypothesized that kinetic changes may not be required in patients presenting with highly abnormal cTn. Patients presenting with suspected AMI to the emergency department were enrolled in a prospective diagnostic study. We assessed the positive predictive value (PPV) of initial high-sensitivity cardiac troponin T (hs-cTnT) blood concentrations alone and in combination with kinetic changes for AMI. Predefined relative changes (δ change of ≥20%) and absolute changes (Δ change ≥9.2 ng/L) within different time intervals (1 h, 2 h, and 4-14 h after presentation) were assessed. The final diagnosis was adjudicated by 2 independent cardiologists. Among 1282 patients, 213 (16.6%) patients had a final diagnosis of AMI. For AMI prediction, PPVs increased from 48.8% for an initial hs-cTnT >14 ng/L to 87.2% for >60 ng/L, whereas PPVs remained unchanged for higher hs-cTnT concentrations at baseline (87.1% for both >80 ng/L and >100 ng/L). With addition of 20% relative Δ change, PPVs were not further improved in patients with baseline hs-cTnT >80 ng/L using the 1-h (84.0%) and 2-h (88.9%) intervals, and only minimally when extending the interval to 4-14 h (91.2% for >80 ng/L and 90.4% for >100 ng/L, respectively). Similar findings were observed when applying absolute changes. In chest pain patients with highly abnormal hs-cTnT concentrations at presentation, subsequent blood draws may not be required, as they do not provide incremental diagnostic value for prediction of AMI diagnosis. © 2016 American Association for Clinical Chemistry.

Misdiagnosis of cerebellar hemorrhage - features of 'pseudo-gastroenteritis' clinical presentations to the ED and primary care.

PubMed

Lee, Seung-Han; Stanton, Victoria; Rothman, Richard E; Crain, Barbara; Wityk, Robert; Wang, Zheyu; Newman-Toker, David E

2017-03-01

Early-stage cerebellar hemorrhage can present with nausea or vomiting absent other neurological symptoms or signs, potentially leading to an incorrect diagnosis of gastroenteritis. We sought to determine the frequency of gastroenteritis-like presentations and delayed or missed diagnoses among patients with spontaneous cerebellar hemorrhage. This is a retrospective, case-control analysis of atraumatic, primary cerebellar hemorrhages derived from a systematic search of surgical pathology and autopsy databases at two large urban, academic medical centers from 1984 to 2006. Hospital visit and clinical symptom data were abstracted from electronic and paper medical records for included patients. Delayed or missed diagnoses were defined as those at least one previous visit for relevant clinical symptoms in the 7 days prior to the correct diagnosis being confirmed. Among 254 records captured by our search filter, we identified 35 cases of pathologically proven primary cerebellar hemorrhage. Four patients (11%) were misdiagnosed initially - three with "gastroenteritis" and one with "hypertension". In this small sample, misdiagnosed patients presented more often with normal mental state (100% vs. 35%, p=0.07) and nausea/vomiting (100% vs. 58%, p=0.22). Although patients deteriorated clinically after the initial misdiagnosis, and potentially dangerous diagnostic tests and treatment strategies were instituted as a result of misdiagnosis, none of the misdiagnosed patients died or suffered major permanent harms due to diagnostic delay. Our study is limited by the small number of identified cases. Nevertheless, it appears that patients with cerebellar hemorrhages can present with relatively unimpressive clinical findings without obvious neurological manifestations. Such individuals are sometimes misdiagnosed with gastroenteritis or other benign disorders initially, possibly when neurologic examination, particularly gait testing, is omitted or abridged. A careful search for subtle cerebellar signs, including dysarthria, limb ataxia, nystagmus or tandem gait instability, absent in true gastroenteritis cases, could potentially reduce misdiagnosis.

Short-term results of physiotherapy in patients with newly diagnosed degenerative cervical spine disease.

PubMed

Hey, H W; Lau, P H; Hee, H T

2012-03-01

Degenerative cervical spine diseases are common, and physiotherapy is widely used as an initial form of treatment. We aimed to analyse the effects of the initial sessions of physiotherapy for patients who were newly diagnosed with degenerative cervical spine disorders. A prospective series of 30 patients with newly diagnosed degenerative cervical spine disease were referred to our department and followed up for the initial two sessions of physiotherapy. The patients were assessed after each session. Outcome parameters studied included pain using a visual analogue scale (VAS), neck range of movements and activities of daily living (ADL). Our study subjects comprised mainly females (60%) in their fifties (46.7%) who worked as clerks or secretaries (53.3%). There was an improvement in the patients' pain score (VAS) from a median of 8 to 4 after two visits to the physiotherapists. Slight improvement in the neck range of movements was also observed. Marked improvement was seen in ADL, especially in the ability to carry heavy objects. Physiotherapy is an effective initial option for patients with newly presented degenerative cervical spine disease. The results of this study can be used to advise patients on the short-term benefits of physiotherapy.

Management of fibular hemimelia using the Ilizarov method at Siriraj Hospital in Thailand.

PubMed

Unprasert, Prangthong; Kaewpornsawan, Kamolporn; Chotigavanichaya, Chatupon; Eamsobhana, Perajit

2014-09-01

Fibular hemimelia is one of the most common congenital longitudinal bone deficiencies. Previous treatment protocols called for amputation of the deficient limb; while others made attempts to save the limb. The objective of treatment is to restore function and achieve patient satisfaction. The authors evaluated the outcomes of the Ilizarov technique for the treatment of leg-length discrepancy and bone associated deformities in patients with fibular hemimelia. The present study also evaluated and assessed complications, knee and ankle function, and patient satisfaction with the treatment. Nine patients with fibular hemimelia who underwent tibial lengthening using the Ilizarov method were reviewed in the present study. Initial condition data, including age, gender type offibular hemimelia, initial limb-length discrepancy, predicted limb-length discrepancy, and the data were collected and analyzed. Activity level, patient satisfaction, complications, and residual leg-length discrepancy were assessed at the end of treatment. According to Achterman and Kalamchi classification, there were 4 patients with Type IA, 3 patients with Type IB, and 2 patients with Type II. In Type IA, the affected leg-length discrepancy and mean age at the initial treatment were 3.25 cm and 7.75 years, respectively. In type IB, the affected leg-length discrepancy and mean age at the initial treatment were 5.83 cm and 4.3 years, respectively. In Type II, the affected leg-length discrepancy and mean age at the initial treatment were 5.5 cm and 5 years, respectively. The mean follow-up was 5 years (range: 7-10). The mean lengthening was 7.52 cm (range: 4-13). The lengthening index was 1.28 mo/cm. The mean residual leg-length discrepancy was 0.94 cm. There was ankle joint stiffness and mild equinous foot in type II cases, but patients could walk well without gait aid. No patients were experiencing pain by the end of treatment. All patients expressed satisfaction with this technique. The Ilizarov technique for bone lengthening of the tibia has shown satisfactory results in the treatment of all types of congenital fibular hemimelia and should be considered an attractive alternative to amputation, as measureable functional improvement can be expected.

Effect of clinical decision rules, patient cost and malpractice information on clinician brain CT image ordering: a randomized controlled trial.

PubMed

Gimbel, Ronald W; Pirrallo, Ronald G; Lowe, Steven C; Wright, David W; Zhang, Lu; Woo, Min-Jae; Fontelo, Paul; Liu, Fang; Connor, Zachary

2018-03-12

The frequency of head computed tomography (CT) imaging for mild head trauma patients has raised safety and cost concerns. Validated clinical decision rules exist in the published literature and on-line sources to guide medical image ordering but are often not used by emergency department (ED) clinicians. Using simulation, we explored whether the presentation of a clinical decision rule (i.e. Canadian CT Head Rule - CCHR), findings from malpractice cases related to clinicians not ordering CT imaging in mild head trauma cases, and estimated patient out-of-pocket cost might influence clinician brain CT ordering. Understanding what type and how information may influence clinical decision making in the ordering advanced medical imaging is important in shaping the optimal design and implementation of related clinical decision support systems. Multi-center, double-blinded simulation-based randomized controlled trial. Following standardized clinical vignette presentation, clinicians made an initial imaging decision for the patient. This was followed by additional information on decision support rules, malpractice outcome review, and patient cost; each with opportunity to modify their initial order. The malpractice and cost information differed by assigned group to test the any temporal relationship. The simulation closed with a second vignette and an imaging decision. One hundred sixteen of the 167 participants (66.9%) initially ordered a brain CT scan. After CCHR presentation, the number of clinicians ordering a CT dropped to 76 (45.8%), representing a 21.1% reduction in CT ordering (P = 0.002). This reduction in CT ordering was maintained, in comparison to initial imaging orders, when presented with malpractice review information (p = 0.002) and patient cost information (p = 0.002). About 57% of clinicians changed their order during study, while 43% never modified their imaging order. This study suggests that ED clinician brain CT imaging decisions may be influenced by clinical decision support rules, patient out-of-pocket cost information and findings from malpractice case review. NCT03449862 , February 27, 2018, Retrospectively registered.

Clinical features and outcomes of patients with hepatocellular carcinoma complicated with bile duct invasion.

PubMed

An, Jihyun; Lee, Kwang Sun; Kim, Kang Mo; Park, Do Hyun; Lee, Sang Soo; Lee, Danbi; Shim, Ju Hyun; Lim, Young-Suk; Lee, Han Chu; Chung, Young-Hwa; Lee, Yung Sang

2017-06-01

Little is known about the treatment or outcomes of hepatocellular carcinoma (HCC) complicated with bile duct invasion. A total of 247 consecutive HCC patients with bile duct invasion at initial diagnosis were retrospectively included. The majority of patients had Barcelona Clinic Liver Cancer (BCLC) stage C HCC (66.8%). Portal vein tumor thrombosis was present in 166 (67.2%) patients. Median survival was 4.1 months. Various modalities of treatment were initially employed including surgical resection (10.9%), repeated transarterial chemoembolization (TACE) (42.5%), and conservative management (42.9%). Among the patients with obstructive jaundice (n=88), successful biliary drainage was associated with better overall survival rate. Among the patients with BCLC stage C, overall survival differed depending on the initial treatment for HCC; surgical resection, TACE, systemic chemotherapy, and conservative management showed overall survival rates of 11.5, 6.0 ,2.4, and 1.6 months, respectively. After adjusting for confounders, surgical resection and repeated TACE were significant prognostic factors for HCC patients with bile duct invasion (hazard ratios 0.47 and 0.39, Ps <0.001, respectively). The survival of HCC patients with bile duct invasion at initial diagnosis is generally poor. However, aggressive treatments for HCC such as resection or biliary drainage may be beneficial therapeutic options for patients with preserved liver function.

Tumors masquerading in patients with thyroid eye disease.

PubMed

Griepentrog, Gregory J; Burkat, Cat N; Kikkawa, Don O; Lucarelli, Mark J

2013-08-01

Thyroid eye disease (TED) is the most common cause of proptosis in adults. The external manifestations of TED are characteristic and the diagnosis is typically made without imaging. Although there are multiple descriptions of primary and secondary orbital tumors initially mistaken for TED in the literature, there are limited reports detailing the findings of patients with long-standing TED whom developed an orbital tumor at a later date. Herein, we present a 6-year retrospective multi-center report of three patients with long-standing TED who developed an initially unsuspected orbital or cavernous sinus tumor.

Adult-onset Still's disease initially thought to be an odontogenic infection: A case report.

PubMed

Hino, Shunsuke; Nakamura, Satoshi; Kaneko, Takahiro; Horie, Norio; Shimoyama, Tetsuo

2018-06-01

To present a case of Adult-onset Still's disease (AOSD) initially suspected to be odontogenic inflammation. Adult-onset Still's disease is a rare, complex autoinflammatory disease and a known cause of fever of unknown origin. The patient had both a fever and dental pain. Following meticulous examination, the patient was diagnosed with AOSD. Clinicians should keep in mind that a patient such as AOSD may visit their clinics. © 2018 John Wiley & Sons A/S and The Gerodontology Association. Published by John Wiley & Sons Ltd.

[Gastric perforation caused by primary gastric diffuse large B cell lymphoma].

PubMed

Kim, Ju Seok; Rou, Woo Sun; Ahn, Byung Moo; Moon, Hee Seok; Kang, Sun Hyung; Sung, Jae Kyu; Jeong, Hyun Yong; Song, Kyu-Sang

2015-01-01

Spontaneous gastric perforation is a rare complication of gastric lymphoma that is potentially life threatening since it can progress to sepsis and multi-organ failure. Morbidity also increases due to prolonged hospitalization and delay in initiating chemotherapy. Therefore prompt diagnosis and appropriate treatment is critical to improve prognosis. A 64-year-old man presented to the emergency department with severe abdominal pain. Chest X-ray showed free air below the right diaphragm. Abdominal CT scan also demonstrated free air in the peritoneal cavity with large wall defect in the lesser curvature of gastric lower body. Therefore, the patient underwent emergency operation and primary closure was done. Pathologic specimen obtained during surgery was compatible to diffuse large B cell lymphoma. Fifteen days after primary closure, the patient received subtotal gastrectomy and chemotherapy was initiated after recovery. Patient is currently being followed-up at outpatient department without any particular complications. Herein, we report a rare case of gastric lymphoma that initially presented as peritonitis because of spontaneous gastric perforation.

Payments for acute myocardial infarction episodes-of-care initiated at hospitals with and without interventional capabilities.

PubMed

Ben-Josef, Gal; Ott, Lesli S; Spivack, Steven B; Wang, Changqin; Ross, Joseph S; Shah, Sachin J; Curtis, Jeptha P; Kim, Nancy; Krumholz, Harlan M; Bernheim, Susannah M

2014-11-01

It is unknown whether hospitals with percutaneous coronary intervention (PCI) capability provide costlier care than hospitals without PCI capability for patients with acute myocardial infarction. The growing number of PCI hospitals and higher rate of PCI use may result in higher costs for episodes-of-care initiated at PCI hospitals. However, higher rates of transfers and postacute care procedures may result in higher costs for episodes-of-care initiated at non-PCI hospitals. We identified all 2008 acute myocardial infarction admissions among Medicare fee-for-service beneficiaries by principal discharge diagnosis and classified hospitals as PCI- or non-PCI-capable on the basis of hospitals' 2007 PCI performance. We added all payments from admission through 30 days postadmission, including payments to hospitals other than the admitting hospital. We calculated and compared risk-standardized payment for PCI and non-PCI hospitals using 2-level hierarchical generalized linear models, adjusting for patient demographics and clinical characteristics. PCI hospitals had a higher mean 30-day risk-standardized payment than non-PCI hospitals (PCI, $20 340; non-PCI, $19 713; P<0.001). Patients presenting to PCI hospitals had higher PCI rates (39.2% versus 13.2%; P<0.001) and higher coronary artery bypass graft rates (9.5% versus 4.4%; P<0.001) during index admissions, lower transfer rates (2.2% versus 25.4%; P<0.001), and lower revascularization rates within 30 days (0.15% versus 0.27%; P<0.0001) than those presenting to non-PCI hospitals. Despite higher PCI and coronary artery bypass graft rates for Medicare patients initially presenting to PCI hospitals, PCI hospitals were only $627 costlier than non-PCI hospitals for the treatment of patients with acute myocardial infarction in 2008. © 2014 American Heart Association, Inc.

Epilepsy in children with subacute sclerosing panencephalitis.

PubMed

Jović, Nebojša J

2013-01-01

Subacute sclerosing panencephalitis (SSPE) is a rare, progressive, fatal neurodegenerative disease of childhood and early adolescence caused by defective measles virus. The initial symptoms of SSPE usually involve regression in cognitive functioning and behavior or recurrent myoclonic jerks. Seizures revealing SSPE and epilepsy during the clinical course can occur. The aim of the study was to analyze clinical and EEG characteristics of both initially occurred seizures and epilepsy which developed in the course of the disease. Retrospective study was carried out on 19 children (14 boys, 5 girls) with SSPE diagnosed and treated at our Clinic from 1995 to 2010. Seizures revealed SSPE in our patients aged from 6.5 to 11.5 years (mean 8.6 years). SSPE onset ranged from 4.5 to 16.5 years (mean 10.05). Complete vaccination was performed in nine patients. Cognitive and behavioral decline was preceeded by 6-18 months in two children with intractable focal motor seizures with secondary generalization, one child with complex partial seizures and one with atypical absences. During the clinical course of the disease epilepsy developed in 10 (52.6%) cases, including four patients with seizures as the initial SSPE sign. It occurred mainly in the first year, while in three cases seizures appeared between 1 and 5 years of the disease evolution. Myoclonus was present independently from seizures. No significant inter-group differences were found relating to the type of SSPE progression and history of epilepsy. The only child with fulminant SSPE presented with initial seizures. Favorable seizure control was achieved in 60.0% patients. Intractable epilepsy developed in four patients. Atypical SSPE presentation can include mainly focal intractable seizures. Epilepsy developed during clinical course in 52.6% cases. No significant influence was found of the history of epilepsy on the type of SSPE progression.

Impact of generic antiretroviral therapy (ART) and free ART programs on time to initiation of ART at a tertiary HIV care center in Chennai, India.

PubMed

Solomon, Sunil S; Lucas, Gregory M; Kumarasamy, Nagalingeswaran; Yepthomi, Tokugha; Balakrishnan, Pachamuthu; Ganesh, Aylur K; Anand, Santhanam; Moore, Richard D; Solomon, Suniti; Mehta, Shruti H

2013-08-01

Antiretroviral therapy (ART) access in the developing world has improved, but whether increased access has translated to more rapid treatment initiation among those who need it is unknown. We characterize time to ART initiation across three eras of ART availability in Chennai, India (1996-1999: pregeneric; 2000-2003: generic; 2004-2007: free rollout). Between 1996 and 2007, 11,171 patients registered for care at the YR Gaitonde Centre for AIDS Research and Education (YRGCARE), a tertiary HIV referral center in southern India. Of these, 5726 patients became eligible for ART during this period as per Indian guidelines for initiation of ART. Generalized gamma survival models were used to estimate relative times (RT) to ART initiation by calendar periods of eligibility. Time to initiation of ART among patients in Chennai, India was also compared to an HIV clinical cohort in Baltimore, USA. Median age of the YRGCARE patients was 34 years; 77% were male. The median CD4 at presentation was 140 cells/µl. After adjustment for demographics, CD4 and WHO stage, persons in the pregeneric era took 3.25 times longer (95% confidence interval [CI]: 2.53-4.17) to initiate ART versus the generic era and persons in the free rollout era initiated ART more rapidly than the generic era (RT: 0.73; 95% CI: 0.63-0.83). Adjusting for differences across centers, patients at YRGCARE took longer than patients in the Johns Hopkins Clinical Cohort (JHCC) to initiate ART in the pregeneric era (RT: 4.90; 95% CI: 3.37-7.13) but in the free rollout era, YRGCARE patients took only about a quarter of the time (RT: 0.31; 95% CI: 0.22-0.44). These data demonstrate the benefits of generic ART and government rollouts on time to initiation of ART in one developing country setting and suggests that access to ART may be comparable to developed country settings.

Heart failure diagnosis in acute conditions has high agreement with inpatient diagnosis.

PubMed

Seronde, Marie-France; Laribi, Said; Collins, Sean P; Deye, Nicolas; Logeart, Damien; Plaisance, Patrick; Cohen-Solal, Alain; Mebazaa, Alexandre

2016-06-01

Acute heart failure (AHF) is frequently encountered in the emergency department (ED) or in the cardiac care unit (CCU)/ICU. Discrimination between cardiac and noncardiac cause of dyspnea by clinical means and standard testing is sometimes inadequate. The aim of our study was to assess AHF diagnosis agreement as determined by: (a) the attending physician, (b) the hospital discharge diagnosis, and (c) an adjudication committee. Between 2010 and 2011, consecutive patients arriving for dyspnea in our hospital were prospectively included. A convenience sample of patients was enrolled in this analysis. Patients were admitted through the ED (280 patients) or through CCU/ICU (112 patients) for undifferentiated dyspnea. Overall, few differences were observed between the initial diagnosis and the hospital discharge diagnosis or the adjudicated diagnosis. Among the 200 patients with an initial diagnosis of AHF, hospital discharge diagnosis confirmed AHF (alone or combined) in 191 (95.5%) patients and the adjudication committee confirmed AHF (alone or combined) in 196 (98%) patients. Our study showed considerable agreement between different AHF diagnostic standards. An initial AHF diagnosis on the basis of clinical signs and biological parameters utilizing B-type natriuretic peptide testing has high agreement and accuracy with the hospital discharge and adjudicated diagnosis of AHF. The present study also shows that the accuracy of the initial AHF diagnosis allows rapid inclusion in AHF trials. These results, if confirmed in a broader cohort of patients, suggest that the initial ED diagnosis is highly accurate and reliable to guide further inpatient management.

Leadership, safety climate, and continuous quality improvement: impact on process quality and patient safety.

PubMed

McFadden, Kathleen L; Stock, Gregory N; Gowen, Charles R

2014-10-01

Successful amelioration of medical errors represents a significant problem in the health care industry. There is a need for greater understanding of the factors that lead to improved process quality and patient safety outcomes in hospitals. We present a research model that shows how transformational leadership, safety climate, and continuous quality improvement (CQI) initiatives are related to objective quality and patient safety outcome measures. The proposed framework is tested using structural equation modeling, based on data collected for 204 hospitals, and supplemented with objective outcome data from the Centers for Medicare and Medicaid Services. The results provide empirical evidence that a safety climate, which is connected to the chief executive officer's transformational leadership style, is related to CQI initiatives, which are linked to improved process quality. A unique finding of this study is that, although CQI initiatives are positively associated with improved process quality, they are also associated with higher hospital-acquired condition rates, a measure of patient safety. Likewise, safety climate is directly related to improved patient safety outcomes. The notion that patient safety climate and CQI initiatives are not interchangeable or universally beneficial is an important contribution to the literature. The results confirm the importance of using CQI to effectively enhance process quality in hospitals, and patient safety climate to improve patient safety outcomes. The overall pattern of findings suggests that simultaneous implementation of CQI initiatives and patient safety climate produces greater combined benefits.

Leadership, safety climate, and continuous quality improvement: impact on process quality and patient safety.

PubMed

McFadden, Kathleen L; Stock, Gregory N; Gowen, Charles R

2015-01-01

Successful amelioration of medical errors represents a significant problem in the health care industry. There is a need for greater understanding of the factors that lead to improved process quality and patient safety outcomes in hospitals. We present a research model that shows how transformational leadership, safety climate, and continuous quality improvement (CQI) initiatives are related to objective quality and patient safety outcome measures. The proposed framework is tested using structural equation modeling, based on data collected for 204 hospitals, and supplemented with objective outcome data from the Centers for Medicare and Medicaid Services. The results provide empirical evidence that a safety climate, which is connected to the chief executive officer's transformational leadership style, is related to CQI initiatives, which are linked to improved process quality. A unique finding of this study is that, although CQI initiatives are positively associated with improved process quality, they are also associated with higher hospital-acquired condition rates, a measure of patient safety. Likewise, safety climate is directly related to improved patient safety outcomes. The notion that patient safety climate and CQI initiatives are not interchangeable or universally beneficial is an important contribution to the literature. The results confirm the importance of using CQI to effectively enhance process quality in hospitals, and patient safety climate to improve patient safety outcomes. The overall pattern of findings suggests that simultaneous implementation of CQI initiatives and patient safety climate produces greater combined benefits.

Predicting Likelihood of Surgery Prior to First Visit in Patients with Back and Lower Extremity Symptoms: A simple mathematical model based on over 8000 patients.

PubMed

Boden, Lauren M; Boden, Stephanie A; Premkumar, Ajay; Gottschalk, Michael B; Boden, Scott D

2018-02-09

Retrospective analysis of prospectively collected data. To create a data-driven triage system stratifying patients by likelihood of undergoing spinal surgery within one year of presentation. Low back pain (LBP) and radicular lower extremity (LE) symptoms are common musculoskeletal problems. There is currently no standard data-derived triage process based on information that can be obtained prior to the initial physician-patient encounter to direct patients to the optimal physician type. We analyzed patient-reported data from 8006 patients with a chief complaint of LBP and/or LE radicular symptoms who presented to surgeons at a large multidisciplinary spine center between September 1, 2005 and June 30, 2016. Univariate and multivariate analysis identified independent risk factors for undergoing spinal surgery within one year of initial visit. A model incorporating these risk factors was created using a random sample of 80% of the total patients in our cohort, and validated on the remaining 20%. The baseline one-year surgery rate within our cohort was 39% for all patients and 42% for patients with LE symptoms. Those identified as high likelihood by the center's existing triage process had a surgery rate of 45%. The new triage scoring system proposed in this study was able to identify a high likelihood group in which 58% underwent surgery, which is a 46% higher surgery rate than in non-triaged patients and a 29% improvement from our institution's existing triage system. The data-driven triage model and scoring system derived and validated in this study (Spine Surgery Likelihood model [SSL-11]), significantly improved existing processes in predicting the likelihood of undergoing spinal surgery within one year of initial presentation. This triage system will allow centers to more selectively screen for surgical candidates and more effectively direct patients to surgeons or non-operative spine specialists. 4.

Prognosis of patients in coma after acute subdural hematoma due to ruptured intracranial aneurysm.

PubMed

Torné, Ramon; Rodríguez-Hernández, Ana; Romero-Chala, Fabián; Arikan, Fuat; Vilalta, Jordi; Sahuquillo, Juan

2016-04-01

Acute subdural hematomas (aSDH) secondary to intracranial aneurysm rupture are rare. Most patients present with coma and their functional prognosis has been classically considered to be very poor. Previous studies mixed good-grade and poor-grade patients and reported variable outcomes. We reviewed our experience by focusing on patients in coma only and hypothesized that aSDH might worsen initial mortality but not long-term functional outcome. Between 2005 and 2013, 440 subarachnoid hemorrhage (SAH) patients were admitted to our center. Nineteen (4.3%) were found to have an associated aSDH and 13 (2.9%) of these presented with coma. Their prospectively collected clinical and outcome data were reviewed and compared with that of 104 SAH patients without aSDH who presented with coma during the same period. Median aSDH thickness was 10mm. Four patients presented with an associated aneurysmal cortical laceration and only one had good recovery. Overall, we observed good long-term outcomes in both SAH patients in coma with aSDH and those without aSDH (38.5% versus 26.4%). Associated aSDH does not appear to indicate a poorer long-term functional prognosis in SAH patients presenting with coma. Anisocoria and brain herniation are observed in patients with aSDH thicknesses that are smaller than those observed in trauma patients. Despite a high initial mortality, early surgery to remove the aSDH results in a good outcome in over 60% of survivors. Aneurysmal cortical laceration appears to be an independent entity which shows a poorer prognosis than other types of aneurysmal aSDH. Copyright © 2015 Elsevier Ltd. All rights reserved.

Cardiac Injury After All-Terrain Vehicle Accidents in 2 Children and a Review of the Literature.

PubMed

Ngo, Kimberly D; Pian, Phillip; Hanfland, Robert; Nichols, Christopher S; Merritt, Glenn R; Campbell, David; Ing, Richard J

2016-07-01

All-terrain vehicle (ATV) accidents leading to severe morbidity and mortality are common. At our institution, 2 children presented within weeks of each other after ATV accidents. Both children required cardiac valve surgery. The surgical management of these 2 children is discussed, and the literature is reviewed. On initial patient presentation, the diagnosis of a ruptured cardiac valve or ventricular septal defect (VSD) associated with these types of accidents is often delayed. We propose that patients presenting with evidence of high-energy blunt thoracic trauma after an ATV accident should undergo an electrocardiogram, cardiac enzyme assessment, and cardiac echocardiogram as part of the initial work-up to rule out significant myocardial injury.

Mortality outcomes of ruptured abdominal aortic aneurysms and rural presentation.

PubMed

Munday, Emily; Walker, Stuart

2016-10-01

Centralisation of vascular surgery services has coincided with a move towards endovascular repair of ruptured abdominal aortic aneurysms with the goal to improve patient outcomes. The aim of this study was to assess the effect of rural presentation and transfer times on survival from ruptured abdominal aortic aneurysm. A retrospective review. All patients presenting with ruptured abdominal aortic aneurysm to public hospitals in Tasmania between July 2006 and April 2013. Demographic data, Glasgow aneurysm score, Hardman index, transfer times, operative technique and 30-day mortality were collected from medical records. Over the study period 127 patients presented to public hospitals in Tasmania with ruptured abdominal aortic aneurysm. A total of 27 presented to north west hospitals where no vascular surgery service is provided (NWRH), 23 to a northern hospital where an intermittent vascular surgery service is provided (LGH) and 77 to the state tertiary vascular surgery service (RHH). Of these, 4 (14.8%) died at NWRH, 6 (26.1%) died at LGH and 43 (55.8%) died at RHH without operation. Of the 35 patients transferred from NWRH and LGH to RHH, 5 died without operation. Median time from presentation to theatre at RHH if transferred from NWRH was 6.25 hours, from the LGH 4.75 hours, compared to 2.75 hours when presenting directly to RHH. Open repair was performed in 41 patients and endovascular repair in 23 patients. Overall 30-day mortality in those treated at RHH was 26.6% (39.0% for open repair, 4.3% for endovascular repair). Mortality for intended operative patients initially presenting to non-RHH hospitals was 33.3% vs. 32.3% for those initially presenting to RHH. p Value 0.93. There was no clinical or statistical disadvantage to rural presentation and transfer for patients presenting with ruptured abdominal aortic aneurysm in Tasmania. Endovascular repair has a role despite long transfer times. © The Author(s) 2015.

Rhabdomyolysis Secondary to Clenbuterol Use and Exercise.

PubMed

Grimmer, Nicole M; Gimbar, Renee Petzel; Bursua, Adam; Patel, Meet

2016-02-01

The literature regarding rhabdomyolysis secondary to illicit drug use is sparse. Clenbuterol is a bronchodilator approved for veterinary use, which in high doses can increase protein deposition and lipolysis similarly to anabolic steroids, and is thereby abused for bodybuilding and weight loss effects. Clenbuterol has previously been described in case reports to be cardiotoxic, with patient presentations similar to overdoses of sympathomimetic substances, but reports of rhabdomyolysis are limited to a single case series in horses. We report the first case of rhabdomyolysis secondary to clenbuterol in a human. Our patient used clenbuterol for muscle-building effects in addition to exercise for multiple days prior to presentation. The patient's chief complaint at Emergency Department (ED) presentation was discolored urine. Workup for rhabdomyolysis was initiated, and an initial creatine kinase was measured at 122,933 units/L. Our patient's rhabdomyolysis was successfully treated with supportive therapy, and the patient was eventually discharged to home with no identifiable disability. The patient's kidney function remained at baseline, and no acute kidney injury was experienced secondary to rhabdomyolysis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Patients presenting to the ED may have been unintentionally exposed through cutting of illicit substances or through intentional use in bodybuilding. Clenbuterol has well-described cardiotoxic effects, and we report the additional toxicity of rhabdomyolysis with its use. Copyright © 2016 Elsevier Inc. All rights reserved.

PubMed

Borges, D P; Santos, A W A; Magalhaes, S M M; Sidrim, J J; Rocha, M F G; Cordeiro, R A; Brilhante, R S N; Bandeira, S P; Valença Junior, J T; Pinheiro, R F

2018-06-01

Severely immunocompromised patients are at increased risk for uncommon infectious diseases with atypical presentations. Fusarium sp., has been reported in patients with hematological malignancies and prompt diagnosis is necessary due to high mortality. We report a myelodysplastic syndrome (MDS) patient who presented Fusarium solani infection associated with granulocytic sarcoma as an initial presentation of acute myeloid leukemia (AML) transformation. We performed histological examination, immunohistochemistry analysis, culture of the biopsy tissue and DNA sequencing to make a conclusive diagnosis of F. solani and granulocytic sarcoma, reinforcing the necessity of performing complete evaluation of skin lesions in immunocompromised patients. Copyright © 2018 Elsevier Masson SAS. All rights reserved.

Choosing Wisely: A Neurosurgical Perspective on Neuroimaging for Headaches

PubMed Central

Hawasli, Ammar H.; Chicoine, Michael R.; Dacey, Ralph G.

2016-01-01

Multiple national initiatives seek to curb spending in order to address increasing health care costs in the United States. The Choosing Wisely® initiative is one popular initiative that focuses on reducing health care spending by setting guidelines to limit tests and procedures requested by patients and ordered by physicians. To reduce spending on neuroimaging, the Choosing Wisely® initiative and other organizations have offered guidelines to limit neuroimaging for headaches. Although the intentions are laudable, these guidelines are inconsistent with the neurosurgeon’s experience with brain tumor patients. If adopted by governing or funding organizations, these guidelines threaten to negatively impact the care and outcomes of patients with brain tumors, who frequently present with minimal symptoms or isolated headaches syndromes. As we grapple with the difficult conflict between evidence-based cost-cutting guidelines and individualized patient-tailored medicine, a physician must carefully balance the costs and benefits of discretionary services such as neuroimaging for headaches. By participating in the development of validated clinical decision rules on neuroimaging for headaches, neurosurgeons can advocate for their patients and improve their patients’ outcomes. PMID:25255253

Periodontal treatment in a generalized severe chronic periodontitis patient: A case report with 7-year follow-up.

PubMed

Agrali, Omer Birkan; Kuru, Bahar Eren

2015-01-01

The aim of the periodontal treatment is to provide healthy and functional dentition all through a lifetime. In this report, periodontal treatment of a 42-year-old male patient with generalized severe chronic periodontitis is presented. He received initial periodontal treatment together with adjunctive antimicrobials. The devital teeth were endodontically treated, and free gingival grafts were placed at the inadequate keratinized tissue zones before regenerative surgery. Following the surgical treatment using enamel matrix derivatives and xenogenic bone graft combination, the patient was put on a strict recall program. After 12 months, favorable clinical and radiographical improvements were obtained. The 7-year maintenance of the present case with several initially hopeless teeth has been shown and discussed in this report. It can be concluded that optimum oral hygiene level as well as the positive cooperation of the patient enhanced the success of periodontal treatment results even in extremely severe periodontal destruction.

Lightning can strike twice: an unlucky patient of neurological interest.

PubMed

Gilbee, Ebony S

2013-06-24

Poliomyelitis, once a worldwide epidemic, is becoming increasingly rare owing to the introduction of the polio vaccine in the 1950s. It is estimated that the number of cases of polio has reduced by 99% since the Global Polio Eradication Initiative (GPEI) started in 1988. Amyotrophic lateral sclerosis (ALS) is another relatively uncommon condition which also affects anterior horn cells with debilitating neurological, and deadly, consequences. An unusual case of an aggressive form of ALS developing in a 72-year-old patient with paralytic poliomyelitis in childhood is presented. Her initial presentation was puzzling, and our approach to the diagnostic dilemma is discussed.

Lightning can strike twice: an unlucky patient of neurological interest

PubMed Central

Gilbee, Ebony S

2013-01-01

Poliomyelitis, once a worldwide epidemic, is becoming increasingly rare owing to the introduction of the polio vaccine in the 1950s. It is estimated that the number of cases of polio has reduced by 99% since the Global Polio Eradication Initiative (GPEI) started in 1988. Amyotrophic lateral sclerosis (ALS) is another relatively uncommon condition which also affects anterior horn cells with debilitating neurological, and deadly, consequences. An unusual case of an aggressive form of ALS developing in a 72-year-old patient with paralytic poliomyelitis in childhood is presented. Her initial presentation was puzzling, and our approach to the diagnostic dilemma is discussed. PMID:23814000

Emergencies in Hematology and Oncology.

PubMed

Halfdanarson, Thorvardur R; Hogan, William J; Madsen, Bo E

2017-04-01

The development of medical emergencies related to the underlying disease or as a result of complications of therapy are common in patients with hematologic or solid tumors. These oncological emergencies can occur as an initial presentation or in a patient with an established diagnosis and are encountered in all medical care settings, ranging from primary care to the emergency department and various subspecialty environments. Therefore, it is critically important that all physicians have a working knowledge of the potential oncological emergencies that may present in their practice and how to provide the most effective care without delay. This article reviews the most common oncological emergencies and provides practical guidance for initial management of these patients. Copyright © 2017 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.

Aspergillus vertebral osteomyelitis and epidural abscess.

PubMed

Tew, C W; Han, F C; Jureen, R; Tey, B H

2009-04-01

We present the first reported case of Aspergillus vertebral osteomyelitis and epidural abscess in Singapore in a 50-year-old man with post-tuberculous bronchiectasis. The patient presented with acute urinary retention and flaccid paraplegia. Despite surgical debridement and treatment with voriconazole, the patient developed multiorgan failure and died two weeks after presentation. Early diagnosis and prompt initiation of treatment are emphasised in the hope of improving the outcome of this aggressive condition.

Subsequent pancreatitis and haemothorax in a patient of expanded dengue syndrome.

PubMed

Anam, Ahmad Mursel; Rabbani, Raihan; Shumy, Farzana; Polash, M Mufizul Islam

2016-01-01

We report a case of expanded dengue syndrome, where two different presentations occurred subsequently. A patient of dengue haemorrhagic fever initially was admitted with acute pancreatitis, complicated with left pancreatic effusion, but later on, during resolution of pancreatitis and effusion, developed spontaneous right haemothorax. Such presentations, besides being rare themselves, have not been reported to occur subsequently, in the same patient, during the same disease process. © The Author(s) 2015.

Malformations of cortical development: clinical spectrum in a series of 101 patients and review of the literature (Part I).

PubMed

Güngör, Serdal; Yalnizoğlu, Dilek; Turanli, Güzide; Saatçi, Işil; Erdoğan-Bakar, Emel; Topçu, Meral

2007-01-01

Patients with malformations of cortical development (MCD) present with a wide spectrum of clinical manifestations ranging from asymptomatic cases to those with epilepsy and neurodevelopmental problems. Thorough clinical delineation of patients with MCD may provide clues for future phenotype-genotype correlation studies. We studied clinical features of patients with MCD, including developmental risk factors and family history. We evaluated 10 patients with MCD at Hacettepe University Children's Hospital, Department of Pediatric Neurology. All patients underwent neurological evaluation with detailed medical and family history, and neuropsychological evaluation. Routine EEG and MRI were obtained. The patients were between 1 month and 19 years of age (mean: 6.1 +/- 4.4 years). Fifty-four patients were diagnosed with polymicrogyria (PMG), 23 patients with lissencephaly, 12 patients with schizencephaly, and 12 patients with heterotopia. Parents were relatives in 31.7% of the cases; consanguinity was most common in patients with lissencephaly and other MCDs with diffuse/bilateral involvement. Initial clinical presentation was seizures in 61.4% of the cases, developmental delays in 12.9%, and microcephaly in 9.9%. Neurological evaluation revealed most severe abnormalities in patients with lissencephaly, and relatively better outcome in patients with heterotopias. Cognitive functions were better in patients with heterotopias compared to other groups. Overall, 71.3% of patients ha epilepsy. In conclusion, initial presentation and clinical course of patients with MCD are variable and seem to be correlated with the extent of cortical involvement. Epilepsy and mental retardation are the most common problems. The most severe clinical outcome was seen in patients with lissencephaly.

Electrocardiographic Indicators of Acute Coronary Syndrome are More Common in Patients with Ambulance Transport Compared to Those who Self-Transport to the Emergency Department Journal of Electrocardiology

PubMed Central

Pickham, David; Pelter, Michele M

2016-01-01

Introduction The American Heart Association recommends individuals with symptoms suggestive of acute coronary syndrome (ACS) activate the Emergency Medical Services’ (EMS) 911 system for ambulance transport to the emergency department (ED), which enables treatment to begin prior to hospital arrival. Despite this recommendation, the majority of patients with symptoms suspicious of ACS continue to self-transport to the ED. The IMMEDIATE AIM study was a prospective study that enrolled individuals who presented to the ED with ischemic symptoms. Objectives The purpose of this secondary analysis was to determine differences in patients presenting the ED for possible ACS who arrive by ambulance versus self-transport on: 1) Time-to-initial hospital electrocardiogram (ECG), 2) presence of ischemic ECG changes, and 3) patient characteristics. Methods Initial 12-lead ECGs acquired upon patient arrival to the ED were evaluated for ST-elevation, ST-depression, and T-wave inversion. ECG signs of ischemia were analyzed both individually and collapsed into an independent dichotomous variable (ED ECG ischemia yes/no) for statistical analysis. Patient characteristics tested included: gender, age, race, ethnicity, English speaking, living alone, mode of transport, and presenting symptoms (chest pain, jaw pain, shortness of breath, nausea/vomiting, syncope, and clinical history). Results In 1299 patients (mean age 63.9, 46.7% male), 384 (29.6%) patients arrived by ambulance to the ED. The mean time-to-initial ECG was 47 minutes for ambulance patients versus 53 minutes for self-transport patients (p<0.001). Mode of transport was found to be an independent predictor for time-to-initial ECG controlling for age, gender, and race (p=0.004). There were significantly higher rates of ECG changes of ischemia for patients who arrived by ambulance versus self-transport (p=0.02), and patient characteristics differed by mode of transport to the ED. Discussion Our findings indicate that less than 30% of individuals with symptoms of ACS activate the EMS ‘911’ system for ambulance transport to the ED. Individuals more likely to activate 911 have timelier ECG but higher rates of ischemic changes, specifically ST-depression and T-wave inversion. Individuals least likely to activate 911 are women, younger individuals, Latino ethnicity, live with a significant other, and those experiencing chest or jaw pain. PMID:27614946

Serial electrophysiological findings in Guillain-Barré syndrome not fulfilling AIDP or AMAN criteria.

PubMed

Hosokawa, Takafumi; Nakajima, Hideto; Unoda, Kiichi; Yamane, Kazushi; Doi, Yoshimitsu; Ishida, Shimon; Kimura, Fumiharu; Hanafusa, Toshiaki

2016-09-01

Guillain-Barré syndrome (GBS) is categorized into two major subtypes: acute inflammatory demyelinating polyneuropathy (AIDP) and acute motor axonal neuropathy (AMAN). However, a proportion of patients are electrophysiologically unclassified because of electrophysiological findings that do not fulfil AIDP or AMAN criteria, and underlying pathophysiological mechanisms and lesion distributions of unclassified patients are not well defined. The aims of this study are to elucidate disease pathophysiology and lesion distribution in unclassified patients. We retrospectively studied 48 consecutive GBS patients. Patients were classified on the basis of initial electrophysiological findings according to Ho's criteria. Clinical and serial electrophysiological examinations of unclassified patients were conducted. Twelve (25 %) GBS patients were unclassified. All unclassified patients were able to walk independently at 21 days after onset. No unclassified patients, except one patient with diabetes mellitus, had sensory nerve involvement. Eight patients underwent a follow-up study within 15 days of the initial study. Distal motor latencies (DMLs) of the left median motor nerve were found to be significantly and uniformly decreased compared with initial studies (p = 0.008). DMLs (p < 0.0001) and distal compound action potential (CMAP) durations (p = 0.002) of all nerves were significantly decreased, and distal CMAP amplitudes (p = 0.026) significantly increased compared with initial studies. In unclassified GBS patients, DML values during initial electrophysiological studies would be prolonged compared with expected values in the same patient unaffected by GBS and later improve rapidly with increased distal CMAP amplitudes without the development of excessive temporal dispersions. Lesions are also present in distal nerve segments caused by reversible conduction failure.

Ethnographic Observational Study of the Biologic Initiation Conversation Between Rheumatologists and Biologic-Naive Rheumatoid Arthritis Patients.

PubMed

Kottak, Nicholas; Tesser, John; Leibowitz, Evan; Rosenberg, Melissa; Parenti, Dennis; DeHoratius, Raphael

2018-01-30

This ethnographic market research study investigated the biologic initiation conversation between rheumatologists and biologic-naive patients with rheumatoid arthritis to assess how therapy options, particularly mode of administration, were discussed. Consenting rheumatologists (n = 16) and patients (n = 48) were videotaped during medical visits and interviewed by a trained ethnographer. The content, structure, and timing of conversations regarding biologic initiation were analyzed. The mean duration of physician-patient visits was approximately 15 minutes; biologic therapies were discussed for a mean of 5.6 minutes. Subcutaneous (SC) and intravenous (IV) therapy options were mentioned in 45 and 35 visits, respectively, out of a total of 48 visits. All patients had some familiarity with SC administration, but nearly half of patients (22 of 48) were unfamiliar with IV therapy going into the visit. IV administration was not defined or described by rheumatologists in 77% of visits (27 of 35) mentioning IV therapy. Thus, 19 of 22 patients who were initially unfamiliar with IV therapy remained unfamiliar after the visit. Disparities in physician-patient perceptions were revealed, as all rheumatologists (16 of 16) believed IV therapy would be less convenient than SC therapy for patients, while 46% of patients (22 of 48) felt this way. In post-visit interviews, some patients seemed confused and overwhelmed, particularly when presented with many treatment choices in a visit. Some patients stated they would benefit from visual aids or summary sheets of key points. This study revealed significant educational opportunities to improve the biologic initiation conversation and indicated a disparity between patients' and rheumatologists' perception of IV therapy. © 2018 The Authors. Arthritis Care & Research published by Wiley Periodicals, Inc. on behalf of American College of Rheumatology.

Incidence and predictors of herpes zoster among antiretroviral therapy-naïve patients initiating HIV treatment in Johannesburg, South Africa

PubMed Central

Maskew, Mhairi; Ajayi, Toyin; Berhanu, Rebecca; Majuba, Pappie; Sanne, Ian; Fox, Matthew P.

2014-01-01

Summary Objectives To describe the characteristics of HIV-infected patients experiencing herpes zoster after antiretroviral therapy (ART) initiation and to describe the incidence and predictors of a herpes zoster diagnosis. Methods Adult patients initiating ART from April 2004 to September 2011 at the Themba Lethu Clinic in Johannesburg, South Africa were included. Patients were followed from ART initiation until the date of first herpes zoster diagnosis, or death, transfer, loss to follow-up, or dataset closure. Herpes zoster is described using incidence rates (IR) and predictors of herpes zoster are presented as subdistribution hazard ratios (sHR) and 95% confidence intervals (95% CI). Results Fifteen thousand and twenty-five patients were included; 62% were female, the median age was 36.6 years, and the median baseline CD4 count was 98 cells/mm3. Three hundred and forty patients (2.3%) experienced herpes zoster in a median of 26.1 weeks after ART initiation. Most (71.5%) occurred within 1 year of initiation, for a 1-year IR of 18.1/1000 person-years. In an adjusted model, patients with low CD4 counts (<50 vs. ≥200 cells/mm3; sHR: 1.71, 95% CI: 1.21–2.47) and with a prior episode of herpes zoster (sHR: 1.53, 95% CI: 0.97–2.28) were at increased risk of incident herpes zoster. Conclusions While only 2% of patients were diagnosed with herpes zoster in this cohort, patients with low CD4 counts and those with prior episodes of herpes zoster were at higher risk for a herpes zoster diagnosis. PMID:24680820

Addison's Disease in Evolution: An Illustrative Case and Literature Review.

PubMed

Hinz, Laura E; Kline, Gregory A; Dias, Valerian C

2014-09-01

To present a case of symptomatic autoimmune adrenal insufficiency with initially normal serum cortisol and to caution about limitations of the current diagnostic algorithm for adrenal insufficiency, which does not reflect the pathophysiology of early disease. We describe the clinical presentation and relevant investigations of a patient ultimately found to have Addison's disease, which is followed by a focused review of the literature. A 41-year-old Caucasian woman with autoimmune hypothyroidism, premature ovarian failure, and microscopic colitis presented with nausea, salt craving, increased skin pigmentation, and postural hypotension. Initial bloodwork revealed a normal morning cortisol of level of 19.2 μg/dL (normal, 7.2 to 25 μg/dL) but an adrenocorticotropic hormone (ACTH) level 10 times normal, at 513.6 pg/mL (normal, <52.5 pg/mL). Her potassium was normal, but her aldosterone level was 4.12 ng/dL (normal, 12.3 to 62.5 ng/dL) and her renin activity was increased (23.0 mg/dL/hour; normal, <6.0 mg/dL/hour). Six weeks after initial presentation, she was found to have anti-adrenal antibodies. It was not until 10 weeks after her initial symptomatic presentation that her morning cortisol level was found to be subnormal and a formal diagnosis of adrenal insufficiency was made. The present case and literature review reveal that common diagnostic approaches will miss patients with (possibly symptomatic) early adrenal insufficiency. We suggest that serum ACTH level testing or tests of mineralocorticoid function be included in the initial step of investigation for suspected primary adrenal insufficiency.

Characterization of Patients with Amyotrophic Lateral Sclerosis attending the Muscular Dystrophy Association-Supported Clinics in Puerto Rico.

PubMed

Deliz, Brenda; Ramos, Kathya; Pérez, Cynthia M

2018-03-01

To evaluate the sociodemographic characteristics and clinical and functional profile of amyotrophic lateral sclerosis (ALS) patients evaluated at Puerto Rico's Muscular Dystrophy Association-supported (MDA) clinics. A retrospective review of 76 medical records of ALS patients evaluated at any of four MDA-sponsored clinics in Puerto Rico. The mean age of diagnosis was 57.4 ± 11.1 yrs. Most of the patients (52.3%) were women. The majority of the cases were sporadic (48.7%). Over 40% of the patients were diagnosed at one year or earlier. Patients with initial upper extremity involvement (63.2%) were diagnosed earlier (≤ 6 months) than any of the others. The most common presentation of the disease overall was lower extremity weakness (34.2%), which was followed by a bulbar presentation (31.6%). There was a marked difference between men and women in disease presentation, with bulbar involvement in 75% of the women. This study characterized a sample of ALS patients in Puerto Rico who are receiving services at the MDA-sponsored clinics. Puerto Rican patients have similarities with published data from the United States and other countries, including: sporadic pattern, initial symptoms in extremities, and time to diagnosis. Major differences are that the disease was more common in women than in men and that a higher than expected percentage of patients presented with bulbar onset. This may partly account for the overall predominance of the disease in women over men as found in our study, since the bulbar presentation has been reported to be more common in women. Studies with a greater number of patients are needed to determine whether our findings are reproducible. This study will serve as a basis for designing future analytic studies regarding etiology or the factors that might modulate disease progression.

Creatinine as predictor value of mortality and acute kidney injury in rhabdomyolysis.

PubMed

Baeza-Trinidad, R; Brea-Hernando, A; Morera-Rodriguez, S; Brito-Diaz, Y; Sanchez-Hernandez, S; El Bikri, L; Ramalle-Gomara, E; Garcia-Alvarez, J L

2015-11-01

Rhabdomyolysis (RB) is a syndrome characterised by decomposition of skeletal muscle that could be life threatening, so the identification of biomarkers of its severity could help us in its treatment. Creatine kinase (CK) is usually taken as a reference in patients with RB in order to stratify prognosis, however that is not probably the most effective parameter. The present study was designed to analyse the specific features and mortality of patients with RB and the relation between creatinine, CK and mortality. Retrospective cohort analysis among patients admitted to San Pedro Hospital in Logroño (Spain) with RB (CK levels higher than 2000 U/L) diagnosed since 1 January 2009 until 31 December 2; 013 522 patients with RB patients diagnosed of RB were collected. The aetiology and the analytical feature (creatinine, CK, calcium, phosphorus, pH and bicarbonate), as well as 30-year mortality, were investigated. Among the 522 patients, there were 138 deaths. Four patients required renal replacement therapy. The most common cause of RB was trauma (29%). Infectious aetiology had the highest mortality (41.2%). The median CK was 3451 u/L (interquartile range 3348), and the mean creatinine at admission was 132.6 umol/L (±110.5). Initial CK levels do not have predictive ability on mortality or renal dysfunction in contrast to initial creatinine values. Each state of acute kidney injury (AKI) increased mortality compared with those who have not presented this renal dysfunction (P < 0.0001). Age, calcium, phosphorus, bicarbonate and pH are associated with AKI. Despite being a diagnostic marker for RB, initial CK levels do not predict mortality. However, creatinine initial levels are related to progression to acute renal injury and mortality at 30 days. © 2015 Royal Australasian College of Physicians.

Economic Evaluation of Urgent-Start Peritoneal Dialysis Versus Urgent-Start Hemodialysis in the United States

PubMed Central

Liu, Frank Xiaoqing; Ghaffari, Arshia; Dhatt, Harman; Kumar, Vijay; Balsera, Cristina; Wallace, Eric; Khairullah, Quresh; Lesher, Beth; Gao, Xin; Henderson, Heather; LaFleur, Paula; Delgado, Edna M.; Alvarez, Melissa M.; Hartley, Janett; McClernon, Marilyn; Walton, Surrey; Guest, Steven

2014-01-01

Abstract Patients presenting late in the course of kidney disease who require urgent initiation of dialysis have traditionally received temporary vascular catheters followed by hemodialysis. Recent changes in Medicare payment policy for dialysis in the USA incentivized the use of peritoneal dialysis (PD). Consequently, the use of more expeditious PD for late-presenting patients (urgent-start PD) has received new attention. Urgent-start PD has been shown to be safe and effective, and offers a mechanism for increasing PD utilization. However, there has been no assessment of the dialysis-related costs over the first 90 days of care. The objective of this study was to characterize the costs associated with urgent-start PD, urgent-start hemodialysis (HD), or a dual approach (urgent-start HD followed by urgent-start PD) over the first 90 days of treatment from a provider perspective. A survey of practitioners from 5 clinics known to use urgent-start PD was conducted to provide inputs for a cost model representing typical patients. Model inputs were obtained from the survey, literature review, and available cost data. Sensitivity analyses were also conducted. The estimated per patient cost over the first 90 days for urgent-start PD was $16,398. Dialysis access represented 15% of total costs, dialysis services 48%, and initial hospitalization 37%. For urgent-start HD, total per patient costs were $19,352, and dialysis access accounted for 27%, dialysis services 42%, and initial hospitalization 31%. The estimated cost for dual patients was $19,400. Urgent-start PD may offer a cost saving approach for the initiation of dialysis in eligible patients requiring an urgent-start to dialysis. PMID:25526471

Vascular Physiology according to Clinical Scenario in Patients with Acute Heart Failure: Evaluation using the Cardio-Ankle Vascular Index.

PubMed

Goto, Toshihiko; Wakami, Kazuaki; Mori, Kento; Kikuchi, Shohei; Fukuta, Hidekatsu; Ohte, Nobuyuki

2016-09-01

Increased aortic stiffness may be an important cause of acute heart failure (AHF). Clinical scenario (CS), which classifies the pathophysiology of AHF based on the initial systolic blood pressure (sBP), was proposed to provide the most appropriate therapy for AHF patients. In CS, elevated aortic stiffness, vascular failure, has been considered as a feature of patients categorized as CS1 (sBP > 140 mmHg at initial presentation). However, whether elevated aortic stiffness, vascular failure, is present in such patients has not been fully elucidated. Therefore, we assessed aortic stiffness in AHF patients using the cardio-ankle vascular index (CAVI), which is considered to be independent of instantaneous blood pressure. Sixty-four consecutive AHF patients (mean age, 70.6 ± 12.8 years; 39 men) were classified with CS, based on their initial sBP: CS1: sBP > 140 mmHg (n = 29); CS2: sBP 100-140 mmHg (n = 22); and CS3: sBP < 100 mmHg (n = 13). There were significant group differences in CAVI (CS1 vs. CS2 vs. CS3: 9.7 ± 1.4 vs. 8.4 ± 1.7 vs. 8.3 ± 1.7, p = 0.006, analysis of variance). CAVI was significantly higher in CS1 than in CS2 (p = 0.02) and CS3 (p = 0.04). CAVI did not significantly correlate with sBP at the time of measurement of CAVI (r = 0.24 and p = 0.06). Aortic stiffness assessed using blood pressure-independent methodology apparently increased in CS1 AHF patients. We conclude that vascular failure is a feature of CS1 AHF initiation.

Locoregional disease patterns in well-differentiated and dedifferentiated retroperitoneal liposarcoma: implications for the extent of resection?

PubMed

Tseng, William W; Madewell, John E; Wei, Wei; Somaiah, Neeta; Lazar, Alexander J; Ghadimi, Markus P; Hoffman, Aviad; Pisters, Peter W T; Lev, Dina C; Pollock, Raphael E

2014-07-01

Well-differentiated (WD)/dedifferentiated (DD) liposarcoma is the most common soft tissue sarcoma of the retroperitoneum. The frequency of distant metastasis is low and the major burden of disease is locoregional. We sought to define the patterns of locoregional disease to help guide surgical decision making. Data were collected from 247 patients with de novo or recurrent tumors treated at our institution from 1993 to early 2012. The number and location of tumors at both initial presentation and subsequent locoregional recurrence were determined by combined analysis of operative dictations and radiologic imaging. Thirty-four percent of patients had multifocal locoregional disease (two or more tumors) at initial presentation to our institution, including 9 % who had tumors at synchronous remote retroperitoneal sites. The impact of multifocal disease on overall survival was dependent on histologic subtype (WD vs. DD) and disease presentation (de novo vs. recurrence) at the time of resection. Among patients with initial unifocal disease, 57 % progressed to multifocal locoregional disease with subsequent recurrence, including 11 % with new tumors outside of the original resection field. No clinicopathologic or treatment-related variable, including the type or extent of resection, was predictive of either multifocal or 'outside field' progression. Multifocal disease is common in patients with WD/DD retroperitoneal liposarcoma, and tumors can also develop at remote, locoregional sites. Surgical resection remains the primary method of locoregional control in this disease; however, the aggressiveness of resection should be individualized, with consideration of both tumor and patient-related factors.

[Initial deficits in Alzheimer's disease: 3 practical examples].

PubMed

Jódar-Vicente, M

The aim of the first studies to determine the neuropsychological features of Alzheimer's disease (AD) were based on the concept of the disease as an homogeneous entity. However, clinical observations and the most recent research studies have demonstrated that Alzheimer's disease may present several other neuropsychological deficits on its clinical onset. in the initial process of cognitive function loss, memory deficits are seen as a consequence of hippocampal degeneration; however, a great interindividual variability is observed in the appearance of other cortical deficits. In addiction, new advances in epidemiology, neurochemistry and neuropathology support the idea that AD represents a neuropsychologically heterogeneous disorder. In AD three different subgroups have been established: patients with initial deficits in visuospatial abilities, patients with a major deterioration of linguistic abilities, and a third group with altered visuospatial and linguistic abilities. The most sensitive neuropsychological tests capable of distinguish among these differences were The Boston Naming Test (BNT) and the copy of a drawing. These results have been confirmed with single photon emission computed tomography (SPECT) images, and has been observed that patients with a pattern of a elevated right-hemispheric deterioration presented also a higher right-hipofunctionality. At the same time, patients with an elevated linguistic deficit showed a higher hipofunctionality image in the left hemisphere. In this work we present three patients from a prospective study in course, who have similar background, education, gender and disease evolution, but with an onset of the illness corresponding to each of the patterns previously described All three patients were explored with an extense neuropsychological battery of tests specially chosen for this study.

Clinical outcomes of anti-androgen withdrawal and subsequent alternative anti-androgen therapy for advanced prostate cancer following failure of initial maximum androgen blockade

PubMed Central

MOMOZONO, HIROYUKI; MIYAKE, HIDEAKI; TEI, HIROMOTO; HARADA, KEN-ICHI; FUJISAWA, MASATO

2016-01-01

The present study aimed to investigate the significance of anti-androgen withdrawal and/or subsequent alternative anti-androgen therapy in patients with advanced prostate cancer (PC) who relapsed after initial maximum androgen blockade (MAB). The present study evaluated the clinical outcomes of 272 consecutive advanced PC patients undergoing anti-androgen withdrawal and/or subsequent alternative anti-androgen therapy with flutamide following the failure of initial MAB using bicalutamide. With the exception of 41 patients (15.1%) who did not undergo anti-androgen withdrawal due to the characteristics of PC suggesting aggressive diseases, prostate-specific antigen (PSA) declined from the baseline value in 83 patients (35.9%), including 18 (7.8%) with PSA decline >50%, but not in the remaining 148 (64.1%). No significant difference in the overall survival (OS) or cancer-specific survival (CSS) among the three groups was observed based on the response to anti-androgen withdrawal. Following the introduction of alternative anti-androgen therapy with flutamide, PSA decline was observed in 185 patients (68.0%), including 103 (37.9%) who achieved a PSA reduction of >50%; however, the PSA level continued to elevate in the remaining 87 (32.0%). Furthermore, of the numerous factors examined, only the duration of the initial MAB therapy was shown to be significantly correlated with the PSA decline following alternative anti-androgen therapy. Multivariate analysis of several factors identified revealed that only PSA decline following alternative anti-androgen therapy was an independent predictor of CSS and OS. If initial MAB is effective, the introduction of alternative anti-androgen therapy may be considered; however, anti-androgen withdrawal should be omitted, irrespective of the characteristics of advanced PC. PMID:27123292

Patients or volunteers? The impact of motivation for trial participation on the efficacy of patient decision Aids: a secondary analysis of a Cochrane systematic review.

PubMed

Brown, James G; Joyce, Kerry E; Stacey, Dawn; Thomson, Richard G

2015-05-01

Efficacy of patient decision aids (PtDAs) may be influenced by trial participants' identity either as patients seeking to benefit personally from involvement or as volunteers supporting the research effort. To determine if study characteristics indicative of participants' trial identity might influence PtDA efficacy. We undertook exploratory subgroup meta-analysis of the 2011 Cochrane review of PtDAs, including trials that compared PtDA with usual care for treatment decisions. We extracted data on whether participants initiated the care pathway, setting, practitioner interactions, and 6 outcome variables (knowledge, risk perception, decisional conflict, feeling informed, feeling clear about values, and participation). The main subgroup analysis categorized trials as "volunteerism" or "patienthood" on the basis of whether participants initiated the care pathway. A supplementary subgroup analysis categorized trials on the basis of whether any volunteerism factors were present (participants had not initiated the care pathway, had attended a research setting, or had a face-to-face interaction with a researcher). Twenty-nine trials were included. Compared with volunteerism trials, pooled effect sizes were higher in patienthood trials (where participants initiated the care pathway) for knowledge, decisional conflict, feeling informed, feeling clear, and participation. The subgroup difference was statistically significant for knowledge only (P = 0.03). When trials were compared on the basis of whether volunteerism factors were present, knowledge was significantly greater in patienthood trials (P < 0.001), but there was otherwise no consistent pattern of differences in effects across outcomes. There is a tendency toward greater PtDA efficacy in trials in which participants initiate the pathway of care. Knowledge acquisition appears to be greater in trials where participants are predominantly patients rather than volunteers. © The Author(s) 2015.

Pericarditis as presenting manifestation of acute nonlymphocytic leukemia in a young child.

PubMed

Chu, J Y; Demello, D; O'Connor, D M; Chen, S C; Gale, G B

1983-07-15

A case of acute nonlymphocytic leukemia presenting as pericarditis is reported in a five-year-old boy. Initially, a clinical diagnosis of viral pericarditis was made, because the child did not demonstrate hematologic or clinical manifestations of leukemia. Acute undifferentiated or lymphocytic leukemia. Acute undifferentiated or lymphocytic leukemia was diagnosed one week after admission when his peripheral blood count became abnormal. The patient did not respond to vincristine and prednisone. When cytochemical evaluation indicated acute myelomonocytic leukemia, employment of cytosine arabinoside and 6-thioguanine was instituted and the child began to improve. Currently, he is still in good remission and has no evidence of recurrence of pericarditis, 1 1/2 years after his initial presentation. In reviewing the literature, we found 17 patients who had leukemic pericardial effusion with cardiac tamponade. There are three reported cases of young children with pericardial effusion as the initial manifestation of acute lymphocytic leukemia, but no reported cases due to nonlymphocytic leukemia, as in this child.

Can cognitive assessment really discriminate early stages of Alzheimer's and behavioural variant frontotemporal dementia at initial clinical presentation?

PubMed

Reul, Sophia; Lohmann, Hubertus; Wiendl, Heinz; Duning, Thomas; Johnen, Andreas

2017-08-09

Neuropsychological testing is considered crucial for differential diagnosis of Alzheimer's disease (AD) and behavioural variant frontotemporal dementia (bvFTD). In-depth neuropsychological assessment revealed specific dysfunctions in the two dementia syndromes. However, a significant overlap of cognitive impairments exists in early disease stages. We questioned whether a standard neuropsychological assessment at initial clinical presentation can delineate patients with AD versus bvFTD. In a retrospective approach, we evaluated and compared how cognitive profiles assessed at initial clinical presentation predicted the diagnosis of later verified AD (n = 43) and bvFTD (n = 26). Additionally, the neuropsychological standard domains memory, language, visuospatial skills, executive functions, praxis and social cognition were subjected to stepwise discriminant analysis to compare their differential contribution to diagnosis. Regardless of diagnosis, a percentage of patients presented with major deterioration in a wide range of cognitive domains when compared with age-matched normative data. Only few significant differences were detected on the group level: Patients with AD were relatively more impaired in the verbal recall, verbal recognition, figure copy, and surprisingly in the executive subdomains, set shifting and processing speed whereas bvFTD was characterised by more deficits in imitation of face postures. A combination of tests for verbal recall, imitation of limb and face postures, and figure copy showed the greatest discriminatory power. Our results imply that the contribution of a standard neuropsychological assessment is limited for differential diagnosis of AD and bvFTD at initial presentation. In contrast to current clinical guidelines, executive functions are neither particularly nor exclusively impaired in patients with bvFTD when assessed within a standard clinical neuropsychological test battery. The significant overlap of bvFTD and AD concerning the profile of cognitive impairments questions current neuropsychological diagnostic criteria and calls for revision, regarding both the degree and the profile of cognitive deficits.

Approach to managing patients with sulfa allergy

PubMed Central

Ponka, David

2006-01-01

OBJECTIVE To present an approach to use of sulfonamide-based (sulfa) medications for patients with sulfa allergy and to explore whether sulfa medications are contraindicated for patients who require them but are allergic to them. SOURCES OF INFORMATION A search of current pharmacology textbooks and of MEDLINE from 1966 to the present using the MeSH key words “sulfonamide” and “drug sensitivity” revealed review articles, case reports, one observational study (level II evidence), and reports of consensus opinion (level III evidence). MAIN MESSAGE Cross-reactivity between sulfa antibiotics and nonantibiotics is rare, but on occasion it can affect the pharmacologic and clinical management of patients with sulfa allergy. CONCLUSION How a physician approaches using sulfa medications for patients with sulfa allergy depends on the certainty and severity of the initial allergy, on whether alternatives are available, and on whether the contemplated agent belongs to the same category of sulfa medications (ie, antibiotic or nonantibiotic) as the initial offending agent. PMID:17279201

Primary Undifferentiated Pleomorphic Sarcoma of the Penis

PubMed Central

Yoo, Hyung Sun; Satti, Suma

2017-01-01

Background: Primary penile sarcoma is a rare disease that affects men of all ages. Different subtypes of primary penile sarcoma exist, with the rarest being pleomorphic sarcoma. Delays in presentation and diagnosis of primary penile sarcoma have been reported because of its benign-appearing presenting features and rarity. If penile sarcoma is left untreated, the clinical consequence is metastasis that is fatal in most cases. Case Report: We report an extremely rare case of undifferentiated pleomorphic sarcoma of the penis in a 59-year-old patient who initially presented with a slow-growing penile nodule. The tumor was surgically excised, but the patient experienced local recurrence and, despite receiving chemotherapy and surgery, died of metastatic disease 15 months after initial presentation. Conclusion: Vigilance regarding biopsy and intervention for penile nodules may lead to early diagnosis and improved clinical outcomes. PMID:29230132

Long-Term Endovascular Treatment Outcome of 46 Patients with Cavernous Sinus Dural Arteriovenous Fistulas Presenting with Ophthalmic Symptoms

PubMed Central

Pashapour, Ali; Mohammadian, Reza; Salehpour, Firooz; Sharifipour, Ehsan; Mansourizade, Reza; Mahdavifard, Ali; Salehi, Mohamadgharib; Mirzaii, Farhad; Sariaslani, Payam; Fatahzade Ardalani, Ghasem; Altafi, Davar

2014-01-01

Summary Ocular symptoms are regularly observed in patients with cavernous sinus dural arteriovenous fistulas (cDAVF). We aimed to evaluate the long-term efficacy and safety of endovascular approaches in patients with cDAVF presenting with different ocular symptoms. In a prospective study between June 2008 and March 2013, 46 patients with ocular symptoms due to cDAVF who were not eligible for conservative therapy, met the inclusion criteria and underwent endovascular treatment. They underwent a transarterial approach with histoacryl glue injections or transvenous coil embolization, all in one session. They were followed up for a mean period of 17.3 months (range 7 to 30 months) clinically and using angiography. The mean age of patients was 36.8 years (18-60) and 65% of them were male. All patients showed venous drainage into the superior and inferior orbital veins. Access to the cavernous sinus was transvenous in ten patients, transarterial in 26 patients, and mixed in ten patients. Initial symptoms were improved in 97.8% of patients and did not recur during the study follow-up. The procedural complications included: blurred vision, transient sixth nerve palsy and exacerbation of chemoproptosis in two, one and two patients respectively that completely resolved in initial weeks with no recurrence. No patient worsened or developed new symptoms suggestive of a recurrent fistula during the follow-up period. One patient experienced intracranial dissection of the internal carotid artery and ischemic stroke with an unfinished procedure. The relief of early presentation was durable in long-term follow-up and the cured lesions were stable in angiographic controls. Favorable and durable outcomes could be obtained following endovascular approaches for cDAVF presenting with different ocular symptoms. PMID:25196621

Nonstandard Advance Directives in Emergency Medicine: What Should We Do?

PubMed

Iserson, Kenneth V

2018-07-01

Critically ill or injured emergency department or prehospital patients who lack decision-making capacity sometimes present with a non-standard advance directive, such as a "Do Not Resuscitate" tattoo or medallion. Emergency clinicians must immediately address the question of whether to withhold treatment based on what may or may not be a valid patient directive. Advance directives have been standardized for a good reason. Emergency department or prehospital healthcare providers must be able to immediately interpret and act on them without needing a legal interpretation. When faced with non-standard directives, physicians can follow them, ignore them, or simply use them as an additional piece of information about the individual's wishes for some situations at one point in his or her life. Absent the patient's input or that of aknowledgeable surrogate, both the patient's initial reasons for their non-standard directive and his or her present wishes concerning resuscitation cannot be independently known. Therefore, healthcare providers must initiate treatment while they buy time, attempt to return the patient to lucidity, and search for probative information regarding their current wishes concerning medical treatment. Without such additional information, the moral weight will always favor initiating treatment, since withholding treatment is often irreversible and any treatment instituted can later be withdrawn. Copyright © 2018 Elsevier Inc. All rights reserved.

Diagnostic challenges of celiac disease in a young child: A case report and a review of the literature.

PubMed

Mărginean, Cristina Oana; Meliţ, Lorena Elena; Stefănuţ Săsăran, Vlăduţ; Mărginean, Cristian Dan; Mărginean, Maria Oana

2018-06-01

Celiac disease is a chronic, immune-mediated, multiorgan disorder that affects susceptible individuals, and it is triggered by gluten and other prolamins. We present the case of a 1-year-old male child, with a history of idiopathic pericardial effusion, admitted in our clinic for severe abdominal bloating, irritability, loss of appetite and intermittent diarrheic stools. The clinical findings were: influenced general status, irritability, distended abdomen, and diffuse abdominal tenderness. The initial laboratory tests revealed anemia, leukocytosis, increased inflammatory biomarkers, high levels of transaminases, and hypoalbuminemia. The stool culture identified an enterocolitis with enteropathogenic Escherichia coli (E. coli). We initiated antibiotic treatment, substitution therapy with human albumin and probiotics with initial favorable evolution, but after 1 month, the patient was re-admitted for the persistence of intermittent diarrheic stools and abdominal bloating, when we established the diagnosis of cow's milk protein allergy. We initiated diary-free diet. Unfortunately, the patient was re-admitted after another 8 months, presenting the same clinical and laboratory findings as during the initial admission. We repeated the serology for celiac disease and we performed an upper gastrointestinal endoscopy with duodenal biopsies, which established the diagnosis of celiac disease. After 1 month of gluten-free diet, the patient's evolution improved considerably. Enterocolitis with E. coli could be considered as trigger for CD in our case. The diagnosis of CD in small children can be hindered by an insufficient gluten-exposure, and can lead to a delay in the diagnosis as in the case presented above.

Crusted scabies-associated immune reconstitution inflammatory syndrome

PubMed Central

2012-01-01

Background Despite the widely accepted association between crusted scabies and human immunodeficiency virus (HIV)-infection, crusted scabies has not been included in the spectrum of infections associated with immune reconstitution inflammatory syndrome in HIV-infected patients initiating antiretroviral therapy. Case presentation We report a case of a 28-year-old Mexican individual with late HIV-infection, who had no apparent skin lesions but soon after initiation of antiretroviral therapy, he developed an aggressive form of crusted scabies with rapid progression of lesions. Severe infestation by Sarcoptes scabiei was confirmed by microscopic examination of the scale and skin biopsy. Due to the atypical presentation of scabies in a patient responding to antiretroviral therapy, preceded by no apparent skin lesions at initiation of antiretroviral therapy, the episode was interpreted for the first time as “unmasking crusted scabies-associated immune reconstitution inflammatory syndrome”. Conclusion This case illustrates that when crusted scabies is observed in HIV-infected patients responding to antiretroviral therapy, it might as well be considered as a possible manifestation of immune reconstitution inflammatory syndrome. Patient context should be considered for adequate diagnosis and treatment of conditions exacerbated by antiretroviral therapy-induced immune reconstitution. PMID:23181485

Impact of an emergency medicine pharmacist on initial antibiotic prophylaxis for open fractures in trauma patients.

PubMed

Harvey, Somer; Brad Hall, A; Wilson, Kayla

2018-02-01

Targeted antibiotic treatment reduces the infection risk of open fractures when soft tissue and bone are exposed to the environment. The risk of infection increases with higher degrees of injury. The Gustilo-Anderson system was developed to identify the degree of injury of open fractures and can be utilized to guide initial antibiotic therapy. Few studies have been published evaluating the potential impact of emergency medicine pharmacists in trauma, and currently no study has evaluated a pharmacist's influence on antibiotic selection and timing for open fractures. The objective of this study was to determine the impact of an emergency medicine pharmacist on initial antibiotic selection and timing in trauma patients with open fractures. This was a retrospective cohort study. Trauma alerts with open fractures from May 1, 2014 to June 30, 2016 were eligible for inclusion. The primary outcome was to determine if pharmacist participation during trauma resuscitation was associated with an increased proportion of initial antibiotic selection meeting guideline recommendations. The secondary outcome was the door-to-antibiotic administration time during resuscitation. Initial prophylactic antibiotic recommendations were met in 81% of trauma resuscitations when a pharmacist was present versus 47% without a pharmacist present (p<0.01). The median door-to-antibiotic time was 14min in the PHARM group versus 20min in the NO-PHARM group (p=0.02). The participation of an EM pharmacist during initial trauma resuscitation resulted in improved initial antibiotic selection and faster door-to-antibiotic administration times in trauma patients with open fractures. Copyright © 2017 Elsevier Inc. All rights reserved.

What do patients expect from treatment with Dental Implants? Perceptions, expectations and misconceptions: a multicenter study.

PubMed

Yao, Jie; Li, Ming; Tang, Hua; Wang, Peng-Lai; Zhao, Yu-Xiao; McGrath, Colman; Mattheos, Nikos

2017-03-01

While research in terms of patient-centered care in implant therapy is growing, few studies have investigated patients' initial perceptions prior to consultation with the implant dentist. The aim of this cross-sectional study was to capture patients' initial information level, perceptions, as well as expectations from the implant therapy. A 34-item questionnaire was developed to investigate patients' preoperative information, perceptions and expectations from treatment with Dental Implants. The study was conducted in three locations (Hong Kong, SiChuan and JiangSu) during 2014-2015 with 277 patients. The main information source about implant therapy was the dentist or hygienist for less than half of the patients (n = 113, 42%). About 62.8% of participants considered that they were in general informed about implants, but only 17.7% felt confident with the information they had. More than 30% of the sample appeared to maintain dangerous misperceptions about Dental Implants: "Dental Implants require less care than natural teeth"; "Treatment with Dental Implants is appropriate for all patients with missing teeth"; "Dental Implants last longer than natural teeth"; and "Treatments with Dental Implants have no risks or complications." Patients were divided when asked whether "Dental Implants are as functional as natural teeth" (agreement frequency = 52.7%). Expectations from treatment outcome were commonly high, while there was a significant correlation between the overall mean of perception scores and outcome expectation scores (r = 0.32, P < 0.001). Overall, younger subjects (<45 years) and those with higher education level (bachelor and postgraduate) tended to present more realistic perceptions and lower outcome expectations. The majority of patients in this study presented relatively realistic perceptions. However, an alarming portion of the sample presented with inaccurate perceptions and unrealistic expectations, which the dental team would need to diagnose and correct prior to initiating implant treatment. © 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Clinical course of thyroid function and thyroid associated-ophthalmopathy in patients with euthyroid Graves' disease.

PubMed

Suzuki, Nami; Noh, Jaeduk Yoshimura; Kameda, Toshiaki; Yoshihara, Ai; Ohye, Hidemi; Suzuki, Miho; Matsumoto, Masako; Kunii, Yo; Iwaku, Kenji; Watanabe, Natsuko; Mukasa, Koji; Kozaki, Ai; Inoue, Toshu; Sugino, Kiminori; Ito, Koichi

2018-01-01

Euthyroid Graves' disease (EGD) is a rare condition defined as the presence of thyroid-associated ophthalmopathy (TAO) in patients with normal thyroid function. Due to the rarity of this disease, only a limited number of studies and case reports are available for further evaluation of the characteristics of the disease. The aim of this study was to examine the changes in the thyroid function, thyrotropin receptor antibodies (TRAb) and eye symptoms, and then determine whether TRAb is related to TAO in EGD patients. TRAb in this study was defined as including both thyrotropin-binding inhibitory immunoglobulin (TBII) and thyroid-stimulating immunoglobulin (TSAb). Medical records of patients diagnosed with EGD were reviewed. Ophthalmologists specializing in TAO examined the eyes of all subjects. Of the 58 patients diagnosed with EGD, 24.1% developed hyperthyroidism, while 3.4% developed hypothyroidism. A total of 72.4% of the 58 patients remained euthyroid throughout the entire follow-up period. At the initial presentation, TBII and TSAb were positive in 74.5% and 70.5%, respectively. Ophthalmic treatments were administered to 30 (51.7%) out of the 58 patients. A significant spontaneous improvement of the eye symptoms was found in 28 of the EGD patients who did not require eye treatments. EGD patients exhibited positive rates for both TBII and TSAb, with the number of the TRAb-positive patients gradually decreasing while the eye symptoms spontaneously improved over time. There were no correlations found between TRAb at initial presentation and the eye symptoms. TBII and TSAb were positive in about 70% of EGD patients at their initial visit. Thyroid functions of EGD patients who have been euthyroid for more than 6.7 years may continue to remain euthyroid in the future.

Antiphospholipid antibodies and antiphospholipid syndrome in patients presenting with immune thrombocytopenic purpura: a prospective cohort study.

PubMed

Diz-Küçükkaya, R; Hacihanefioğlu, A; Yenerel, M; Turgut, M; Keskin, H; Nalçaci, M; Inanç, M

2001-09-15

The pathogenetic role and the clinical importance of the presence of antiphospholipid antibodies (APAs) in patients with immune thrombocytopenic purpura (ITP) are not clear. In this study, the prevalence and clinical significance of APAs were investigated in patients with ITP. Eighty-two newly diagnosed ITP patients were prospectively studied. They were evaluated for the presence of lupus anticoagulant (LA) and immunoglobulin G/M anticardiolipin antibodies (ACAs). Thirty-one patients (37.8%) were APA positive at diagnosis. No statistically significant differences were found between the APA-positive and APA-negative groups regarding gender, initial platelet counts, or response to methylprednisolone therapy. After 5 years of follow-up, cumulative thrombosis-free survival of APA-positive (n = 31) and APA-negative (n = 51) ITP patients was 39% and 97.7%, respectively. A significant difference was found between these groups by log-rank test (P =.0004). In addition, LA was an important risk marker for the development of thrombosis in ITP patients. After a median follow-up of 38 months, 14 ITP patients (45%) who had APA positivity developed clinical features (thrombosis or fetal losses) of antiphospholipid syndrome (APS). There were no differences between the APA-positive patients with and without APS regarding the initial platelet counts, response to the therapy, or ACA positivity. The positivity rate for LA was significantly higher in those patients with ITP who developed APS (chi(2): P =.0036; relative risk 7.15; 95% confidence interval, 1.7-47). In conclusion, this study indicates that a significant proportion of patients initially presenting with ITP and APA positivity developed APS. In patients with ITP, the persistent presence of APAs is an important risk factor for the development of APS.

Characteristics of intraretinal deposits in acute central serous chorioretinopathy.

PubMed

Plateroti, Andrea M; Witmer, Matthew T; Kiss, Szilárd; D'Amico, Donald J

2014-01-01

To describe the temporal and spatial characteristics of intraretinal deposits in patients with acute central serous chorioretinopathy (CSC) using spectral domain optical coherence tomography (OCT). We retrospectively reviewed the medical records of all patients that presented with acute CSC to Weill Cornell Medical College from January 2012 to May 2013. Acute CSC was defined as a diagnosis of CSC within 4 months of the onset of symptoms. Only one eye per patient was included in the study. Each patient was imaged with spectral domain OCT at the initial office visit. The decision to reimage these patients was made by the treating physician. A total of 25 patients (25 eyes; 17 men and eight nonpregnant women) were included in this review. Seven of 25 patients (28%) demonstrated intraretinal deposits within the outer plexiform layer during the initial OCT, with deposits appearing as early as the same day as the onset of symptoms. A total of 25 of 25 patients (100%) demonstrated intraretinal deposits in the outer nuclear layer upon initial (76%) or follow-up OCT, as early as 2 days after the onset of symptoms. A total of 24 of 25 patients (96%) demonstrated deposits in the external limiting membrane upon a follow-up OCT, as early as 7 days from symptoms appearing. A total of 24 of 25 patients (96%) developed intraretinal deposits in the inner segment/outer segment layer upon follow-up OCT, appearing as early as 14 days after symptom onset. At the time of resolution of subretinal fluid, 20 of 25 patients (80%) demonstrated intraretinal deposits. Intraretinal deposits are present in the outer retinal layers in patients with acute CSC, with the deposits appearing progressively deeper within the retina as the condition evolves. Upon resolution of subretinal fluid, the deposits slowly resolve.

Clinical features and outcomes of patients with hepatocellular carcinoma complicated with bile duct invasion

PubMed Central

An, Jihyun; Lee, Kwang Sun; Park, Do Hyun; Lee, Sang Soo; Lee, Danbi; Shim, Ju Hyun; Lim, Young-Suk; Lee, Han Chu; Chung, Young-Hwa; Lee, Yung Sang

2017-01-01

Background/Aims Little is known about the treatment or outcomes of hepatocellular carcinoma (HCC) complicated with bile duct invasion. Methods A total of 247 consecutive HCC patients with bile duct invasion at initial diagnosis were retrospectively included. Results The majority of patients had Barcelona Clinic Liver Cancer (BCLC) stage C HCC (66.8%). Portal vein tumor thrombosis was present in 166 (67.2%) patients. Median survival was 4.1 months. Various modalities of treatment were initially employed including surgical resection (10.9%), repeated transarterial chemoembolization (TACE) (42.5%), and conservative management (42.9%). Among the patients with obstructive jaundice (n=88), successful biliary drainage was associated with better overall survival rate. Among the patients with BCLC stage C, overall survival differed depending on the initial treatment for HCC; surgical resection, TACE, systemic chemotherapy, and conservative management showed overall survival rates of 11.5, 6.0 ,2.4, and 1.6 months, respectively. After adjusting for confounders, surgical resection and repeated TACE were significant prognostic factors for HCC patients with bile duct invasion (hazard ratios 0.47 and 0.39, Ps <0.001, respectively). Conclusions The survival of HCC patients with bile duct invasion at initial diagnosis is generally poor. However, aggressive treatments for HCC such as resection or biliary drainage may be beneficial therapeutic options for patients with preserved liver function. PMID:28506055

Open and endovascular aneurysm repair in the Society for Vascular Surgery Vascular Quality Initiative.

PubMed

Spangler, Emily L; Beck, Adam W

2017-12-01

The Society for Vascular Surgery Vascular Quality Initiative is a patient safety organization and a collection of procedure-based registries that can be utilized for quality improvement initiatives and clinical outcomes research. The Vascular Quality Initiative consists of voluntary participation by centers to collect data prospectively on all consecutive cases within specific registries which physicians and centers elect to participate. The data capture extends from preoperative demographics and risk factors (including indications for operation), through the perioperative period, to outcomes data at up to 1-year of follow-up. Additionally, longer-term follow-up can be achieved by matching with Medicare claims data, providing long-term longitudinal follow-up for a majority of patients within the Vascular Quality Initiative registries. We present the unique characteristics of the Vascular Quality Initiative registries and highlight important insights gained specific to open and endovascular abdominal aortic aneurysm repair. Copyright © 2017 Elsevier Inc. All rights reserved.

Counterheroism, Common Knowledge, and Ergonomics: Concepts from Aviation That Could Improve Patient Safety

PubMed Central

Lewis, Geraint H; Vaithianathan, Rhema; Hockey, Peter M; Hirst, Guy; Bagian, James P

2011-01-01

Context: Many safety initiatives have been transferred successfully from commercial aviation to health care. This article develops a typology of aviation safety initiatives, applies this to health care, and proposes safety measures that might be adopted more widely. It then presents an economic framework for determining the likely costs and benefits of different patient safety initiatives. Methods: This article describes fifteen examples of error countermeasures that are used in public transport aviation, many of which are not routinely used in health care at present. Examples are the sterile cockpit rule, flight envelope protection, the first-names-only rule, and incentivized no-fault reporting. It develops a conceptual schema that is then used to argue why analogous initiatives might be usefully applied to health care and why physicians may resist them. Each example is measured against a set of economic criteria adopted from the taxation literature. Findings: The initiatives considered in the article fall into three themes: safety concepts that seek to downplay the role of heroic individuals and instead emphasize the importance of teams and whole organizations; concepts that seek to increase and apply group knowledge of safety information and values; and concepts that promote safety by design. The salient costs to be considered by organizations wishing to adopt these suggestions are the compliance costs to clinicians, the administration costs to the organization, and the costs of behavioral distortions. Conclusions: This article concludes that there is a range of safety initiatives used in commercial aviation that could have a positive impact on patient safety, and that adopting such initiatives may alter the safety culture of health care teams. The desirability of implementing each initiative, however, depends on the projected costs and benefits, which must be assessed for each situation. PMID:21418311

Counterheroism, common knowledge, and ergonomics: concepts from aviation that could improve patient safety.

PubMed

Lewis, Geraint H; Vaithianathan, Rhema; Hockey, Peter M; Hirst, Guy; Bagian, James P

2011-03-01

Many safety initiatives have been transferred successfully from commercial aviation to health care. This article develops a typology of aviation safety initiatives, applies this to health care, and proposes safety measures that might be adopted more widely. It then presents an economic framework for determining the likely costs and benefits of different patient safety initiatives. This article describes fifteen examples of error countermeasures that are used in public transport aviation, many of which are not routinely used in health care at present. Examples are the sterile cockpit rule, flight envelope protection, the first-names-only rule, and incentivized no-fault reporting. It develops a conceptual schema that is then used to argue why analogous initiatives might be usefully applied to health care and why physicians may resist them. Each example is measured against a set of economic criteria adopted from the taxation literature. The initiatives considered in the article fall into three themes: safety concepts that seek to downplay the role of heroic individuals and instead emphasize the importance of teams and whole organizations; concepts that seek to increase and apply group knowledge of safety information and values; and concepts that promote safety by design. The salient costs to be considered by organizations wishing to adopt these suggestions are the compliance costs to clinicians, the administration costs to the organization, and the costs of behavioral distortions. This article concludes that there is a range of safety initiatives used in commercial aviation that could have a positive impact on patient safety, and that adopting such initiatives may alter the safety culture of health care teams. The desirability of implementing each initiative, however, depends on the projected costs and benefits, which must be assessed for each situation. © 2011 Milbank Memorial Fund. Published by Wiley Periodicals Inc.

Repeat neuroimaging of mild traumatic brain-injured patients with acute traumatic intracranial hemorrhage: clinical outcomes and radiographic features.

PubMed

Kreitzer, Natalie; Lyons, Michael S; Hart, Kim; Lindsell, Cristopher J; Chung, Sora; Yick, Andrew; Bonomo, Jordan

2014-10-01

Emergency department (ED) management of mild traumatic brain injury (TBI) patients with any form of traumatic intracranial hemorrhage (ICH) is variable. Since 2000, our center's standard practice has been to obtain a repeat head computed tomography (CT) at least 6 hours after initial imaging. Patients are eligible for discharge if clinical and CT findings are stable. Whether this practice is safe is unknown. This study characterized clinical outcomes in mild TBI patients with acute traumatic ICH seen on initial ED neuroimaging. This retrospective cohort study included patients presenting to the ED with blunt mild TBI with Glasgow Coma Scale (GCS) scores of 14 or 15 and stable vital signs, during the period from January 2001 to January 2010. Patients with any ICH on initial head CT and repeat head CT within 24 hours were eligible. Cases were excluded for initial GCS < 14, injury > 24 hours old, pregnancy, concomitant nonminor injuries, and coagulopathy. A single investigator abstracted data from records using a standardized case report form and data dictionary. Primary endpoints included death, neurosurgical procedures, and for discharged patients, return to the ED within 7 days. Differences in proportions were computed with 95% confidence intervals (CIs). Of 1,011 patients who presented to the ED and had two head CTs within 24 hours, 323 (32%) met inclusion criteria. The median time between CT scans was 6 hours (interquartile range = 5 to 7 hours). A total of 153 (47%) patients had subarachnoid hemorrhage, 132 (41%) patients had subdural hemorrhage, 11 (3%) patients had epidural hemorrhage, 78 (24%) patients had cerebral contusions, and 59 (18%) patients had intraparenchymal hemorrhage. Four of 323 (1.2%, 95% CI = 0.3% to 3.2%) patients died within 2 weeks of injury. Three of the patients who died had been admitted from the ED on their initial visits, and one had been discharged home. There were 206 patients (64%) discharged from the ED, 28 (13.6%) of whom returned to the ED within 1 week. Of the 92 who were hospitalized, three (0.9%, 95% CI = 0.2% to 2.7%) required neurosurgical intervention. Discharge after a repeat head CT and brief period of observation in the ED allowed early discharge of a cohort of mild TBI patients with traumatic ICH without delayed adverse outcomes. Whether this justifies the cost and radiation exposure involved with this pattern of practice requires further study. © 2014 by the Society for Academic Emergency Medicine.

[The long-term results and indications for use of Gore-Texgrafts in the femoropopliteal position in patients with atherosclerotic lesion of lower limb arteries].

PubMed

Pokrovskiĭ, A V; Dan, V N; Zotikov, A E; Chupin, A V; Shubin, A A; Chikharev, M V

2004-01-01

Presented herein are the long-term results of femoropopliteal reconstructions above the knee joint fisure in patients with atherosclerotic lesion of the femoropopliteal segment using Gore-Tex grafts. The retrospective study accrued 108 patients. Of these, IIB degree lower limb ischemia (according to the A.V. Pokrovsky classification) was initially present in 64 (60.2%) and critical ischemia in 52 (40.8%) patients. Patients suffering from lower limb ischemia of varying degree did not significantly differ in the age or coexistent diseases. The mean value of the ankle/brachial index (ABI) accounted for 0.46+/-0.23 in patients with IIB degree ischemia and for 0.40+/-0.27 in patients with critical lower limb ischemia. All the patients were evaluated for the condition of the distal bed according to the scheme proposed by Rutherford et al. in 1997. The patients were distributed into three groups: patients with "good" runoff (from 1 to 4 points, n=65), patients with "satisfactory" runoff (from 5 to 7 points, n=36), and those with an "unsatisfactory" condition of the distal bed (runoff point over 7, n=7). The long-term results were assessed in 81 (75%) patients over the period as long as 105 months. The mean follow up accounted for 58,4 months. One year later the graft patency in the total patient group constituted 73.1%, after 3 years it was equal to 54.8%, and after 5 years to 49.9%. It is demonstrated that the initial runoff point exerted a significant effect on the graft patency. It is noteworthy that in patients with an initially "good" runoff point, 57.5% of the grafts were patent 5 years after operation whereas in patients with a "satisfactory" point only 35.3% turned out patent (p<0.05). Patients with an initially "unsatisfactory" runoff point developed thrombosis of all grafts over the period as long as 6 months following operation. The five-year limb salvage was observed in 77.6% of patients. It has been revealed over the 5-year period that the degree of initial limb ischemia did not produce any significant effect on the graft patency or limb salvage. The scheme for runoff assessment allows to define in a differentiated way the indications for use of Gore-Tex grafts in the femoropopliteal position. The runoff point had a significant effect on the long-term 5-year patency of the grafts.

Functional Stroke Mimics: Incidence and Characteristics at a Primary Stroke Center in the Middle East

PubMed Central

Wilkins, Stacy Schantz; Bourke, Paula; Salam, Abdul; Akhtar, Naveed; D'Souza, Atlantic; Kamran, Saadat; Bhutta, Zain; Shuaib, Ashfaq

2018-01-01

ABSTRACT Objective Approximately 30% of individuals who initially present with stroke are found to be stroke mimics (SM), with functional/psychological SM (FSM) accounting for up to 6.4% of all stroke presentations. Middle Eastern countries may have higher rates of somatization of emotional distress. The aim of this study was to evaluate the incidence and characteristics of FSM at a large general hospital in the Middle East. Methods All patients presenting with an initial diagnosis of stroke from June 2015 to September 2016 were eligible for this study. Clinical and sociodemographic data were obtained from the hospital's stroke database. All SM and strokes were diagnosed by Joint Commission International–certified stroke program neurologists. SM was defined as any discharge diagnosis (other than acute stroke) for symptoms that prompted initial admission for suspected stroke. FSM were compared with medical stroke mimics (MSM) and strokes (ischemic, hemorrhagic, and transient ischemic attacks). Results A total of 1961 patients were identified; 161 FSM (8.2%), 390 MSM (19.9%), and 1410 strokes (71.9%) (985 ischemic strokes, 196 transient ischemic attacks, 229 intracerebral hemorrhages). Admission with FSM was related to patients' nationality, with the highest frequency in Arabic (15.6%) and African (16.8%) patients. FSM patients were younger, more often female, and had fewer cardiovascular risk factors except for smoking compared with the strokes. FSM patients presented with more left-sided weakness and had more magnetic resonance imagings than the stroke and MSM groups. A total of 9.9% of FSM patients received thrombolysis versus only 0.5% of the MSM and 16.4% of ischemic strokes. Conclusions FSM frequencies varied by nationality, with Arab and African nationals being twice as prevalent. Stress, vulnerable status as expats, sociopolitical instability, and exposure to trauma are proposed as potential factors contributing to FSM. PMID:29394187

Epidemiological findings and clinical and magnetic resonance presentations in subacute sclerosing panencephalitis.

PubMed

Cece, H; Tokay, L; Yildiz, S; Karakas, O; Karakas, E; Iscan, A

2011-01-01

Subacute sclerosing panencephalitis (SSPE) is a rare, progressive, inflammatory neurodegenerative disease. This study investigated the relationships of clinical stage with epidemiological and magnetic resonance imaging (MRI) findings in SSPE by retrospective review of 76 cases (57 male) diagnosed by typical periodic electroencephalographic features, clinical symptoms and elevated measles antibody titre in cerebrospinal fluid. Clinical stage at diagnosis was I or II in 48 patients, III in 25 and IV in three. Prominent findings at presentation were atonic/myoclonic seizures (57.9%) and mental deterioration with behaviour alteration (30.3%). Frequent MRI findings (13 - 32 patients) were subcortical, periventricular and cortical involvement and brain atrophy; the corpus callosum, basal ganglia, cerebellum and brainstem were less frequently involved. Five patients had pseudotumour cerebri. Cranial MRI at initial diagnosis was normal in 21 patients (19 stage I/II, two stage III/IV). Abnormal MRI findings were significantly more frequent in the later stages, thus a normal initial cranial MRI does not exclude SSPE, which should, therefore, be kept in mind in childhood demyelinating diseases even when the presentation is unusual.

Tics as an initial manifestation of juvenile Huntington's disease: case report and literature review.

PubMed

Cui, Shi-Shuang; Ren, Ru-Jing; Wang, Ying; Wang, Gang; Chen, Sheng-Di

2017-08-08

Huntington's disease (HD) is an autosomal dominant disorder, typically characterized by chorea due to a trinucleotide repeat expansion in the HTT gene, although the clinical manifestations of patients with juvenile HD (JHD) are atypical. A 17-year-old boy with initial presentation of tics attended our clinic and his DNA analysis demonstrated mutation in the HTT gene (49 CAG repeats). After treatment, his symptoms improved. Furthermore, we performed literature review through searching the databases and summarized clinical features in 33 JHD patients. The most prevalent symptoms are ataxia, and two cases reported that tics as initial and prominent manifestation in JHD. Among them, 88% patients carried CAG repeats beyond 60 and most of them have family history. This case here illustrates the variable range of clinical symptoms of JHD and the necessity of testing for the HD mutation in young patients with tics with symptoms unable to be explained by Tourette's syndrome (TS).

False-positive cerebrospinal fluid cryptococcus antigen in Libman-Sacks endocarditis.

PubMed

Isseh, Iyad N; Bourgi, Kassem; Nakhle, Asaad; Ali, Mahmoud; Zervos, Marcus J

2016-12-01

Cryptococcus meningoencephalitis is a serious opportunistic infection associated with high morbidity and mortality in immunocompromised hosts, particularly patients with advanced AIDS disease. The diagnosis is established through cerebrospinal fluid (CSF) cryptococcus antigen detection and cultures. Cryptococcus antigen testing is usually the initial test of choice due its high sensitivity and specificity along with the quick availability of the results. We hereby report a case of a false-positive CSF cryptococcus antigen assay in a patient with systemic lupus erythematosus presenting with acute confusion. While initial CSF evaluation revealed a positive cryptococcus antigen assay, the patient's symptoms were inconsistent with cryptococcus meningoencephalitis. A repeat CSF evaluation, done 3 days later, revealed a negative CSF cryptococcus antigen assay. Given the patient's active lupus disease and the elevated antinuclear antibody titers, we believe that the initial positive result was a false positive caused by interference from autoantibodies.

Stage IV-S neuroblastoma. Results with definitive therapy

DOE Office of Scientific and Technical Information (OSTI.GOV)

Stokes, S.H.; Thomas, P.R.; Perez, C.A.

1984-05-15

The results of management of 14 patients with Stage IV-S neuroblastoma are reported. The treatment policy, although not consistent over this time span, in general used a combination of radiotherapy and chemotherapy or infrequently one modality alone. Twelve of 14 (86%) survived more than 6 years. One patient, with a solitary mediastinal primary tumor, died of rapidly progressive disease at three months. The other death occurred in a 4.5-year-old presenting with hepatomegaly at diagnosis followed by skeletal dissemination 2.5 years later. Thirteen of the patients were younger than 1 year of age. Of the 11 patients that received radiotherapy, 4more » experienced mild asymptomatic scoliosis or kyphoscoliosis at 3 to 12 years after initial therapy. A review of the literature indicates that spontaneous regression in this tumor is very frequent; therefore, it is recommended that for the common presentation of massive hepatomegaly in an infant, close observation is warranted, unless life threatening complications occur. However, initial therapeutic intervention may be indicated in those patients with life threatening presentations. This data did not substantiate the necessity for complete surgical excision of the primary tumor, as has been suggested by others.« less

Parameters indicative of persistence of valvular pathology at initial diagnosis in acute rheumatic carditis: the role of albumin and CD19 expression.

PubMed

Oner, Taliha; Ozdemir, Rahmi; Genc, Dildar Bahar; Kucuk, Mehmet; Karadeniz, Cem; Demirpence, Savas; Yilmazer, Murat Muhtar; Mese, Timur; Tavli, Vedide; Genel, Ferah

The aim of this study is to define the predictors of chronic carditis in patients with acute rheumatic carditis (ARC). Patients diagnosed with ARC between May 2010 and May 2011 were included in the study. Echocardiography, electrocardiography, lymphocyte subset analysis, acute phase reactants, plasma albumin levels, and antistreptolysin-O (ASO) tests were performed at initial presentation. The echocardiographic assessments were repeated at the sixth month of follow-up. The patients were divided into two groups according to persistence of valvular pathology at 6th month as Group 1 and Group 2, and all clinical and laboratory parameters at admission were compared between two groups of valvular involvement. During the one-year study period, 22 patients had valvular disease. Seventeen (77.2%) patients showed regression in valvular pathology. An initial mild regurgitation disappeared in eight patients (36.3%). Among seven (31.8%) patients with moderate regurgitation initially, the regurgitation disappeared in three, and four patients improved to mild regurgitation. Two patients with a severe regurgitation initially improved to moderate regurgitation (9.1%). In five (22.8%) patients, the grade of regurgitation [moderate regurgitation in one (4.6%), and severe regurgitation in 4 (18.2%)] remained unchanged. The albumin level was significantly lower at diagnosis in Group 2 (2.6±0.48g/dL). Lymphocyte subset analysis showed a significant decrease in the CD8 percentage and a significant increase in CD19 percentage at diagnosis in Group 2 compared to Group 1. The blood albumin level and the percentage of CD8 and CD19 (+) lymphocytes at diagnosis may help to predict chronic valvular disease risk in patients with acute rheumatic carditis. Copyright © 2016. Published by Elsevier Editora Ltda.

Normotensive cardiomyopathy and malignant hypertension in phaeochromocytoma

PubMed Central

Shapiro, L. M.; Trethowan, N.; Singh, S. P.

1982-01-01

A patient with two different presentations of phaeochromocytoma is described. She initially presented with normal blood pressure and heart failure following a prolonged feverish prodrome. A provisional diagnosis of myocarditis or early congestive cardiomyopathy was made and she improved with digoxin and diuretics. Eighteen months later, after a period of normotension free from heart failure, she developed malignant hypertension with recurrence of heart failure. A phaeochromocytoma was surgically removed, with return to normal of blood pressure and cardiac status. It would seem that the initial presentation of the phaeochromocytoma was a catecholamine-induced myocarditis without hypertension and this resolved with the subsequent development of malignant hypertension. The possible mechanisms responsible for this are discussed and it is concluded that phaeochromocytoma should be considered in patients who have heart failure and persistent features of myocarditis. PMID:7100023

The use of bioabsorbable staple line reinforcement for circular stapler (BSG "Seamguard") in colorectal surgery: initial experience.

PubMed

Franklin, Morris E; Ramila, Guillermo Portillo; Treviño, Jorge M; González, John J; Russek, Karla; Glass, Jeffrey L; Kim, Greg

2006-12-01

Of all the complications associated with colorectal surgery, the most devastating and constant, despite all techniques being performed properly is anastomotic leakage, especially in left colon and rectal resections with rates as high as 50% when the rectum is involved. In 2005, our center published the preliminary experience with the use of linear staple line reinforcement for colon surgery. The purpose of this paper is to present a series of cases using a new conformation of bioabsorbable reinforcement for circular staplers in 5 patients, 2 patients with rectal cancer, 2 patients with diverticular disease, and 1 patient with sigmoid cancer. These initial data are very promising and has encouraged us to continue using this device on further patients.

Automatic control of arterial carbon dioxide tension in mechanically ventilated patients.

PubMed

Fernando, Tyrone; Cade, John; Packer, John

2002-12-01

This paper presents a method of controlling the arterial carbon dioxide tension of patients receiving mechanical ventilation. Controlling of the CO2 tension is achieved by regulating the ventilator initiated breath frequency and also volume per breath.

Contrast-enhanced [18F] fluorodeoxyglucose-positron emission tomography-computed tomography as an initial imaging modality in patients presenting with metastatic malignancy of undefined primary origin

PubMed Central

Jain, Avani; Srivastava, Madhur Kumar; Pawaskar, Alok Suresh; Shelley, Simon; Elangovan, Indirani; Jain, Hasmukh; Pandey, Somnath; Kalal, Shilpa; Amalachandran, Jaykanth

2015-01-01

Background: To evaluate the advantages of contrast enhanced F-18-fluorodeoxyglucose (FDG) positron emission tomography-computed tomography (PET-contrast enhanced CT [CECT]) when used as an initial imaging modality in patients presenting with metastatic malignancy of undefined primary origin (MUO). Materials and Methods: A total of 243 patients with fine needle aspiration cytology/biopsy proven MUO were included in this prospective study. Patients who were thoroughly evaluated for primary or primary tumor was detected by any other investigation were excluded from the analysis. Totally, 163 patients with pathological diagnosis of malignancy but no apparent sites of the primary tumor were finally selected for analysis. The site of probable primary malignancy suggested by PET-CECT was confirmed by biopsy/follow-up. Results: PET-CECT suggested probable site of primary in 128/163 (78.52%) patients. In 30/35 remaining patients, primary tumor was not detected even after extensive work-up. In 5 patients, where PET-CECT was negative, primary was found on further extensive investigations or follow-up. The sensitivity, specificity, positive predictive value and negative predictive value of the study were 95.76%, 66.67%, 88.28% and 85.71% respectively. Conclusions: F-18 FDG PET-CECT aptly serves the purpose of initial imaging modality owing to high sensitivity, negative and positive predictive value. PET-CECT not only surveys the whole body for the primary malignancy but also stages the disease accurately. Use of contrast improves the diagnostic utility of modality as well as help in staging of the primary tumor. Although benefits of using PET-CECT as initial diagnostic modality are obvious from this study, there is a need for a larger study comparing conventional methods for diagnosing primary in patients with MUO versus PET-CECT. PMID:26170563

Revisiting the pancreaticoduodenectomy for trauma: a single institution's experience.

PubMed

Thompson, Callie M; Shalhub, Sherene; DeBoard, Zachary M; Maier, Ronald V

2013-08-01

Major pancreaticoduodenal injury can be devastating even if identified and controlled early. To date, both morbidity and mortality have resisted the improvements achieved with many other life-threatening injuries, with reported mortalities of 31% to 50%. We sought to elucidate the impact of the initial operation in the management of severe pancreaticoduodenal injury. A retrospective review of all patients presenting to a single Level I trauma center who required pancreaticoduodenectomy for trauma from 1996 to 2010 was performed. We collected demographic and in-hospital data and compared subjects based on their initial operation. Fifteen patients (median age, 29 years; 93% male; median Injury Severity Score [ISS], 35) underwent pancreaticoduodenectomy following blunt (n = 5) or penetrating trauma (n = 10). Twelve patients (80%) underwent damage-control surgery (DCS) with or without the initial stage of Whipple resection as their first operation. Three patients (20%) underwent a complete Whipple procedure, including reconstruction, as their first operation. Overall, 87% of patients (13 of 15) were acidotic, hypothermic, and coagulopathic during their first operation. Average operative time was longer for the completion pancreaticoduodenectomy versus DCS (460 [98] minutes vs. 243 [112] minutes). There were no overall differences in complication rates, although the two patients who did not experience a complication had DCS. In-hospital mortality was 13% (n = 2). We present both the largest series of patients to date who underwent a DCS or staged Whipple procedure for complex pancreaticoduodenal trauma and the largest series with blunt trauma. Using a staged approach, we report the lowest mortality rate for such injuries in the literature, less than half of that reported in the most recent series (33%). Given the frequent occurrence and recognized detrimental impact of acidosis, hypothermia, and coagulopathy in patients with severe pancreaticoduodenal trauma as well as the proven benefits of DCS, we propose that these patients should undergo initial DCS and staged reconstruction.

Blastic plasmacytoid dendritic cell neoplasm: clinical features in 90 patients.

PubMed

Julia, F; Petrella, T; Beylot-Barry, M; Bagot, M; Lipsker, D; Machet, L; Joly, P; Dereure, O; Wetterwald, M; d'Incan, M; Grange, F; Cornillon, J; Tertian, G; Maubec, E; Saiag, P; Barete, S; Templier, I; Aubin, F; Dalle, S

2013-09-01

Blastic plasmacytoid dendritic cell neoplasm (BPDCN) is a rare disease characterized by malignant proliferation of a contingent blastic plasmacytoid dendritic cell. This rare entity is recognized mostly by cutaneous spreading, or not having a leukaemic component. The prognosis is very poor. To study a large cohort of 90 patients with BPDCN, to define additional symptoms to form a correct diagnosis earlier, and to manage such patients accordingly. We retrospectively reviewed BPDCN cases registered in the French Study Group on Cutaneous Lymphoma database between November 1995 and January 2012. Ninety patients were studied. Demographic data, clinical presentation, initial staging and outcome were recorded. The group contained 62 male and 28 female patients (sex ratio 2·2). Their ages ranged from 8 to 103 years at the time of diagnosis (mean 67·2 years). Three major different clinical presentations were identified. Sixty-six patients (73%) presented with nodular lesions only, 11 patients (12%) with 'bruise-like' patches and 13 (14%) with disseminated lesions (patches and nodules). Mucosal lesions were seen in five patients (6%). The median survival in patients with BPDCN was 12 months. We here distinguish three different clinical presentations of BPDCN. A nodular pattern is a more common feature than the originally reported 'bruise-like' pattern. Despite the fact that BPDCN may initially appear as a localized skin tumour, aggressive management including allogeneic bone marrow transplantation should be considered immediately, as it is currently the only option associated with long-term survival. © 2013 The Authors BJD © 2013 British Association of Dermatologists.

Sporadic Jakob-Creutzfeldt Disease Presenting as Primary Progressive Aphasia

PubMed Central

Johnson, David Y.; Dunkelberger, Diana L.; Henry, Maya; Haman, Aissatou; Greicius, Michael D.; Wong, Katherine; DeArmond, Stephen J.; Miller, Bruce L.; Gorno-Tempini, Maria Luisa; Geschwind, Michael D.

2015-01-01

Objective To report the clinical, neuropsychological, linguistic, imaging, and neuropathological features of a unique case of sporadic Jakob-Creutzfeldt disease in which the patient presented with a logopenic variant of primary progressive aphasia. Design Case report. Setting Large referral center for atypical memory and aging disorders, particularly Jakob-Creutzfeldt disease. Patient Patient presenting with logopenic variant primary progressive aphasia initially thought to be due to Alzheimer disease. Results Despite the long, slow 3.5-year course, the patient was shown to have pathology-proven sporadic Jakob-Creutzfeldt disease. Conclusions These findings expand the differential of primary progressive aphasia to include prion disease. PMID:23400721

Plain radiologic findings and chronological changes of incipient phase osteosarcoma overlooked by primary physicians.

PubMed

Song, Won Seok; Jeon, Dae-Geun; Cho, Wan Hyeong; Kong, Chang-Bae; Cho, Sang Hyun; Lee, Jung Wook; Lee, Soo-Yong

2014-06-01

We assessed the plain radiographic characteristics of 10 cases of osteosarcomas during the initial painful period that had been overlooked by a primary physician. In addition, we evaluated chronologic changes in radiographic findings from initial symptomatic period to the time of accurate diagnosis. The clinical records were reviewed for clinical parameters including age, sex, location, presenting symptoms, initial diagnosis, duration from initial symptoms to definite diagnosis, and initial and follow-up plain radiographic findings of the lesion. Initial clinical diagnoses included a sprain in 6, growing pain in 2, stress fracture in 1, and infection in 1 patient. Initial plain radiographic findings were trabecular destruction (100%), cortical disruption (60%), periosteal reaction (60%), and soft tissue mass (10%). Intramedullary matrix changes were osteosclerosis in 6 and osteolysis in 4 patients. On progression, 4 cases with minimal sclerosis changed to osteoblastic lesion in 3 patients and osteolytic lesion in 1. Four cases with faint osteolytic foci transformed into osteolytic lesion in 3 and mixed pattern in 1. Notable plain radiologic findings of incipient-stage osteosarcoma include trabecular disruption along with faint osteosclerosis or osteolysis. In symptomatic patients with trabecular destruction, additional imaging study including magnetic resonance imaging should be performed to exclude osteosarcoma in the incipient phase, even without radiologic findings suggesting malignant tumor, such as cortical destruction or periosteal reaction.

Diagnosis of systemic lupus erythematosus in an unusual presentation: what a primary care physician should know.

PubMed

Pramanik, Bimalendu

2014-01-01

Systemic Lupus Erythematosus (SLE) is a multisystem autoimmune disease affecting millions of people worldwide. It can affect any organ systems of the body. However, all systems may not be involved initially rather than they may be affected gradually, sometimes over years. Diagnosis depends on characteristic clinical features and laboratory test results. Some features such as skin rash, joint symptoms and oral ulcers are common in SLE. But initial presentation of many patients is unusual because either they do not have these common features of the disease or the presentation mimics other illnesses. As a result, delayed diagnosis and misdiagnosis are common. Therefore, high index of initial suspicion of SLE is critical. In clinical practice, SLE should be suspected in any patient presenting with an unexplained disease process involving two or more organ systems. To make a diagnosis in an unusual presentation, thorough clinical evaluation with details history of both present and past illnesses as well as laboratory tests for SLE should be performed. Usually primary-care physicians first evaluate SLE patients; but there is no single article, where all the information on when to suspect SLE in an unusual presentation, is available in an integrated form. In this article, a list of conditions, when SLE should be suspected in an unusual presentation, has been given and some relatively common areas with diagnostic challenges of SLE have been briefly described. To prepare this manuscript, most articles have been identified through 'Pubmed' search using keywords-atypical/ unusual presentation of SLE, case reports on SLE, gastrointestinal manifestations of SLE, neuropsychiatric SLE, diagnostic challenges with SLE, etc. Selected most articles are from currently medline-indexed journals.

Treatment Patterns and Early Outcomes of ALK-Positive Non-Small Cell Lung Cancer Patients Receiving Ceritinib: A Chart Review Study.

PubMed

Bendaly, Edmond; Dalal, Anand A; Culver, Kenneth; Galebach, Philip; Bocharova, Iryna; Foster, Rebekah; Sasane, Medha; Macalalad, Alexander R; Guérin, Annie

2017-05-01

This study aimed to provide the first real-world description of the characteristics, treatments, dosing patterns, and early outcomes of patients with ALK-positive non-small cell lung cancer (NSCLC) who received ceritinib in US clinical practice. US oncologists provided data from medical charts of adult patients diagnosed with locally advanced or metastatic ALK-positive NSCLC who received ceritinib following crizotinib. Patient characteristics, treatment patterns, ceritinib dosing, early outcomes, and occurrence of gastrointestinal adverse events (AEs) by dose and instructions on food intake were assessed, and Kaplan-Meier analysis was used to describe clinician-defined progression-free survival (PFS) on ceritinib. Medical charts of 58 ALK-positive NSCLC patients treated with ceritinib were reviewed (median age 63 years; 41% male; 21% with prior chemotherapy experience). At ceritinib initiation, 44 patients had multiple distant metastases, most commonly in the liver (60%), bone (53%), and brain (38%). Initial ceritinib dose varied: 71% received 750 mg, 19% 600 mg, and 10% 450 mg. Although median follow-up after ceritinib initiation was short (3.8 months), most patients achieved either a complete or partial response (69%) on ceritinib, regardless of metastatic sites present at initiation or initial dose. Median PFS on ceritinib was 12.9 months. 17% of patients had a gastrointestinal AE reported during follow-up. The majority of events occurred in patients instructed to fast; no patients instructed to take a lower dose of ceritinib with food reported gastrointestinal AEs. These early findings of ceritinib use in clinical practice suggest that ceritinib is effective at treating crizotinib-experienced ALK-positive NSCLC patients, regardless of metastatic sites or initial dose, and dosing ceritinib with food may lead to fewer gastrointestinal AEs. Future studies with larger sample size and longer follow-up are warranted, including an ongoing randomized trial to assess the gastrointestinal tolerability of ceritinib 450 and 600 mg with low-fat meals. Novartis Pharmaceutical Corporation.

Extramedullary plasmacytoma of the testicle.

PubMed

Carrion, Diego M; Álvarez-Maestro, Mario; Gómez Rivas, Juan; González-Peramato, Pilar; Cisneros Ledo, Jesús

2017-12-01

We present the case of a patient diagnosed with a testicular extramedullary plasmacytoma (EMP), and perform a brief review of the literature of this pathology. A 64 year-old male patient, with history of multiple myeloma successfully treated three years before, presented with left testicular swelling. Initial work-up was compatible with a testicular tumor and radical inguinal orchiectomy was performed. Histologic examination of the testis revealed extensive intertubular infiltration by CD138 and CD56 atypical plasma cells, with diffuse staining for IgA, compatible with EMP. Invasion of the testis in multiple myeloma patients as a recurrence of the disease is an extremely rare condition, as EMPs are more common in other organ systems. Initial treatment should be the same as a primary testicular tumor with radical inguinal orchiectomy, and definitive diagnosis is established in histologic analysis.

Imitating the Great Imitator The Intersection of Sarcoidosis and Hodgkin's Lymphoma A Report of Two Cases.

PubMed

Outlaw, Darryl; Mehta, Amitkumar; Dalvi, Sam R

2018-06-01

Sarcoidosis and Hodgkin's lymphoma represent two distinct diseases with different pathogenic mechanisms, therapeutic interventions, and prognoses. Nevertheless, both diseases can have overlapping presentations, thus blurring the line between successful identification and treatment. A propensity to develop one of these diseases following diagnosis of the other has long been appreciated. Here we review two cases of presumed sarcoidosis that were ultimately diagnosed as Hodgkin's lymphoma. Both patients initially presented with non-specific symptoms and underwent a thorough workup, including histological evaluation demonstrating non-caseating granulomas without evidence of malignancy. Both patients started sarcoid-directed therapies with relapse of symptoms. Repeat imaging and tissue biopsy eventually led to the diagnosis of stage IVB Hodgkin's lymphoma. After the initiation of Hodgkin's-directed therapies, both patients showed marked clinical responses, and entered complete remission.

DOE Office of Scientific and Technical Information (OSTI.GOV)

Stanley, P.; Geer, G.D.; Miller, J.H.

The clinical features, radiologic investigation, and treatment of 20 infants with hepatic hemangiomas are presented. Palpable abdominal mass (n = 18) and cardiac failure (n = 11) were the common presenting features. Nine patients had hyperconsumptive coagulopathy. Seven patients had other hemangiomas. Ultrasound (n = 15) showed the number and distribution of the hemangiomas within the liver. Hypoechoic and hyperechoic elements were present in addition to prominent vascular channels and diminished caliber of the distal aorta. Radionuclide sulfur colloid (n = 12) and labeled red blood cell (n = 7) studies showed the distribution and vascularity of the hemangiomas. Computedmore » tomography (n = 8) revealed central hypointensity with marked peripheral enhancement after contrast. Arteriography now performed only as a prelude to therapeutic embolization demonstrated hypervascularity in each patient, contrast pooling in six and early draining veins in five. Magnetic resonance scanning (n = 3) showed decreased signal intensity on T1 images and high intensity signal on T2. In two patients, there was resolution or improvement of the hemangiomas without therapy. Four patients had surgery (lobectomy (2), trisegmentectomy (1), and surgical evacuation of a central hematoma (1)). Steroids and radiation were given to seven patients, and one patient also required therapeutic embolization. Steroids were the initial therapy in five patients, one of whom later required therapeutic embolization and another cyclophosphamide. Two patients were treated initially with radiation therapy, one of whom also needed emergency hepatic artery ligation. Seventeen of the 20 patients are alive and well from 6 months to 14 years after diagnosis.« less

Cannabis and intractable chronic pain: an explorative retrospective analysis of Italian cohort of 614 patients

PubMed Central

Fanelli, Guido; De Carolis, Giuliano; Leonardi, Claudio; Longobardi, Adele; Sarli, Ennio; Allegri, Massimo; Schatman, Michael E

2017-01-01

Background Despite growing interest in the therapeutic use of cannabis to manage chronic pain, only limited data that address these issues are available. In recent years, a number of nations have introduced specific laws to allow patients to use cannabis preparations to treat a variety of medical conditions. In 2015, the Italian government authorized the use of cannabis to treat several diseases, including chronic pain generally, spasticity in multiple sclerosis, cachexia and anorexia among AIDS and cancer patients, glaucoma, Tourette syndrome, and certain types of epilepsy. We present the first snapshot of the Italian experience with cannabis use for chronic pain over the initial year of its use. Methods This is a retrospective case series analysis of all chronic pain patients treated with oral or vaporized cannabis in six hubs during the initial year following the approval of the new Italian law (December 2015 to November 2016). We evaluated routes of administration, types of cannabis products utilized, dosing, and effectiveness and safety of the treatment. Results As only one of the six centers has extensively used cannabinoids for intractable chronic pain (614 patients of 659), only the population from Azienda Ospedaliero Universitaria Pisana (Pisa) was considered. Cannabis tea was the primary mode of delivery, and in almost all cases, it was used in association with all the other pain treatments. Initial and follow-up cannabinoid concentrations were found to vary considerably. At initial follow-up, 76.2% of patients continued the treatment, and <15% stopped the treatment due to side effects (none of which were severe). Conclusion We present the first analysis of Italian clinical practice of the use of cannabinoids for a large variety of chronic pain syndromes. From this initial snapshot, we determined that the treatment seems to be effective and safe, although more data and subsequent trials are needed to better investigate its ideal clinical indication. PMID:28579820

Cannabis and intractable chronic pain: an explorative retrospective analysis of Italian cohort of 614 patients.

PubMed

Fanelli, Guido; De Carolis, Giuliano; Leonardi, Claudio; Longobardi, Adele; Sarli, Ennio; Allegri, Massimo; Schatman, Michael E

2017-01-01

Despite growing interest in the therapeutic use of cannabis to manage chronic pain, only limited data that address these issues are available. In recent years, a number of nations have introduced specific laws to allow patients to use cannabis preparations to treat a variety of medical conditions. In 2015, the Italian government authorized the use of cannabis to treat several diseases, including chronic pain generally, spasticity in multiple sclerosis, cachexia and anorexia among AIDS and cancer patients, glaucoma, Tourette syndrome, and certain types of epilepsy. We present the first snapshot of the Italian experience with cannabis use for chronic pain over the initial year of its use. This is a retrospective case series analysis of all chronic pain patients treated with oral or vaporized cannabis in six hubs during the initial year following the approval of the new Italian law (December 2015 to November 2016). We evaluated routes of administration, types of cannabis products utilized, dosing, and effectiveness and safety of the treatment. As only one of the six centers has extensively used cannabinoids for intractable chronic pain (614 patients of 659), only the population from Azienda Ospedaliero Universitaria Pisana (Pisa) was considered. Cannabis tea was the primary mode of delivery, and in almost all cases, it was used in association with all the other pain treatments. Initial and follow-up cannabinoid concentrations were found to vary considerably. At initial follow-up, 76.2% of patients continued the treatment, and <15% stopped the treatment due to side effects (none of which were severe). We present the first analysis of Italian clinical practice of the use of cannabinoids for a large variety of chronic pain syndromes. From this initial snapshot, we determined that the treatment seems to be effective and safe, although more data and subsequent trials are needed to better investigate its ideal clinical indication.

Stroke as the Initial Manifestation of Atrial Fibrillation: The Framingham Heart Study.

PubMed

Lubitz, Steven A; Yin, Xiaoyan; McManus, David D; Weng, Lu-Chen; Aparicio, Hugo J; Walkey, Allan J; Rafael Romero, Jose; Kase, Carlos S; Ellinor, Patrick T; Wolf, Philip A; Seshadri, Sudha; Benjamin, Emelia J

2017-02-01

To prevent strokes that may occur as the first manifestation of atrial fibrillation (AF), screening programs have been proposed to identify patients with undiagnosed AF who may be eligible for treatment with anticoagulation. However, the frequency with which patients with AF present with stroke as the initial manifestation of the arrhythmia is unknown. We estimated the frequency with which AF may present as a stroke in 1809 community-based Framingham Heart Study participants with first-detected AF and without previous strokes, by tabulating the frequencies of strokes occurring on the same day, within 30 days before, 90 days before, and 365 days before first-detected AF. Using previously reported AF incidence rates, we estimated the incidence of strokes that may represent the initial manifestation of AF. We observed 87 strokes that occurred ≤1 year before AF detection, corresponding to 1.7% on the same day, 3.4% within 30 days before, 3.7% within 90 days before, and 4.8% ≤1 year before AF detection. We estimated that strokes may present as the initial manifestation of AF at a rate of 2 to 5 per 10 000 person-years, in both men and women. We observed that stroke is an uncommon but measureable presenting feature of AF. Our data imply that emphasizing cost-effectiveness of population-wide AF-screening efforts will be important given the relative infrequency with which stroke represents the initial manifestation of AF. © 2017 American Heart Association, Inc.

Impact of the moon on cerebral aneurysm rupture.

PubMed

Kamp, Marcel A; Dibué, Maxine; Slotty, Philipp; Steiger, Hans-Jakob; Hänggi, Daniel

2013-08-01

Several external and internal risk factors for cerebral aneurysm rupture have been identified to date. Recently, it has been reported that moon phases correlate with the incidence of aneurysmal subarachnoid hemorrhage (SAH), however, another author found no such association. Therefore, the present study investigates the influence of the lunar cycle on the incidence of aneurysmal rupture, the initial clinical presentation, and the amount of subarachnoid blood. Lunar phase and the particular day of the lunar cycle were correlated to the date of aneurysm rupture, aneurysm location, initial clinical presentation, and amount of subarachnoid blood assessed from CT scans of all patients treated for basal SAH in our department from 2003 to 2010. We found no correlation between incidence of aneurysmal SAH, location of the aneurysm, initial clinical presentation, or amount of subarachnoid blood and the lunar cycle. The moon influences neither the incidence of aneurysmal SAH nor the grade of initial neurological deterioration or amount of subarachnoid blood.

Five-year study of ocular injuries due to fireworks in India.

PubMed

Malik, Archana; Bhala, Soniya; Arya, Sudesh K; Sood, Sunandan; Narang, Subina

2013-08-01

To study the demographic profile, cause, type and severity of ocular injuries, their complications and final visual outcome following fireworks around the time of Deepawali in India. Case records of patients who presented with firework-related injuries during 2005-2009 at the time of Deepawali were reviewed. Data with respect to demographic profile of patients, cause and time of injury, time of presentation and types of intervention were analyzed. Visual acuity at presentation and final follow-up, anterior and posterior segment findings, and any diagnostic and surgical interventions carried out were noted. One hundred and one patients presented with firework-related ocular injuries, of which 77.5 % were male. The mean age was 17.60 ± 11.9 years, with 54 % being ≤14 years of age. The mean time of presentation was 8.9 h. Seventeen patients had open globe injury (OGI) and 84 had closed globe injury (CGI). Fountains were the most common cause of CGI and bullet bombs were the most common cause of OGI. Mean log MAR visual acuity at presentation was 0.64 and 1.22 and at last follow-up was 0.09 and 0.58 for CGI and OGI, respectively (p < 0.05). Patients with CGI had a better visual outcome. Three patients with OGI developed permanent blindness. Factors associated with poor visual outcome included poor initial visual acuity, OGI, intraocular foreign body (IOFB), retinal detachment and development of endophthalmitis. Firework injuries were seen mostly in males and children. Poor visual outcome was associated with poor initial visual acuity, OGI, IOFB, retinal detachment and development of endophthalmitis, while most patients with CGI regained good vision.

Beta-blocker withdrawal among patients presenting for surgery from home

PubMed Central

Schonberger, Robert B.; Lukens, Carrie L.; Turkoglu, O. Dicle; Feinleib, Jessica L.; Haspel, Kenneth L.; Burg, Matthew M.

2012-01-01

Structured Abstract Objective This study sought to measure the incidence of perioperative beta-blocker non-compliance by patients who were prescribed chronic beta blocker therapy and presented for surgery from home. The effect of patient non-compliance on day of surgery presenting heart rate was also examined. Design Prospective observational study with outcome data obtained from review of the medical record. Setting The preoperative clinic and operating rooms of a Veterans Administration hospital. Participants Patients on chronic beta blocker therapy who presented from home for surgery. Interventions None. Measurements and Main Results Demographic and comorbidity data as well as data on self-reported compliance to beta-blocker therapy, initial day of surgery vital signs, and recent ambulatory vital signs were collected. Ten out of fifty subjects (20%; 95% CI = 9-31%) reported not taking their day of surgery beta-blocker. These self-reported non-adherers demonstrated a higher presenting heart rate on the day of surgery vs. adherent subjects (median of 78 beats per minute vs. 65 beats per minute, p=0.02 by Wilcoxon Rank-Sum Test). The difference-in-difference between baseline primary care and day of surgery heart rate was also statistically significant between compliant and non-compliant subjects (-7 beats per minute vs. +12.5 beats per minute, p<0.00001). Conclusions Patient self-report and physiologic data documented failure to take beta-blockers and possible beta-blocker withdrawal in 20% of patients who presented for surgery from home. If these findings are confirmed in larger studies, improved patient understanding of and compliance with medication instructions during preoperative visits should be a focus of future quality improvement initiatives. PMID:22418043

Variation in promptness of presentation among 10,297 patients subsequently diagnosed with one of 18 cancers: Evidence from a National Audit of Cancer Diagnosis in Primary Care

PubMed Central

Keeble, Stuart; Abel, Gary A; Saunders, Catherine L; McPhail, Sean; Walter, Fiona M; Neal, Richard D; Rubin, Gregory P; Lyratzopoulos, Georgios

2014-01-01

Cancer awareness public campaigns aim to shorten the interval between symptom onset and presentation to a doctor (the ‘patient interval’). Appreciating variation in promptness of presentation can help to better target awareness campaigns. We explored variation in patient intervals recorded in consultations with general practitioners among 10,297 English patients subsequently diagnosed with one of 18 cancers (bladder, brain, breast, colorectal, endometrial, leukaemia, lung, lymphoma, melanoma, multiple myeloma, oesophageal, oro-pharyngeal, ovarian, pancreatic, prostate, renal, stomach, and unknown primary) using data from of the National Audit of Cancer Diagnosis in Primary Care (2009–2010). Proportions of patients with ‘prompt’/‘non-prompt’ presentation (0–14 or 15+ days from symptom onset, respectively) were described and respective odds ratios were calculated by multivariable logistic regression. The overall median recorded patient interval was 10 days (IQR 0–38). Of all patients, 56% presented promptly. Prompt presentation was more frequent among older or housebound patients (p < 0.001). Prompt presentation was most frequent for bladder and renal cancer (74% and 70%, respectively); and least frequent for oro-pharyngeal and oesophageal cancer (34% and 39%, respectively, p <.001). Using lung cancer as reference, the adjusted odds ratios of non-prompt presentation were 2.26 (95% confidence interval 1.57–3.25) and 0.42 (0.34–0.52) for oro-pharyngeal and bladder cancer, respectively. Sensitivity analyses produced similar findings. Routinely recorded patient interval data reveal considerable variation in the promptness of presentation. These findings can help to prioritise public awareness initiatives and research focusing on symptoms of cancers associated with greater risk of non-prompt presentation, such as oro-pharyngeal and oesophageal cancer. What's new? A critical aspect of cancer diagnosis is how promptly patients consult a doctor after they first notice initial symptoms. Here, the authors examine differences in this so-called patient interval in English patients subsequently diagnosed with one of 18 cancers. On average, patients with bladder and renal cancer as well as older and housebound patients consulted a doctor relatively promptly while patients with oro-pharyngeal and oesophageal cancer took the longest until first presenting to a general practitioner. The authors point out that cancer awareness campaigns should encompass symptoms of oro-pharyngeal and oesophageal cancer aiming to shorten the patient interval for these cancers. PMID:24515930

Trousseau's syndrome in a patient with advanced stage gastric cancer.

PubMed

Chien, Tai-Long; Rau, Kung-Ming; Chung, Wen-Jung; Tai, Wei-Chen; Wang, Shih-Ho; Chiu, Yi-Chun; Wu, Keng-Liang; Chou, Yeh-Pin; Wu, Chia-Che; Chen, Yen-Hao; Chuah, Seng-Kee

2015-09-14

Patients with cancer are at high risk for thrombotic events, which are known collectively as Trousseau's syndrome. Herein, we report a 66-year-old male patient who was diagnosed with terminal stage gastric cancer and liver metastasis and who had an initial clinical presentation of upper gastrointestinal bleeding. Acute ischemia of the left lower leg that resulted in gangrenous changes occurred during admission. Subsequent angiography of the left lower limb was then performed. This procedure revealed arterial thrombosis of the left common iliac artery with extension to the external iliac artery, the left common iliac artery, the posterior tibial artery, and the peroneal artery, which were occluded by thrombi. Aspiration of the thrombi demonstrated that these were not tumor thrombi. The interesting aspect of our case was that the disease it presented as arterial thrombotic events, which may correlate with gastric adenocarcinoma. In summary, we suggested that the unexplained thrombotic events might be one of the initial presentations of occult malignancy and that thromboprophylaxis should always be considered.

Crohn's disease in black patients.

PubMed Central

Paul, H.; Barnes, R. W.; Reese, V. E.; Childress, M. H.; Scott, V.; Leffall, L. D.

1990-01-01

Crohn's disease is less prevalent in blacks than in whites. However, when it does occur, it is associated with a high degree of morbidity and is frequently unrecognized at initial presentation. Forty-three patients with Crohn's disease presented to Howard University Hospital between 1965 and 1987. There were 156 hospital admissions, 47 emergency room visits, and 76 clinic visits over this 22-year period. Twenty-eight patients were female and 15 were male. The age of presentation for males ranged from 18 to 63 years and for females, 12 to 74 years. Crohn's disease should be considered in black patients who present with chronic abdominal pain and diarrhea. With correct diagnosis and appropriate medical therapy, patients should have an enhanced quality of life with less morbidity. Images Figure 1 Figure 2 Figure 3 PMID:2280420

Paraneoplastic limbic encephalitis presenting as acute viral encephalitis.

PubMed

Kararizou, E; Markou, I; Zalonis, I; Gkiatas, K; Triantafyllou, N; Kararizos, G; Likomanos, D; Zambelis, T; Vassilopoulos, D

2005-11-01

To describe a case of limbic encephalitis which initially presented as viral limbic encephalitis and during the clinical evaluation a renal carcinoma was diagnosed. Patient with history of peripheral paresis of right facial nerve, 1 month after symptoms appearance and treatment, developed fever, vomiting, grand mal seizure, decreased level of consciousness, confusion, hallucinations and agitation. The patient initially presented a clinical picture of viral LE. which confirmed by CSF. MRI brain showed areas with pathological intensity signal in the region of limbic system unilateral. During the clinical evaluation a renal carcinoma was discovered and a nephrectomy has been performed. Although PLE typically presents as a chronic or subacute disease, it may be fulminant and clinically indistinguishable from an acute HSVE. This association pose the problem of a possible relation between this two syndromes and the correct diagnosis is very important, because there are effective treatments.

Clinical characteristics and outcomes of fall-related open globe injuries in Japan.

PubMed

Morikawa, Shohei; Okamoto, Yoshifumi; Okamoto, Fumiki; Inomoto, Naoki; Ishikawa, Hiroto; Harimoto, Kozo; Ueda, Tetsuo; Sakamoto, Taiji; Oshika, Tetsuro

2018-07-01

To investigate the clinical characteristics and visual outcomes in patients with fall-related open globe injuries and to evaluate differences between fall-related and non-fall-related open globe injuries in Japan. A retrospective review of patients with open globe injury who presented to Japan-Clinical Research of Study (J-CREST) hospitals between 2005 and 2015 was enrolled. Clinical information including age, sex, initial visual acuity, final visual acuity, type of injury, status of the crystalline lens, zone of injury, wound length, presence of retinal detachment, proliferative vitreoretinopathy, expulsive hemorrhage, and endophthalmitis was recorded. A total of 374 eyes were enrolled, of which 120 (32.1%) suffered from fall-related injury with average age of 73.7 ± 15.9 years (range, 11-101 years). A majority of patients were female (55.8%). Of 120 patients with fall-related injury, 109 (90.8%) presented with rupture and 11 (9.2%) with laceration. A multiple regression analysis revealed that final visual acuity was significantly associated with initial visual acuity (r = 0.99, P < 0.001). Compared to non-fall-related open globe injuries, fall-related open globe injuries were associated with elderly age, female sex, poorer initial and final visual acuity, rupture, absence of the lens, larger wound size, retinal detachment, expulsive hemorrhage, and absence of endophthalmitis (P < 0.01). Fall-related open globe injuries were more frequent in elderly female and accompanied by larger wound lengths and severer ocular complications. Visual outcomes in patients with fall-related open globe injuries were related to initial visual acuity.

Patterns of failure in patients with medulloblastoma

DOE Office of Scientific and Technical Information (OSTI.GOV)

Jereb, B.; Reid, A.; Ahuja, R.K.

1982-12-15

Fifty-two patients with medulloblastoma were seen at Memorial Sloan-Kettering Cancer Center (MSKCC) between 1959 and 1979. All patients had their primary surgery at other institutions; 27 were referred postoperatively for the initial course of radiation therapy; 24 were referred for treatment of recurrence and 1 patient for adjuvant chemotherapy only. The patients were classified as: (1) Group I: small, localized tumor which was completely excised, (2) Group II: large, localized, incompletely excised tumor, (3) Group II: tumor spread within the central nervous system, (4) Group IV: hematogenous metastases at initial presentation. Of the 27 patients who received initial radiation treatmentsmore » at MSKCC, six were of the Groups III and IV and all of these have died. Of the remaining 21 patients with localized disease ten are alive and disease-free with follow-up from 20 to 81 months. The extent of disease at the initial treatment was the most important prognostic factor. There were no survivors in the Groups III and IV. The most common site of recurrence was the posterior fossa, 21 of 40 patients, six patients had recurrence at the cribriform plate and the adjoining medial frontal lobes, and five had their first recurrence outside the CNS. None of the patients who received less than 3400 rad to the craniospinal axis or less than 5000 rad to the posterior fossa is alive. The duration of treatment seems to be of less importance for the outcome than the total dose of radiation delivered. (JMT)« less

Painless thyroiditis associated to thyroid carcinoma: role of initial ultrasonography evaluation.

PubMed

Valentini, Raisa Bressan; Macedo, Bruno Mussoi de; Izquierdo, Rogério Friedrich; Meyer, Erika Laurini Souza

2016-04-01

Even though it is a rare event, most associations of thyroid carcinoma with subacute thyroiditis described in the literature are related to its granulomatous form (Quervain's thyroiditis). We present a patient with subacute lymphocytic thyroiditis (painless thyroiditis) and papillary thyroid cancer that was first suspected in an initial ultrasound evaluation. A 30-year old female patient who was referred to the emergency room due to hyperthyroidism symptoms was diagnosed with painless thyroiditis established by physical examination and laboratory findings. With the presence of a palpable painless thyroid nodule an ultrasound was prescribed and the images revealed a suspicious thyroid nodule, microcalcification focus in the heterogeneous thyroid parenquima and cervical lymphadenopathy. Fine needle aspiration biopsy was taken from this nodule; cytology was assessed for compatibility with papillary thyroid carcinoma. Postsurgical pathology evaluation showed a multicentric papillary carcinoma and lymphocytic infiltration. Subacute thyroiditis, regardless of type, may produce transitory ultrasound changes that obscure the coexistence of papillary carcinoma. Due to this, initial thyroid ultrasound evaluation should be delayed until clinical recovery. We recommended a thyroid ultrasound exam for initial evaluation of painless thyroiditis, particularly in patients with palpable thyroid nodule. Further cytological examination is recommended in cases presenting with suspect thyroid nodule and/or non-nodular hypoechoic (> 1 cm) or heterogeneous areas with microcalcification focus.

Is a high initial World Federation of Neurosurgery (WFNS) grade really associated with a poor clinical outcome in elderly patients with ruptured intracranial aneurysms treated with coiling?

PubMed

Iosif, Christina; Di Maria, Federico; Sourour, Nader; Degos, Vincent; Bonneville, Fabrice; Biondi, Alessandra; Jean, Betty; Colonne, Chantal; Nouet, Aurelien; Chiras, Jacques; Clarençon, Frédéric

2014-05-01

Coiling of ruptured intracranial aneurysms in elderly patients remains debatable in terms of technical feasibility and clinical outcome. In this observational cohort study we aimed to assess the technical feasibility, complication profile and clinical outcomes of elderly patients with subarachnoid hemorrhage (SAH) treated with endovascular therapy. The study included 59 consecutive patients (47 women) aged ≥70 years (mean age 76 years, range 71-84) admitted to our institution with SAH from January 2002 to July 2011. The patients were treated for 66 aneurysms (regular coiling: n=62 (94%), balloon-assisted technique: n=2 (3%), stent and coil technique: n=2 (3%)). World Federation of Neurosurgery (WFNS) grade at admission was 1 in 13 patients, 2 in 23 patients, 3 in 8 patients, 4 in 11 patients and 5 in 4 patients. We analysed data by univariate and multivariate statistical analyses with an emphasis on the initial clinical situation, complications and clinical outcome. The technical success rate was 98% with a procedure-related deficit rate of 10% and procedure-related death rate of 5%. The Glasgow Outcome Scale score at 6 months was 1 in 15 patients (25.4%), 2 in 8 patients (13.6%), 3 in 14 patients (23.7%), 4 in 11 patients (18.6%) and 5 in 11 patients (18.6%). Patients admitted with a high initial WFNS grade did not differ statistically in terms of clinical outcome. The final clinical outcome was not significantly correlated with age, initial Fisher score or procedure-related complications. Endovascular treatment of elderly patients with ruptured cerebral aneurysms is feasible, safe and beneficial regardless of the presenting WFNS score.

A case study from a nursing and occupational therapy perspective - Providing care for a patient with a traumatic brachial plexus injury.

PubMed

Wellington, Beverley; McGeehan, Claire

2015-02-01

This paper presents a case study that demonstrates how collaborative working between professionals enhanced the holistic care for a patient following a traumatic brachial plexus injury. The paper will describe the patient's journey of care from initial presentation, diagnosis and assessment, acute care provision, discharge & rehabilitation to ongoing supportive counselling. The care encompasses input from both a nursing and occupational therapy perspective. Copyright © 2014 Elsevier Ltd. All rights reserved.

Practice Guidelines for the Diagnosis and Management of Patients With Q Fever by the Armed Forces Infectious Diseases Society

DTIC Science & Technology

2012-05-01

clinical presentations but typically presents as a flu-like illness. The most common chronic manifestation is endocarditis . Most providers are not...to years after initial infection.1,7 Manifestations of chronic infection may include endocarditis , other endovascular infec- tions, granulomatous... endocarditis conducted in France, PCR on blood or serum samples was positive in 23 of 70 patients (33%) tested.27 In a follow-up of 686 patients from the

Varied Presentation of Congenital Segmental Dilatation of the Intestine in Neonates: Report of Three Cases

PubMed Central

Rai, Binod Kumar; Mirza, Bilal; Hashim, Imran; Saleem, Muhammad

2016-01-01

Congenital segmental dilatation (CSD) of the intestine is a rare developmental anomaly characterized by sharply demarcated dilatation of a gastrointestinal segment and may present with intestinal obstruction. We report three cases of CSD of the intestine in neonates with varied presentation. First patient was mistaken as pneumoperitoneum on abdominal radiograph, which led to initial abdominal drain placement. The 2nd patient was a case of anorectal malformation associated with congenital pouch colon (CPC) and CSD of ileum; and the third case presented as neonatal intestinal obstruction and found to have CSD of ileum. All the patients were successfully managed in our department. PMID:27896163

Early identification of ‘acute-onset’ chronic inflammatory demyelinating polyneuropathy

PubMed Central

Sung, Jia-Ying; Tani, Jowy; Park, Susanna B.; Kiernan, Matthew C.

2014-01-01

Distinguishing patients with acute-onset chronic inflammatory demyelinating polyneuropathy from acute inflammatory demyelinating polyneuropathy prior to relapse is often challenging at the onset of their clinical presentation. In the present study, nerve excitability tests were used in conjunction with the clinical phenotype and disease staging, to differentiate between patients with acute-onset chronic inflammatory demyelinating polyneuropathy and patients with acute inflammatory demyelinating polyneuropathy at an early stage, with the aim to better guide treatment. Clinical assessment, staging and nerve excitability tests were undertaken on patients initially fulfilling the diagnostic criteria of acute inflammatory demyelinating polyneuropathy soon after symptom onset and their initial presentation. Patients were subsequently followed up for minimum of 12 months to determine if their clinical presentations were more consistent with acute-onset chronic inflammatory demyelinating polyneuropathy. Clinical severity as evaluated by Medical Research Council sum score and Hughes functional grading scale were not significantly different between the two cohorts. There was no difference between the time of onset of initial symptoms and nerve excitability test assessment between the two cohorts nor were there significant differences in conventional nerve conduction study parameters. However, nerve excitability test profiles obtained from patients with acute inflammatory demyelinating polyneuropathy demonstrated abnormalities in the recovery cycle of excitability, including significantly reduced superexcitability (P < 0.001) and prolonged relative refractory period (P < 0.01), without changes in threshold electrotonus. In contrast, in patients with acute-onset chronic inflammatory demyelinating polyneuropathy, a different pattern occurred with the recovery cycle shifted downward (increased superexcitability, P < 0.05; decreased subexcitability, P < 0.05) and increased threshold change in threshold electrotonus in both hyperpolarizing and depolarizing directions [depolarizing threshold electrotonus (90–100 ms) P < 0.005, hyperpolarizing threshold electrotonus (10–20 ms), P < 0.01, hyperpolarizing threshold electrotonus (90–100 ms), P < 0.05], perhaps suggesting early hyperpolarization. In addition, using excitability parameters superexcitability, subexcitability and hyperpolarizing threshold electrotonus (10–20 ms), the patients with acute inflammatory demyelinating polyneuropathy and acute-onset chronic inflammatory demyelinating polyneuropathy could be clearly separated into two non-overlapping groups. Studies of nerve excitability may be able to differentiate acute from acute-onset chronic inflammatory demyelinating polyneuropathy at an early stage. Characteristic nerve excitability parameter changes occur in early acute-onset chronic inflammatory demyelinating polyneuropathy, to match the clinical phenotype. Importantly, this pattern of change was strikingly different to that shown by patients with acute inflammatory demyelinating polyneuropathy, suggesting that nerve excitability techniques may be useful in distinguishing acute-onset chronic inflammatory demyelinating polyneuropathy from acute inflammatory demyelinating polyneuropathy at the initial stage. PMID:24983276

Videothoracoscopy in the treatment of spontaneous pneumothorax: an initial experience.

PubMed Central

Waller, D. A.; Yoruk, Y.; Morritt, G. N.; Forty, J.; Dark, J. H.

1993-01-01

We report an initial experience with the new and potentially advantageous technique of videothoracoscopy in the treatment of pneumothorax. A series of 18 consecutive patients (14 male, 4 female) presenting with spontaneous pneumothorax over a 4-month period underwent surgical treatment by this method. The indication for surgery was recurrent pneumothorax in nine patients and persistent air leak in the remainder (median duration 15 days, range 5-28 days). Stapled apical bullectomy with apical parietal pleurectomy was performed in 14 patients, bullectomy alone was performed in one patient and pleurectomy alone in three patients. Additional talc pleurodesis was carried out in three of these patients. Median duration of operation was 53.5 min (range 35-120 min). The median postoperative drainage was 300 ml in 24 h (range 50-580 ml). The median duration of intercostal drainage was 48 h (range 24-384 h) and of postoperative hospital stay 4 days (range 3-18 days). The mean postoperative analgesic requirement was 1.3 mg morphine/h. Three complications required reoperation. In two patients a large air leak persisted after operation; one proceeded to thoracotomy for suturing of the air leak and in the other this was accomplished by videothoracoscopy. A further patient re-presented at 2 weeks with recurrent pneumothorax which was treated at thoracotomy. At a median follow-up of 68.5 days (range 10-124 days) this is the only recurrence. These complications were caused by errors in surgical technique early in our series. This initial experience of videothoracoscopic pleurectomy suggests it is an effective, well-tolerated treatment of spontaneous pneumothorax. PMID:8379623

Exploring Delirium’s Heterogeneity: Association between Arousal Subtypes at Initial Presentation and 6-month Mortality in Older Emergency Department Patients

PubMed Central

Han, Jin H.; Brummel, Nathan E.; Chandrasekhar, Rameela; Wilson, Jo Ellen; Liu, Xulei; Vasilevskis, Eduard E.; Girard, Timothy D.; Carlo, Maria E.; Dittus, Robert S.; Schnelle, John F.; Ely, E. Wesley

2016-01-01

Objectives To determine how delirium subtyped by level of arousal at initial presentation affects 6-month mortality. Design This was a preplanned secondary analysis of two prospective cohort studies. Setting Academic tertiary care emergency department (ED). Participants 1,084 ED patients who were 65 years old or older. Measurements At the time of enrollment, trained research personnel performed the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) and Richmond Agitation Sedation Scale (RASS) to determine delirium and level of arousal, respectively. Patients were categorized as having no delirium, delirium with normal arousal, delirium with decreased arousal, or delirium with increased arousal. Death was ascertained by medical record review and the Social Security Death Index. Cox proportional hazard regression was used to analyze the association between delirium arousal subtypes and 6-month mortality. Results Delirium with normal arousal was the only subtype that was significantly associated with increased 6-month mortality (HR=3.1, 95%CI: 1.3 – 7.4) compared with the no delirium group after adjusting for confounders. The HRs for delirium with decreased and increased arousal were 1.4 (95%CI: 0.9 – 2.1) and 1.3 (95%CI: 0.3 – 5.4), respectively. Conclusion Delirious ED patients with normal arousal at initial presentation had a three-fold increased hazard of death within 6-months compared to patients without delirium. There was a trend towards increased hazard of death in delirious ED patients with decreased arousal, but this relationship did not reach statistical significance. These data suggest that subtyping delirium by arousal may have prognostic value but requires confirmation with a larger study. PMID:27623552

[Stroke in paediatric patients with sickle-cell anaemia].

PubMed

Díaz-Díaz, Judit; Camacho-Salas, Ana; Núñez-Enamorado, Noemí; Carro-Rodríguez, Miguel A; Sánchez-Galán, Victoria; Martínez de Aragón, Ana; Simón-De Las Heras, Rogelio

2014-08-16

Sickle-cell anaemia is the severe homozygotic form of drepanocytosis, a genetic disorder that often occurs among black people and which is characterised by the production of haemoglobin S, chronic hemolytic anaemia and tissue ischaemia due to alterations in blood flow. A quarter of the patients presented neurological manifestations; 8-10% of children will have a stroke. AIM. To analyse the cases of stroke in children with sickle-cell anaemia in our centre. We conducted a retrospective descriptive study of children with sickle-cell anaemia and stroke. Five patients (two Dominicans and three Guineans) with sickle-cell anaemia and stroke; one patient suffered two episodes of stroke. The mean age was 27 months. Five of the episodes were ischaemic infarctions. Stroke was the initial form of presentation of drepanocytosis on three occasions. Two of the strokes occurred within a context of pneumococcal meningitis. Four of the patients had previously reported fever. The initial clinical picture was hemiparesis in four cases. Mean haemoglobin on diagnosing the stroke was 6.5 g/dL. Transcranial ultrasound imaging revealed alterations in three patients and, in all the patients, magnetic resonance imaging revealed lesions, which were bilateral in half the cases. Following the stroke, a hypertransfusion regimen protocol was established and only one patient presented a new stroke. This same patient went on to develop moya-moya disease and was submitted to an indirect revascularisation; the patient progressed well, without presenting any new ischaemic events. Drepanocytosis is a disease that is emerging in our setting as a result of immigration. It should be suspected in cases of paediatric strokes associated to anaemia, above all in black children under the age of five who were not submitted to neonatal screening.

The Cambridge Otology Quality of Life Questionnaire: an otology-specific patient-recorded outcome measure. A paper describing the instrument design and a report of preliminary reliability and validity.

PubMed

Martin, T P C; Moualed, D; Paul, A; Ronan, N; Tysome, J R; Donnelly, N P; Cook, R; Axon, P R

2015-04-01

The Cambridge Otology Quality of Life Questionnaire (COQOL) is a patient-recorded outcome measurement (PROM) designed to quantify the quality of life of patients attending otology clinics. Item-reduction model. A systematically designed long-form version (74 items) was tested with patient focus groups before being presented to adult otology patients (n. 137). Preliminary item analysis tested reliability, reducing the COQOL to 24 questions. This was then presented in conjunction with the SF-36 (V1) questionnaire to a total of 203 patients. Subsequently, these were re-presented at T + 3 months, and patients recorded whether they felt their condition had improved, deteriorated or remained the same. Non-responders were contacted by post. A correlation between COQOL scores and patient perception of change was examined to analyse content validity. Teaching hospital and university psychology department. Adult patients attending otology clinics with a wide range of otological conditions. Item reliability measured by item–total correlation, internal consistency and test– retest reliability. Validity measured by correlation between COQOL scores and patient-reported symptom change. Reliability: the COQOL showed excellent internal consistency at both initial presentation (a = 0.90) and 3 months later (a = 0.93). Validity: One-way analysis of variance showed a significant difference between groups reporting change and those reporting no change in quality of life (F(2, 80) = 5.866, P < 0.01). The COQOL is the first otology-specific PROM. Initial studies demonstrate excellent reliability and encouraging preliminary criterion validity: further studies will allow a deeper validation of the instrument.

Limb Salvage After Failed Initial Operative Management of Bimalleolar Ankle Fractures in Diabetic Neuropathy.

PubMed

Vaudreuil, Nicholas J; Fourman, Mitchell S; Wukich, Dane K

2017-03-01

Ankle fractures in patients with diabetes mellitus (DM) can be difficult to manage, especially in the presence of peripheral neuropathy. In patients who fail initial operative management, attempts at limb salvage can be challenging, and no clear treatment algorithm exists. This study examined outcomes of different procedures performed for limb salvage in this population. This study retrospectively reviewed 17 patients with DM complicated by peripheral neuropathy who sustained a bimalleolar ankle fracture and failed initial operative management. Patients were treated with revision open reduction internal fixation (ORIF) (3/17), closed reduction external fixation (CREF) (8/17), or primary ankle joint fusion (3/17 tibiotalocalcaneal fusion with hindfoot nail [TTCN] and 3/17 with tibiotalar arthrodesis using plates and screws [TTA]). Median follow-up was 20 months. The overall rate of limb salvage was 82.3% (14/17). All patients who went on to amputation presented with infection and were treated initially with CREF (3/3). All patients who achieved successful limb salvage ended up with a clinically fused ankle joint (14/14); 9 underwent a primary or delayed formal fusion and 5 had a clinically fused ankle joint at study conclusion after undergoing revision ORIF or CREF with adjunctive procedures. This small study suggests that in this complicated group of patients it is difficult to achieve limb salvage with an end result of a functional ankle joint. CREF can be a viable option in cases where underlying infection or poor bone quality is present. Treatment with revision ORIF frequently requires supplementary external fixator or tibiotalar Steinman pin placement for additional stability. All patients who underwent revision ORIF ended up with clinically fused ankle joints at the end of the study period. Primary fusion procedures (TTA, TTCN) were associated with a high rate of limb salvage and a decreased number of operations. Level III, retrospective case series.

Colorectal Cancer Initial Diagnosis: Screening Colonoscopy, Diagnostic Colonoscopy, or Emergent Surgery, and Tumor Stage and Size at Initial Presentation.

PubMed

Moreno, Courtney C; Mittal, Pardeep K; Sullivan, Patrick S; Rutherford, Robin; Staley, Charles A; Cardona, Kenneth; Hawk, Natalyn N; Dixon, W Thomas; Kitajima, Hiroumi D; Kang, Jian; Small, William C; Oshinski, John; Votaw, John R

2016-03-01

Rates of colorectal cancer screening are improving but remain suboptimal. Limited information is available regarding how patients are diagnosed with colorectal cancer (for example, asymptomatic screened patients or diagnostic workup because of the presence of symptoms). The purpose of this investigation was to determine how patients were diagnosed with colorectal cancer (screening colonoscopy, diagnostic colonoscopy, or emergent surgery) and tumor stage and size at diagnosis. Adults evaluated between 2011 and 2014 with a diagnosis of colorectal cancer were identified. Clinical notes, endoscopy reports, surgical reports, radiology reports, and pathology reports were reviewed. Sex, race, ethnicity, age at the time of initial diagnosis, method of diagnosis, presenting symptom(s), and primary tumor size and stage at diagnosis were recorded. Colorectal cancer screening history was also recorded. The study population was 54% male (265 of 492) with a mean age of 58.9 years (range, 25-93 years). Initial tissue diagnosis was established at the time of screening colonoscopy in 10.7%, diagnostic colonoscopy in 79.2%, and during emergent surgery in 7.1%. Cancers diagnosed at the time of screening colonoscopy were more likely to be stage 1 than cancers diagnosed at the time of diagnostic colonoscopy or emergent surgery (38.5%, 7.2%, and 0%, respectively). Median tumor size was 3.0 cm for the screening colonoscopy group, 4.6 cm for the diagnostic colonoscopy group, and 5.0 cm for the emergent surgery group. At least 31% of patients diagnosed at the time of screening colonoscopy, 19% of patients diagnosed at the time of diagnostic colonoscopy, and 26% of patients diagnosed at the time of emergent surgery had never undergone a screening colonoscopy. Nearly 90% of colorectal cancer patients were diagnosed after development of symptoms and had more advanced disease than asymptomatic screening patients. Colorectal cancer outcomes will be improved by improving rates of colorectal cancer screening. Copyright © 2016 Elsevier Inc. All rights reserved.

The initial electrocardiogram during admission for myocardial infarction. Use as a predictor of clinical course and facility utilization.

PubMed

Stark, M E; Vacek, J L

1987-05-01

The first electrocardiogram obtained on presentation for suspected myocardial infarction was examined for its usefulness in predicting clinical course and facility use. We studied 221 patients consecutively admitted to a nonuniversity hospital coronary care unit. High-risk patients were identified if the electrocardiographic diagnoses included myocardial infarction, ischemia, left ventricular hypertrophy, left bundle-branch block, or paced rhythm. These 63 patients (29% of total) had significantly greater incidences of serious events, need for procedures, and death than low-risk patients whose initial electrocardiograms did not carry the above diagnoses. Patients with a low-risk initial electrocardiogram may not require the facilities of a coronary care unit and perhaps could be safely observed in an intermediate care area. However, many hospitals do not have an intermediate care facility available, and in those that do, daily costs may not be markedly different than for treatment in a coronary care unit. Whether these low-risk patients could be safely treated in general medicine beds, where potential cost savings would be much greater, is unknown.

Nurses' Interest in Independently Initiating End-of-Life Conversations and Palliative Care Consultations in a Suburban, Community Hospital.

PubMed

Mehta, Ambereen K; Wilks, Steven; Cheng, M Jennifer; Baker, Karen; Berger, Ann

2018-03-01

Patients who receive early palliative care consults have clinical courses and outcomes more consistent with their goals. Nurses have been shown to be advocates for early palliative care involvement and are able to lead advanced care planning discussions. The purpose of this study was to assess whether after a brief educational session, nurses at a suburban, community hospital could demonstrate knowledge of palliative care principles, would want to independently initiate end-of-life conversations with patients and families, and would want to place specialty palliative care consults. Four 1 hour presentations were made at 4 nursing leadership council meetings from November through December 2015. Anonymous pre- and post-presentation surveys were distributed and collected in person. Setting/Participant: Nonprofit, suburban, community hospital in Maryland. Participants were full-time or part-time hospital employees participating in a nursing leadership council who attended the presentation. We compared responses from pre- and post-presentation surveys. Fifty nurses (19 departments) completed pre-presentation surveys (100% response rate) and 49 nurses completed post-presentation surveys (98% response rate). The average score on 7 index questions increased from 71% to 90%. After the presentations, 86% strongly agreed or agreed that nurses should be able to independently order a palliative care consult and 88% strongly agreed or agreed with feeling comfortable initiating an end-of-life conversation. Brief educational sessions can teach palliative care principles to nurses. Most participants of the study would want to be able to directly consult palliative care and would feel comfortable initiating end-of-life conversations after this educational session.

An analysis of online messages about probiotics

PubMed Central

2013-01-01

Internet websites are a resource for patients seeking information about probiotics. We examined a sample of 71 websites presenting probiotic information. We found that descriptions of benefits far outnumbered descriptions of risks and commercial websites presented significantly fewer risks than noncommercial websites. The bias towards the presentation of therapeutic benefits in online content suggests that patients are likely interested in using probiotics and may have unrealistic expectations for therapeutic benefit. Gastroenterologists may find it useful to initiate conversations about probiotics within the context of a comprehensive health management plan and should seek to establish realistic therapeutic expectations with their patients. PMID:23311418

Making an IMPACT on emergency department flow: improving patient processing assisted by consultant at triage.

PubMed

Terris, J; Leman, P; O'Connor, N; Wood, R

2004-09-01

To assess whether initial patient consult by senior clinicians reduces numbers of patients waiting to be seen as an indirect measure of waiting time throughout the emergency department (ED). An emergency medicine consultant and a senior ED nurse (G or F grade), known as the IMPACT team, staffed the triage area for four periods of four hours per week, Monday to Friday between 9 am to 5 pm for three months between December 2001 and February 2002 when staffing levels permitted. Patients normally triaged by a nurse in this area instead had an early consultation with the IMPACT team. Data were collected prospectively on all patients seen by the IMPACT team. The number of patients waiting to be seen (for triage, in majors and in minors) was assessed every two hours during the IMPACT sessions and at corresponding times when no IMPACT team was operational. There was an overall reduction in the number of patients waiting to be seen in the department from 18.3 to 5.5 (p<0.0001) at formal two hourly assessments. The largest difference was seen in minors. Of the patients seen at triage by the IMPACT team, 48.9% were discharged home immediately after assessment and treatment. With the IMPACT team present, no patient waited more than four hours for initial clinical consult. By using a senior clinical team for initial patient consultation, the numbers of patients waiting fell dramatically throughout the ED. Many patients can be effectively treated and discharged after initial consult by the IMPACT team.

The value of routine polymerase chain reaction analysis of intraocular fluid specimens in the diagnosis of infectious posterior uveitis.

PubMed

Scheepers, Marius A; Lecuona, Karin A; Rogers, Graeme; Bunce, Catey; Corcoran, Craig; Michaelides, Michel

2013-01-01

To assess the value of routine polymerase chain reaction (PCR) analysis on intraocular fluid from patients presenting with a first episode of suspected active infectious posterior uveitis in a population with a high prevalence of human immunodeficiency virus infection. Retrospective, interventional case series. Participants. 159 consecutive patients presenting at a tertiary care hospital over a five-year period. PCR analysis was performed for cytomegalovirus, varicella zoster virus, herpes simplex virus types 1 and 2, Toxoplasma gondii, and Mycobacterium tuberculosis. PCR analysis confirmed the initial clinical diagnosis in 55 patients (35%) and altered the initial clinical diagnosis in 36 patients (23%). The clinical diagnosis prior to PCR testing was nonspecific (uncertain) in 51 patients (32%), with PCR providing a definitive final diagnosis in 20 of these patients (39%); necrotizing herpetic retinopathy and ocular toxoplasmosis were particularly difficult to diagnose correctly without the use of PCR analysis. The clinical phenotype alone was unreliable in diagnosing the underlying infectious cause in a quarter of patients in this study. Since the outcome of incorrectly treated infective uveitis can be blinding, PCR analysis of ocular fluids is recommended early in the disease even in resource poor settings.

Delayed auditory pathway maturation and prematurity.

PubMed

Koenighofer, Martin; Parzefall, Thomas; Ramsebner, Reinhard; Lucas, Trevor; Frei, Klemens

2015-06-01

Hearing loss is the most common sensory disorder in developed countries and leads to a severe reduction in quality of life. In this uncontrolled case series, we evaluated the auditory development in patients suffering from congenital nonsyndromic hearing impairment related to preterm birth. Six patients delivered preterm (25th-35th gestational weeks) suffering from mild to profound congenital nonsyndromic hearing impairment, descending from healthy, nonconsanguineous parents and were evaluated by otoacoustic emissions, tympanometry, brainstem-evoked response audiometry, and genetic testing. All patients were treated with hearing aids, and one patient required cochlear implantation. One preterm infant (32nd gestational week) initially presented with a 70 dB hearing loss, accompanied by negative otoacoustic emissions and normal tympanometric findings. The patient was treated with hearing aids and displayed a gradual improvement in bilateral hearing that completely normalized by 14 months of age accompanied by the development of otoacoustic emission responses. Conclusions We present here for the first time a fully documented preterm patient with delayed auditory pathway maturation and normalization of hearing within 14 months of birth. Although rare, postpartum development of the auditory system should, therefore, be considered in the initial stages for treating preterm hearing impaired patients.

Strategies for encouraging patient/family member partnerships with the health care team.

PubMed

Ahmann, Elizabeth; Dokken, Deborah

2012-01-01

The 5th International Conference of the Institute for Patient- and Family-Centered Care (IPFCC), held in Washington, DC, from June 4-6, 2012, offered an opportunity for almost 1,000 conference participants to share and learn about exciting new patient- and family-centered initiatives occurring across the U.S. and in many other countries. One focus addressed by keynote and plenary speakers, as well as numerous conference sessions and poster presentations, was how nurses and other health care professionals can encourage patients and family members to become partners with their health care teams. Various presenters shared strategies ranging from initial approaches to acknowledging family members as part of the team and offering simple, non-threatening roles in care provision, to policies and approaches inviting increased participation in health care encounters, to higher level involvement in the care planning process, and to partnership roles extending beyond care of the individual child and family. A wealth of ideas can be implemented at various levels by individual nurses, units, and health care institutions.

[Long-term prognostic factors in Parkinson's disease (author's transl)].

PubMed

Guillard, A; Chastang, C

1978-05-01

Acturial methods are used to study the correlation between the initial condition and early therapeutic results, and the present condition of 164 parkinsonian patients treated with L. dopa for 4 to 8 years. There is an ineluctable deterioration in motility. There is a lower risk in patients who are autonomous and only slightly akinetic at the beginning of treatment. Intellectual deterioration is seen in some patients only. The risk factors are: males, the clinical forms of Parkinson's disease in which tremor is not predominant, onset of the disease before 60 years of age, and depression and transitory psychotic disorders during the first year of treatment. This deterioration appears 3 to 5 years after starting dopatherapy, which could be the cause. Life expectancy is still reduced by the disease at the present time. It is longer in patients in whom the disease started with isolated tremors, absence of Babinski's sign, and no loss of autonomy, and those in whom a good initial therapeutic result was obtained.

Incompletely treated malignancies of the major salivary gland: Toward evidence-based care.

PubMed

Tam, Samantha; Sandulache, Vlad C; Metwalli, Kareem A; Rock, Crosby D; Eraj, Salman A; Sheu, Tommy; El-Naggar, Adel K; Fuller, Clifton D; Weber, Randal S; Lai, Stephen Y

2018-05-07

Unexpected malignancy is common in major salivary gland tumors due to variability of workup, creating challenging treatment decisions. The purpose of this study was to define treatment-related outcomes for patients with incompletely treated major salivary gland tumors. A retrospective cohort study was completed of patients with incompletely treated major salivary gland tumors. Tumor burden at presentation was established and treatment categorized. The Cox Proportional Hazards model was used to determine predictors of survival and failure. Of the 440 included patients, patients with gross residual or metastatic disease had a worse overall survival (OS; P < .001). Presentation status was an independent predictor of OS on multivariate analysis (gross residual disease adjusted hazard ratio [HR adjusted ] 2.55; 95% confidence interval [CI] 1.20-5.30; metastatic disease HR adjusted 9.53; 95% CI 3.04-27.06). Failure to achieve gross total resection during initial surgery resulted in worse OS. Adequate preoperative planning is required for initial surgical management to optimize tumor control and survival. © 2018 Wiley Periodicals, Inc.

Resolution of hypothyroidism after correction of somatovisceral reflex dysfunction by refusion of the cervical spine.

PubMed

Berkowitz, Murray R

2015-01-01

Psychosis is a rare initial presentation of new-onset hypothyroidism. The author describes the case of a 29-year-old woman who presented with psychosis caused by hypothyroidism, or myxedema madness. Although the patient's psychosis resolved after standard monotherapy using levothyroxine sodium, her hypothyroidism persisted. Imaging of the patient's cervical spine showed that previous C5-C6 and C6-C7 fusions had failed. The failed fusions were corrected, and the patient's hypothyroidism resolved, suggesting that the somatovisceral reflex was the cause of the patient's hypothyroidism. Although somatovisceral reflex dysfunctions are rare, physicians should consider them as potential underlying causes of their patients' presenting medical conditions. © 2015 The American Osteopathic Association.

Management of Cushing's disease: outcome in patients with microadenoma detected on pituitary magnetic resonance imaging.

PubMed

Prevedello, Daniel M; Pouratian, Nader; Sherman, Jonathan; Jane, John A; Vance, Mary Lee; Lopes, M Beatriz; Laws, Edward R

2008-10-01

Outcomes of therapy for Cushing's disease (CD) vary depending on different aspects of presentation and diagnostic studies. The authors designed this study to verify the remission rate and outcomes after transsphenoidal surgery (TSS) for patients with CD who had positive findings on MR imaging. Patients who had presented with CD at the University of Virginia for initial treatment between July 1992 and December 2005 were retrospectively reviewed. The patients included in the study were considered to be optimal surgical candidates, defined as an adult (>18 years of age) with classic clinical features of CD, laboratory studies confirming a central (pituitary/hypothalamic) adrenocorticotropic hormone-dependent source of disease, and an MR imaging study revealing a microadenoma in the sella turcica. A total of 167 patients fulfilled the criteria. Thirty were men (18%) and 137 were women (82%). The mean age was 42.3 years (range 18.2-77 years). All patients underwent TSS. Surgical remission was achieved in 148 patients (88.6%), which was correlated with the surgeon's intraoperative identification of an adenoma (p=0.03). Histopathological confirmation of an adrenocorticotropic hormone-secreting adenoma strongly correlated with remission (p=0.0001). Three patients (1.8%) had postoperative cerebrospinal fluid leaks, and 1 patient had meningitis. Transient diabetes insipidus was diagnosed and treated in 10 patients (6%), whereas permanent diabetes insipidus occurred in 8 patients (4.8%). Panhypopituitarism followed the surgery in 14 patients (8.3%), 13 of whom underwent total hypophysectomy (9 initially and 4 with early reoperations), and in 1 of 10 patients who underwent subtotal hypophysectomy. Nineteen patients (12.8%) who were initially in remission developed recurrent CD after an average of 50 months. The mean follow-up for the 167 patients was 39 months (range 6-157 months). Gamma Knife surgery was the most common modality of radiotherapy used to treat 31 patients (18.5%) who did not achieve remission or later presented with recurrent disease. Bilateral adrenalectomies were performed in 10 patients in the series (6%), 2 of whom developed Nelson's syndrome. The overall posttreatment remission rate was 95.8%. Even in patients with ideal diagnostic criteria of CD, there remain a significant number of cases in which TSS alone is not adequate to assure long-lasting remission. A multidisciplinary approach is essential to the achievement of satisfactory overall remission rates.

Linking Workplace Aggression to Employee Well-Being and Work: The Moderating Role of Family-Supportive Supervisor Behaviors (FSSB).

PubMed

Yragui, Nanette L; Demsky, Caitlin A; Hammer, Leslie B; Van Dyck, Sarah; Neradilek, Moni B

2017-04-01

The present study examined the moderating effects of family-supportive supervisor behaviors (FSSB) on the relationship between two types of workplace aggression (i.e., patient-initiated physical aggression and coworker-initiated psychological aggression) and employee well-being and work outcomes. Data were obtained from a field sample of 417 healthcare workers in two psychiatric hospitals. Hypotheses were tested using moderated multiple regression analyses. Psychiatric care providers' perceptions of FSSB moderated the relationship between patient-initiated physical aggression and physical symptoms, exhaustion and cynicism. In addition, FSSB moderated the relationship between coworker-initiated psychological aggression and physical symptoms and turnover intentions. Based on our findings, family-supportive supervision is a plausible boundary condition for the relationship between workplace aggression and well-being and work outcomes. This study suggests that, in addition to directly addressing aggression prevention and reduction, family-supportive supervision is a trainable resource that healthcare organizations should facilitate to improve employee work and well-being in settings with high workplace aggression. This is the first study to examine the role of FSSB in influencing the relationship between two forms of workplace aggression: patient-initiated physical and coworker- initiated psychological aggression and employee outcomes.

Long-term follow-up of 2 patients treated with 90 Y-rituximab Radioimmunotherapy for relapse of nodular lymphocyte-predominant Hodgkin lymphoma.

PubMed

Golstein, S; Muylle, K; Vercruyssen, M; Spilleboudt, C; de Wind, A; Bron, D

2018-05-02

Nodular lymphocyte-predominant Hodgkin lymphoma (NLPHL) is a rare lymphoma (< 5% of Hodgkin's lymphomas) predominantly affecting the middle-aged man, with an indolent behavior. Given the rare occurrence of this lymphoma, there are currently no clear guidelines for initial treatment or relapse. In this report, we present the follow up of two patients treated by radioimmunotherapy for first relapse of their NLPHL. Both patients were initially treated with rituximab and relapsed 1 year after the end of their treatment. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

Survival in amyotrophic lateral sclerosis with home mechanical ventilation: the impact of systematic respiratory assessment and bulbar involvement.

PubMed

Farrero, Eva; Prats, Enric; Povedano, Mónica; Martinez-Matos, J Antonio; Manresa, Frederic; Escarrabill, Joan

2005-06-01

To analyze (1) the impact of a protocol of early respiratory evaluation of the indications for home mechanical ventilation (HMV) in patients with amyotrophic lateral sclerosis (ALS), and (2) the effects of the protocol and of bulbar involvement on the survival of patients receiving noninvasive ventilation (NIV). Retrospective study in a tertiary care referral center. HMV was indicated in 86 patients with ALS, with 22 patients (25%) presenting with intolerance to treatment associated with bulbar involvement. Treatment with HMV had been initiated in 15 of 64 patients prior to initiating the protocol (group A) and in the remaining 49 patients after protocol initiation (group B). In group A, the majority of patients began treatment with HMV during an acute episode requiring ICU admission (p = 0.001) and tracheal ventilation (p = 0.025), with a lower percentage of patients beginning HMV treatment without respiratory insufficiency (p = 0.013). No significant differences in survival rates were found between groups A and B among patients treated with NIV. Greater survival was observed in group B (p = 0.03) when patients with bulbar involvement were excluded (96%). Patients without bulbar involvement at the start of therapy with NIV presented a significantly better survival rate (p = 0.03). Multivariate analysis showed bulbar involvement to be an independent prognostic factor for survival (relative risk, 1.6; 95% confidence interval, 1.01 to 2.54; p = 0.04). No significant differences in survival were observed between patients with bulbar involvement following treatment with NIV and those with intolerance, except for the subgroup of patients who began NIV treatment with hypercapnia (p = 0.0002). Early systematic respiratory evaluation in patients with ALS is necessary to improve the results of HMV. Further studies are required to confirm the benefits of NIV treatment in patients with bulbar involvement, especially in the early stages.

Presenting characteristics and processing times for culturally and linguistically diverse (CALD) patients with chest pain in an emergency department: Time, Ethnicity, and Delay (TED) Study II.

PubMed

Wechkunanukul, Kannikar; Grantham, Hugh; Teubner, David; Hyun, Karice K; Clark, Robyn A

2016-10-01

To date there has been limited published data presenting the characteristics and timeliness of the management in an Emergency Department (ED) for culturally and linguistically diverse (CALD) patients presenting with chest pain. This study aimed to describe the presenting characteristics and processing times for CALD patients with chest pain compared to the Australian-born population, and current guidelines. This study was a cross sectional analysis of a cohort of patients who presented with chest pain to the metropolitan hospital between 1 July 2012 and 30 June 2014. Of the total study population (n=6640), 1241 (18.7%) were CALD and 5399 (81.3%) were Australian-born. CALD patients were significantly older than Australian-born patients (mean age 62 vs 56years, p<0.001). There were no differences in the proportion of patients who had central chest pain (74.9% vs 75.7%, p=0.526); ambulance utilisation (41.7% vs 41.1%, p=0.697); and time to initial treatment in ED (21 vs 22min, p=0.375). However, CALD patients spent a significantly longer total time in ED (5.4 vs 4.3h, p<0.001). There was no difference in guideline concordance between the two groups with low rates of 12.5% vs 13%, p=0.556. Nonetheless, CALD patients were 22% (95% CI, 0.65, 0.95, p=0.015) less likely to receive the guideline management for chest pain. The initial emergency care was equally provided to all patients in the context of a low rate of concordance with three chest pain related standards from the two guidelines. Nonetheless, CALD patients spent a longer time in ED compared to the Australian-born group. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

[Spontaneous bile duct perforation: a rare cause of acute abdominal pain during childhood].

PubMed

Ozdemir, Tunç; Akgül, Ahsen Karagözlü; Arpaz, Yağmur; Arikan, Ahmet

2008-07-01

Spontaneous perforation of the bile duct (SPBD) is a rare cause of acute abdominal pain during childhood. Pancreatico-biliary malfunction has been postulated to contribute to its etiology. Factors related to diagnosis and treatment and difference from the other common causes of acute abdominal pain are emphasized. Five patients (3 boys, 2 girls, mean age 4.6) were admitted with peritonitis and operated with initial diagnosis of perforated appendicitis. During laparotomy, SPBD was detected. Presentation, laboratory findings and operative technique of the patients were evaluated retrospectively. Common complaints were abdominal pain and bilious vomiting. Abdominal distention was present in all patients. Leukocytosis and mild hyperbilirubinemia were detected in 5, elevated serum transaminase levels in 4, hyperglycemia in 1 and constipation in 1 patient(s). Abdominal ultrasonography showed a large amount of free fluid. During laparotomy, sterile bile peritonitis was detected initially. After exploration, SPBD was seen. T-tube drainage of the bile duct was carried out. Patients were discharged after removal of the T-tubes. Pancreatico-biliary malfunction was detected in 4 of 5 patients. In patients with generalized peritonitis, elevated transaminase levels and hyperbilirubinemia, SPBD must be considered. Even though the T-tube drainage is the treatment of choice, Roux-en-Y hepatico-portoenterostomy may be mandatory in certain patients.

Components of treatment delay in rheumatoid arthritis differ according to autoantibody status: validation of a single-centre observation using national audit data.

PubMed

Pratt, Arthur G; Lendrem, Dennis; Hargreaves, Ben; Aslam, Osman; Galloway, James B; Isaacs, John D

2016-10-01

To determine whether time to treatment following symptom onset differs between RA patients according to autoantibody status. A single-centre retrospective analysis of a UK early RA inception cohort was first undertaken to identify those components of the patient journey that differed by serological subtype. Data from a UK national audit of early inflammatory arthritis patients was accessed to replicate the key finding. A total of 173 RA patients were diagnosed over a 31-month period, of whom 80 (46%) were ACPA/RF double-seropositive (ACPA(+)/RF(+)), 53 (31%) ACPA(-)/RF(-), 17 (10%) ACPA(+)/RF(-) and 23 (13%) RF(+)/ACPA(-) Overall, ACPA(+)/RF(+) patients experienced significantly longer symptom duration before DMARD initiation. This was accounted for by delays in their presentation to primary care following symptom onset-a finding that was robustly confirmed in an independent dataset of 2192 UK early RA patients. In contrast, ACPA(-)/RF(-) patients were significantly more likely to experience delays in DMARD initiation after presenting to secondary care. Causes of treatment delays in early RA differ according to patients' autoantibody status. More insidious symptom onset and/or distinct health-seeking behaviours among ACPA(+)/RF(+) patients may contribute to late presentations in primary care, whereas ACPA(-)/RF(-) patients experience delayed diagnosis and treatment in secondary care. These observations inform the research agenda, potentially influencing the design of service delivery for early arthritis patients. © The Author 2016. Published by Oxford University Press on behalf of the British Society for Rheumatology.

Desmoid-type fibromatosis: a front-line conservative approach to select patients for surgical treatment.

PubMed

Fiore, Marco; Rimareix, Françoise; Mariani, Luigi; Domont, Julien; Collini, Paola; Le Péchoux, Cecile; Casali, Paolo G; Le Cesne, Axel; Gronchi, Alessandro; Bonvalot, Sylvie

2009-09-01

Surgery is still the standard treatment for desmoid-type fibromatosis (DF). Recently, the Institut Gustave Roussy (IGR), Villejuif, France, reported a series of patients treated with a front-line conservative approach (no surgery and no radiotherapy). The disease remained stable in more than half of patients. This study was designed to evaluate this approach on the natural history of the disease in a larger series of patients. A total of 142 patients presenting to the IGR or Istituto Nazionale Tumori (INT), Milan, Italy, were initially treated using a front-line deliberately conservative policy. Their progression-free survival (PFS) was observed and a multivariate analysis was performed for major clinical variables. Seventy-four patients presented with primary tumor, 68 with recurrence. Eighty-three patients received a "wait & see" policy (W&S), whereas 59 were initially offered medical therapy (MT), mainly hormonal therapy and chemotherapy. A family history of sporadic colorectal cancer was present in 8% of patients. The 5-year PFS was 49.9% for the W&S group and 58.6% for the medically treated patients (P = 0.3196). Similar results emerged for primary and recurrent DF. Multivariate analysis identified no clinical variables as independent predictors of PFS. In the event of progression, all patients were subsequently managed safely. A conservative policy could be a safe approach to primary and recurrent DF, which could avoid unnecessary morbidity from surgery and/or radiation therapy. Half of patients had medium-term stable disease after W&S or MT. A multidisciplinary, stepwise approach should be prospectively tested in DF.

The effectiveness of prophylactic etodolac on postendodontic pain.

PubMed

Menke, E R; Jackson, C R; Bagby, M D; Tracy, T S

2000-12-01

To determine if prophylactic etodolac would significantly reduce postendodontic pain, when compared with ibuprofen or placebo, 36 patients consented to single blind oral administration of either 400 mg of etodolac, 600 mg of ibuprofen, or a placebo, before conventional one-appointment root canal therapy. Patient-reported visual analog scale ratings of pain intensity were conducted upon initial clinical presentation, immediately postoperative, 4, 8, 12, 24, 48, and 72 h after initiation of root canal therapy. Results showed that prophylactic ibuprofen administration significantly reduced postendodontic pain at 4 and 8 h after initiation of root canal therapy, when compared with etodolac and a placebo. Patients with a periapical diagnosis of acute apical periodontitis or with a Phoenix abscess showed a significant increased need for additional medication after completion of root canal therapy, compared with all other periapical diagnoses.

Nonalcoholic Steatohepatitis Induced by a High-Fat Diet Promotes Diethylnitrosamine Initiated Early Hepatocarcinogenesis in Rats

USDA-ARS?s Scientific Manuscript database

It has been suggested that patients with nonalcoholic steatohepatitis (NASH) have a high risk for liver cancer. However, it is unknown whether high-fat diet induced NASH promotes chemical carcinogen-initiated hepatocarcinogenesis. In the present study, Sprague-Dawley rats were injected with a low d...

Hemophagocytic syndrome as the initial manifestation of systemic lupus erythematosus.

PubMed

Egües Dubuc, César Antonio; Uriarte Ecenarro, Miren; Meneses Villalba, Carlos; Aldasoro Cáceres, Vicente; Hernando Rubio, Iñaki; Belzunegui Otano, Joaquín

2014-01-01

Hemophagocytic syndrome (HS) occurs in autoimmune diseases and belongs to the hemophagocytic lymphohistiocytosis group of diseases. This paper describes the features of 2 patients with systemic lupus erythematosus (SLE) who presented HS as the initial clinical manifestation. Both patients had prolonged fever not associated to an infectious process and did not respond to broad-spectrum antibiotics. The diagnosis of HS secondary to SLE is complicated, because it has some features in common, but HS is characterized by hyperferritinemia, hipofibrinogemia, hypertriglyceridemia and a decrease in the erythrocyte sedimentation rate, unlike SLE. HS treatment when associated to SLE is not well established, but steroids and/or immunoglobulins are effective as the initial treatment, and in refractory cases, cyclosporine or cyclophosphamide may be associated. HS can be the initial manifestation of SLE and should be suspected in patients with organ enlargement, cytopenias, clotting disorders, liver disorders and prolonged fever unresponsive to antibiotics. Anakinra may be a treatment option in adult HS associated to SLE. Copyright © 2013 Elsevier España, S.L. All rights reserved.

Decomposing mechanisms of abnormal saccade generation in schizophrenia patients: Contributions of volitional initiation, motor preparation, and fixation release.

PubMed

Reuter, Benedikt; Elsner, Björn; Möllers, David; Kathmann, Norbert

2016-11-01

Clinical and theoretical models suggest deficient volitional initiation of action in schizophrenia patients. Recent research provided an experimental model of testing this assumption using saccade tasks. However, inconsistent findings necessitate a specification of conditions on which the deficit may occur. The present study sought to detect mechanisms that may contribute to poor performance. Sixteen schizophrenia patients and 16 healthy control participants performed visually guided and two types of volitional saccade tasks. All tasks varied as to whether the initial fixation stimulus disappeared (fixation stimulus offset) or continued during saccade initiation, and whether a direction cue allowed motor preparation of the specific saccade. Saccade latencies of the two groups were differentially affected by task type, fixation stimulus offset, and cueing, suggesting abnormal volitional saccade generation, fixation release, and motor preparation in schizophrenia. However, substantial performance deficits may only occur if all affected processes are required in a task. © 2016 Society for Psychophysiological Research.

Proctitis as the clinical presentation of lymphogranuloma venereum, a re-emerging disease in developed countries.

PubMed

López-Vicente, Jorge; Rodríguez-Alcalde, Daniel; Hernández-Villalba, Luis; Moreno-Sánchez, Diego; Lumbreras-Cabrera, Mercedes; Barros-Aguado, Carlos; Galán, Juan Carlos

2014-01-01

Lymphogranuloma venereum (LGV) is a sexually transmitted infectious disease caused by serovars L1, L2 and L3 of Chlamydia trachomatis. The initial presentation is usually a painless ulcerated papule on the genitalia or distal proctitis. The progression of the infection can lead to major complications: rectal strictures, intestinal obstruction or perforation. We present five cases of LGV proctitis as the initial presentation of the disease. All patients were male, mean age 44.6 years, with positive serology to human immunodeficiency virus (HIV) and promiscuous men who have sex with men (MSM).The initial diagnosis was made by rectosigmoidoscopy indicated for pain and anal discharge. All cases were confirmed by polymerase chain reaction technique in rectal tissue. Endoscopic images obtained showed a great variety of rectal lesions, from mild erythema of the mucosa and ulcers to deep ulcers with elevated borders and purulent exudate. All cases were resolved after treatment with doxycycline for 3 weeks. It emphasizes the importance of suspecting this re-emerging disease in patients with risk factors (HIV and MSM), with the aim of early treatment and to avoid major complications.

Breast abscess as the initial manifestation of primary pure squamous cell carcinoma: a rare presentation and literature review.

PubMed

Salemis, Nikolaos S

2011-01-01

Primary squamous cell carcinoma of the breast is a very rare tumor accounting for less than 0.4% of all breast cancers. Fewer than 100 cases have been reported in the literature so far. The diagnosis requires strict pathologic criteria to be fulfilled. Due to the rarity of this tumor the optimal treatment and prognosis are both unclear. Breast abscess as the initial presentation of a primary squamous cell breast carcinoma is an extremely rare clinical entity. In this study, we describe a case of a 61-year-old postmenopausal woman who presented with typical manifestations of a breast abscess and was diagnosed with a pure primary squamous cell breast carcinoma. Diagnostic evaluation and management of the patient are discussed along with a review of the literature. Despite its rarity, the possibility of a primary pure squamous cell breast carcinoma should always be considered in the differential diagnosis in postmenopausal patients presenting with manifestations of a breast abscess, especially in those who respond poorly to the initial treatment. Physicians should be aware of this rare malignancy in order to avoid delays in diagnosis and treatment.

Hypnotic relaxation vs amitriptyline for tension-type headache: let the patient choose.

PubMed

Ezra, Yacov; Gotkine, Marc; Goldman, Sylvie; Adahan, Haim Moshe; Ben-Hur, Tamir

2012-05-01

Although both pharmacological and behavioral interventions may relieve tension-type headache, data are lacking regarding treatment preference, long-term patient compliance, and feasibility of behavioral intervention in a standard neurological outpatient clinic setting. To describe patient choice, long-term compliance, and clinical outcome in a neurological clinic setting where patients are given the choice of the approach they wish to pursue. Patients presenting to the headache clinic with a diagnosis of tension-type headache that justified prophylactic therapy (frequent episodic tension-type headache or chronic tension-type headache) were given the choice of amitriptyline (AMT) treatment or hypnotic relaxation (HR), and were treated accordingly. Patients were given the option to cross-over to the other treatment group at each visit. HR was performed during standard length neurology clinic appointments by a neurologist trained to perform hypnosis (Y.E.). Follow-up interviews were performed between 6 and 12 months following treatment initiation to evaluate patient compliance, changes in headache frequency or severity, and quality-of-life parameters. Ninety-eight patients were enrolled, 92 agreed to receive prophylactic therapy of some kind. Fifty-three (57.6%) patients chose HR of which 36 (67.9%) actually initiated this treatment, while 39 (42.4%) chose pharmacological therapy with AMT of which 25 (64.1%) patients actually initiated therapy. Patients with greater analgesic use were more likely to opt for AMT (P= .0002). Eleven of the patients initially choosing AMT and 2 of the patients initially choosing HR crossed over to the other group. Seventy-four percent of the patients in the HR group and 58% of patients in the AMT group had a 50% reduction in the frequency of headaches (P= .16). Long-term adherence to treatment with HR exceeded that of AMT. At the end of the study period, 26 of 47 patients who tried HR compared with 10 of 27 who tried AMT continued receiving their initial treatment. HR treatment was a more popular choice among patients. Patients choosing HR reported greater symptom relief than those choosing AMT and were found to have greater treatment compliance. Patients receiving HR were less likely to change treatments. HR practiced by a neurologist is feasible in a standard neurological outpatient clinic setting; HR training should be considered for neurologists involved in headache treatment. © 2011 American Headache Society.

Bilineal Extramedullary Blast Crisis as an Initial Presentation of Chronic Myeloid Leukemia: A Case Report and Literature Review

PubMed Central

Gao, Xiaoning; Li, Jie; Wang, Lili; Lin, Ji; Jin, Hongshi; Xu, Yihan; Wang, Nan; Zhao, Yu; Liu, Daihong; Yu, Li; Wang, Quanshun

2016-01-01

Patient: Male, 49 Final Diagnosis: T-lymphoid/myeloid bilineal blastic transformation of CML Symptoms: Rapidly enlarging mass in left neck Medication: — Clinical Procedure: Biopsy of the left submandibular lymph nodes Specialty: Hematology Objective: Rare co-existance of disease or pathology Background: Chronic myeloid leukemia (CML) is a clonal myeloproliferative disorder characterized by the Philadelphia chromosome generated by the reciprocal translocation t(9: 22)(q34;q11). CML is usually diagnosed in the chronic phase. Blast crisis represents an advanced phase of CML. Extramedullary blast crisis as the initial presentation of CML with bone marrow remaining in chronic phase is an unusual event. Further, extramedullary blast crisis with T lymphoid/myeloid bilineal phenotype as an initial presentation for CML is extremely unusual. Case Report: Here, we report the case of a 49-year-old male with rapidly enlarged submandibular lymph nodes. Biopsy specimen from the nodes revealed a characteristic appearance with morphologically and immunohistochemically distinct myeloblasts and T lymphoblasts co-localized in 2 adjacent regions, accompanied by chronic phase of the disease in bone marrow. The presence of the BCR/ABL1 fusion gene within both cellular populations in this case confirmed the extramedullary disease represented a localized T lymphoid/myeloid bilineal blastic transformation of CML. After 3 courses of combined chemotherapy plus tyrosine kinase inhibitor treatment, the mass was completely regressed with a 3-log decrease in BCR/ABL1 transcript from baseline. Five months after the diagnosis, the patient showed diminished vision, hand tremors, and weakness of lower extremities. Flow cytometric immunophenotyping of cerebrospinal fluid revealed the presence of myeloid blasts. An isolated central nervous system relapse of leukemia was identified. Following high-dose systemic and intrathecal chemotherapy, the patient continued to do well. Conclusions: The possibility of extramedullary blast crisis as an initial presentation in patients with CML should be considered. Further, an isolated central nervous system blast crisis should be considered if neurological symptoms evolve in patients who have shown a good response to therapy. PMID:27784881

Direct Molecular Detection and Genotyping of Borrelia burgdorferi from Whole Blood of Patients with Early Lyme Disease

PubMed Central

Eshoo, Mark W.; Crowder, Christopher C.; Rebman, Alison W.; Rounds, Megan A.; Matthews, Heather E.; Picuri, John M.; Soloski, Mark J.; Ecker, David J.; Schutzer, Steven E.; Aucott, John N.

2012-01-01

Direct molecular tests in blood for early Lyme disease can be insensitive due to low amount of circulating Borrelia burgdorferi DNA. To address this challenge, we have developed a sensitive strategy to both detect and genotype B. burgdorferi directly from whole blood collected during the initial patient visit. This strategy improved sensitivity by employing 1.25 mL of whole blood, a novel pre-enrichment of the entire specimen extract for Borrelia DNA prior to a multi-locus PCR and electrospray ionization mass spectrometry detection assay. We evaluated the assay on blood collected at the initial presentation from 21 endemic area patients who had both physician-diagnosed erythema migrans (EM) and positive two-tiered serology either at the initial visit or at a follow-up visit after three weeks of antibiotic therapy. Results of this DNA analysis showed detection of B. burgdorferi in 13 of 21 patients (62%). In most cases the new assay also provided the B. burgdorferi genotype. The combined results of our direct detection assay with initial physician visit serology resulted in the detection of early Lyme disease in 19 of 21 (90%) of patients at the initial visit. In 5 of 21 cases we demonstrate the ability to detect B. burgdorferi in early Lyme disease directly from whole blood specimens prior to seroconversion. PMID:22590620

Scalp Metastasis as the First Sign of Small-Cell Lung Cancer: Management and Literature Review

PubMed Central

Salemis, Nikolaos S.; Veloudis, Georgios; Spiliopoulos, Kyriakos; Nakos, Georgios; Vrizidis, Nikolaos; Gourgiotis, Stavros

2014-01-01

Cutaneous metastasis from primary visceral malignancy is a relatively uncommon clinical entity, with a reported incidence ranging from 0.22% to 10% among various series. However, the presence of cutaneous metastasis as the first sign of a clinically silent visceral cancer is exceedingly rare. We describe here a case of an asymptomatic male patient who presented with a solitary scalp metastasis as the initial manifestation of an underlying small-cell lung cancer. Diagnostic evaluation revealed advanced disease. We conclude that the possibility of metastatic skin disease should always be considered in the differential diagnosis in patients with a history of smoking or lung cancer presenting with cutaneous nodules. Physicians should be aware of this rare clinical entity, and appropriate investigation should be arranged for early diagnosis and initiation of the appropriate treatment. The prognosis for most patients remains poor. PMID:25058760

Scalp metastasis as the first sign of small-cell lung cancer: management and literature review.

PubMed

Salemis, Nikolaos S; Veloudis, Georgios; Spiliopoulos, Kyriakos; Nakos, Georgios; Vrizidis, Nikolaos; Gourgiotis, Stavros

2014-01-01

Cutaneous metastasis from primary visceral malignancy is a relatively uncommon clinical entity, with a reported incidence ranging from 0.22% to 10% among various series. However, the presence of cutaneous metastasis as the first sign of a clinically silent visceral cancer is exceedingly rare. We describe here a case of an asymptomatic male patient who presented with a solitary scalp metastasis as the initial manifestation of an underlying small-cell lung cancer. Diagnostic evaluation revealed advanced disease. We conclude that the possibility of metastatic skin disease should always be considered in the differential diagnosis in patients with a history of smoking or lung cancer presenting with cutaneous nodules. Physicians should be aware of this rare clinical entity, and appropriate investigation should be arranged for early diagnosis and initiation of the appropriate treatment. The prognosis for most patients remains poor.

Clinical Characteristics of 17 Patients with Moraxella Keratitis.

PubMed

Tobimatsu, Yui; Inada, Noriko; Shoji, Jun; Yamagami, Satoru

2018-01-08

To retrospectively investigate the clinical characteristics of Moraxella keratitis. We reviewed the medical records of 17 patients with Moraxella keratitis. Onset age, sex, predisposing factors, initial clinical presentations, culture and antimicrobial susceptibility testing, and management and outcome of medical treatment were investigated. Moraxella keratitis was more common in patients older than 40 years of age, and its representative initial presentation was a round-shaped ulcer with endothelial plaque (70.6%) and hypopyon (58.8%). Local predisposing factors were significantly more frequent than systemic predisposing factors (P < 0.005). Isolated strains of Moraxella (M. catarrhalis, M. osloensis, and other Moraxella spp.) were sensitive to all antibiotics tested except ampicillin. The common disease contraction period was <2 weeks. Moraxella keratitis (including the first report of M. osloensis keratitis) had local predisposing factors, high sensitivity to antibiotics, and a tendency to recover within 2 weeks.

Neuropsychiatric manifestations in late-onset urea cycle disorder patients.

PubMed

Serrano, Mercedes; Martins, Cecilia; Pérez-Dueñas, Belén; Gómez-López, Lilian; Murgui, Empar; Fons, Carmen; García-Cazorla, Angels; Artuch, Rafael; Jara, Fernando; Arranz, José A; Häberle, Johannes; Briones, Paz; Campistol, Jaume; Pineda, Mercedes; Vilaseca, Maria A

2010-03-01

Inherited urea cycle disorders represent one of the most common groups of inborn errors of metabolism. Late-onset urea cycle disorders caused by partial enzyme deficiencies may present with unexpected clinical phenotypes. We report 9 patients followed up in our hospital presenting late-onset urea cycle disorders who initially manifested neuropsychiatric/neurodevelopmental symptoms (the most prevalent neuropsychiatric/neurodevelopmental diagnoses were mental retardation, attention-deficit hyperactivity disorder [ADHD], language disorder, and delirium). Generally, these clinical pictures did not benefit from pharmacological treatment. Conversely, dietary treatment improved the symptoms. Regarding biochemical data, 2 patients showed normal ammonium but high glutamine levels. This study highlights the fact that neuropsychiatric/neurodevelopmental findings are common among the initial symptomatology of late-onset urea cycle disorders. The authors recommend that unexplained or nonresponsive neuropsychiatric/neurodevelopmental symptoms appearing during childhood or adolescence be followed by a study of ammonia and amino acid plasmatic levels to rule out a urea cycle disorder.

Prostate cancer in young adults-Seventeen-year clinical experience of a single center.

PubMed

Huang, Tzu-Hao; Kuo, Junne-Yih; Huang, Yi-Hsiu; Chung, Hsiao-Jen; Huang, William J S; Wu, Howard H H; Chang, Yen-Hwa; Lin, Alex T L; Chen, Kuang-Kuo

2017-01-01

In the general population, prostate adenocarcinoma affects predominately older men. If fact, most current guidelines suggest that males over the age of 50 years should undergo prostate cancer screening. However, the clinical behavior and prognosis of prostate cancer in young adults is not well defined. The aim of this study was to evaluate the clinical behavior, pathological characteristics, and prognosis of prostate cancer in young adults. We retrospectively reviewed the records of young patients (age, ≤50 years) in our hospital with prostate adenocarcinoma between 1997 and 2013. We compared data including initial presentation, cancer cell type, Gleason score, disease stage, prostate-specific antigen (PSA) level, prostate volume, treatment, and survival between patients both younger and older than 50 years. Data were analyzed using the Kaplan-Meier method to assess survival. Twenty-six patients were enrolled in our study, accounting for 0.55% of all patients with a diagnosis of prostate cancer at our facility. All 26 patients had a pathology diagnosis of adenocarcinoma, with a mean age on diagnosis of 46.8±2.8 years (range, 39-50 years). On initial presentation, patients older than 50 years more frequently displayed lower urinary tract symptoms (LUTS) than younger patients (62.3% vs. 30.4%, p=0.008). There was no statistical difference in histological grade, disease stage, PSA level, overall survival, and biochemical-free survival between the two groups. The result of our investigation indicated that prostate adenocarcinoma patients younger than 50 years had similar histological grade, disease stage, PSA level, overall survival, and biochemical-free survival as the older population. However, patients younger than 50 years with prostate cancer less frequently showed initial symptoms of LUTS. Copyright © 2016. Published by Elsevier Taiwan LLC.

Conservative management of vestibular schwannoma: Predictors of growth and hearing.

PubMed

Jethanamest, Daniel; Rivera, Andrew M; Ji, Hongzhao; Chokkalingam, Venkatakarthikeyan; Telischi, Fred F; Angeli, Simon I

2015-09-01

To describe the clinical outcomes of patients undergoing serial observation for vestibular schwannoma (VS) and identify factors that may predict tumor growth or hearing loss. Retrospective review. A retrospective review was conducted of patients seen at a tertiary care medical center between 2002 and 2013 with an International Classification of Diseases-9 diagnosis code of 225.1. Patients electing observation as initial management, with at least two documented imaging results, were included. Exclusion criteria comprised bilateral VS, diagnosis of neurofibromatosis type 2, and neoplasms other than VS. Decline in serviceable hearing, tumor growth, and changes in management strategy were recorded. Survival analysis to assess median time to outcomes and multiple logistic regression analyses were performed. A total of 94 patients met inclusion criteria. While undergoing observation, 22.3% of patients underwent a change in management strategy to microsurgical excision or stereotactic radiotherapy. For patients with initial serviceable hearing, 24.3% observed a decline to a nonserviceable level. No significant clinical factors were identified to predict changes in hearing. Survival analysis revealed that an estimated 69.1% of patients electing observation as initial management continued to do so at 5 years. Imbalance or disequilibrium at presentation was found to be associated with an increased adjusted odds ratio (OR) (OR 2.96; 95% confidence interval, 1.03-8.50; P = 0.04) for tumor growth. Serial observation of VS is a viable treatment strategy for selected patients, with two-thirds of patients electing to continue this management option after 5 years. Disequilibrium as a presenting symptom may be associated with subsequent tumor growth. 4. © 2015 The American Laryngological, Rhinological and Otological Society, Inc.

Urethrocutaneous fistulae after hypospadias repair: When do they occur?

PubMed

Liao, Adelene Y; Smith, Grahame Hh

2016-05-01

The aim is to determine the incidence and timing of urethrocutaneous fistula diagnosis after hypospadias surgery. A retrospective review of all patients who had both initial hypospadias surgery and subsequent fistula repair from 1995 to 2012. A comparison was made between patients who had an initial onlay island flap procedure and those who had a tubularised incised plate repair. Patient age at initial surgery ranged from 6 months to 16 years of age. The median time to fistula presentation was 8.5 months with a range of less than 1 month to 13.9 years post-hypospadias surgery. The median time to fistula repair was 17 months. The overall fistula rate was 8%. There was no significant difference between the rates of fistulae for onlay island flap (9%) versus tubularised incised plate procedure (7%). Urethrocutaneous fistulae can present many years after the original hypospadias repair. The majority are diagnosed within the first year after surgery. Rates of fistulae are probably underreported due to short follow-up, but more importantly, due to patients transferring to other surgeons for fistula repair. © 2016 The Author Journal of Paediatrics and Child Health © 2016 Paediatrics and Child Health Division (Royal Australasian College of Physicians).

Diagnostic challenges of early Lyme disease: Lessons from a community case series

PubMed Central

2009-01-01

Background Lyme disease, the most common vector-borne infection in North America, is increasingly reported. When the characteristic rash, erythema migrans, is not recognized and treated, delayed manifestations of disseminated infection may occur. The accuracy of diagnosis and treatment of early Lyme disease in the community is unknown. Methods A retrospective, consecutive case series of 165 patients presenting for possible early Lyme disease between August 1, 2002 and August 1, 2007 to a community-based Lyme referral practice in Maryland. All patients had acute symptoms of less than or equal to 12 weeks duration. Patients were categorized according to the Centers for Disease Control and Prevention criteria and data were collected on presenting history, physical findings, laboratory serology, prior diagnoses and prior treatments. Results The majority (61%) of patients in this case series were diagnosed with early Lyme disease. Of those diagnosed with early Lyme disease, 13% did not present with erythema migrans; of those not presenting with a rash, 54% had been previously misdiagnosed. Among those with a rash, the diagnosis of erythema migrans was initially missed in 23% of patients whose rash was subsequently confirmed. Of all patients previously misdiagnosed, 41% had received initial antibiotics likely to be ineffective against Lyme disease. Conclusion For community physicians practicing in high-risk geographic areas, the diagnosis of Lyme disease remains a challenge. Failure to recognize erythema migrans or alternatively, viral-like presentations without a rash, can lead to missed or delayed diagnosis of Lyme disease, ineffective antibiotic treatment, and the potential for late manifestations. PMID:19486523

Patients with inferior vena cava thrombosis frequently present with lower back pain and bilateral lower-extremity deep vein thrombosis.

PubMed

Kraft, Christiane; Hecking, Carola; Schwonberg, Jan; Schindewolf, Marc; Lindhoff-Last, Edelgard; Linnemann, Birgit

2013-07-01

Inferior vena cava (IVC) thrombosis is rare, and data about the clinical presentation of patients are scarce. Therefore, we reviewed all cases of IVC thrombosis consecutively registered in the MAISTHRO (MAin-ISar-THROmbosis) database and described patients’ characteristics in terms of their clinical presentations in the acute setting of IVC thrombosis. From the MAISTHRO registry, which enrolled 1470 consecutive patients with documented histories of venous thromboembolism, we identified 60 patients (0,4 %; females 60 %) with IVC thrombosis and 888 patients (60.4 %; females 55 %) with isolated lower-extremity deep vein thrombosis (LE-DVT). The median age at the time of IVC thrombosis manifestation was 36.5 years (9 to 83). IVC thrombosis was the initial VTE event in 47 patients (78 %). In the majority of cases, IVC thrombosis extended to the lower-extremity veins, and both lower extremities were affected in 17 cases (28 %). The initial clinical symptom of IVC thrombosis was lower back or abdominal pain which preceded typical symptoms of LE-DVT in 29 (48 %) patients. Symptomatic pulmonary embolism was more frequently observed in IVC thrombosis patients when compared to a sex- and age-matched subgroup of LE-DVT patients, although the difference was not significant (27 % vs. 12 %; p = 0.064). Malignant disease was the only established VTE risk factor with a higher prevalence among IVC thrombosis patients than patients with isolated LE-DVT (27 % vs. 9 %; p = 0.015). Congenital IVC anomalies were identified in another eight IVC thrombosis patients (13 %). IVC thrombosis should be considered a differential diagnosis for inexplicable lower back or abdominal pain especially in young patients. Malignant disease and congenital IVC anomalies seem to be predisposing factors for thrombosis involving the inferior vena cava.

The lung in paracoccidioidomycosis: new insights into old problems

PubMed Central

Costa, Andre Nathan; Benard, Gil; Albuquerque, Andre Luis Pereira; Fujita, Carmem Lucia; Magri, Adriana Satie Kono; Salge, João Marcos; Shikanai-Yasuda, Maria Aparecida; Carvalho, Carlos Roberto Ribeiro

2013-01-01

OBJECTIVES: Chronic paracoccidioidomycosis can diffusely affect the lungs. Even after antifungal therapy, patients may present with residual respiratory abnormalities due to fungus-induced lung fibrosis. METHODS: A cross-sectional analysis of 50 consecutive inactive, chronic paracoccidioidomycosis patients was performed using high resolution computed tomography, pulmonary function tests, ergospirometry, the six-minute walk test and health-related quality of life questionnaires. RESULTS: Radiological abnormalities were present in 98% of cases, the most frequent of which were architectural distortion (90%), reticulate and septal thickening (88%), centrilobular and paraseptal emphysema (84%) and parenchymal bands (74%). Patients typically presented with a mild obstructive disorder and a mild reduction in diffusion capacity with preserved exercise capacity, including VO2max and six-minute walking distance. Patient evaluation with the Saint-George Respiratory Questionnaire showed low impairment in the health-related quality of life, and the Medical Research Council questionnaire indicated a low dyspnea index. There were, however, patients with significant oxygen desaturation upon exercise that was associated with respiratory distress compared with the non-desaturated patients. The initial counterimmunoelectrophoresis of these patients was higher and lung emphysema was more prominent; however, there were no differences in the interstitial fibrotic tomographic abnormalities, tobacco exposure, functional responses, exercise capacity or quality of life. CONCLUSIONS: Inactive, chronic paracoccidioidomycosis patients show persistent and disseminated radiological abnormalities by high resolution computed tomography, short impairments in pulmonary function and low impacts on aerobic capacity and quality of life. However, there was a subset of individuals whose functional impairment was more severe. These patients present with higher initial serology and more severe emphysema, stressing the importance of adequate treatment associated with tobacco exposure cessation. PMID:23778339

Epidemiological and clinical characteristics of multiple sclerosis in paediatric population in Slovenia: A descriptive nation-wide study.

PubMed

Bizjak, Neli; Osredkar, Damjan; Perković Benedik, Mirjana; Šega Jazbec, Saša

2017-11-01

Although multiple sclerosis usually affects young adults, paediatric-onset multiple sclerosis (pMS) is increasingly recognized in the past ten years. The aim of the present study was to evaluate the incidence of pMS in Slovenia and to characterize the clinical, laboratory and neuroradiological characteristics of pMS at the disease onset. We performed a national retrospective descriptive study including all patients diagnosed with pMS between January 1992 and June 2017. We reviewed data of all patients younger than 18 years at the first demyelinating event. The estimated incidence of pMS was 0.66/100,000 children per year. We included 61 patients (77% were female) with a median age at diagnosis of 16.3 years. In 4 patients, onset of pMS was before the age of 12 years old (childhood-onset pMS). Relapsing-remitting multiple sclerosis was most prevalent, with only 2 patients presenting a primary progressive pMS. Polysymptomatic pMS was found at onset in 59% of patients and monosymptomatic in 41%. In the cerebrospinal fluid study, 88% of patients had positive oligoclonal bands. Brain magnetic resonance imaging studies showed a predominant supratentorial involvement (100% of patients). The clinical pattern of pMS in our cohort of patients was characterized by polysymptomatic presentation and predominantly sensory symptoms at onset, developing a relapsing-remitting pMS pattern. It is important to gather more information about the incidence of pMS and its initial presentation and clinical course to improve early recognition and appropriate initiation of immunomodulatory treatment. Copyright © 2017 Elsevier B.V. All rights reserved.

Motor neurone disease presenting as polycythaemia.

PubMed

Santana-Vaz, Natasha; Bwika, Jumaa; Morley, Kirstie; Mukherjee, Rahul

2014-04-28

Motor neurone disease (MND) is a chronic, progressive and currently incurable neurodegenerative disorder. This case report discusses an instance of MND presenting initially as polycythaemia, caused via insidious respiratory failure through ventilatory insufficiency. This case aims to improve clinicians' awareness of this atypical presentation and highlights the need for a high index of suspicion of respiratory failure in any patient with polycythaemia. Finally it demonstrates an improvement in quality of life associated with the use of non-invasive ventilation (NIV) in a patient with MND.

Depressive disorder due to craniopharyngioma.

PubMed Central

Spence, S A; Taylor, D G; Hirsch, S R

1995-01-01

Secondary causes of depression are legion, and must always be considered in patients presenting with features atypical of primary idiopathic depressive disorder. The case described is that of a middle-aged woman presenting initially with a major depressive disorder who was subsequently found to have a craniopharyngioma, leading to a revised diagnosis of mood disorder due to the tumour. Some features of the presentation might have led to earlier diagnosis had their localizing significance been recognized. Diencephalic lesions should always be considered in patients presenting with the hypersomnic-hyperphagic variant of depressive disorder. Images Figure 1 PMID:8544149

Cardiac investigation in patients with diabetes.

PubMed

Tardif, Jean-Claude

2006-02-01

Most patients with type 2 diabetes die from heart disease. Screening for the presence of myocardial ischemia is of clinical importance in the management of this population. The pain response to ischemia can be either absent or blunted in diabetes, resulting in the absence of symptoms or an atypical presentation. Exercise electrocardiogram (ECG) should be the initial test in men who are able to exercise and have a normal resting ECG. Stress cardiac imaging should be the initial test in diabetic men with an abnormal resting ECG or who are not able to exercise. More widespread use of cardiac imaging is probably justified in diabetic women and patients with suspected coronary artery disease. Official guidelines for appropriate and cost-effective cardiac investigation should help physicians manage diabetic patients.

Outcome of Early Initiation of Peritoneal Dialysis in Patients with End-Stage Renal Failure

PubMed Central

Oh, Kook-Hwan; Hwang, Young-Hwan; Cho, Jung-Hwa; Kim, Mira; Ju, Kyung Don; Joo, Kwon Wook; Kim, Dong Ki; Kim, Yon Su; Ahn, Curie

2012-01-01

Recent studies reported that early initiation of hemodialysis may increase mortality. However, studies that assessed the influence of early initiation of peritoneal dialysis (PD) yielded controversial results. In the present study, we evaluated the prognosis of early initiation of PD on the various outcomes of end stage renal failure patients by using propensity-score matching methods. Incident PD patients (n = 491) who started PD at SNU Hospital were enrolled. The patients were divided into 'early starters (n = 244)' and 'late starters (n = 247)' on the basis of the estimated glomerular filtration rate (eGFR) at the start of dialysis. The calculated propensity-score was used for one-to-one matching. After propensity-score-based matching (n = 136, for each group), no significant differences were observed in terms of all-cause mortality (P = 0.17), technique failure (P = 0.62), cardiovascular event (P = 0.96) and composite event (P = 0.86) between the early and late starters. Stratification analysis in the propensity-score quartiles (n = 491) exhibited no trend toward better or poorer survival in terms of all-cause mortality. In conclusion, early commencement of PD does not reduce the mortality risk and other outcomes. Although the recent guidelines suggest that initiation of dialysis at higher eGFR, physicians should not determine the time to initiate PD therapy simply rely on the eGFR alone. PMID:22323864

Observation of patients with vesicoureteral reflux off antibiotic prophylaxis: physician bias on patient selection and risk factors for recurrent febrile urinary tract infection.

PubMed

Drzewiecki, Beth A; Thomas, John C; Pope, John C; Adams, Mark C; Brock, John W; Tanaka, Stacy T

2012-10-01

Observation off continuous antibiotic prophylaxis is an option for vesicoureteral reflux. We evaluated the characteristics of patients observed off continuous antibiotic prophylaxis and risk factors for febrile urinary tract infection. We identified children 1 to 18 years old with primary vesicoureteral reflux between January 1, 2010 and December 31, 2010. We excluded patients with prior surgical correction from analysis. We recorded age, gender, race/ethnicity, primary language, insurance carrier, age at vesicoureteral reflux diagnosis, initial presentation and vesicoureteral reflux severity. We quantified bladder and bowel dysfunction with a validated questionnaire if toilet trained. We compared patients off vs on continuous antibiotic prophylaxis with the chi-square test for categorical variables and the Mann-Whitney U test for continuous variables. We used a univariate Cox proportional hazards model to assess predictors of febrile urinary tract infection during observation off continuous antibiotic prophylaxis. Of 529 eligible patients 224 were observed off continuous antibiotic prophylaxis. Patients off continuous antibiotic prophylaxis tended to be older (p <0.001), to be older at diagnosis (p <0.001), to have an initial presentation other than febrile urinary tract infection (p = 0.05), to have nondilating vesicoureteral reflux on most recent cystogram (p <0.001) and to have lower bladder/bowel dysfunction scores if toilet trained (p <0.001). Of the patients off continuous antibiotic prophylaxis a febrile urinary tract infection developed in 19 (8.5%). Risk factors associated with febrile urinary tract infection included initial presentation of multiple febrile urinary tract infections (p = 0.03), older age at diagnosis (p = 0.03) and older age starting observation off continuous antibiotic prophylaxis (p = 0.0003). Criteria to select patients with vesicoureteral reflux for observation off continuous antibiotic prophylaxis remain poorly defined in the literature. Observation will fail in a subset of patients with vesicoureteral reflux. Physician biases regarding patient selection for observation off continuous antibiotic prophylaxis should be considered when interpreting studies that evaluate treatment strategies. Copyright © 2012 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

WITHDRAWN: Initial management strategies for dyspepsia.

PubMed

Delaney, Brendan; Ford, Alex C; Forman, David; Moayyedi, Paul; Qume, Michelle

2009-10-07

This review considers management strategies (combinations of initial investigation and empirical treatments) for dyspeptic patients. Dyspepsia was defined to include both epigastric pain and heartburn. To determine the effectiveness, acceptability, and cost effectiveness of the following initial management strategies for patients presenting with dyspepsia (a) Initial pharmacological therapy (including endoscopy for treatment failures). (b) Early endoscopy. (c) Testing for Helicobacter pylori (H. pylori )and endoscope only those positive. (d) H. pylori eradication therapy with or without prior testing. Trials were located through electronic searches and extensive contact with trialists. All randomised controlled trials of dyspeptic patients presenting in primary care. Data were collected on dyspeptic symptoms, quality of life and use of resources. An individual patient data meta-analysis of health economic data was conducted Twenty-five papers reporting 27 comparisons were found. Trials comparing proton pump inhibitors (PPI) with antacids (three trials) and histamine H2-receptor antagonists (H2RAs) (three trials), early endoscopy with initial acid suppression (five trials), H. pylori test and endoscope versus usual management (three trials), H. pylori test and treat versus endoscopy (six trials), and test and treat versus acid suppression alone in H. pylori positive patients (four trials), were pooled. PPIs were significantly more effective than both H2RAs and antacids. Relative risks (RR) and 95% confidence intervals (CI) were; for PPI compared with antacid 0.72 (95% CI 0.64 to 0.80), PPI compared with H2RA 0.63 (95% CI 0.47 to 0.85). Results for other drug comparisons were either absent or inconclusive. Initial endoscopy was associated with a small reduction in the risk of recurrent dyspeptic symptoms compared with H. pylori test and treat (OR 0.75, 95% CI 0.58 to 0.96), but was not cost effective (mean additional cost of endoscopy US$401 (95% CI $328 to 474). Test and treat may be more effective than acid suppression alone (RR 0.59 95% CI 0.42 to 0.83). Proton pump inhibitor drugs (PPIs) are effective in the treatment of dyspepsia in these trials which may not adequately exclude patients with gastro-oesophageal reflux disease (GORD). The relative efficacy of histamine H2-receptor antagonists (H2RAs) and PPIs is uncertain. Early investigation by endoscopy or H. pylori testing may benefit some patients with dyspepsia but is not cost effective as part of an overall management strategy.

Urogenital anomalies in girls with sacrococcygeal teratoma: a commonly missed association.

PubMed

Shalaby, Mohamed Sameh; O'Toole, Stuart; Driver, Chris; Bradnock, Tim; Lam, Jimmy; Carachi, Robert

2012-02-01

The association of urogenital (UG) anomalies and sacrococcygeal teratoma (SCT) has not been widely reported. Our aim was to look at the national incidence and presentation of this anomaly in patients with SCT and to provide the first report of a clear anatomical description of this commonly missed association. Sacrococcygeal teratoma cases in Scotland during the last 30 years were identified. Patients with associated UG anomalies were reviewed in detail to identify their presentation, anatomy, and management. Fifty-three patients with SCT were identified, including 41 girls. Five girls (12%) subsequently had a UG anomaly diagnosed, which was not apparent at the initial surgery. Two patients presented with retention, and their anomaly was diagnosed at 6 weeks and 7 months of age. The other 3 presented with incontinence, and despite thorough assessment, including cystoscopy, their UG anomalies were not recognized until the ages of 7, 9, and 13 years. Urogenital anomalies are surprisingly common in girls with SCT. The reason for this association is unclear. None of these cases were diagnosed initially, which means that it was either missed or acquired. Urogenital anomalies should be suspected in girls with SCT and actively excluded in those with voiding difficulties. Copyright © 2012 Elsevier Inc. All rights reserved.

Initial development of a patient-reported outcome measure of experience with cognitive impairment associated with schizophrenia.

PubMed

Welch, Lisa C; Trudeau, Jeremiah J; Silverstein, Steven M; Sand, Michael; Henderson, David C; Rosen, Raymond C

2017-01-01

Cognitive impairment is a serious, often distressing aspect of schizophrenia that affects patients' day-to-day lives. Although several interview-based instruments exist to assess cognitive functioning, a reliable measure developed based on the experiences of patients facing cognitive difficulties is needed to complement the objective performance-based assessments. The present article describes the initial development of a patient-reported outcome (PRO) measure to assess the subjective experience of cognitive impairment among patients with schizophrenia, the Patient-Reported Experience of Cognitive Impairment in Schizophrenia (PRECIS). The phases of development included the construction of a conceptual model based on the existing knowledge and two sets of qualitative interviews with patients: 1) concept elicitation interviews to ensure face and content validity from the perspective of people with schizophrenia and 2) cognitive debriefing of the initial item pool. Input from experts was elicited throughout the process. The initial conceptual model included seven domains. The results from concept elicitation interviews (n=80) supported these domains but yielded substantive changes to concepts within domains and to terminology. Based on these results, an initial pool of 53 items was developed to reflect the most common descriptions and languages used by the study participants. Cognitive debriefing interviews (n=22) resulted in the removal of 18 items and modification of 22 other items. The remaining 35 items represented 23 concepts within six domains plus two items assessing bother. The draft PRO measure is currently undergoing psychometric testing as a precursor to broad-based clinical and research use.

Gastrointestinal injuries from blunt abdominal trauma in children.

PubMed

Ameh, E A; Nmadu, P T

2004-04-01

To determine the pattern, presentation and outcome of gastrointestinal injuries from blunt abdominal trauma in children. A retrospective study. Ahmadu Bello University Teaching Hospital, Zaria, Nigeria. Twenty one children managed for gastrointestinal injuries from blunt trauma from 1984-2002. The pattern, presentation, management and outcome of gastrointestinal injuries from blunt trauma. In the 19 year period, 1984-2002, 92 children were treated for blunt abdominal trauma, 21(23%) of who had injuries to the gastrointestinal tract. Three presenting after 24 hours had evidence of peritonitis. In six children with isolated gastrointestinal tract (GIT) injury who presented within two hours, abdominal signs were vague at initial evaluation but became marked over a few hours at repeated examination. In eight with associated intraabdominal injuries, abdominal signs were marked at initial examination and five presented with shock. Free peritoneal air was present on plain abdominal and chest radiograph in three of ten patients, dilated bowel loops in six and fluid levels in one. Diagnostic peritoneal lavage or paracentesis was positive in four patients with isolated GIT injuries and eight with associated intraabdominal injuries. There were 24 injuries in the 21 patients consisting of 15 perforations, five contusions, two seromuscular tears, and two gangrene from mesenteric injury. The small intestine was involved in 11 patients, colon six, stomach five, duodenum one and rectum one. Seven (35%) patients had associated extraabdominal injuries. Treatment consisted of simple closure of perforations, over sewing of contusions, resection and anastomosis for gangrene and repair with protective stoma for the rectal injury. One patient each developed prolonged ileus, urinary tract infection and chest infection, respectively postoperatively. Mortality was 28%, all of who had associated intraabdominal or extraabdominal injuries. Gastrointestinal injury from blunt abdominal trauma in children, though uncommon, carries a high mortality, usually from associated intraabdominal or extraabdominal injuries.

Delayed Temporal Lobe Hemorrhage After Initiation of Acyclovir in an Immunocompetent Patient with Herpes Simplex Virus-2 Encephalitis: A Case Report.

PubMed

Mueller, Kyle; Ryan, Joshua E; Tai, Alex; Armonda, Rocco A

2017-01-15

Herpes simplex virus (HSV) is the most common cause of non-epidemic, sporadic, acute focal encephalitis in the United States. Inflammation of the vasculature makes them friable and susceptible to hemorrhage. Massive hemorrhage, though rare, can present in a delayed fashion after initiation of acyclovir and often requires surgical intervention. We report a unique case of delayed temporal lobe hemorrhage after initiation of acyclovir in an immunocompetent patient, specifically for its presentation, virology, and surgical management. A 40-year-old left-handed Caucasian female with chronic headaches, along with a 20-pack-year smoking history, presented to an outside facility with one week of diffuse, generalized headache, fever, nausea, and vomiting. Initial cranial imaging was negative for hemorrhage. Cerebrospinal fluid (CSF) studies showed a lymphocytic pleocytosis with elevated protein, along with polymerase chain reaction (PCR) positive staining for HSV, establishing the diagnosis of HSV-2 encephalitis, which is less common in adults. Acyclovir was initiated and one week later while still hospitalized, the patient developed acute altered mental status with cranial imaging showing a large right temporal lobe hemorrhage with significant midline shift. She was transferred to our facility for surgical intervention. Computed tomography angiography (CTA) was negative for any underlying vascular lesion. She was taken to the operating room for a decompressive unilateral (right) hemicraniectomy and temporal lobectomy. She had no postoperative complications and completed a three-week course of acyclovir. She was discharged to acute rehab with plans to return at a later date for cranioplasty. Intracerebral hemorrhage is an uncommon, although possible sequela, of herpes encephalitis. Despite initiation of early antiviral therapy, close monitoring is warranted, given the pathophysiology of the vasculature. Any decline in the neurological exam and/or increasing symptomatology of increased intracranial pressure mandates immediate cranial imaging to evaluate for possible hemorrhage. Emergent surgical intervention is warranted with large temporal lobe hemorrhages.

Quality of life in newly diagnosed glaucoma patients : The Collaborative Initial Glaucoma Treatment Study.

PubMed

Janz, N K; Wren, P A; Lichter, P R; Musch, D C; Gillespie, B W; Guire, K E

2001-05-01

The Collaborative Initial Glaucoma Treatment Study (CIGTS) was designed to determine whether patients with newly diagnosed open-angle glaucoma are better treated initially by medicine or immediate filtering surgery. This paper describes the quality-of-life (QOL) measurement approach, instruments included, and the CIGTS participants' QOL findings at the time of diagnosis. Baseline results from a randomized, controlled clinical trial. Six hundred seven patients from 14 clinical centers were enrolled. Patients randomized to initial medication received a stepped medical regimen (n = 307). Those randomized to initial surgery underwent a trabeculectomy (n = 300). The baseline interview was conducted before treatment initiation. All baseline and posttreatment QOL assessments were conducted by telephone from a centralized interviewing center. The primary outcome measure described in this paper was QOL. The QOL instrument is multidimensional and incorporates both disease-specific and generic measures, including the Visual Activities Questionnaire, Sickness Impact Profile, and a Symptom and Health Problem CHECKLIST: The correlations between QOL measures and clinical outcomes were in the expected direction, but relatively weak. At initial diagnosis, difficulty with bright lights and with light and dark adaptation were the most frequently reported symptoms related to visual function, whereas visual distortion was the most bothersome. Approximately half of the patients reported at least some worry or concern about the possibility of blindness. Within the Visual Activities Questionnaire, higher scores on the Peripheral Vision subscale were associated with more field loss (P < 0.01). In regression analyses controlling for sociodemographics and nonocular comorbidities, increased visual field loss was significantly associated with higher dysfunction among five disease-specific QOL measures (P < 0.05). Newly diagnosed glaucoma patients reported experiencing some visual function symptoms at the time of diagnosis that would not be intuitively expected based on clinical testing. Some discussion about the association between clinical presentation and worry about blindness may reduce unnecessary concern. These results provide the basis for long-term comparisons of the QOL effects of initial medical and surgical treatment for open-angle glaucoma.

Factors associated with the initiation of disease-modifying antirheumatic drugs in newly diagnosed rheumatoid arthritis: a retrospective claims database study.

PubMed

Bonafede, Machaon M K; Fox, Kathleen M; Johnson, Barbara H; Watson, Crystal; Gandra, Shravanthi R

2012-02-01

The objectives of this study were to quantify the proportion of US patients with newly diagnosed rheumatoid arthritis (RA) in whom disease-modifying antirheumatic drug (DMARD) therapy was initiated within 12 months following diagnosis, to determine mean time to initiation, to compare the characteristics of initiators versus noninitiators, and to identify factors associated with noninitiation. A retrospective study was conducted using claims from the databases of commercial managed care and Medicare supplemental managed care to identify patients with claims containing codes for RA dated January 1, 2004, through September 30, 2008. The percentage of patients with RA and a prescription for a DMARD within 12 months after the index date (initiators) was evaluated. The characteristics of DMARD initiators and noninitiators during the preindex period were compared, including demographic and clinical characteristics, health care resource utilization, and cost variables. The probability of DMARD initiation was determined using survival analysis. Multivariate analysis was performed to estimate mean time from diagnosis to DMARD initiation based on demographic and clinical variables. Of 26,911 patients with newly diagnosed RA identified in the database searches, 63% had been prescribed a DMARD within 12 months after diagnosis. DMARD initiators were significantly more likely to have had a rheumatologist visit and rheumatoid factor testing and were more likely to have received a corticosteroid and/or an NSAID (all, P < 0.001). DMARD initiators had significantly lower total costs ($10,534 vs $12,725, respectively) and pharmacy drug costs ($2438 vs $2822) over the preindex period compared with noninitiators (both, P < 0.001). Independent factors associated with a greater likelihood of DMARD initiation included a rheumatologist visit, rheumatoid factor testing, NSAID use, and corticosteroid use. Age ≥85 years and the presence of comorbidities were associated with a significantly lower likelihood of DMARD initiation. Among managed care enrollees in the present analysis, 37% of patients newly diagnosed with RA were not being treated with DMARDs in the first 12 months after diagnosis. Time to DMARD initiation plateaued after 90 days, suggesting that if a patient was not prescribed a DMARD soon after RA diagnosis, he or she was not likely to receive one. Copyright © 2012 Elsevier HS Journals, Inc. All rights reserved.

Takotsubo Cardiomyopathy Associated with Thyrotoxicosis: A Case Report and Review of the Literature

PubMed Central

El-Maouche, Diala; Choudhary, Chitra; Zinsmeister, Bruce; Burman, Kenneth D.

2014-01-01

Background: Takotsubo or stress-induced cardiomyopathy is a form of reversible cardiomyopathy commonly associated with emotional or physical stress. Thyrotoxicosis has been identified as a rare cause of Takotsubo cardiomyopathy, with only 12 cases reported in the literature. Here, we report a case of thyroid storm presenting with Takotsubo cardiomyopathy in the setting of Graves' disease. Patient Findings: A 71-year-old woman presented with abdominal pain, vomiting, confusion, and history of weight loss. She was initially diagnosed and treated for diabetic ketoacidosis at another hospital and was transferred to our hospital one day after initial presentation because of concern for acute coronary syndrome. A diagnosis of Takotsubo cardiomyopathy was made on the basis of cardiac catheterization. At that time, she was diagnosed and treated for thyroid storm. Follow-up 7 weeks later revealed improvement of her cardiac function and near-normalization of thyroid hormone levels. Summary: In this patient, who presented with symptoms of heart failure, acute coronary syndrome was initially considered, but the diagnosis of Takotsubo cardiomyopathy associated with thyroid storm was ultimately made based on cardiac catheterization and laboratory investigation. Conclusions: Thyrotoxicosis is associated with adverse disturbances in the cardiovascular system. Takotsubo cardiomyopathy could be a presenting manifestation of thyroid storm, perhaps related to excess catecholamine levels or sensitivity. PMID:23560557

Depersonalisation and schizophrenia: Comparative study of initial and multiple episodes of schizophrenia.

PubMed

Luque-Luque, Rogelio; Chauca-Chauca, Geli Marie; Alonso-Lobato, Pablo; Jaen-Moreno, M Jose

2016-01-01

The phenomena of depersonalisation/derealisation have classically been associated with the initial phases of psychosis, and it is assumed that they would precede (even by years) the onset of clinical psychosis, being much more common in the prodromal and acute phases of the illness. The aims of the present study are to analyse the differences in depersonalisation/derealisation between patients with initial and multiple episodes and the factors that could influence this. A descriptive, controlled and cross-sectional study of 48 patients diagnosed with paranoid schizophrenia (20 with an initial episode and 28 with multiple episodes). These patients were assessed using scales such as the Cambridge Depersonalization Scale, the Positive and Negative Symptom Scale, and the Dissociative Experiences Scale. Participants with initial episodes score higher on both the Cambridge Depersonalisation Scale, and the subscale of the Dissociative Experiences Scale that evaluates such experiences. There were no associations between these types of experience and the positive symptoms subscale of the Positive and Negative Symptom Scale. Depersonalisation/derealisation experiences appear with greater frequency, duration and intensity in patients in the early stages of the illnesses, gradually decreasing as they become chronic. Copyright © 2016 SEP y SEPB. Published by Elsevier España. All rights reserved.

Emergency presentation of colorectal cancer in Northwestern Saudi Arabia.

PubMed

Albalawi, Ibrahim A; Abdullah, Ahmad A; Mohammed, Mohammed E

2017-05-01

To investigate the frequency and clinical characteristics of emergency presentation of colorectal carcinoma (CRC) in Tabuk Region of Saudi Arabia.  Methods: This is a retrospective, descriptive hospital-based study. All cases with CRC that presented to the main referral hospitals in Tabuk, Saudi Arabia between 2010 and 2015 were retrieved. The relevant hospitals are: King Salman Military Hospital, King Khalid Hospital, and King Fahad Hospital.  Results: Seventy-three patients were included in the study. Twenty-two patients presented emergency constituting 30.6% of the total. Emergency CRC presentation was more common in elderly patients (81.8%), but a greater proportion of young patients was also affected (40% versus 29% in elderly patients). The disease is more common in females (37%) than males (26.7%) and intestinal obstruction was the sole form of presentation. Patients presenting emergency had more right-sided (61.9%) than left-sided tumors (30.2%). Advanced presentation with metastasis was noted in 40% of the patients presenting acutely. Conclusion: Emergency CRC presentation is common in the Tabuk region. Patients tend to present at an advanced stage, which necessitates an endeavor to detect the disease in its early stages, possibly through initiation of health education programs and suitable screening projects.

Time course for memory dysfunction in early-life and late-life major depression: a longitudinal study from the Juntendo University Mood Disorder Project.

PubMed

Maeshima, Hitoshi; Baba, Hajime; Nakano, Yoshiyuki; Satomura, Emi; Namekawa, Yuki; Takebayashi, Naoko; Nomoto, Hiroshi; Suzuki, Toshihito; Mimura, Masaru; Arai, Heii

2013-10-01

Previous studies have demonstrated that patients with depression also have memory dysfunctions during depressive episodes. These dysfunctions partially remain immediately after remission from a depressive state; however, it is unclear whether these residual memory dysfunctions may disappear through long-term remission from depression. The present study compared patients during early-life (age<60) and late-life (age ≥ 60) depression while in their remitted stage with healthy controls to elucidate the impact of a long-term course on memory. Logical memory from the Wechsler Memory Scale-Revised was administered to 67 patients with major depressive disorder (MDD) (47 patients with early-life depression and residual 20 patients with late-life depression) and 50 healthy controls. MDD patients received memory assessments at the time of their initial remission and at a follow-up three years after remission. At the time of initial remission, scores for logical memory were significantly lower in both patient groups compared to matched controls. At follow-up, memory dysfunction for early-life MDD patients disappeared, whereas scores in the late-life MDD group remained significantly lower than those of matched controls. All patients in the present study were on antidepressant medications. Our findings suggested that the progress of memory performance in late-life MDD patients may be different from early-life MDD patients. © 2013 Elsevier B.V. All rights reserved.

Prognostic EEG patterns in patients resuscitated from cardiac arrest with particular focus on Generalized Periodic Epileptiform Discharges (GPEDs).

PubMed

Milani, P; Malissin, I; Tran-Dinh, Y R; Deye, N; Baud, F; Lévy, B I; Kubis, N

2014-04-01

We assessed clinical and early electrophysiological characteristics, in particular Generalized Periodic Epileptiform Discharges (GPEDs) patterns, of consecutive patients during a 1-year period, hospitalized in the Intensive Care Unit (ICU) after resuscitation following cardiac arrest (CA). Consecutive patients resuscitated from cardiac arrest (CA) with first EEG recordings within 48hours were included. Clinical data were collected from hospital records, in particular therapeutic hypothermia. Electroencephalograms (EEGs) were re-analyzed retrospectively. Sixty-two patients were included. Forty-two patients (68%) were treated with therapeutic hypothermia according to international guidelines. Global mortality was 74% but not significantly different between patients who benefited from therapeutic hypothermia compared to those who did not. All the patients who did not have an initial background activity (36/62; 58%) died. By contrast, initial background activity was present in 26/62 (42%) and among these patients, 16/26 (61%) survived. Electroencephalography demonstrated GPEDs patterns in 5 patients, all treated by therapeutic hypothermia and antiepileptic drugs. One of these survived and showed persistent background activity with responsiveness to benzodiazepine intravenous injection. Patients presenting suppressed background activity, even when treated by hypothermia, have a high probability of poor outcome. Thorough analysis of EEG patterns might help to identify patients with a better chance of survival. Copyright © 2014 Elsevier Masson SAS. All rights reserved.

Idiopathic constipation: A challenging but manageable problem.

PubMed

Bischoff, Andrea; Brisighelli, Giulia; Dickie, Belinda; Frischer, Jason; Levitt, Marc A; Peña, Alberto

2017-10-10

A protocol to treat idiopathic constipation is presented. A contrast enema is performed in every patient and, when indicated, patients are initially submitted to a "clean out" protocol. All patients are started on a Senna-based laxative. The initial dosage is empirically determined and adjusted daily, during a one week period, based on history and abdominal radiographs, until the amount of Senna that empties the colon is reached. The management is considered successful when patients empty their colon daily and stop soiling. If the laxatives dose provokes abdominal cramping, distension, and vomiting, without producing bowel movements, patients are considered nonmanageable. From 2005 to 2012, 215 patients were treated. 121 (56%) were males. The average age was 8.2years (range: 1-20). 160 patients (74%) presented encopresis. 67 patients (32%) needed a clean out. After one week, 181 patients (84%) achieved successful management, with an average Senna dose of 67mg (range: 5-175mg). In 34 patients (16%) the treatment was unsuccessful: 19 were nonmanageable, 3 noncompliant, and 12 continued soiling. At a later follow-up (median: 329days) the success rate for 174 patients was 81%. We designed a successful protocol to manage idiopathic constipation. The key points are clean out before starting laxatives, individual adjustments of laxative, and radiological monitoring of colonic emptying. Level IV. Copyright © 2017 Elsevier Inc. All rights reserved.

Gingival enlargement in a pregnant woman with acute monocytic leukaemia: a case report.

PubMed

Fu, Y-W; Xu, H-Z

2017-09-01

The objective of the present study was to report the case of a pregnant woman with severe gingival enlargement for 3 months with undiagnosed acute leukaemia. The pregnant woman presented with anaemia and generalized gingival enlargement. A provisional diagnosis of gingival enlargement in pregnancy was made. Twelve days after the initial treatment, the patient was referred and admitted to the haematology department of a local hospital with clinical signs of anaemia and thrombocytopenia. Blood count showed a white blood cell count of 9.68 × 10 9 /L, with a haemoglobin count of 64.0 g/L and a platelet count of 17 × 10 9 /L. Bone marrow aspiration showed 94.5% monoblasts, and the morphological diagnosis was acute monocytic leukaemia. One day after admission, the patient delivered a male infant by Caesarean section. Ten days after the Caesarean section, the patient was started on a course of chemotherapy. Pulmonary infection, hypokalaemia, and respiratory failure developed, and the patient died 23 days after the Caesarean section. The present case shows the importance of awareness of severe gingival enlargement as an initial oral sign of acute leukaemia. © 2017 Australian Dental Association.

Toxoplasmosis myelopathy and myopathy in an AIDS patient: a case of immune reconstitution inflammatory syndrome?

PubMed

Kung, Doris Hichi; Hubenthal, Erica A; Kwan, Justin Y; Shelburne, Samuel A; Goodman, Jerry C; Kass, Joseph S

2011-01-01

concurrent toxoplasmosis infection of the brain, spinal cord, and muscle has never been reported together in a patient antemortem. Toxoplasma gondii is the most common focal central nervous system opportunistic infection in the acquired immune deficiency syndrome (AIDS) population. Despite this fact, isolated toxoplasmosis infection in the spinal cord is rarely reported. In addition, toxoplasmic myositis is also rarely diagnosed and Toxoplasma cysts are seldom found on biopsy. We present a patient with AIDS and toxoplasmosis resistant to standard anti-Toxoplasma therapy. a 34-year-old man with a history of untreated AIDS presented with symptoms of myelopathy. Pathologically proven toxoplasmosis of the spinal cord was diagnosed and no brain lesions were found. However, despite appropriate treatment and initiation of highly active antiretroviral therapy, the patient developed worsening symptoms, including myopathy and autonomic instability. Muscle biopsy revealed Toxoplasma cysts, and there was laboratory evidence of a restored immune system. we report the first case of toxoplasmosis presenting initially with myelitis in the absence of encephalitis that subsequently progressed to myositis despite antiparasitic treatment. We also discuss the possibility of immune reconstitution inflammatory syndrome as a cause of his deterioration.

A novel rapid access testicular cancer clinic: prospective evaluation after one year.

PubMed

Carey, K; Davis, N F; Elamin, S; Ahern, P; Brady, C M; Sweeney, P

2016-02-01

Our institution has recently developed a rapid access outpatient clinic to investigate men with testicular lumps and/or pain suspicious for testicular cancer (TCa). To present our experience after 12 months. All referrals to the rapid access testicular clinic (RATC) clinic were prospectively analysed from 01/01/2013 to 01/01/2014. The primary outcome variable was incidence of TCa in the referred patient cohort. Secondary outcome variables were waiting times prior to clinical review and waiting times prior to radical orchidectomy in patients diagnosed with TCa. Seventy-four new patients were referred to the RATC during the 1-year period and the mean age was 34 (range 15-81 years). TCa was the most common diagnosis and was found in 18 (25 %) patients. Patients diagnosed with TCa underwent radical orchidectomy, a median of 3 (range 1-5) days after their initial GP referral. Patients requiring surgical intervention for benign scrotal pathology underwent their procedure a median of 32 (range 3-61) days after their initial referral. Of the 18 patients diagnosed with TCa, 9 (50 %) were diagnosed with a seminomatous germ cell tumour on histopathology. The RATC is a new initiative in Ireland that provides expedient and definitive treatment of patients with newly diagnosed TCa. Early treatment will ultimately improve long-term prognosis in this patient cohort.

Natural stent in the management of post-intubation tracheal stenosis.

PubMed

Park, Hye Yun; Kim, Hojoong; Koh, Won-Jung; Suh, Gee Young; Chung, Man Pyo; Kwon, O Jung

2009-05-01

The treatment choice for post-intubation tracheal stenosis (PITS) in patients for whom surgery is not initially feasible is bronchoscopic silicone stenting. A new silicone stent, called the Natural stent (N stent), was investigated for its clinical efficacy and safety in patients with PITS. A retrospective review was conducted of 32 patients with PITS who underwent N stenting between November 2001 and December 2006 and were followed for at least 12 months. Airway dilatation with combined modalities such as Nd:YAG laser, ballooning or bougienage was followed by N stent insertion. After intervention, all patients had symptomatic and spirometric improvement without immediate complications. Removal of the stent without re-stenosis was successful in 38% of the patients at a median time of 7 months after insertion. The stent could not be removed or needed reinsertion in 31% of patients, and 16% of patients underwent surgery after initial stabilization by stenting. Late complications were stent migration (34%), mucostasis (31%), granulation tissue formation (38%) and re-stenosis (40%). All patients tolerated the management of complications during a median follow up of 22 months. Bronchoscopic N stenting is an effective treatment for patients with PITS in whom surgery is not feasible on initial presentation. Further stent development is necessary to reduce the late complication rate.

Tumor-initiating CD49f cells are a hallmark of chemoresistant triple negative breast cancer.

PubMed

Gomez-Miragaya, Jorge; González-Suárez, Eva

2017-01-01

Taxanes are mainstay treatment of triple negative breast cancer (TNBC) patients but resistance often develops. Using TNBC patient-derived orthoxenografts (PDX) we have recently discovered that a CD49f+ chemoresistant population with tumor-initiating ability is present in sensitive tumors and expands in tumors that have acquired resistance. Importantly, sensitivity to taxanes is recovered after long-term drug interruption. The characterization of this chemoresistant CD49f+ cells provides a unique opportunity to identify novel targets for the treatment of chemoresistant TNBC.

Eruptive Condyloma Accuminata after Initiation of Infliximab Treatment for Folliculitis Decalvans

PubMed Central

Wu, Douglas C.; Salopek, Thomas G.

2013-01-01

We report a patient with recalcitrant folliculitis decalvans who was placed on infliximab due to failure to respond to numerous immunosuppressive drugs and antibiotics. After the second infusion of infliximab the patient reported a cutaneous eruption to the bilateral groin, penis, scrotum, perineum, and perianal region consistent with genital warts. The case highlights the need to inquire about a past or current history of genital or anal warts prior to the initiation of anti-TNF therapy, particularly with infliximab. If present, consideration should be given to concurrent antiwart therapy. PMID:24368947

Can patients at risk for persistent negative symptoms be identified during their first episode of psychosis?

PubMed

Malla, Ashok K; Norman, Ross M G; Takhar, Jatinder; Manchanda, Rahul; Townsend, Laurel; Scholten, Derek; Haricharan, Raj

2004-07-01

Patients with schizophrenia who show persistent negative symptoms are an important subgroup, but they are difficult to identify early in the course of illness. The objective of this study was to examine characteristics that discriminate between first-episode psychosis (FEP) patients in whom primary negative symptoms did or did not persist after 1 year of treatment. Patients with a DSM-IV diagnosis of FEP whose primary negative symptoms did (N = 36) or did not (N = 35) persist at 1 year were contrasted on their baseline and 1-year characteristics. Results showed that patients with persistent primary negative symptoms (N = 36) had a significantly longer duration of untreated psychosis (p < .005), worse premorbid adjustment during early (p < .001) and late adolescence (p < .01), and a higher level of affective flattening (p < .01) at initial presentation compared with patients with transitory primary negative symptoms. The former group also showed significantly lower remission rates at 1 year (p < .001). Multiple regression analysis confirmed the independent contribution of duration of untreated psychosis, premorbid adjustment, and affective flattening at baseline to the patients' likelihood of developing persistent negative symptoms. It may therefore be possible to distinguish a subgroup of FEP patients whose primary negative symptoms are likely to persist on the basis of characteristics shown at initial presentation for treatment.

Revisiting the Pancreaticoduodenectomy for Trauma: a Single Institution’s Experience

PubMed Central

Thompson, Callie M.; Shalhub, Sherene; DeBoard, Zachary M.; Maier, Ronald V.

2013-01-01

STRUCTURED ABSTRACT Background Major pancreaticoduodenal injury can be devastating even if identified and controlled early. To date, both morbidity and mortality have resisted the improvements achieved with many other life-threatening injuries, with reported mortalities of 31–50%. We sought to elucidate the impact of the initial operation in the management of severe pancreaticoduodenal injury. Methods A retrospective review of all patients presenting to a single level-one trauma center who required pancreaticoduodenectomy for trauma from 1996–2010. We collected demographic and in-hospital data and compared subjects based on their initial operation. Results Fifteen patients (median age 29 yrs, 93% male, median ISS=35) underwent pancreaticoduodenectomy following blunt (n =5) or penetrating trauma (n=10). Twelve (80%) underwent damage control surgery (DCS) +/− the initial stage of Whipple resection as their first operation. Three (20%) underwent a complete Whipple procedure, including reconstruction, as their first operation. Overall, 87% of patients (13 of 15) were acidotic, hypothermic and coagulopathic during their first operation. Average operative time was longer for the completion pancreaticoduodenectomy vs. DCS (460±98 mins vs. 243±112 mins). There were no overall differences in complication rates, although the two patients that did not suffer a complication had DCS. In-hospital mortality was 13% (n=2). Conclusions We present both the largest series of patients to date who underwent a DCS or staged-Whipple procedure for complex pancreaticoduodenal trauma and the largest series due to blunt trauma. Using a staged approach, we report the lowest mortality rate for such injuries in the literature; less than half of that reported in the most recent series (33%). Given the frequent occurrence and recognized detrimental impact of acidosis, hypothermia and coagulopathy in patients with severe pancreaticoduodenal trauma, and proven benefits of DCS, we propose that these patients should undergo initial damage control surgery and staged reconstruction. PMID:23823615

Clinical features of adult-onset chronic active Epstein-Barr virus infection: a retrospective analysis.

PubMed

Arai, Ayako; Imadome, Ken-Ichi; Watanabe, Yuko; Yoshimori, Mayumi; Koyama, Takatoshi; Kawaguchi, Takeharu; Nakaseko, Chiaki; Fujiwara, Shigeyoshi; Miura, Osamu

2011-05-01

We performed a retrospective analysis of patients with adult-onset chronic active Epstein-Barr virus infection (CAEBV). First, we analyzed five patients (aged 28-72) diagnosed at our hospitals with EBV-infected clonally proliferating T cells. Four patients were administered cyclophosphamide/doxorubicin/vincristine/prednisone (CHOP) chemotherapy, but no remarkable decrease of viral load was observed in three of the patients. The other patient died 19 days after initiation of CHOP treatment due to disease progression. Addition of high-dose cytarabine to the regimens of two of the patients was discontinued shortly after administration, due to the development of grade 4 pericardial effusion. Together, these regimens may be insufficient for treating adult-onset CAEBV. We next reviewed 23 adult-onset CAEBV patients, adding 18 previously reported patients to the five patients described in the present study. T cells were frequently infected (87%), whereas NK- and T-cell types are known to be almost equally prevalent in childhood-onset cases. The time duration from the onset of disease to initiation of treatment averaged 20 months. Reports showed that 12 patients died; seven patients died at an average of 8 months after initiation of treatment. Patients' disease courses seemed to be rapidly progressive and more aggressive than those of childhood-onset cases. More cases must be studied to clarify clinical features and establish an optimal treatment strategy.

Contribution of Transjugular Liver Biopsy in Patients with the Clinical Presentation of Acute Liver Failure

DOE Office of Scientific and Technical Information (OSTI.GOV)

Miraglia, Roberto, E-mail: rmiraglia@ismett.edu; Luca, Angelo; Gruttadauria, Salvatore

2006-12-15

Purpose. Acute liver failure (ALF) treated with conservative therapy has a poor prognosis, although individual survival varies greatly. In these patients, the eligibility for liver transplantation must be quickly decided. The aim of this study was to assess the role of transjugular liver biopsy (TJLB) in the management of patients with the clinical presentation of ALF. Methods. Seventeen patients with the clinical presentation of ALF were referred to our institution during a 52 month period. A TJLB was performed using the Cook Quick-Core needle biopsy. Clinical data, procedural complications, and histologic findings were evaluated. Results. Causes of ALF were virusmore » hepatitis B infection in 7 patients, drug toxicity in 4, mushroom in 1, Wilson's disease in 1, and unknown origin in 4. TJLB was technically successful in all patients without procedure-related complications. Tissue specimens were satisfactory for diagnosis in all cases. In 14 of 17 patients the initial clinical diagnosis was confirmed by TJLB; in 3 patients the initial diagnosis was altered by the presence of unknown cirrhosis. Seven patients with necrosis <60% were successfully treated with medical therapy; 6 patients with submassive or massive necrosis ({>=}85%) were treated with liver transplantation. Four patients died, 3 had cirrhosis, and 1 had submassive necrosis. There was a strict statistical correlation (r = 0.972, p < 0.0001) between the amount of necrosis at the frozen section examination and the necrosis found at routine histologic examination. The average time for TJLB and frozen section examination was 80 min. Conclusion. In patients with the clinical presentation of ALF, submassive or massive liver necrosis and cirrhosis are predictors of poor prognosis. TLJB using an automated device and frozen section examination can be a quick and effective tool in clinical decision-making, especially in deciding patient selection and the best timing for liver transplantation.« less

Videothoracoscopy in the treatment of early empyema: an initial experience.

PubMed Central

Hornick, P.; Townsend, E. R.; Clark, D.; Fountain, S. W.

1996-01-01

Seventeen consecutive patients were referred for management of empyema between April 1991 and March 1992. Fourteen patients defined as having an 'early' empyema were initially treated by videothoracoscopy. The other three patients, defined as having a 'late' empyema proceeded directly to thoracotomy. Videothoracoscopy was successful in 10 out of the 14 patients. The mean postoperative stay was 7.8 days. At a mean follow-up at 16.7 months, these patients were rendered apyrexial with full lung expansion and no residual pleural collection. The postoperative results were at least equivalent to other conventional forms of treatment without an undue level of complications. In this series, thoracoscopy was found to be successful when symptoms had been present up to 31 days before presentation at the first hospital, and the mean length of treatment before referral to Harefield was 47 days. It is now our policy to videothoracoscope all patients with empyema thoracis, regardless of the length of referral. It may circumvent the need for a thoracotomy, it does not add any increased risk of complications, and does not appreciably increase the length of hospital stay should thoracotomy ultimately be required. PMID:8659973

Inguinoscrotal region as an unusual site of extra-pancreatic collections in infected pancreatic necrosis.

PubMed

Kalia, Saurabh; Gupta, Rahul; Shenvi, Sunil D; Kumar, Hemanth; Gupta, Rajesh; Kang, Mandeep; Rana, Surinder Singh; Bhasin, Deepak Kumar; Singh, Rajinder

2016-08-01

Severe acute pancreatitis often leads to pancreatic and peripancreatic collections but, rarely, it can lead to collections at sites remote from the pancreas. Three male patients presented with abdominal pain and inguinoscrotal swelling. They were initially misdiagnosed with obstructed inguinal hernia, epididymo-orchitis and hydrocele, respectively. Later, their diagnosis of acute pancreatitis was revealed on laparotomy in one patient and on computed tomography (CT) in the remaining two patients. All these cases had extensive peripancreatic necrosis and paracolic collections tracking along the psoas muscle, downwards towards the pelvis. These collections were initially managed by percutaneous drainage and saline irrigation as a part of the 'step-up' approach. Two of these patients required open necrosectomy, while all required incision and drainage of inguinoscrotal collections. All the patients were discharged in satisfactory condition. Inguinoscrotal swelling is unusual as a first presentation of acute pancreatitis. A high index of suspicion, with careful study of patient's history and examination along with CT, may provide an accurate diagnosis. Local drainage may be required to control sepsis and also provide an egress route for intra-abdominal collections. © The Author(s) 2015. Published by Oxford University Press and the Digestive Science Publishing Co. Limited.

Perforated peptic ulcer following gastric bypass for obesity.

PubMed

Macgregor, A M; Pickens, N E; Thoburn, E K

1999-03-01

Peptic ulcer in the excluded segment of a gastric bypass performed in the management of morbid obesity has only rarely been reported in the literature. The purpose of this study is to review our experience with the condition in a series of 4300 patients who underwent gastric-restrictive surgery between 1978 and 1997. Eleven patients presented with acute perforation of a peptic ulcer in the excluded gastric segment. Nine ulcers were duodenal, one was gastric, and one patient had both gastric and duodenal perforations. The time between primary gastric-restrictive surgery and ulcer perforation varied from 20 days to 12 years. All patients presented with upper abdominal pain. The classical radiological sign of perforated peptic ulcer, free air under the diaphragm, did not occur in any patient. Nine patients were initially treated by primary closure of the perforation with subsequent definitive ulcer therapy by vagotomy, pyloroplasty, or gastrectomy. One case, initially treated elsewhere, was managed by placement of a Malecot catheter through the duodenal perforation, gastrostomy, and peritoneal drainage. One recent case remains symptom-free on H2 blockers after simple closure. There was no mortality. Six cases were previously reported in the literature with a 33 per cent mortality rate.

Hypereosinophilia Secondary to Disseminated Paracoccidioidomycosis

PubMed Central

Mejia-Zuluaga, Mateo; Rosas, Samuel; Vélez, Verónica Posada; Quintero, Pedro A.

2017-01-01

Patient: Male, 28 Final Diagnosis: Disseminated paracoccidioidomycosis Symptoms: Fever • rash Medication: — Clinical Procedure: — Specialty: Infectious Diseases Objective: Unusual clinical course Background: Paracoccidioidomycosis is an endemic mycosis in Central and South America caused by the thermally dimorphic fungus Paracoccidioides brasiliensis. Despite its self-limited course and usually asymptomatic infection, some patients may present with a systemic illness mimicking multiple conditions and thus question the general state of their immune system. Case Report: A 28-year-old male presented to the hospital with fever, dry cough, and non-pruritic rash with no characteristic distribution for the past 10 days. Past medical history revealed that the patient had worked as a farmer three years ago, had abused cocaine paste over the same period, and also had in the last month presented to the hospital for acute appendicitis. Initial laboratory tests revealed hypereosinophilia greater than 10,000 eosinophils/mL. Infection of P. brasiliensis was confirmed by lymph node, skin, and colonoscopy biopsies. After treatment with itraconazole, the patient’s eosinophil count returned to normal and his symptoms resolved. Conclusions: Paracoccidioidomycosis may present as a systemic illness with only marked eosinophilia on initial diagnostic tests. Furthermore, in our patient’s case, the high degree of eosinophilia may have contributed towards the patient’s appendicitis in the weeks preceding the subacute infection. It is possible that the patient’s history of working at a farm and abusing cocaine paste may have contributed to the initial colonization by the fungus. PMID:29042530

Is It Acute Stroke or Not - A Prospective Observational Study from a Multidisciplinary Emergency Department.

PubMed

Wolf, Marc E; Chatzikonstantinou, Anastasios; Grüttner, Joachim; Ebert, Anne D; Walter, Thomas; Hennerici, Michael G; Fatar, Marc

2016-01-01

Acute stroke is a medical emergency with various clinical presentations. Since the introduction of systemic thrombolytic treatment, stroke diagnosis has been made quickly and with great caution, and the trend of rapid presentation at hospitals has increased. In our multidisciplinary Emergency Department, we prospectively collected and analysed data of consecutive patients presenting with suspected acute stroke (SAS) or transient ischemic attack (TIA). Four hundred ten patients (200 men, mean age 68 ± 16, range 17-93 years) with SAS were admitted of which 105 were prehospitally announced as within the time-window for thrombolytic treatment (TW). Diagnosis of acute stroke/TIA was retained in 147 (35.9%). The initially reported TW <4.5 h was wrong in 35.3%. Thrombolysis was performed in 27 patients (23.5% of ischemic stroke patients; 6.6% of all SAS). Diagnosis of another neurologic disease was made in 62 (15.1%). Major differential diagnoses came from the field of internal medicine, psychiatry or otorhinolaryngology. One hundred fifty patients (36.6%) were rapidly discharged. About half the number of our patients admitted for SAS did not suffer from an acute neurologic disease. Residual symptoms post-stroke might be partly responsible for initial misinterpretation. The crucial difference between symptom onset and symptom recognition needs to be emphasized to improve the prehospital assessment of the TW. © 2016 S. Karger AG, Basel.

Breast cancers with EGFR and HER2 co-amplification favor distant metastasis and poor clinical outcome

PubMed Central

Guo, Peng; Pu, Tianjie; Chen, Shinan; Qiu, Yan; Zhong, Xiaorong; Zheng, Hong; Chen, Lina; Bu, Hong; Ye, Feng

2017-01-01

ErbB signaling serves essential roles in invasive ductal carcinoma (IDC). The aim of the present study was to assess gene amplification in ErbB family members in IDC with clinical implications. Quantitative polymerase chain reaction and fluorescence in situ hybridization were performed on formalin-fixed paraffin-embedded tumor samples for gene amplification detection. The clinical and histopathological characteristics, as well as the prognostic significance, were analyzed. Among the 119 IDC patients evaluated, epidermal growth factor receptor [EGFR; also known as human epidermal growth factor receptor (HER)1], HER2, HER3 and HER4 gene amplification was observed in 30 (25.2%), 44 (36.9%), 0 (0.0%) and 1 (0.8%) patients, respectively. EGFR amplification was associated with estrogen receptor status (P=0.028) and higher possibilities of recurrence (P=0.015) and distant metastasis (following initial surgery) (P=0.011). In survival analysis, EGFR amplification was also associated with disease-free survival (DFS) (P=0.001) and overall survival (OS) (P=0.003). HER2 amplification was associated with larger tumor size (P=0.006), later clinical stage (P=0.003) and distant metastasis (following initial surgery) (P=0.006). In survival analysis, HER2 amplification was also associated with DFS (P=0.011). Notably, the present study identified a group of patients in whom EGFR and HER2 were co-amplified. This group of patients appeared to have a higher possibility of metastasis (when diagnosed) (P=0.014) and distant metastasis (following initial surgery) (P<0.001). In survival analysis, these patients were noticed to be associated with DFS (P<0.001) and OS (P=0.002). With respect to treatment regimen, this was also true for the DFS association with chemotherapy (P<0.001), radiotherapy (P<0.001) and hormonal therapy (P=0.001). The present results suggest that EGFR and HER2 amplification favor distant metastasis following initial surgery and are significantly associated with poor clinical outcome in breast cancer patients. PMID:29181099

OK-432 sclerotherapy in head and neck lymphangiomas: long-term follow-up result.

PubMed

Yoo, Jae Chul; Ahn, Youngjin; Lim, Yune Syung; Hah, J Hun; Kwon, Tack-Kyun; Sung, Myung-Whun; Kim, Kwang Hyun

2009-01-01

Nonsurgical treatments, such as sclerotherapy have been attempted for head and neck lymphagiomas. Of the available sclerosing agents, picibanil has shown satisfactory short-term treatment results in many studies, but no study has presented long-term treatment results. Accordingly, in the present study, the authors retrospectively reviewed the long-term treatment results of picibanil sclerotherapy. Fifty-five lymphangioma patients who underwent picibanil sclerotherapy were enrolled. Data about initial and long-term response, recurrence, and excision rate were collected. Initial response rates were 83.5 percent and long-term response rates were 76.3 percent. Initial and the long-term response rate were equally good for lymphangioma.

Treatment Extends Survival for Women with Cervical Cancer

Cancer.gov

Patients with locally advanced cervical cancer who received gemcitabine (Gemzar®) both as part of initial treatment and as part of therapy following primary treatment had improved survival compared with patients whose treatment did not include gemcitabine, according to findings presented at the 2009 ASCO meeting in Orlando.

Atypical pyoderma gangrenosum mimicking an infectious process.

PubMed

To, Derek; Wong, Aaron; Montessori, Valentina

2014-01-01

We present a patient with atypical pyoderma gangrenosum (APG), which involved the patient's arm and hand. Hemorrhagic bullae and progressive ulcerations were initially thought to be secondary to an infectious process, but a biopsy revealed PG. Awareness of APG by infectious disease services may prevent unnecessary use of broad-spectrum antibiotics.

Initiating an ophthalmic laser program for VA outpatients.

PubMed

Newcomb, R D

1995-08-01

Administrative and clinical considerations for the establishment of an ophthalmic laser program at a VA Outpatient Clinic are discussed. Outcomes of the first 320 patients treated over a 3-year period of time are presented. The program is evaluated from the perspectives of patient care, safety, maintenance, education, and economics.

Serious unexpected sinus infection discovered by CT scanning for presumed neurological disease.

PubMed

Swift, A C; Gill, G V

1994-03-01

Serious infection in the paranasal sinuses may present with symptoms suggestive of neurological disease and thus lead to delay in the diagnosis and subsequent treatment. We present three such cases in whom the initial diagnoses had been acute optic neuritis, a posterior communicating aneurysm and an intracranial space occupying lesion. The fourth patient had meningitis but the paranasal sinuses had not initially been considered as a possible source of infection. The current methods of diagnosing sinusitis are discussed.

Pleomorphic adenoma of the palate in a child.

PubMed

Bovino, Brian F; Sohn, Andy; Winston, Daniel

2013-01-01

Presented is a pleomorphic adenoma of the palate in a 12-year-old boy. Pleomorphic adenoma is usually found in adults and is rarely found in patients under 20 years of age. We present initial exam, diagnosis, treatment and a review of literature.

Pleuropulmonary blastoma--case report of a patient presenting in a moribund state.

PubMed

Chauke, Risenga Frank; Muthuphei, M Nelson

2003-11-01

A 4-year-old girl presented with an intrathoracic tumour that was pleural in origin, invading the right lower lobe. The patient underwent urgent right thoracotomy and surgical excision of the tumour and right lower lobectomy as the tumour was invading that lobe. The histological report initially reported it as a rhabdomyosarcoma, embryonal type, but after consultation it was changed to type III pleuropulmonary blastoma. The patient was treated with chemotherapy but succumbed to the disease 12 months after the diagnosis. Relevant literature on pleuropulmonary blastoma is reviewed.

Guide to conducting tinnitus retraining therapy initial and follow-up interviews.

PubMed

Henry, James A; Jastreboff, Margaret M; Jastreboff, Pawel J; Schechter, Martin A; Fausti, Stephen A

2003-01-01

Tinnitus Retraining Therapy (TRT) is a structured method of tinnitus treatment that has been performed since 1990. The TRT Initial Interview form was developed to guide clinicians in obtaining essential information from patients that would specify treatment needs. The TRT Follow-up Interview form is similar to the initial interview form and is designed to evaluate outcomes of treatment. The clinician administers these forms verbally. The forms have been used in a highly abbreviated format with the potential for inconsistent interview administration between examiners. This project was to expand the forms to provide specific wording for each question. The expanded forms are presented in this article, and the intent of each question is explained. Standardized administration of these interview forms will facilitate greater uniformity in the initial evaluation and outcomes analyses of patients treated with TRT.

Care related and transit neuronal injuries after cervical spine trauma: state of care and practice in Nigeria.

PubMed

Mezue, Wilfred C; Onyia, Ephraim; Illoabachie, Izuchukwu C; Chikani, Mark C; Ohaegbulam, Samuel C

2013-09-15

Suboptimal care during extraction and transfer after spinal trauma predisposes patients to additional spinal cord injury. This study examines the factors that contribute to care related and transit injuries and suggests steps to improve standard of care in spinal trauma patients in Nigeria. It is a questionnaire-based prospective study of patients admitted with cervical cord injury to two neurosurgical centers in Enugu, Nigeria, between March 2008 and October 2010. Demography, mechanism of injury, mode of extraction from the scene and transportation to first visited hospital, precautions taken during transportation, and treatment received before arriving at the neurosurgical unit were analyzed. There were 53 (77.9%) males, the mean age was 33.9 years, and 23.5% had concomitant head injury. Average delay was 3.5 h between trauma and presentation to initial care and 10.4 days before presentation to definitive care. Only 26.5% presented primarily to tertiary centers with trauma services. About 94.1% were extracted by passersby. None of the patients received cervical spine protection either during extrication or in the course of transportation to initial care, and 35.3% were sitting in a motor vehicle or supported on a motorbike during transport. Of the 43 patients transported lying down, 41.9% were in the back seat of a sedan, and only 11.8% were transported in an ambulance. Neurological dysfunction was first noticed after removal from the scene by 41.2% of patients, while 7.4% noticed it on the way to or during initial care. During subsequent transfer to definitive centers, only 36% had cervical support, although 78% were transported in ambulances. Ignorance of pre-hospital management of cervically injured patients exists in the general population and even among medical personnel and results in preventable injuries. There is need for urgent training, provision of paramedical services, and public enlightenment.

Interstitial lung disease in patients with polymyositis, dermatomyositis and amyopathic dermatomyositis.

PubMed

Kang, E H; Lee, E B; Shin, K C; Im, C H; Chung, D H; Han, S K; Song, Y W

2005-10-01

To assess the prevalence, characteristics and prognostic factors of interstitial lung disease (ILD) in Korean patients with polymyositis (PM), dermatomyositis (DM) and amyopathic dermatomyositis (ADM). We reviewed the medical records of 72 consecutive PM and DM patients, including six patients with ADM, who were seen at the Rheumatology Clinic of Seoul National University Hospital between 1984 and 2003. Twenty-nine PM/DM patients (40.3%) developed ILD. Anti-Jo-1 antibody and arthralgia were associated with the presence of ILD (P = 0.022 and P = 0.041, respectively), whereas dysphagia was more frequently found in patients without ILD (P = 0.041). Lung biopsies revealed diffuse alveolar damage (DAD) (n = 2), usual interstitial pneumonia (UIP) with DAD (n = 2), UIP (n = 1), and non-specific interstitial pneumonia (n = 2). Of the 29 patients, 11 (37.9%) died. The mean survival time in ILD patients was significantly shorter than in those without ILD (13.8+/-1.8 vs 19.2+/-0.9 yr, P = 0.017). Poor survival in ILD patients was associated with a Hamman-Rich-like presentation (P = 0.0000), ADM features (P = 0.0001) and an initial forced vital capacity (FVC) < or =60% (P = 0.024). ILD was observed in 40.3% of Korean PM/DM patients and was associated with poor survival. A Hamman-Rich-like presentation, ADM features and an initial FVC < or =60% were associated with poor survival in ILD.

[The use of phototherapy and photochromotherapy in the combined treatment of the patients presenting with astheno-depressive syndrome and neurotic disorders].

PubMed

Kir'ianova, V V; Baburin, I N; goncharova, V G; Veselovskiĭ, A B

2012-01-01

The objective of the present clinical and psychopathological study was to estimate the influence of high-intensity white and yellow phototherapy on the clinical condition of 41 and 18 patients respectively presenting with astheno-depressive syndrome. The control group was comprised of 42 patients who were treated by standard pharmacotherapy. Clinical observations of the patients were supplemented by the evaluation of their conditions and characteristics using the Symptom Checklist-90 questionnaire, the Bekhterev Depression Inventory, and the Beck Depression Inventory. The patients of the three groups were surveyed before and within 20 days after the initiation of the treatment. It was shown that white light phototherapy considerably reduced the severity of asthenia and depression. Yellow light phototherapy proved more efficacious in the patients with asthenia and somatovegetative dysfunctions.

Posterior cortical atrophy variant of Alzheimer's dementia-A case report.

PubMed

Mukku, Shiva Shanker Reddy; Chintala, Haripriya; Nagaraj, Chandana; Mangalore, Sandhya; Sivakumar, Palanimuthu T; Varghese, Mathew

2018-05-17

Alzheimer's dementia (AD) is the commonest type of dementia presenting with initial episodic memory decline followed by involvement of other cognitive domains. Posterior cortical atrophy (PCA) is one of the variants of Alzheimer's dementia (AD) characterized by the atypical presentation of relatively persevered memory in the initial stage. PCA is an uncommon early onset dementia affecting adults between 50 and 65 years. It presents predominantly with visuo-spatial and visuo-perceptual deficits. PCA is a phenotype with varied etiology most common being Alzheimer's disease. The complex and atypical presentation with preserved memory and insight in patients with PCA poses challenge to clinicians in diagnosing at initial stages. There is also paucity of research on prevalence, course, prognosis and management of PCA. In this article we describe a middle aged gentlemen presenting with clinical features suggestive of PCA. We also discussed relevant literature. Copyright © 2018 Elsevier B.V. All rights reserved.

[Initial clinical experience of proton therapy at Shizuoka Cancer Center].

PubMed

Murayama, Shigeyuki; Fuji, Hiroshi; Yamashita, Haruo; Futami, Yasuyuki; Numano, Masumi; Harada, Hideyuki; Kamata, Minoru; Nishimura, Tetsuo

2005-10-01

To present the initial experience and preliminary clinical results of patients treated mainly with proton irradiation at the newly developed proton therapy facility at Shizuoka Cancer Center. We reviewed 125 patients who underwent proton therapy between July 2003 and December 2004. Of these 125 patients, 11 had head and neck malignancies, 15 non-small cell lung cancers, 22 hepatocellular carcinomas, 62 prostate cancers, and 15 other malignant tumors. Most patients experienced Grade 0-1 acute morbidities (NCI-CTC) in skin or mucosa, while a temporary Grade 2-3 reaction was observed in a high dose area. Response rates were 73% for H & N malignancies, 100% for NSCLC, and 77% for HCC. PSA evaluation for patients with prostate cancer revealed a high rate of complete response. The efficacy and safety of proton therapy at Shizuoka Cancer Center was demonstrated for patients with early-stage cancer or locally advanced disease.

Clinical features of ocular toxoplasmosis in Korean patients.

PubMed

Park, Young-Hoon; Han, Jae-Hyung; Nam, Ho-Woo

2011-06-01

We report here the records of 10 consecutive Korean patients (10 eyes) with ocular toxoplasmosis which showed the typical clinical manifestations with seropositivity for Toxoplasma gondii specific IgG antibodies by micro-ELISA between 2006 and 2010. Nine patients were males and 1 was female; their age was 50.5 ± 13.8 years. The most common accompanying signs were vitritis (100%), anterior uveitis (70%), and scattered white deposit (80%). Pre-existing retinochoroidal scar was found in 1 (10%) patient. All patients received antiparasitic chemotherapy and systemic corticosteroid treatment, which resolved the presenting attack and recovered the visual acuity better than initial one in 9 patients and worse in 1. Optic atrophy, cataract, and retinal neovascularization were observed during the follow-up period and recurrence was detected in 3 eyes (30%) 6 to 20 months after the initial attack. In Korea, although rarely detected and reported, ocular toxoplasmosis needs more attention in clinical field of retinal diseases.

Predicting factors of fistula healing and clinical remission after infliximab-based combined therapy for perianal fistulizing Crohn's disease.

PubMed

Tougeron, David; Savoye, Guillaume; Savoye-Collet, Céline; Koning, Edith; Michot, Francis; Lerebours, Eric

2009-08-01

Perianal fistulizing Crohn's disease (PFCD) treatment is based on fistula drainage, antibiotics, immunosuppressant (IS) drugs, and infliximab. Our aim was to study the effectiveness of combination therapy on PFCD and to search for clinical or imaging features associated with the initial complete clinical response and its stability overtime. All patients with PFCD treated in our tertiary center between 2000 and 2005 by infliximab in combination with seton placement and/or IS and evaluated by MRI before treatment were included in the study. Basal clinical and MRI characteristics were recorded. Response to treatment was evaluated after the infliximab induction regiment and at the end of the follow-up. Twenty-six patients were included and followed-up for an average 4.9 years. A complex fistula was present in 69% (18/26 patients) of cases and eight (8/26 patients) had an ano-vaginal fistula. After infliximab induction therapy, 13 patients (50%) achieved a complete clinical response. The initial clinical response was significantly associated with the absence of both, active intestinal disease (54% vs. 8%, P = 0.03) and active proctitis (77% vs. 23%, P = 0.01). No initial MRI characteristics were linked to the initial response. In multivariate analysis, only the presence of active proctitis was associated with the lack of response (P = 0.047). At the end of the follow-up, 42% of the patients remained in clinical remission. No clinical characteristics were associated to sustained response when among long-standing responders two exhibited a normal post-treatment MRI. An initial complete response of PFCD was observed in half of the patients after combined therapy including infliximab that decreased to 42% later on. Complete healing of fistulas on MRI was possible but unusual. The initial response seemed related to the absence of active intestinal disease, especially in the rectum, when the long-term response could not be predicted by the basal characteristics of patients.

Integration and task shifting for TB/HIV care and treatment in highly resource-scarce settings: one size may not fit all.

PubMed

Van Rie, Annelies; Patel, Monita R; Nana, Mbonze; Vanden Driessche, Koen; Tabala, Martine; Yotebieng, Marcel; Behets, Frieda

2014-03-01

A crucial question in managing HIV-infected patients with tuberculosis (TB) concerns when and how to initiate antiretroviral therapy (ART). The effectiveness of CD4-stratified ART initiation in a nurse-centered, integrated TB/HIV program at primary care in Kinshasa, Democratic Republic of Congo, was assessed. Prospective cohort study was conducted to assess the effect of CD4-stratified ART initiation by primary care nurses (513 TB patients, August 2007 to November 2009). ART was to be initiated at 1 month of TB treatment if CD4 count is <100 cells per cubic millimeter, at 2 months if CD4 count is 100-350 cells per cubic millimeter, and at the end of TB treatment after CD4 count reassessment if CD4 count is >350 cells per cubic millimeter. ART uptake and mortality were compared with a historical prospective cohort of 373 HIV-infected TB patients referred for ART to a centralized facility and 3577 HIV-negative TB patients (January 2006 to May 2007). ART uptake increased (17%-69%, P < 0.0001) and mortality during TB treatment decreased (20.1% vs 9.8%, P < 0.0003) after decentralized, nurse-initiated, CD4-stratified ART. Mortality among TB patients with CD4 count >100 cells per cubic millimeter was similar to that of HIV-negative TB patients (5.6% vs 6.3%, P = 0.65), but mortality among those with CD4 count <100 cells per cubic millimeter remained high (18.8%). Nurse-centered, CD4-stratified ART initiation at primary care level was effective in increasing timely ART uptake and reducing mortality among TB patients but may not be adequate to prevent mortality among those presenting with severe immunosuppression. Further research is needed to determine the optimal management at primary care level of TB patients with CD4 counts <100 cells per cubic millimeter.

Comparative effectiveness of chemotherapy vs resection of the primary tumour as the initial treatment in older patients with Stage IV colorectal cancer.

PubMed

Mehta, H B; Vargas, G M; Adhikari, D; Dimou, F; Riall, T S

2017-06-01

The objectives were to determine trends in the use of chemotherapy as the initial treatment and to evaluate the comparative effectiveness of initial chemotherapy vs resection of the primary tumour on survival (intention-to-treat analysis) in Stage IV colorectal cancer (CRC). This cohort study used 2000-2011 data from the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database, including patients ≥ 66 years of age presenting with Stage IV CRC. Cox proportional hazards models and instrumental variable analysis were used to compare the effectiveness of chemotherapy as the initial treatment with resection of the primary tumour as the initial treatment, with 2-year survival as the end point. The use of chemotherapy as the first treatment increased over time, from 26.8% in 2001 to 46.9% in 2009 (P < 0.0001). The traditional Cox model showed that chemotherapy as the initial treatment was associated with a higher risk of mortality [hazard ratio (HR) = 1.35; 95% CI: 1.27-1.44]. When accounting for known and unknown confounders in an instrumental variable analysis, chemotherapy as the initial treatment suggested benefit on 2-year survival (HR = 0.68; 95% CI: 0.44-1.04); however, the association did not reach statistical significance. The study findings were similar in six subgroup analyses. The use of chemotherapy as the initial therapy for CRC increased substantially from 2001 to 2009. Instrumental variable analysis found that, compared with resection, chemotherapy as the initial treatment offers similar or better 2-year survival in patients with Stage IV CRC. Given the morbidity and mortality associated with colorectal resection in elderly patients, chemotherapy provides an option to patients who are not good candidates for resection. Colorectal Disease © 2017 The Association of Coloproctology of Great Britain and Ireland.

Predicting Post-Treatment-Initiation Alcohol Use among Patients with Severe Mental Illness and Alcohol Use Disorders

ERIC Educational Resources Information Center

Bradizza, Clara M.; Maisto, Stephen A.; Vincent, Paula C.; Stasiewicz, Paul R.; Connors, Gerard J.; Mercer, Nicole D.

2009-01-01

Few investigators studying alcohol abuse among individuals with a severe mental illness (SMI) have examined predictors of posttreatment alcohol outcomes. In the present study, a multivariate approach based on a theoretical model was used to study the relationship between psychosocial factors and post-treatment-initiation alcohol use. Predictors of…

Acute methaemoglobinaemia initially treated as organophosphate poisoning leading to atropine toxicity.

PubMed

Kakhandki, Srinivas; Yahya, Mohammed; Praveen, Mudalgi

2012-07-01

A case of unknown compound poisoning is presented. It was initially treated as organophosphate poisoning with lack of response. A timely diagnosis of acute methaemoglobinaemia and iatrogenic atropine toxicity was made based on clinical evaluation. Treatment of methaemoglobinaemia using oral methylene blue and of atropine toxicity with supportive measures could save the patient.

Internationally adopted children with cleft lip and/or palate: A retrospective cohort study.

PubMed

Werker, C L; de Wilde, H; Mink van der Molen, A B; Breugem, C C

2017-12-01

The treatment approach for internationally adopted children with cleft lip and/or palate differs from locally born children with cleft lip and/or palate. They are older at initial presentation, may have had treatment abroad of different quality, and are establishing new and still fragile relationships with their adoptive parents. The aim of this study was to describe the characteristics and initial care and treatment of this group. A retrospective cohort study was performed including all internationally adopted children with cleft lip and/or palate presenting to the cleft team outpatient clinic in the Wilhelmina Children's Hospital between January 1994 and December 2014. Medical records of all patients were reviewed; information concerning demographic characteristics, characteristics at initial presentation, and treatment were obtained. A total number of 132 adopted patients were included: 15% had cleft lip, 7% had cleft palate, and 78% had cleft lip and palate. The average age at the time of adoption was 26.5 months. In most cases, China was the country of origin. Seventy-eight percent had surgery in their country of origin, primarily lip repair. Fistulae in need of revision surgery were found in 8% of the patients. Pharyngoplasty was needed in 48% of the patients. No significant differences were found for mean age at adoption, gender, cleft type, and one- or two-stage palatal closure. Internationally adopted children with cleft lip and/or palate are a very diverse group of patients with challenging treatment. These children undergo surgery late and frequently need additional surgery. Copyright © 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Effect of the human chorionic gonadotropin diet on patient outcomes.

PubMed

Goodbar, Nancy H; Foushee, Jaime A; Eagerton, David H; Haynes, Katie B; Johnson, Amanda A

2013-05-01

To report a case of left lower extremity deep vein thrombosis (DVT) and bilateral pulmonary embolisms in a patient who initiated the human chorionic gonadotropin (HCG) diet 2 weeks prior to presentation. A 64-year-old white female presented with leg swelling and shortness of breath. Lower extremity ultrasound revealed left leg DVT, and a computed tomography angiogram revealed bilateral pulmonary embolisms. A complete history and physical examination were unremarkable for any risk factors for acute thrombosis, with the exception of the initiation of the HCG diet approximately 2 weeks prior to presentation; the patient was taking 20 sublingual drops of HCG twice daily. Results of her hypercoagulable workup were negative. Upon admission, therapy was started with enoxaparin 120 mg subcutaneously twice daily and warfarin 5 mg orally once daily. According to the Naranjo probability scale, initiation of the HCG diet was a probable cause of our patient's adverse effects. The HCG diet has very few efficacy studies and no significant safety studies associated with its use. Six relevant studies were identified for assessment of efficacy, and only 1 was associated with a significant weight reduction in the HCG diet study population. All of these studies evaluated the use of the HCG diet via injections of the hormone and significant calorie restriction, which is known as the Simeons method. Currently marketed HCG products include sublingual drops, lozenges, and pellets, but none of these methods has an evidence-based efficacy and safety standard. As popularity of the HCG diet continues to increase, so do the potential adverse events associated with the management of weight loss via an unproven strategy. Patient safety information regarding this dieting strategy should be recognized by medical professionals.

Flashes and floaters - a practical approach to assessment and management.

PubMed

Kahawita, Shyalle; Simon, Sumu; Gilhotra, Jolly

2014-04-01

Flashes and floaters are common ophthalmic issues for which patients may initially present to their general practitioner. It may be a sign of benign, 
age-related changes of the vitreous or more serious retinal detachment. This article provides a guide to the assessment and management of a patient presenting with flashes and floaters. Although most patients presenting with flashes and floaters have benign 
age-related changes, they must be referred to an ophthalmologist to rule out sight-threatening conditions. Key examination features include the nature of the flashes and floaters, whether one or both eyes are affected and changes in visual acuity or visual field.

A case series of patients diagnosed with orofacial granulomatosis presenting primarily with dense infiltrates and severe periorbital edema.

PubMed

Sabet-Peyman, Esfandiar J; Woodward, Julie A

2014-01-01

Orofacial granulomatosis is a relapsing nonnecrotizing granulomatous syndrome that classically presents with lip and perioral swelling. Over the years, several patients have been referred to the Duke Eye Center Oculoplastics Department for severe, progressive, recurrent eyelid swelling interfering with both their functional vision and their appearance. In this IRB approved retrospective case series, we describe the clinical course of 5 such patients, including their presenting symptoms, diagnosis, and response to treatment. We hope that oculoplastics specialists will consider this entity in the differential diagnosis of periorbital edema and consider initiating localized anti-inflammatory treatment once the diagnosis has been made.

Successful initiation and maintenance of hemodialysis in an adult patient with complete transposition of the great arteries.

PubMed

Yamada, Shunsuke; Yotsueda, Hideki; Taniguchi, Masatomo; Tsuruya, Kazuhiko; Hirakata, Hideki; Iida, Mitsuo

2010-10-01

Cyanotic congenital heart disease (CCHD) is a life-threatening cardiac defect that requires palliative or corrective surgery in early life. Major advances in medical and surgical management have resulted in the survival of CCHD patients to adulthood with or without corrective surgery, though some are at risk of development of end-stage renal disease (ESRD) due to cyanotic nephropathy (CN). There is little or no information on the initiation and maintenance of hemodialysis (HD) in such patients. We present here a case of a 44-year-old man with complete transposition of the great arteries and CN-related ESRD. He had only received a bi-directional Glenn's operation and still suffered persistent severe hypoxemia and impaired cardiac function. ESRD was successfully treated with HD over more than 4 years. The case emphasizes the need for special attention in the selection and initiation of renal replacement therapy.

Insulin Oedema in Newly Diagnosed Type 1 Diabetes Mellitus

PubMed Central

Çetinkaya, Semra; Yılmaz Ağladıoğlu, Sebahat; Peltek Kendirici, Havva Nur; Bilgili, Hatice; Yıldırım, Nurdan; Aycan, Zehra

2010-01-01

Despite the essential role of insulin in the management of patients with insulin deficiency, insulin use can lead to adverse effects such as hypoglycaemia and weight gain. Rarely, crucial fluid retention can occur with insulin therapy, resulting in an oedematous condition. Peripheral or generalised oedema is an extremely rare complication of insulin therapy in the absence of heart, liver or renal involvement. It has been reported in newly diagnosed type 1 diabetes, in poorly controlled type 2 diabetes following the initiation of insulin therapy, and in underweight patients on large doses of insulin. The oedema occurs shortly after the initiation of intensive insulin therapy. We describe two adolescent girls with newly diagnosed type 1 diabetes, who presented with oedema of the lower extremities approximately one week after the initiation of insulin treatment; other causes of oedema were excluded. Spontaneous recovery was observed in both patients. Conflict of interest:None declared. PMID:21274337

Holospinal epidural abscesses - Institutional experience.

PubMed

Bridges, Kelly J; Than, Khoi D

2018-02-01

The authors present a holospinal epidural abscesses (HEA) case series and a single institution's experience with varied surgical approaches and outcomes. Medical records were queried and reviewed (6 years) for patients with a spinal abscess diagnosis; HEA were selected. Medical history, comorbidities, blood and epidural pathogens, presentation symptoms, abscess location, presence of mass effect, surgical procedures, treatment regimens, and neurological outcomes were collected. Eight patients with HEA were treated; all underwent surgery. In the index procedure, one (12.5%) underwent laminectomy of the entire spinal column, four (50%) focal laminectomies at the area of mass effect, and three (37.5%) skip laminectomies. Of the four patients who initially had focal laminectomies, three (75%) required additional operations for abscess evacuation in other spine regions. Average number of laminectomies per patient was 8.6. Neurologically, 50% of patients improved, 37.5% remained stable, and 12.5% worsened. There was no difference in outcome between patients who underwent skip versus panspinal laminectomies. No differences in outcomes were noted in timing from presentation to surgery (median 5.3 h), location of mass effect, dorsal versus ventral abscesses, or initial symptoms. Of the four patients who had cervical laminectomy without fusion, two developed post-laminectomy kyphosis requiring fusion. Cervical instability occurred in half the patients who underwent cervical laminectomies without fusion, and there were no adverse outcomes in the patients who were fused in the setting of infection. For lower cervical abscess, upper thoracic laminectomy with catheter irrigation may be sufficient for decompression, minimizing risk of future instability. Copyright © 2017 Elsevier Ltd. All rights reserved.

Stevens-Johnson syndrome following use of metronidazole in a dental patient.

PubMed

Mazumdar, Goutameswar; Shome, Koushik

2014-01-01

Metronidazole alone rarely causes Stevens-Johnson syndrome (SJS). We present a case of an elderly male patient who, following metronidazole use, developed neurological symptoms followed by pain and blisters on both soles, erythema of face and neck, scrotal itching and erosion, and hemorrhagic encrustation around the lips and oral mucous membrane. Initial neurological symptoms followed by mucocutaneous manifestation of SJS following metronidazole use is probably a new presentation of this case.

A Case of Sporadic Creutzfeldt-Jakob Disease Presenting as Conversion Disorder.

PubMed

Yegya-Raman, Nikhil; Aziz, Rehan; Schneider, Daniel; Tobia, Anthony; Leitch, Megan; Nwobi, Onyi

2017-01-01

Background . Creutzfeldt-Jakob disease is a rare disorder of the central nervous system. Its initial diagnosis may be obscured by its variable presentation. This case report illustrates the complexity of diagnosing this disease early in the clinical course, especially when the initial symptoms may be psychiatric. It offers a brief review of the literature and reinforces a role for consultation psychiatry services. Methods . PUBMED/MEDLINE was searched using the terms "Creutzfeldt-Jakob disease", "psychiatric symptoms", "conversion disorder", "somatic symptom disorder", "functional movement disorder", and "functional neurologic disorder". Case . The patient was a 64-year-old woman with no prior psychiatric history who was initially diagnosed with conversion disorder and unspecified anxiety disorder but soon thereafter was discovered to have Creutzfeldt-Jakob disease. Discussion . This case highlights the central role of psychiatric symptoms in early presentations of Creutzfeldt-Jakob disease. Still, few other cases in the literature report functional neurological symptoms as an initial sign. The consultation psychiatrist must remain alert to changing clinical symptoms, especially with uncharacteristic disease presentations.

A Kinect based intelligent e-rehabilitation system in physical therapy.

PubMed

Gal, Norbert; Andrei, Diana; Nemeş, Dan Ion; Nădăşan, Emanuela; Stoicu-Tivadar, Vasile

2015-01-01

This paper presents an intelligent Kinect and fuzzy inference system based e-rehabilitation system. The Kinect can detect the posture and motion of the patients while the fuzzy inference system can interpret the acquired data on the cognitive level. The system is capable to assess the initial posture and motion ranges of 20 joints. Using angles to describe the motion of the joints, exercise patterns can be developed for each patient. Using the exercise descriptors the fuzzy inference system can track the patient and deliver real-time feedback to maximize the efficiency of the rehabilitation. The first laboratory tests confirm the utility of this system for the initial posture detection, motion range and exercise tracking.

Principles of management in injuries to the cervical spine.

PubMed

Krasuski, M; Kiwerski, J E

2000-03-30

Thorough and prompt diagnostics and selection of the proper course of treatment are often crucial for desirable outcome in patients with cervical spine trauma complicated by SCI. This is indicated by the fact that even among patients with initial presentation of a complete of a complete cord lesion, a certain percentage (ca. 15 percent) of appropriately managed patients can achieve significant improvement in their neurological status. It frequently happens, however, that poor radiological documentation, careless preliminary examination, improper transport from the accident scene, or treatment ill-suited to the actual lesion render neurological improvement impossible, and at times even bring about a deterioration of neurological status in comparison to the initial examination.

Computed tomographic imaging in the pediatric patient with a seatbelt sign: still not good enough.

PubMed

Kopelman, Tammy R; Jamshidi, Ramin; Pieri, Paola G; Davis, Karole; Bogert, James; Vail, Sydney J; Gridley, Daniel; Singer Pressman, Melissa A

2018-02-01

Considering the improvements in CT over the past decade, this study aimed to determine whether CT can diagnose HVI in pediatric trauma patients with seatbelt signs (SBS). We retrospectively identified pediatric patients with SBS who had abdominopelvic CT performed on initial evaluation over 5 1/2years. Abnormal CT was defined by identification of any intra-abdominal abnormality possibly related to trauma. One hundred twenty patients met inclusion criteria. CT was abnormal in 38/120 (32%) patients: 34 scans had evidence of HVI and 6 showed solid organ injury (SOI). Of the 34 with suspicion for HVI, 15 (44%) had small amounts of isolated pelvic free fluid as the only abnormal CT finding; none required intervention. Ultimately, 16/120 (13%) patients suffered HVI and underwent celiotomy. Three patients initially had a normal CT but required celiotomy for clinical deterioration within 20h of presentation. False negative CT rate was 3.6%. The sensitivity, specificity and accuracy of CT to diagnose significant HVI in the presence of SBS were 81%, 80%, and 80%, respectively. Despite improvements in CT, pediatric patients with SBS may have HVI not evident on initial CT confirming the need to observation for delayed manifestation of HVI. Level II Study of a Diagnostic Test. Copyright © 2017 Elsevier Inc. All rights reserved.

CD8+ T cells with characteristic T cell receptor beta motif are detected in blood and expanded in synovial fluid of ankylosing spondylitis patients.

PubMed

Komech, Ekaterina A; Pogorelyy, Mikhail V; Egorov, Evgeniy S; Britanova, Olga V; Rebrikov, Denis V; Bochkova, Anna G; Shmidt, Evgeniya I; Shostak, Nadejda A; Shugay, Mikhail; Lukyanov, Sergey; Mamedov, Ilgar Z; Lebedev, Yuriy B; Chudakov, Dmitriy M; Zvyagin, Ivan V

2018-02-22

The risk of AS is associated with genomic variants related to antigen presentation and specific cytokine signalling pathways, suggesting the involvement of cellular immunity in disease initiation/progression. The aim of the present study was to explore the repertoire of TCR sequences in healthy donors and AS patients to uncover AS-linked TCR variants. Using quantitative molecular-barcoded 5'-RACE, we performed deep TCR β repertoire profiling of peripheral blood (PB) and SF samples for 25 AS patients and 108 healthy donors. AS-linked TCR variants were identified using a new computational approach that relies on a probabilistic model of the VDJ rearrangement process. Using the donor-agnostic probabilistic model, we reveal a TCR β motif characteristic for PB of AS patients, represented by eight highly homologous amino acid sequence variants. Some of these variants were previously reported in SF and PB of patients with ReA and in PB of AS patients. We demonstrate that identified AS-linked clones have a CD8+ phenotype, present at relatively low frequencies in PB, and are significantly enriched in matched SF samples of AS patients. Our results suggest the involvement of a particular antigen-specific subset of CD8+ T cells in AS pathogenesis, confirming and expanding earlier findings. The high similarity of the clonotypes with the ones found in ReA implies common mechanisms for the initiation of the diseases.

Features of Hepatitis in Hepatitis-associated Aplastic Anemia: Clinical and Histopathologic Study.

PubMed

Patel, Kalyani R; Bertuch, Alison; Sasa, Ghadir S; Himes, Ryan W; Wu, Hao

2017-01-01

Hepatitis-associated aplastic anemia (HAA) is a rare variant of aplastic anemia in which patients present with severe pancytopenia after an episode of acute hepatitis. The marrow failure is often rapid, severe, and usually fatal if untreated. The preceding hepatitis is largely under-studied. Retrospective study of the clinical and histopathologic features of hepatitis in pediatric patients who subsequently developed aplastic anemia and comparison with consecutive cases of acute liver failure and random cases of autoimmune hepatitis during the same time frame. All 7 patients of HAA had significant elevations in aminotransferases and conjugated hyperbilirubinemia at initial presentation. Echoing liver function indices, cholestatic hepatitis with sinusoidal obstruction-type endothelial injury was seen histomorphologically. Autoimmune hepatitis serology such as anti-F-actin, anti-liver/kidney microsome, and hypergammaglobulinemia was negative in all patients. Five of 7 patients (71.4%) had, however, elevated antinuclear antibody, all with a speckled pattern. Hepatitis virus serology was negative in all patients. By immunohistochemical staining, the lobular CD8/CD4 lymphocyte ratio was markedly elevated in all of the initial samples with significant reduction in this ratio (P = 0.03) in 3 patients post treatment (ursodiol, antibiotics, and/or immunosuppressive therapy). Hepatitis preceding HAA is characterized by marked elevation of aminotransferases, conjugated hyperbilirubinemia, elevated antinuclear antibody with a speckled pattern, cholestatic hepatitis with sinusoidal obstruction morphology, and CD8 dominant lobular infiltrates. The present study suggests HAA may result from cytotoxic T-cell-mediated sinusoidal endothelial and hepatocytic injury.

Effect of {sup 18}F-FDG PET/CT Imaging in Patients With Clinical Stage II and III Breast Cancer

DOE Office of Scientific and Technical Information (OSTI.GOV)

Groheux, David; Moretti, Jean-Luc; EAD Imagerie Moleculaire Diagnostique et Ciblage Therapeutique, IUH, University of Paris VII, Paris

2008-07-01

Purpose: To investigate the potential effect of using {sup 18}F-fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) in the initial assessment of patients with clinical Stage II or III breast cancer. Methods and Materials: During 14 consecutive months, 39 patients (40 tumors) who presented with Stage II or III breast cancer on the basis of a routine extension assessment were prospectively included in this study. PET/CT was performed in addition to the initial assessment. Results: In 3 cases, PET/CT showed extra-axillary lymph node involvement that had not been demonstrated with conventional techniques. Two of these patients had hypermetabolic lymph nodes in themore » subpectoral and infraclavicular regions, and the third had a hypermetabolic internal mammary node. PET/CT showed distant uptake in 4 women. Of these 4 women, 1 had pleural involvement and 3 had bone metastasis. Overall, of the 39 women, the PET/CT results modified the initial stage in 7 (18%). The modified staging altered the treatment plan for 5 patients (13%). It led to radiotherapy in 4 patients (bone metastasis, pleural lesion, subpectoral lymph nodes, and internal mammary nodes) and excision of, and radiotherapy to, the infraclavicular lymph nodes in 1 patient. Conclusions: PET/CT can provide information on extra-axillary lymph node involvement and can uncover occult distant metastases in a significant percentage of patients. Therefore, initial PET/CT could enable better treatment planning for patients with Stage II and III breast cancer.« less

Prospective nailfold capillaroscopy evaluation of Raynaud's phenomenon in children and adolescents.

PubMed

Piotto, Daniela G P; Hilário, Maria O E; Carvalho, Natalia S; Len, Cláudio A; Andrade, Luis E C; Terreri, Maria T R A

2013-01-01

To evaluate prospectively the clinical features and nailfold capillaroscopy findings of a cohort of children and adolescents who presented Raynaud's phenomenon (RP) without criteria for autoimmune rheumatic diseases. 40 children and adolescents with isolated RP were included. Evidence of systemic autoimmune rheumatic diseases (SARD) was ruled out by thorough clinical and laboratory examination. Concomitantly we also performed wide-field nailfold capillaroscopy evaluation using an optical microscope with magnifications of 10 and 16X. All patients were prospectively re-evaluated within a mean interval time between evaluations of 1.6 years. Thirty (75%) out of 40 patients were female with a mean age of 14.6 years and mean follow-up time of 4.2 years. The mean age of disease onset was 10.4 years and the mean time until diagnosis was 1.4 years. Fourteen out of 40 patients (35%) presented antinuclear antibodies (ANA). Five (12.5%) patients had altered nailfold capillaroscopy at first examination: four presented non-specific microangiopathy and one presented scleroderma pattern. At the re-evaluation three patients (7.5%) presented nailfold capillaroscopy alterations (two SD pattern and one non-specific microangiopathy). The two patients who showed scleroderma pattern at the nailfold capillaroscopy presented along the follow-up a diagnosis of mixed connective tissue disease and hypothyroidism, respectively. One 10 year-old girl with normal nailfold capillaroscopy and presence of autoantibodies (ANA 1/640, nuclear homogeneous pattern, anti-native DNA 1/80) was diagnosed with systemic lupus erythematosus after 1 year of initial evaluation. None of the other children presented diagnosis of SARD along the follow-up. Primary Raynaud´s phenomenon remained the diagnosis in most cases in this series of children and adolescents presenting with initial RP complaint. Nailfold capillaroscopy and determination of autoantibodies were useful ancillary tools in the investigation of possible evolution towards SARD.

Patients living in impoverished areas have more severe ischemic strokes.

PubMed

Kleindorfer, Dawn; Lindsell, Christopher; Alwell, Kathleen A; Moomaw, Charles J; Woo, Daniel; Flaherty, Matthew L; Khatri, Pooja; Adeoye, Opeolu; Ferioli, Simona; Kissela, Brett M

2012-08-01

Initial stroke severity is one of the strongest predictors of eventual stroke outcome. However, predictors of initial stroke severity have not been well-described within a population. We hypothesized that poorer patients would have a higher initial stroke severity on presentation to medical attention. We identified all cases of hospital-ascertained ischemic stroke occurring in 2005 within a biracial population of 1.3 million. "Community" socioecomic status was determined for each patient based on the percentage below poverty in the census tract in which the patient resided. Linear regression was used to model the effect of socioeconomic status on stroke severity. Models were adjusted for race, gender, age, prestroke disability, and history of medical comorbidities. There were 1895 ischemic stroke events detected in 2005 included in this analysis; 22% were black, 52% were female, and the mean age was 71 years (range, 19-104). The median National Institutes of Health Stroke Scale was 3 (range, 0-40). The poorest community socioeconomic status was associated with a significantly increased initial National Institutes of Health Stroke Scale by 1.5 points (95% confidence interval, 0.5-2.6; P<0.001) compared with the richest category in the univariate analysis, which increased to 2.2 points after adjustment for demographics and comorbidities. We found that increasing community poverty was associated with worse stroke severity at presentation, independent of other known factors associated with stroke outcomes. Socioeconomic status may impact stroke severity via medication compliance, access to care, and cultural factors, or may be a proxy measure for undiagnosed disease states.

Chronic lymphocytic thyroiditis does not influence the risk of recurrence in patients with papillary thyroid carcinoma and excellent response to initial therapy.

PubMed

Carvalho, Marina S; Rosario, Pedro W; Mourão, Gabriela F; Calsolari, Maria R

2017-03-01

This study evaluated the recurrence in patients with papillary thyroid cancer and an excellent response to initial therapy, comparing those with and without chronic lymphocytic thyroiditis. This was a prospective study. Patients who met the following criteria were selected: diagnosis of papillary thyroid cancer; submitted to total thyroidectomy followed or not by ablation with 131 I; and neck ultrasonography without abnormalities, nonstimulated thyroglobulina (Tg) ≤0.2 ng/ml, and undetectable antithyroglobulin antibodies (TgAb) 12-18 months after initial therapy. The patients were divided into two groups: group A, with chronic lymphocytic thyroiditis on histology; group B, without chronic lymphocytic thyroiditis on histology. Groups A and B were similar in terms of sex and age of the patients, characteristics of the tumor, tumor-node-metastase stage and risk category. The time of follow-up ranged from 24 to 120 months (median 66 months). During follow-up, 5 patients of group A (2.6 %) and 9 patients of group B (2 %) developed recurrence (p = 0.77). Patients with chronic lymphocytic thyroiditis were more likely to progress to persistently borderline TgAb. No patient had positive TgAb (above the reference value) during follow-up. Recurrences occurred in 12/588 patients (2 %) with undetectable TgAb in all measurements, in 1/32 (3.1 %) with detectable TgAb on some occasion but that returned to undetectable spontaneously, and in 1/13 (7.7 %) with persistently borderline TgAb. These rates did not differ significantly (p = 0.25). The results of the present study showed the absence of an association between chronic lymphocytic thyroiditis and recurrence risk at least in patients with an excellent response to initial therapy.

Initial postmarketing experience with crotalidae polyvalent immune Fab for treatment of rattlesnake envenomation.

PubMed

Ruha, Anne-Michelle; Curry, Steven C; Beuhler, Michael; Katz, Ken; Brooks, Daniel E; Graeme, Kimberlie A; Wallace, Kevin; Gerkin, Richard; Lovecchio, Frank; Wax, Paul; Selden, Brad

2002-06-01

We describe our postmarketing experience with patients receiving Crotalidae polyvalent immune Fab (CroFab; FabAV) antivenom for treatment of rattlesnake envenomation. The charts of 28 patients admitted between March 1 and September 9, 2001, with rattlesnake envenomation and treated with FabAV were reviewed for demographic information, time until antivenom treatment, laboratory findings, evidence of hypersensitivity reaction, length of hospital stay, and readmission to the hospital. All patients had swelling, 20 patients had elevated prothrombin times (>14 seconds), 12 patients had low fibrinogen levels (<170 mg/dL), and 6 patients had thrombocytopenia (platelet count <120,000/mm(3)) on presentation. The total dose of FabAV ranged from 10 to 47 vials per patient. Hypofibrinogenemia was resistant to FabAV in some patients. On follow-up, recurrence of coagulopathy was detected in 3 patients, and recurrence of thrombocytopenia was detected in 1 patient. Two patients demonstrated delayed-onset severe thrombocytopenia. Recurrence or delayed-onset toxicity might have been underestimated because of incomplete follow-up in some patients. No acute hypersensitivity reactions occurred. Two patients reported mild symptoms of possible serum sickness on follow-up. FabAV effectively controlled the effects of envenomation; however, initial control of coagulopathy was difficult to achieve in some cases, and recurrence or delayed-onset hematotoxicity was common. When initially managing hematotoxicity, a trend toward normalization of laboratory values might be a more reasonable end point for FabAV treatment than attainment of normal reference values in nonbleeding patients.

A review of the lung transplantation programme in Ireland 2005-2007.

PubMed

Bartosik, Waldemar; Egan, Jim J; Soo, Alan; Remund, Kaspar F; Nölke, Lars; McCarthy, James F; Wood, Alfred E

2009-05-01

Lung transplantation is a recognised surgical option for patients with end stage respiratory disease. We present data relating to the initiation of the Irish lung transplant programme in 2005. Seventeen patients: 7 male and 10 female have undergone lung transplantation. The indications for lung transplantation included COPD (n=8), idiopathic pulmonary fibrosis (n=5), bronchiolitis obliterans (n=2), lymphangioleiomyomatosis (n=1), and cystic fibrosis (n=1). Eleven single lungs transplants were completed, while six patients underwent double sequential lung transplantation. The immunosuppression regimen included basiliximab as induction therapy, with steroids, mycophenolate mofetil nd cyclosporine or tacrolimus. The operative mortality was zero. One patient died at 10 months post double lung transplantation secondary to bronchiolitis obliterans. Primary graft dysfunction was observed in two patients who required ventilatory support for 3 and 5 days respectively. Acute cellular rejection was observed in four patients (grade A2 n=3, grade A3 n=2). The cumulative 1-year survival was 94.1%, which compares favourably to an international standard of 78%. The initiation of a lung transplant programme in Ireland has been successfully undertaken and initially provided results comparable to established lung transplant programs.

Early identification of 'acute-onset' chronic inflammatory demyelinating polyneuropathy.

PubMed

Sung, Jia-Ying; Tani, Jowy; Park, Susanna B; Kiernan, Matthew C; Lin, Cindy Shin-Yi

2014-08-01

Distinguishing patients with acute-onset chronic inflammatory demyelinating polyneuropathy from acute inflammatory demyelinating polyneuropathy prior to relapse is often challenging at the onset of their clinical presentation. In the present study, nerve excitability tests were used in conjunction with the clinical phenotype and disease staging, to differentiate between patients with acute-onset chronic inflammatory demyelinating polyneuropathy and patients with acute inflammatory demyelinating polyneuropathy at an early stage, with the aim to better guide treatment. Clinical assessment, staging and nerve excitability tests were undertaken on patients initially fulfilling the diagnostic criteria of acute inflammatory demyelinating polyneuropathy soon after symptom onset and their initial presentation. Patients were subsequently followed up for minimum of 12 months to determine if their clinical presentations were more consistent with acute-onset chronic inflammatory demyelinating polyneuropathy. Clinical severity as evaluated by Medical Research Council sum score and Hughes functional grading scale were not significantly different between the two cohorts. There was no difference between the time of onset of initial symptoms and nerve excitability test assessment between the two cohorts nor were there significant differences in conventional nerve conduction study parameters. However, nerve excitability test profiles obtained from patients with acute inflammatory demyelinating polyneuropathy demonstrated abnormalities in the recovery cycle of excitability, including significantly reduced superexcitability (P < 0.001) and prolonged relative refractory period (P < 0.01), without changes in threshold electrotonus. In contrast, in patients with acute-onset chronic inflammatory demyelinating polyneuropathy, a different pattern occurred with the recovery cycle shifted downward (increased superexcitability, P < 0.05; decreased subexcitability, P < 0.05) and increased threshold change in threshold electrotonus in both hyperpolarizing and depolarizing directions [depolarizing threshold electrotonus (90-100 ms) P < 0.005, hyperpolarizing threshold electrotonus (10-20 ms), P < 0.01, hyperpolarizing threshold electrotonus (90-100 ms), P < 0.05], perhaps suggesting early hyperpolarization. In addition, using excitability parameters superexcitability, subexcitability and hyperpolarizing threshold electrotonus (10-20 ms), the patients with acute inflammatory demyelinating polyneuropathy and acute-onset chronic inflammatory demyelinating polyneuropathy could be clearly separated into two non-overlapping groups. Studies of nerve excitability may be able to differentiate acute from acute-onset chronic inflammatory demyelinating polyneuropathy at an early stage. Characteristic nerve excitability parameter changes occur in early acute-onset chronic inflammatory demyelinating polyneuropathy, to match the clinical phenotype. Importantly, this pattern of change was strikingly different to that shown by patients with acute inflammatory demyelinating polyneuropathy, suggesting that nerve excitability techniques may be useful in distinguishing acute-onset chronic inflammatory demyelinating polyneuropathy from acute inflammatory demyelinating polyneuropathy at the initial stage. © The Author (2014). Published by Oxford University Press on behalf of the Guarantors of Brain. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Uveitis as an initial manifestation of acquired immunodeficiency syndrome.

PubMed

Tsen, Chui-Lien; Chen, Shih-Chou; Chen, Yao-Shen; Sheu, Shwu-Jiuan

2017-10-01

Human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) is a multisystem disease that can involve the human eyes. Using ophthalmic examination records from January 2006 to November 2015, we retrospectively reviewed all patients who were diagnosed with HIV/AIDS in our hospital. The study was performed at a tertiary referral center in southern Taiwan. Data included age, gender, ophthalmic examinations, systemic conditions, CD4 cell counts, course, and treatment. Eleven patients were identified as having AIDS with uveitis as their presenting manifestation. All were men, with a mean age of 39.5 ± 11.4 years (range 24-56). The mean CD4 + T-cell counts were 91.7 ± 50.3 cells/μl (range 27-169). Ocular diagnoses included cytomegalovirus (CMV) retinitis in five patients, ocular syphilis in four patients, and ocular toxoplasmosis in two patients. Uveitis resolved in all patients after medical treatment. However, a retinal detachment developed in two eyes in CMV retinitis and one eye in ocular syphilis. Ocular manifestations are among the most common clinical features in patients with HIV/AIDS who have varying clinical presentations that affect almost all ocular structures. This study demonstrated that ocular findings could be an initial manifestation of an underlying disease. Awareness of ocular lesions in HIV/AIDS is important for early recognition and management.

The Neurological Compromised Spine Due to Ewing Sarcoma. What First: Surgery or Chemotherapy? Therapy, Survival, and Neurological Outcome of 15 Cases With Primary Ewing Sarcoma of the Vertebral Column.

PubMed

Mirzaei, Lida; Kaal, Suzanne E J; Schreuder, Hendrik W B; Bartels, Ronald H M A

2015-11-01

The vertebral column is an infrequent site of primary involvement in Ewing sarcoma. Yet when Ewing sarcoma is found in the spine, the urge for decompression is high because of the often symptomatic compression of neural structures. It is unclear in alleviating a neurological deficit whether chemotherapy is preferred over decompressive laminectomy. To underline, in this case series, the efficiency of initial chemotherapy before upfront surgery in the setting of high-grade spinal cord or cauda equina compression of primary Ewing sarcoma. Fifteen patients with Ewing sarcoma primarily located in the spine were treated at our institution between 1983 and 2015. Localization, neurological deficit expressed as Frankel grade, and outcome expressed as Rankin scale before and after initial chemotherapy, the recurrence rate, and overall survival were evaluated. The multidisciplinary approach of 1 case will be discussed in detail. Nine patients (60%) were female. The age at presentation was 15.0 ± 5.5 years (range: 0.9-22.8 years). Ten patients (67%) were initially treated with chemotherapy, and 1 patient (7%) was treated primarily with radiotherapy followed by chemotherapy. The remaining 4 patients (27%) were initially treated with decompressive surgery. All patients treated primarily nonsurgically improved neurologically at follow-up, showing the importance of chemotherapy as an effective initial treatment option. Adequate and quick decompression of neural structures with similar results can be achieved by chemotherapy and radiotherapy, avoiding the local spill of malignant cells.

Inflammatory Breast Carcinoma Presenting with Two Different Patterns of Cutaneous Metastases: Carcinoma Telangiectaticum and Carcinoma Erysipeloides

PubMed Central

Yaghoobi, Reza; Talaizade, Abdolhasan; Lal, Karan; Ranjbari, Nastaran; Sohrabiaan, Nasibe

2015-01-01

Cutaneous metastases can have many different clinical presentations. They are seen in patients with advanced malignant disease; however, they can be the initial manifestation of undetected malignancies. Inflammatory breast carcinoma is a rare and aggressive form of breast cancer that has a nonspecific appearance mimicking many benign conditions including mastitis, breast abscesses, and/or dermatitis. The authors report the case of a 40-year-old woman with inflammatory breast carcinoma presenting with violaceous papulovesicular lesions resembling lymphangioma circumscriptum and erythematous patches resembling erysipelas. These lesions represent two different types of cutaneous metastases, both of which were the initial signs of inflammatory breast carcinoma in the patient described herein. Skin biopsy of lesions confirmed invasive breast cancer and further prompted a work up for inflammatory breast carcinoma. This case demonstrates the importance of follow-up for all breast lesions, even those considered to be of benign nature, for they can be presenting signs of metastatic breast cancer. PMID:26345728

Lymphocutaneous sporotrichosis in an adolescent girl presenting as mycetoma.

PubMed

Tilak, Ragini; Kumari, Varsha; Bansal, Manish; Sharma, Taniya; Pandey, Shyam Sunder

2012-09-01

A 13-year-old girl presented with multiple painless purulent ulcers with raised borders on the medial aspect of the sole of her right foot associated with inguinal lymphadenopathy for the past 4 years. There was history of local trauma at the site prior to the formation of ulcers. There were no other significant associated signs or symptoms. The patient was initially treated with multiple antibiotics with minimal improvement. Fungal cultures of biopsy specimens demonstrated the presence of colonies of Sporothrix schenckii thus confirming the diagnosis of sporotrichosis. Oral itraconazole at the dose of 100 mg twice daily was initiated with marked response at 4 weeks. This case demonstrated a rare morphological presentation of the lymphocutaneous sporotrichosis as mycetoma. The possible diagnosis of sporotrichosis should be kept in mind in such a clinical presentation not responding to antibiotics. Cutaneous sporotrichosis should be diagnosed and treated as early as possible because untreated cases may disseminate to cause visceral involvement with fatal outcome in immunocompromised patients.

Functional neuroimaging and presenting psychiatric features in frontotemporal dementia

PubMed Central

Mendez, M F; McMurtray, A; Chen, A K; Shapira, J S; Mishkin, F; Miller, B L

2006-01-01

Background Frontotemporal dementia (FTD) is a behavioural syndrome caused by degeneration of the frontal and anterior temporal lobes. Behavioural disturbances include psychiatric features. Whether patients with FTD present with psychiatric features varies with the initial neuroanatomical variability of FTD. Objective To identify presenting psychiatric changes not part of diagnostic criteria of FTD and contrast them with the degree of hemispheric asymmetry and frontal and temporal hypoperfusion on single photon emission computed tomography (SPECT) imaging. Methods 74 patients who met consensus criteria for FTD were evaluated at a two year follow up. All had brain SPECT on initial presentation. Results of an FTD psychiatric checklist were contrasted with ratings of regional hypoperfusion. Results The regions of predominant hypoperfusion did not correlate with differences on FTD demographic variables but were associated with presenting psychiatric features. Dysthymia and anxiety were associated with right temporal hypoperfusion. “Moria” or frivolous behaviour also occurred with temporal lobe changes, especially on the right. The only significant frontal lobe feature was the presence of a peculiar physical bearing in association with right frontal hypoperfusion. Conclusions Patients with FTD may present with psychiatric changes distinct from the behavioural diagnostic criteria for this disorder. Early temporal involvement is associated with frivolous behaviour and right temporal involvement is associated with emotional disturbances. In contrast, those with right frontal disease may present with alterations in non‐verbal behaviour. PMID:16043457

Predisposing factors to severe external root resorption associated to orthodontic treatment.

PubMed

Picanço, Gracemia Vasconcelos; de Freitas, Karina Maria Salvatore; Cançado, Rodrigo Hermont; Valarelli, Fabricio Pinelli; Picanço, Paulo Roberto Barroso; Feijão, Camila Pontes

2013-01-01

The aim of this study was to evaluate predisposing factors among patients who developed moderate or severe external root resorption (Malmgren's grades 3 and 4), on the maxillary incisors, during fixed orthodontic treatment in the permanent dentition. Ninety-nine patients who underwent orthodontic treatment with fixed edgewise appliances were selected. Patients were divided into two groups: G1 - 50 patients with no root resorption or presenting only apical irregularities (Malmgren's grades 0 and 1) at the end of the treatment, with mean initial age of 16.79 years and mean treatment time of 3.21 years; G2 - 49 patients presenting moderate or severe root resorption (Malmgren's grades 3 and 4) at the end of treatment on the maxillary incisors, with mean initial age of 19.92 years and mean treatment time of 3.98 years. Periapical radiographs and lateral cephalograms were evaluated. Factors that could influence the occurrence of severe root resorption were also recorded. Statistical analysis included chi-square tests, Fisher's exact test and independent t tests. The results demonstrated significant difference between the groups for the variables: Extractions, initial degree of root resorption, root length and crown/root ratio at the beginning, and cortical thickness of the alveolar bone. It can be concluded that: Presence of root resorption before the beginning of treatment, extractions, reduced root length, decreased crown/root ratio and thin alveolar bone represent risk factors for severe root resorption in maxillary incisors during orthodontic treatment.

INFLAMMATORY INDEX AND TREATMENT OF BRAIN ABSCESS

PubMed Central

OYAMA, HIROFUMI; KITO, AKIRA; MAKI, HIDEKI; HATTORI, KENICHI; NODA, TOMOYUKI; WADA, KENTARO

2012-01-01

ABSTRACT This study retrospectively analyzed 12 patients with brain abscesses. Half of the patients were diagnosed inaccurately in the initial stage, and 7.2 days were required to achieve the final diagnosis of brain abscess. The patients presented only with a moderately elevated leukocyte count, serum CRP levels, or body temperatures during the initial stage. These markers changed, first with an increase in the leukocyte count, followed by the CRP and body temperature. The degree of elevation tended to be less prominent, and the time for each inflammatory index to reach its maximum value tended to be longer in the patients without ventriculitis than in those with it. The causative organisms of a brain abscess were detected in 10 cases. The primary causative organisms from dental caries were Streptococcus viridians or milleri, and Fusobacterium nucleatum. Nocardia sp. or farcinica were common when the abscess was found in other regions. The primary causative organisms of unrecognized sources of infection were Streptococcus milleri and Prolionibacterium sp. Nocardia is resistant to many antibiotics. However, carbapenem, tetracycline and quinolone were effective for Nocardia as well as many other kinds of bacteria. In summary, the brain abscesses presented with only mildly elevated inflammatory markers of body temperature, leukocyte and CRP. These inflammatory markers were less obvious in the patients without ventriculitis and/or meningitis. The source of infection tended to suggest some specific primary causative organism. It was reasonable to initiate therapy with carbapenem. PMID:23092104

Long-term prognosis of acute lateral ankle ligamentous sprains: high incidence of recurrences and residual symptoms.

PubMed

Kemler, Ellen; Thijs, Karin M; Badenbroek, Ilse; van de Port, Ingrid G L; Hoes, Arno W; Backx, Frank J G

2016-12-01

Acute lateral ankle ligamentous sprains (ALALS) are common injuries. This injury does not always have a favourable long-term outcome. Studies reporting the prognosis of ALALS after functional treatment are scarce. To determine the prognosis of functionally treated ALALS, in terms of recurrent ALALS and residual symptoms. Retrospective cohort study. Patients were recruited from 20 family practices, nine physical therapy practices, the emergency departments of a regional hospital and a university hospital. Adult patients with an ALALS caused by an inversion trauma were invited to participate in this study 2.5-5 years after their initial injury. Functional treatment of the initial ALALS. Acute lateral ankle ligamentous sprain recurrences and residual symptoms. A total of 44 patients were included, with an average follow-up period after the initial ankle sprain of 204 weeks (range 150-274 weeks). Eight patients (18.1%) had reinjured their ankle. Explicit pain around the ankle joint at physical examination was experienced by 45.5%. Clinical symptoms of anterior ankle impingement were present in 25% (all athletes), with radiologically confirmed tibiotalar osteophyte bone formation in 82% of them. A large proportion of patients with ALALS experience recurrences and persistent symptoms after their initial ankle injury. The high percentage of patients with anterior ankle impingement syndromes illustrates the need for early assessment of this impairment in patients with persistent complaints. © The Author 2016. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Early Rivaroxaban Use After Cardioembolic Stroke May Not Result in Hemorrhagic Transformation: A Prospective Magnetic Resonance Imaging Study.

PubMed

Gioia, Laura C; Kate, Mahesh; Sivakumar, Leka; Hussain, Dulara; Kalashyan, Hayrapet; Buck, Brian; Bussiere, Miguel; Jeerakathil, Thomas; Shuaib, Ashfaq; Emery, Derek; Butcher, Ken

2016-07-01

Early anticoagulation after cardioembolic stroke remains controversial because of the potential for hemorrhagic transformation (HT). We tested the safety and feasibility of initiating rivaroxaban ≤14 days after cardioembolic stroke/transient ischemic attack. A prospective, open-label study of patients with atrial fibrillation treated with rivaroxaban ≤14 days of transient ischemic attack or ischemic stroke (National Institute of Health Stroke Scale <9). All patients underwent magnetic resonance imaging <24 hours of rivaroxaban initiation and day 7. The primary end point was symptomatic HT at day 7. Sixty patients (mean±SD age 71±19 years, 82% stroke/18% transient ischemic attack) were enrolled. Median (interquartile range) time from onset to rivaroxaban was 3 (5) days. At treatment initiation, median National Institute of Health Stroke Scale was 2 (4), and median diffusion-weighted imaging volume was 7.9 (13.7) mL. At baseline, HT was present in 25 (42%) patients (hemorrhagic infarct [HI]1=19, HI2=6). On follow-up magnetic resonance imaging, no patients developed symptomatic HT. New asymptomatic HI1 developed in 3 patients, and asymptomatic progression from HI1 to HI2 occurred in 5 patients; otherwise, HT remained unchanged at day 7. These data support the safety of rivaroxaban initiation ≤14 days of mild-moderate cardioembolic stroke/transient ischemic attack. Magnetic resonance imaging evidence of petechial HT, which is common, does not appear to increase the risk of symptomatic HT. © 2016 American Heart Association, Inc.

Linking Workplace Aggression to Employee Well-Being and Work: The Moderating Role of Family-Supportive Supervisor Behaviors (FSSB)

PubMed Central

Demsky, Caitlin A.; Hammer, Leslie B.; Van Dyck, Sarah; Neradilek, Moni B.

2018-01-01

Purpose The present study examined the moderating effects of family-supportive supervisor behaviors (FSSB) on the relationship between two types of workplace aggression (i.e., patient-initiated physical aggression and coworker-initiated psychological aggression) and employee well-being and work outcomes. Methodology Data were obtained from a field sample of 417 healthcare workers in two psychiatric hospitals. Hypotheses were tested using moderated multiple regression analyses. Findings Psychiatric care providers’ perceptions of FSSB moderated the relationship between patient-initiated physical aggression and physical symptoms, exhaustion and cynicism. In addition, FSSB moderated the relationship between coworker-initiated psychological aggression and physical symptoms and turnover intentions. Implications Based on our findings, family-supportive supervision is a plausible boundary condition for the relationship between workplace aggression and well-being and work outcomes. This study suggests that, in addition to directly addressing aggression prevention and reduction, family-supportive supervision is a trainable resource that healthcare organizations should facilitate to improve employee work and well-being in settings with high workplace aggression. Originality This is the first study to examine the role of FSSB in influencing the relationship between two forms of workplace aggression: patient-initiated physical and coworker- initiated psychological aggression and employee outcomes. PMID:29563665

Treatment intensification using long-acting insulin -predictors of future basal insulin supported oral therapy in the DIVE registry.

PubMed

Danne, Thomas; Bluhmki, Tobias; Seufert, Jochen; Kaltheuner, Matthias; Rathmann, Wolfgang; Beyersmann, Jan; Bramlage, Peter

2015-10-07

In patients with type-2 diabetes receiving oral antidiabetic drugs (OADs), the addition of insulin is frequently required to achieve sufficient control over blood glucose levels. It is, however, difficult to predict if, when and in which patients insulin therapy will be needed. We aimed to identify patient related variables associated with the addition of basal insulin to oral therapy resulting in a basal supported oral therapy (BOT). DIVE (DIabetes Versorgungs-Evaluation) is a prospective, observational, multi-centre diabetes registry established in Germany in 2011. For the present explorative analysis, 31,008 patients with type-2 diabetes prescribed at least one OAD were included. Patients who had previously received insulin and those over 90 years old were excluded. The event of interest was defined as the initiation of BOT during the observational period. Cause-specific Cox proportional hazards models based on a competing risk framework were applied for risk quantification. Multivariable adjusted hazard ratios demonstrated that longer diabetes duration, higher BMI, poorer glycaemic control, documentation of any micro- or macrovascular comorbidity, the presence of concomitant non-antidiabetic pharmacotherapies, and greater numbers of prescribed OADs increased the likelihood of BOT initiation. On the other hand BOT initiation was less likely in patients with older age and female gender. Analysing the likelihood of OAD termination without initiation of BOT provided supportive evidence for the variables predictive of BOT initiation. Analysis of the DIVE registry has resulted in the identification of a number of factors that may be predictive for the initiation of BOT for type-2 diabetes patients initially prescribed one or more OADs. Poor glycaemic control, the presence of vascular comorbidities and concomitant medications, and a greater number of OADs were all detected to increase the risk of a switch to BOT. Female gender and younger age showed protective properties. The close monitoring of patients displaying these characteristics may help to identify individuals who might benefit from early addition of insulin therapy to their oral treatment regimen.

Clinical Management of ADHD in a Family Medicine Residency Program: Comparison with AAP Guidelines.

PubMed

Skelley, Jessica W; Carpenter, P Chase; Morehead, M Shawn; Murphy, Patrick L

2016-06-01

Attention-deficit/hyperactivity disorder (ADHD) is the most common neurobehavioral disorder. Research has shown that even with the growing incidence of children diagnosed as having ADHD, physicians may find providing optimal care to these patients challenging. Our objective was to contrast existing clinical management of ADHD in a family medicine setting with published American Academy of Pediatrics guidelines and review the literature pertinent to differences. A report was generated for all visits with "ADHD" or "ADD" (attention-deficit disorder) as a current or past medical problem that had been addressed at the family medicine clinic from July 2012 to June 2014. A total of 60 pediatric patients were identified. A retrospective chart review of clinical practice and management patterns for these patients was completed using a standardized data collection form based on the 2011 ADHD treatment guidelines set by the American Academy of Pediatrics. Fifty-seven (95%) patients had documentation of at least one core symptom of ADHD, and 27 (45%) patients had documentation of these symptoms in more than one setting (clinic/school/home). Only 30 (50%) patients were assessed at the initial ADHD visit for coexisting conditions. Coexisting conditions were found to be present in 20 (33.3%) patients. Of these 20 patients, coexisting conditions were not addressed during the visit in 12 (60%) patients before drug therapy for ADHD was initially prescribed. Behavioral therapy was initiated as first-line monotherapy in one of the nine preschool-age patients (4-5 years old). Fifty-two (86.7%) patients received a preferred initial medication as identified by guidelines, and 41 (78.8%) of those patients received an appropriate initial dose. Fifty-one (85%) patients were assessed for improvement of symptoms, and 39 (65%) were assessed for adverse events. Of 62 documented medication adjustments, 54 (87.1%) adjustments coincided with current practice guidelines. Sixteen (26.7%) patients were referred to mental health specialists. This retrospective review identified areas of strength and weakness for attending physicians and medical residents in the diagnosis, evaluation, and treatment of children with ADHD. A significant need was identified for more physician-focused education on the evaluation of coexisting conditions and long-term management associated with ADHD therapy. Further training in the initiation of behavioral therapy as a first-line treatment above drug therapy and proper medication selection in children aged 4 to 5 years also are recommended.

Management of third branchial pouch anomalies - an evolution of a minimally invasive technique.

PubMed

Wong, Phui Yee; Moore, Andrew; Daya, Hamid

2014-03-01

The management of third branchial pouch anomalies has evolved in recent times with the popularisation of the endoscopic diathermy technique to sclerose the pyriform fossa sinus opening. We present our experience in managing 3 children with third branchial pouch anomalies and propose a minimally invasive management algorithm avoiding open neck surgery. Retrospective case review of 3 patients including demographics, mode of presentation, investigations, management and complications. Three children, two male and one female of mean age 9.6 years presented with painful left anterior neck swelling. Axial neck imaging showed a superficial abscess with air locules and a sinus tract leading towards the left pharynx. Diagnosis was confirmed by endoscopic examination of the pyriform fossa revealing a sinus opening. Two patients underwent open excision; one combined with diathermy to the sinus opening. The last patient was diagnosed at his initial presentation and managed with endoscopic diathermy of the sinus opening combined with percutaneous needle aspiration of the neck abscess at the same sitting. One patient had two recurrences, the first after initial open surgery and the second after the first cautery. Two patients developed temporary hoarseness after the procedure, which resolved within two weeks. All patients were free from recurrences at follow-up. Introduction of the technique of endoscopic diathermy to the pyriform fossa sinus opening in children with third branchial pouch anomalies has revolutionised their management avoiding open and potentially morbid surgery. Our algorithm takes this further by advocating percutaneous needle aspiration of the infective component and performing diathermy to the sinus opening at the first presentation. Crown Copyright © 2013. Published by Elsevier Ireland Ltd. All rights reserved.

Fever of unknown origin as initial manifestation of large vessel giant cell arteritis: diagnosis by colour-coded sonography and 18-FDG-PET.

PubMed

Czihal, M; Tatò, F; Förster, S; Rademacher, A; Schulze-Koops, H; Hoffmann, U

2010-01-01

To evaluate the clinical characteristics and imaging results (CDS, 18-FDG-PET) of patients with large vessel giant cell arteritis (LV-GCA) presenting as fever of unknown origin (FUO). From a series of 82 patients with GCA we identified 8 patients with FUO as initial disease manifestation. Clinical characteristics and results of CDS and 18-FDG-PET were analysed. Patients with FUO and those with other clinical manifestations of GCA were compared. 18-FDG-PET-scans were available for 6/8 patients, revealing enhanced tracer uptake of the thoracic aorta and the aortic branches in all patients. CDS was performed in 8/8 patients, with detection of hypoechogenic wall thickening related to LV-GCA in 7/8 patients. Subjects with FUO were significantly younger (60.9 vs. 69.3 years, p<0.01) and had a stronger humoral inflammatory response (CRP 12.6 vs. 7.1 mg/dl, p<0.01; ESR 110 vs. 71 mm/hour, p<0.01), when compared to the other GCA-patients. LV-GCA should be considered as important differential diagnosis in patients with FUO. In addition to 18-FDG-PET, which is known to be a valuable method in the diagnostic work-up of FUO, we recommend CDS of the supraaortal and femoropopliteal arteries for the initial diagnostic work-up.

Redo esophageal surgery: the diagnosis and management of recurrent tracheoesophageal fistula.

PubMed

Coran, Arnold G

2013-10-01

This article presents a 30-year review of 38 recurrent tracheoesophageal fistulas. The initial 26 cases were presented in 2009 at the annual meeting of the British Association of Pediatric Surgeons and the European Association of Pediatric Surgeons Joint Conference and published in the Journal of Pediatric Surgery (Bruchet al. J Pediatr Surg 45:337-340, 2010). In the initial cohort of 26 patients, 18 had a leak after their primary operation and 22 had respiratory symptoms leading to the discovery of the recurrent fistula. The diagnosis was made by a contrast study in 24. The repairs entailed replacing a catheter through the fistula, separating the trachea and esophagus completely using sharp dissection and placing vascularized tissue, either pleura or pericardium between the suture lines. Postoperative complications included seven anastomotic leaks, four strictures and three recurrent fistulas. Long-term follow-up (median of 84 months) showed that 21 took all of their nutrition by mouth, three were tube fed and two required a combination of both. Of the 23 patients with growth chart data, 16 fell into the first quartile of the growth chart, whereas none fell between the 75th and 100th percentile. In conclusion, this initial series of 26 patients along with the updated additional series of 12 patients is the largest series thus far reported in the literature. All 38 patients represent the characteristics of recurrent tracheoesophageal fistulas, including techniques to make the diagnosis and to provide a secure closure of the fistula, and the long-term outcomes of these patients.

European guidelines for empirical antibacterial therapy for febrile neutropenic patients in the era of growing resistance: summary of the 2011 4th European Conference on Infections in Leukemia

PubMed Central

Averbuch, Diana; Orasch, Christina; Cordonnier, Catherine; Livermore, David M.; Mikulska, Małgorzata; Viscoli, Claudio; Gyssens, Inge C.; Kern, Winfried V.; Klyasova, Galina; Marchetti, Oscar; Engelhard, Dan; Akova, Murat

2013-01-01

Owing to increasing resistance and the limited arsenal of new antibiotics, especially against Gram-negative pathogens, carefully designed antibiotic regimens are obligatory for febrile neutropenic patients, along with effective infection control. The Expert Group of the 4th European Conference on Infections in Leukemia has developed guidelines for initial empirical therapy in febrile neutropenic patients, based on: i) the local resistance epidemiology; and ii) the patient’s risk factors for resistant bacteria and for a complicated clinical course. An ‘escalation’ approach, avoiding empirical carbapenems and combinations, should be employed in patients without particular risk factors. A ‘de-escalation’ approach, with initial broad-spectrum antibiotics or combinations, should be used only in those patients with: i) known prior colonization or infection with resistant pathogens; or ii) complicated presentation; or iii) in centers where resistant pathogens are prevalent at the onset of febrile neutropenia. In the latter case, infection control and antibiotic stewardship also need urgent review. Modification of the initial regimen at 72–96 h should be based on the patient’s clinical course and the microbiological results. Discontinuation of antibiotics after 72 h or later should be considered in neutropenic patients with fever of unknown origin who are hemodynamically stable since presentation and afebrile for at least 48 h, irrespective of neutrophil count and expected duration of neutropenia. This strategy aims to minimize the collateral damage associated with antibiotic overuse, and the further selection of resistance. PMID:24323983

A Copay Foundation Assistance Support Program for Patients Receiving Intravenous Cancer Therapy

PubMed Central

Rajurkar, Swapnil P.; Presant, Cary A.; Bosserman, Linda D.; McNatt, Wendy J.

2011-01-01

Purpose: With the advent of newer cancer therapies (eg, biologic and cytotoxic), treatment is becoming increasingly expensive for patients with cancer. Patients enrolled in Medicare and commercial insurance plans often have large copay requirements with each treatment cycle. Often, these patients undergo significant financial hardship, and some patients decline treatment. We have developed a support program that works closely with all copay assistance foundations to secure financial assistance to facilitate appropriate treatment. Methods: In September, 2008 we initiated a coordinated program with various copay assistance foundations, including Healthwell, Cancer Care, Patient Access, Chronic Disease Fund, Beckstrand Cancer, Lilly Cares and the Leukemia and Lymphoma Society. Patients requesting assistance with chemotherapy copay were enrolled in this program. Information about income level, chemotherapy regimens, and associated copay was given to these foundations, who then determined the amount of monetary assistance. Results: Since the initiation of this program, of 201 patients who began receiving chemotherapy, 25 (12.4%) requested assistance with this program for either intravenous or oral treatments. The current results of time delays for foundation decision, success rates and administrative costs to secure funding will be presented at the time of the poster presentation. Conclusion: Copay for chemotherapy drugs is a financial hardship for a significant number of patients. Coordinated resources must be provided and reimbursed to facilitate appropriate and sustainable cancer care. This program is a successful model for other centers to adopt. PMID:21731517

Self-appraisals and episodic memory: Different psychological factors related to patient versus informant reports of apathy in severe traumatic brain injury.

PubMed

Arnould, Annabelle; Rochat, Lucien; Azouvi, Philippe; van der Linden, Martial

2018-01-09

Apathy is a core feature in patients with traumatic brain injury (TBI). The psychological processes underlying apathy are still unclear, and the few studies conducted on this subject have essentially focused on cognitive processes and informant reports of apathetic manifestations. The aims of the present study were to examine self-reports versus informant reports of diminished initiative/interest, as well as their relationship with different cognitive factors (attention/executive mechanisms, episodic memory, and multitasking) and personal identity factors (self-esteem and self-efficacy beliefs). To this end, 74 participants (38 patients with severe TBI matched with 36 control participants) were given three questionnaires to assess self-esteem, general self-efficacy beliefs, and anxio-depressive symptoms and five tasks to assess cognitive processes, including real-life multitasking. In addition, a questionnaire that assessed self-awareness of functional competencies and a questionnaire that assessed lack of initiative/interest were administered to each participant and their relatives. The main results showed that patients demonstrated an awareness of their lack of initiative/interest and that self-reported lack of initiative/interest was best predicted by low general self-efficacy beliefs and self-esteem, whereas informant-reported lack of initiative/interest was predicted by episodic memory difficulties. These results shed new light on the psychological processes related to apathetic manifestations, as well as the differing perspectives and lived experiences of patients and external observers in the TBI population, which opens interesting prospects for psychological interventions.

Atypical manifestation of progressive outer retinal necrosis in AIDS patient with CD4+ T-cell counts more than 100 cells/microL on highly active antiretroviral therapy.

PubMed

Vichitvejpaisal, Pornpattana; Reeponmahar, Somporn; Tantisiriwat, Woraphot

2009-06-01

Typical progressive outer retinal necrosis (PORN) is an acute ocular infectious disease in acquired immunodeficiency syndrome (AIDS) patients with extremely low CD4+ T-cell counts. It is a form of the Varicella- zoster virus (VZV) infection. This destructive infection has an extremely rapid course that may lead to blindness in affected eyes within days or weeks. Attempts at its treatment have had limited success. We describe the case of a bilateral PORN in an AIDS patient with an initial CD4+ T-cell count >100 cells/microL that developed after initiation of highly active antiretroviral therapy (HAART). A 29-year-old Thai female initially diagnosed with human immunodeficiency virus (HIV) in 1998, presented with bilaterally decreased visual acuity after initiating HAART two months earlier. Multiple yellowish spots appeared in the deep retina without evidence of intraocular inflammation or retinal vasculitis. Her CD4+ T-cell count was 127 cells/microL. She was diagnosed as having PORN based on clinical features and positive VZV in the aqueous humor and vitreous by polymerase chain reaction (PCR). Despite combined treatment with intravenous acyclovir and intravitreous ganciclovir, the patient's visual acuity worsened with no light-perception in either eye. This case suggests that PORN should be included in the differential diagnosis of reduced visual acuity in AIDS patients initiating HAART with higher CD4+ T-cell counts. PORN may be a manifestation of the immune reconstitution syndrome.

Evidence-Based Guidelines for Empirical Therapy of Neutropenic Fever in Korea

PubMed Central

Kim, Sung-Han; Kim, Soo Young; Kim, Chung-Jong; Park, Wan Beom; Song, Young Goo; Choi, Jung-Hyun

2011-01-01

Neutrophils play an important role in immunological function. Neutropenic patients are vulnerable to infection, and except fever is present, inflammatory reactions are scarce in many cases. Additionally, because infections can worsen rapidly, early evaluation and treatments are especially important in febrile neutropenic patients. In cases in which febrile neutropenia is anticipated due to anticancer chemotherapy, antibiotic prophylaxis can be used, based on the risk of infection. Antifungal prophylaxis may also be considered if long-term neutropenia or mucosal damage is expected. When fever is observed in patients suspected to have neutropenia, an adequate physical examination and blood and sputum cultures should be performed. Initial antibiotics should be chosen by considering the risk of complications following the infection; if the risk is low, oral antibiotics can be used. For initial intravenous antibiotics, monotherapy with a broad-spectrum antibiotic or combination therapy with two antibiotics is recommended. At 3-5 days after beginning the initial antibiotic therapy, the condition of the patient is assessed again to determine whether the fever has subsided or symptoms have worsened. If the patient's condition has improved, intravenous antibiotics can be replaced with oral antibiotics; if the condition has deteriorated, a change of antibiotics or addition of antifungal agents should be considered. If the causative microorganism is identified, initial antimicrobial or antifungal agents should be changed accordingly. When the cause is not detected, the initial agents should continue to be used until the neutrophil count recovers. PMID:21716917

Biomarkers from distinct biological pathways improve early risk stratification in medical emergency patients: the multinational, prospective, observational TRIAGE study.

PubMed

Schuetz, Philipp; Hausfater, Pierre; Amin, Devendra; Amin, Adina; Haubitz, Sebastian; Faessler, Lukas; Kutz, Alexander; Conca, Antoinette; Reutlinger, Barbara; Canavaggio, Pauline; Sauvin, Gabrielle; Bernard, Maguy; Huber, Andreas; Mueller, Beat

2015-10-29

Early risk stratification in the emergency department (ED) is vital to reduce time to effective treatment in high-risk patients and to improve patient flow. Yet, there is a lack of investigations evaluating the incremental usefulness of multiple biomarkers measured upon admission from distinct biological pathways for predicting fatal outcome and high initial treatment urgency in unselected ED patients in a multicenter and multinational setting. We included consecutive, adult, medical patients seeking ED care into this observational, cohort study in Switzerland, France and the USA. We recorded initial clinical parameters and batch-measured prognostic biomarkers of inflammation (pro-adrenomedullin [ProADM]), stress (copeptin) and infection (procalcitonin). During a 30-day follow-up, 331 of 7132 (4.6 %) participants reached the primary endpoint of death within 30 days. In logistic regression models adjusted for conventional risk factors available at ED admission, all three biomarkers strongly predicted the risk of death (AUC 0.83, 0.78 and 0.75), ICU admission (AUC 0.67, 0.69 and 0.62) and high initial triage priority (0.67, 0.66 and 0.58). For the prediction of death, ProADM significantly improved regression models including (a) clinical information available at ED admission (AUC increase from 0.79 to 0.84), (b) full clinical information at ED discharge (AUC increase from 0.85 to 0.88), and (c) triage information (AUC increase from 0.67 to 0.83) (p <0.01 for each comparison). Similarly, ProADM also improved clinical models for prediction of ICU admission and high initial treatment urgency. Results were robust in regard to predefined patient subgroups by center, main diagnosis, presenting symptoms, age and gender. Combination of clinical information with results of blood biomarkers measured upon ED admission allows early and more adequate risk stratification in individual unselected medical ED patients. A randomized trial is needed to answer the question whether biomarker-guided initial patient triage reduces time to initial treatment of high-risk patients in the ED and thereby improves patient flow and clinical outcomes. ClinicalTrials.gov NCT01768494 . Registered January 9, 2013.

Spontaneous renal hemorrhage secondary to choriocarcinoma in a man with congenital hypospadias and cryptorchidism: a case report and literature review.

PubMed

Li, Yi; Chen, Gang; Chen, Han; Wen, Shuang; Xiong, Chao-Yu; Yang, Zi-Yi; Zhu, Yun-Xiao; Jeffreys, Nathan

2018-05-08

Choriocarcinoma is a rare malignant germ-cell tumour, most commonly found in adult women. It infrequently presents as spontaneous renal haemorrhage (SRH). Genital malformation and SRH secondary to choriocarcinoma has previously been only reported in females. We present what we believe to be the first case of a male patient with genital malformation (hypospadias and cryptorchidism) and SRH at presentation of choriocarcinoma. A 25-year-old man presented to the department with intense pain in the right flank region and lower back. Initial investigations showed spontaneous renal haemorrhage, for which an emergency partial nephrectomy was performed. Clinical, radiological, and pathological investigations suggested a diagnosis of testicular choriocarcinoma with metastases to the right kidney, both lungs, and brain. Initial treatment was with a chemotherapy regimen of cisplatin, etoposide and bleomycin and whole brain radiotherapy; however, 6 months after diagnosis the patient developed liver metastasis, after which time the BEP protocol was switched to ITP with oral apatinib. Despite best efforts, the liver and lung metastasis continued to grow and a decision was made to discontinue active treatment and provide only palliative care until the patient passed away. Choriocarcinoma is a difficult cancer to diagnose pre-operatively. In male patients with early metastasis, prognosis may be much poorer than in the commoner gestational choriocarcinoma. A multidisciplinary with comprehensive post-surgical intervention is of great importance in the treatment of these patients.

An unusual tachycardia.

PubMed

Hanon, Sam; Shapiro, Michael; Schweitzer, Paul

2004-07-01

The following article presents an unusual case of atrial tachycardia, initially misdiagnosed due to a lack of clear P waves. The diagnosis was eventually confirmed using the atrial electrogram from the patient's pacemaker.

Does the circadian pattern for acute cardiac events presentation vary with fasting?

PubMed

Al Suwaidi, J; Bener, A; Gehani, A A; Behair, S; Al Mohanadi, D; Salam, A; Al Binali, H A

2006-01-01

Over one billion Muslims fast worldwide during the month of Ramadan. The impact of fasting on circadian presentation with acute cardiac events is unknown. To determine if fasting has any effect on the circadian presentation of acute cardiac events. A prospective study in a general hospital. Patients with acute coronary events were divided into two groups based on the history of fasting. Information about age, gender, cardiovascular risk factor profiles and outcome was collected. The relationship of time of presentation of initial symptoms with fasting was evaluated using Student's t-test, Mann-Whitney U-test and chi2 analysis. Of the 1019 patients hospitalized during the study period, 162 were fasting. Although, fasting patients were more likely to present to the emergency department in the time periods 5-6 AM (10.5% vs 6.3%) and 11 PM (11.1% vs 7.1%) and were less likely to present in the time periods 1-2 PM (3.7% vs 7.2%) and 5-6 PM (3.7% vs 7.0%); these differences were not statistically significant. Fasting patients were less likely to have their symptoms start between 5 and 8 AM (11.1% vs 19.4%) and more likely to have symptoms between 5 and 6 PM (11.1% vs 6.0%) and 3 and 4 AM (11.1% vs 6.9%). These differences for time of initial symptoms were statistically significant (P=0.002). Exogenous factors associated with fasting, namely, the changes in food intake and/or sleep timings, affect the circadian rhythm and influence the timing of presentation of acute coronary events.

Synchronous Pulmonary Malignancies: Atypical Presentation of Mantle Cell Lymphoma Masking a Lung Malignancy

PubMed Central

Masha, Luke; Zinchuk, Andrey; Boosalis, Valia

2015-01-01

We present a case of a pleural space malignancy masked by an atypical presentation of mantle cell lymphoma. Our patient presented with a large pleural effusion and right sided pleural studding, initially attributed to a new diagnosis of mantle cell lymphoma. Rare atypical epithelial cells were also seen amongst the clonal population of lymphocytes. The patient lacked systemic manifestations of mantle cell lymphoma and did not improve with chemotherapy. A pleural biopsy ultimately revealed the presence of an undifferentiated carcinoma, favoring a lung primary. A discussion of synchronous pleural space malignancies involving lymphomas is given. PMID:26500732

Synchronous Pulmonary Malignancies: Atypical Presentation of Mantle Cell Lymphoma Masking a Lung Malignancy.

PubMed

Masha, Luke; Zinchuk, Andrey; Boosalis, Valia

2015-09-07

We present a case of a pleural space malignancy masked by an atypical presentation of mantle cell lymphoma. Our patient presented with a large pleural effusion and right sided pleural studding, initially attributed to a new diagnosis of mantle cell lymphoma. Rare atypical epithelial cells were also seen amongst the clonal population of lymphocytes. The patient lacked systemic manifestations of mantle cell lymphoma and did not improve with chemotherapy. A pleural biopsy ultimately revealed the presence of an undifferentiated carcinoma, favoring a lung primary. A discussion of synchronous pleural space malignancies involving lymphomas is given.

Bone scintigraphy in hypervitaminosis A

DOE Office of Scientific and Technical Information (OSTI.GOV)

Miller, J.H.; Hayon, I.I.

1985-04-01

The diagnosis of vitamin A intoxification may be difficult at the time of initial presentation. The radionuclide bone scan in cases of vitamin A toxicity may serve as a more sensitive indicator of the presence of this disease than radiographs in the initial evaluation and follow-up of patients with skeletal involvement. This is achieved at a lower radiation dose to the patient. The authors present a case in which bone scintigraphy played a crucial role in the early identification of this disorder. The radionuclide examination was the first method that indicated the presence of this disorder, significantly before changes demonstrablemore » on conventional radiography. The clinical and scintigraphic appearance of this process should be recognized to allow identification of hypervitaminosis A before the clinical symptoms become severe or permanent skeletal deformities result.« less

Outcome of patients presenting with idiopathic facial nerve paralysis (Bell's palsy) in a tertiary centre--a five year experience.

PubMed

Tang, I P; Lee, S C; Shashinder, S; Raman, R

2009-06-01

This is a retrospective study. The objective of this study is to review the factors influencing the outcome of treatment for the patients presented with idiopathic facial nerve paralysis. The demographic data, clinical presentation and management of 84 patients with idiopathic facial nerve paralysis (Bell's palsy) were collected from the medical record office, reviewed and analyzed from 2000 to 2005. Thirty-four (72.3%) out of 47 patients who were treated with oral prednisolone alone, fully recovered from Bell's palsy meanwhile 36 (97%) out of 37 patients who were treated with combination of oral prednisolone and acyclovir fully recovered. The difference was statistically significant. 42 (93.3%) out of 45 patients who presented within three days to our clinic, fully recovered while 28 (71.8%) out of 39 patients presented later then three days had full recovery from Bell's palsy. The difference was statistically significant. The outcome of full recovery is better with the patients treated with combined acyclovir and prednisolone compared with prednisolone alone. The patients who were treated after three days of clinical presentation, who were more than 50 years of age, who had concurrent chronic medical illness and facial nerve paralysis HB Grade IV to VI during initial presentation have reduced chance of full recovery of facial nerve paralysis.

Improving ED efficiency to capture additional revenue.

PubMed

Mandavia, Sujal; Samaniego, Loretta

2016-06-01

An increase in the number of patients visiting emergency departments (EDs) presents an opportunity for additional revenue if hospitals take four steps to optimize resources: Streamline the patient pathway and reduce the amount of time each patient occupies a bed in the ED. Schedule staff according to the busy and light times for patient arrivals. Perform registration and triage bedside, reducing initial wait times. Create an area for patients to wait for test results so beds can be freed up for new arrivals.

Extra-adrenal pheochromocytoma: an unusual cause of deep vein thrombosis.

PubMed

Stevenson, Susan; Ramani, Vijay; Nasim, Akhtar

2005-09-01

We report a case of extra-adrenal pheochromocytoma within the organ of Zuckerkandl that presented initially with a left iliofemoral deep venous thrombosis (DVT). At the time of presentation, the DVT was thought to be idiopathic as no underlying cause was detected. Subsequently, because of a series of medical events, the patient was further investigated. This led to a diagnosis of extra-adrenal pheochromocytoma. We discuss the management of patients presenting with DVT, the nature of pheochromocytoma within the organ of Zuckerkandl, and problems relating to its diagnosis.

Awareness, concern, and communication between physicians and patients on bone health in cancer.

PubMed

Tripathy, Debu; Durie, Brian G M; Mautner, Beatrice; Ferenz, Krag S; Moul, Judd W

2014-06-01

This study aims to explore physician-patient communications about bone metastases and cancer treatment-induced bone loss (CTIBL). The study utilizes online survey of patients with breast cancer, prostate cancer, and multiple myeloma, and the physicians who treat them. Even though 69 and 48 % of patients with nonmetastatic breast and prostate cancer aware of treatment-induced bone loss, only 39 and 23 %, respectively, were concerned about bone loss. Yet, 62 and 71 % of oncologists treating breast and prostate cancer felt that their patients were concerned. Among patients with metastatic breast and prostate cancer, two thirds had not discussed treatment for bone metastases with their doctor; when discussed, 88 and 91 % of discussions were initiated by the doctor, usually prior to initiating treatment. Most myeloma patients (77 %) had discussed treatment options with their physicians; 99 % of hematologists reported discussing treatment of bone disease with patients. Physicians are primary sources of information to patients regarding bone health. There is a gap between what physicians assume their patients know about bone health and the patients' perceptions, presenting a need for systematic awareness and education.

Intermediate-dose cidofovir without probenecid in the treatment of BK virus allograft nephropathy.

PubMed

Araya, Carlos E; Lew, Judy F; Fennell, Robert S; Neiberger, Richard E; Dharnidharka, Vikas R

2006-02-01

BK virus allograft nephropathy (BKVAN) is a rising complication in kidney transplant recipients. Reducing immunosuppression has been the initial form of therapy in most cases, but is not always associated with improvement in graft function. Anti-viral therapy with low-dose cidofovir (0.25-0.42 mg/kg/dose) has been used successfully in some patients, but dose-related nephrotoxicity has limited its use. We present our experience with 3 kidney transplant recipients diagnosed with BKVAN who received intermediate-dose cidofovir (0.75-1.0 mg/kg/dose) without probenecid, and without concomitant nephrotoxicity. Three female patients, ages 8, 19 and 20 yr, presented with elevated serum creatinine (SCr) values, BK virus stain positive on renal biopsy and high plasma BK viral loads. As a result of viral loads being >2 million copies/ml in two patients and a lack of response to reduction in immunosuppression in the third, we initiated therapy with low-dose cidofovir. Because of persistent positive BK stain and positive plasma viral load, we then administered intermediate-dose cidofovir, without probenecid, for several subsequent doses (seven to 15 infusions till date). All patients tolerated the intermediate-dose cidofovir with no significant rise in SCr during the course of the infusions. The most recent SCr values in all three patients were improved from those at the initial diagnosis of BKVAN. All three patients showed a marked drop in BK viral loads when on intermediate-dose cidofovir, with complete clearing of viremia in two patients. In our experience, intermediate-dose cidofovir without probenecid, used judiciously, is not associated with additional nephrotoxicity and may provide an additional alternative for treatment.

Unsuspected Critical Illness Among Emergency Department Patients Presenting for Acute Alcohol Intoxication.

PubMed

Klein, Lauren R; Cole, Jon B; Driver, Brian E; Battista, Christopher; Jelinek, Ryan; Martel, Marc L

2018-03-01

Emergency department (ED) visits for acute alcohol intoxication are common, but this population is at risk for decompensation and occult critical illness. The purpose of this study is to describe the incidence and predictors of unsuspected critical illness among patients with acute alcohol intoxication. This was a retrospective observational study of ED patients from 2011 to 2016 with acute alcohol intoxication. The study cohort included patients presenting for alcohol intoxication, whose initial assessment was uncomplicated alcohol intoxication without any other active acute medical or traumatic complaints. The primary outcome was defined as the unanticipated subsequent use of critical care resources during the encounter or admission to an ICU. We investigated potential predictors for this outcome with generalized estimating equations. We identified 31,364 eligible patient encounters (median age 38 years; 71% men; median breath alcohol concentration 234 mg/dL); 325 encounters (1%) used critical care resources. The most common diagnoses per 1,000 ED encounters were acute hypoxic respiratory failure (3.1), alcohol withdrawal (1.7), sepsis or infection (1.1), and intracranial hemorrhage (1.0). Three patients sustained a cardiac arrest. Presence of the following had an increased adjusted odds ratio (aOR) of developing critical illness: hypoglycemia (aOR 9.2), hypotension (aOR 3.8), tachycardia (aOR 1.8), fever (aOR 7.6), hypoxia (aOR 3.8), hypothermia (aOR 4.2), and parenteral sedation (aOR 2.4). The initial blood alcohol concentration aOR was 1.0. Critical care resources were used for 1% of ED patients with alcohol intoxication who were initially assessed by physicians to have low risk. Abnormal vital signs, hypoglycemia, and chemical sedation were associated with increased odds of critical illness. Copyright © 2017 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

Determining early referral criteria for patients with suspected inflammatory arthritis presenting to primary care physicians: a cross-sectional study.

PubMed

Almoallim, Hani; Janoudi, Nahid; Attar, Suzan M; Garout, Mohammed; Algohary, Shereen; Siddiqui, Muhammad Irfanullah; Alosaimi, Hanan; Ibrahim, Ashraf; Badokhon, Amira; Algasemi, Zaki

2017-01-01

Early diagnosis and initiation of treatment for inflammatory arthritis can greatly improve patient outcome. We aimed to provide standardized and validated criteria for use by primary care physicians (PCPs) in the identification of individuals requiring referral to a rheumatologist. We analyzed the predictive value of a wide variety of demographic variables, patient-reported complaints, physical examination results, and biomarkers in order to identify the most useful factors for indicating a requirement for referral. Patients for this cross-sectional study were enrolled from various centers of the city of Jeddah, Saudi Arabia, if they were ≥18 years of age and presented to a PCP with small joint pain that had been present for more than 6 weeks. A total of 203 patients were enrolled, as indicated by the sample size calculation. Each patient underwent a standardized physical examination, which was subsequently compared to ultrasound findings. Biomarker analysis and a patient interview were also carried out. Results were then correlated with the final diagnosis made by a rheumatologist. A total of 9 variables were identified as having high specificity and good predictive value: loss of appetite, swelling of metacarpophalangeal joint 2 or 5, swelling of proximal inter-phalangeal joint 2 or 3, wrist swelling, wrist tenderness, a positive test for rheumatoid factor, and a positive test for anti-citrullinated protein antibodies. Nine variables should be the basis of early referral criteria. It should aid PCPs in making appropriate early referrals of patients with suspected inflammatory arthritis, accelerating diagnosis and initiation of treatment.

Long-term follow-up of two patients with oligocone trichromacy.

PubMed

Smirnov, Vasily; Drumare, Isabelle; Bouacha, Ikram; Puech, Bernard; Defoort-Dhellemmes, Sabine

2015-10-01

Oligocone trichromacy (OT) is an uncommon cone dysfunction disorder, the mechanism of which remains poorly understood. OT has been thought to be non-progressive, but its long-term visual outcome has been seldom reported in the literature. Our aim was to present two OT patients followed at our institution over 18 years. Complete ocular examination, color vision, visual fields, and full-field electroretinography (ERG) were performed at initial presentation and follow-up. Spectral-domain optical coherence tomography (OCT) was performed during follow-up when available at our institution. Initial ocular examination showed satisfactory visual acuities with normal fundus examination and near-to-normal color vision. However, computerized perimetry demonstrated a ring-shaped scotoma around fixation, and ERG showed a profound cone dysfunction. The discrepancy between preserved color vision and profound cone dysfunction leads to the diagnosis of OT. Subsequent follow-ups over 18 years showed subtle degradation of visual acuities along with progression of the myopia in both patients and slight worsening of color vision in one patient. Initial OCT revealed a focal interruption of the ellipsoid line along with decreased thickness of the perifoveal macula. Subsequent OCT imaging performed 2 years later did not show any macular changes. Although OT is known to be a non-progressive cone dysfunction, our results suggest that subtle degradation of the visual function might happen over time.

Communication patterns in audiologic rehabilitation history-taking: audiologists, patients, and their companions.

PubMed

Grenness, Caitlin; Hickson, Louise; Laplante-Lévesque, Ariane; Meyer, Carly; Davidson, Bronwyn

2015-01-01

The nature of communication between patient and practitioner influences patient outcomes. Specifically, the history-taking phase of a consultation plays a role in the development of a relationship and in the success of subsequent shared decision making. There is limited research investigating patient-centered communication in audiology, and this study may be the first to investigate verbal communication in an adult audiologic rehabilitation context. This research aimed, first, to describe the nature of verbal communication involving audiologists, patients, and companions in the history-taking phase of initial audiology consultations and, second, to determine factors associated with communication dynamics. Sixty-three initial audiology consultations involving patients over the age of 55, their companions when present, and audiologists were audio-video recorded. Consultations were coded using the Roter Interaction Analysis System and divided into three consultation phases: history, examination, and counseling. This study analyzed only the history-taking phase in terms of opening structure, communication profiles of each speaker, and communication dynamics. Associations between communication dynamics (verbal dominance, content balance, and communication control) and 11 variables were evaluated using Linear Mixed Model methods. The mean length of the history-taking phase was 8.8 min (range 1.7 to 22.6). A companion was present in 27% of consultations. Results were grouped into three areas of communication: opening structure, information exchange, and relationship building. Examination of the history opening structure revealed audiologists' tendency to control the agenda by initiating consultations with a closed-ended question 62% of the time, followed by interruption of patient talk after 21.3 sec, on average. The aforementioned behaviors were associated with increased verbal dominance throughout the history and increased control over the content of questions. For the remainder of the history, audiologists asked 97% of the questions and did so primarily in closed-ended form. This resulted in the audiologist talking as much as the patient and much more than the companions when they were present. Questions asked by the audiologist were balanced in topic: biomedical and psychosocial/lifestyle; however, few emotionally focused utterances were observed from any speaker (less than 5% of utter ances). Analysis of verbal communication involving audiologists, patients, and companions in the history-taking phase in 63 initial audiology consultations revealed a communicative exchange that was audiologist-controlled and structured, but covered both medical and lifestyle content. Audiologists often attempted to create a relationship with their patients; however, little emotional relationship building occurred, which may have implications later in the consultation when management decisions are being made. These results are not in line with patient-centered communication principles. Further research and changes to clinical practice are warranted to transform patient-centered communication from an ideal to a reality.

Atypical Pyoderma Gangrenosum Mimicking an Infectious Process

PubMed Central

To, Derek; Wong, Aaron; Montessori, Valentina

2014-01-01

We present a patient with atypical pyoderma gangrenosum (APG), which involved the patient's arm and hand. Hemorrhagic bullae and progressive ulcerations were initially thought to be secondary to an infectious process, but a biopsy revealed PG. Awareness of APG by infectious disease services may prevent unnecessary use of broad-spectrum antibiotics. PMID:25024856

Changes in co-morbidity pattern in patients starting renal replacement therapy in Europe-data from the ERA-EDTA Registry.

PubMed

Ceretta, Maria L; Noordzij, Marlies; Luxardo, Rosario; De Meester, Johan; Abad Diez, Jose M; Finne, Patrik; Heaf, James G; Couchoud, Cécile; Kramar, Reinhard; Collart, Frederic; Cases, Aleix; Palsson, Runolfur; Reisæter, Anna V; Rydell, Helena; Massy, Ziad A; Jager, Kitty J; Kramer, Anneke

2018-01-18

Patients starting renal replacement therapy (RRT) for end-stage renal disease often present with one or more co-morbidities. This study explored the prevalence of co-morbidities in patients who started RRT in Europe during the period from 2005 to 2014. Using data from patients aged 20 years or older from all 11 national or regional registries providing co-morbidity data to the European Renal Association - European Dialysis and Transplant Association Registry, we examined the prevalence of the following co-morbidities: diabetes mellitus (DM) (primary renal disease and/or co-morbidity), ischaemic heart disease (IHD), congestive heart failure (CHF), peripheral vascular disease (PVD), cerebrovascular disease (CVD) and malignancy. Overall, 70% of 7578 patients who initiated RRT in 2014 presented with at least one co-morbidity: 39.0% presented with DM, 25.0% with IHD, 22.3% with CHF, 17.7% with PVD, 16.4% with malignancy and 15.5% with CVD. These percentages differed substantially between countries. Co-morbidities were more common in men than in women, in older patients than in younger patients, and in patients on haemodialysis at Day 91 when compared with patients on peritoneal dialysis. Between 2005 and 2014 the prevalence of DM and malignancy increased over time, whereas the prevalence of IHD and PVD declined. More than two-thirds of patients initiating RRT in Europe have at least one co-morbidity. With the rising age at the start of RRT over the last decade, there have been changes in the co-morbidity pattern: the prevalence of cardiovascular co-morbidities decreased, while the prevalence of DM and malignancy increased. © The Author(s) 2018. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Differential diagnosis and management of an older runner with an atypical neurodynamic presentation: a case for clinical reasoning.

PubMed

Sylvain, Jonathan; Reiman, Michael P

2015-04-01

Case Report. The purpose of this case report is to describe the clinical reasoning process involved with the differential diagnosis and management of a 69 year-old male runner reporting a six month history of insidious onset of left sided low back and buttock pain of low to medium degree of irritability. The case presented describes the utilization of clinical reasoning by a clinician in fellowship training when a patient with atypical adverse neurodynamic dysfunction related to running was encountered. The patient's physical examination was relatively unremarkable. Assessment of the patient's subjective history, self-report measures [Oswestry Disability Index (ODI), global rating of change scale (GROC)], objective findings, and tests and measures led to a working diagnosis of atypical adverse peripheral neurodynamic dysfunction. The lumbar spine, sacroiliac joint, hip joint and lower extremity were ruled out by a comprehensive subjective and objective examination. The diagnosis of adverse neurodynamic dysfunction became a diagnosis of exclusion. Returning two and a half weeks after initial evaluation the patient reported no pain with running. Twelve weeks after the initiation of physical therapy, the patient was contacted via email. He was sent, and asked to fill out an ODI. The patient demonstrated an improvement in ODI from 10% to 2%. He also reported that he continued to run after treatment without pain. Determining the source of a patient complaint can occasionally be an arduous undertaking. Pathological sources of a patient's symptoms may not be easily determined. Development of differential diagnosis and clinical reasoning skills is imperative. Improving clinical reasoning skills requires deliberate practice through reflective thinking before, during, and after patient interactions. Refinement of these skills leads to the primary goal of identifying the patient's clinical presentation, thus matching it with the most effective treatment approach. Level 4.

[Uncommon cutaneous presentation of visceral Leishmaniasis associated with HIV].

PubMed

Cossart, C; Le Moal, G; Garcia, M; Frouin, E; Hainaut-Wierzbicka, E; Roblot, F

2016-12-01

Visceral leishmaniasis is not normally expressed in skin. Herein, we describe the case of an HIV-positive patient who developed two unusual skin manifestations during an episode of visceral leishmaniasis. A 48-year-old female patient consulted initially for infiltrated purpura of all four limbs. Skin biopsy revealed leukocytoclastic vasculitis with Leishman-Donovan bodies. Laboratory tests showed medullary, splenic, gastric and colic involvement, suggesting systemic disease, and enabling visceral leishmaniasis to be diagnosed. Two years later, despite prolonged treatment, the patient presented maculopapular exanthema, and histology revealed persistent Leishman-Donovan bodies. We report herein an association of two rare skin manifestations in an HIV-positive patient with visceral leishmaniasis: infiltrated purpura and maculopapular exanthema. However, the underlying mechanisms remain hypothetical. The initial leukocytoclastic exanthema could be secondary to either polyclonal hypergammaglobulinaemia or to IgA deposits, or possibly to mechanical impairment of blood vessels by the actual parasite. The maculopapular exanthema occurring later raised the possibility of post-Kala-Azar leishmaniasis due to blood-borne dissemination in an anergic subject or perhaps even immune reconstitution inflammatory syndrome. Copyright © 2016 Elsevier Masson SAS. All rights reserved.

Rhabdomyolysis in a Patient with Severe Hypothyroidism.

PubMed

Salehi, Nooshin; Agoston, Endre; Munir, Iqbal; Thompson, Gary J

2017-08-22

BACKGROUND Muscular symptoms, including stiffness, myalgia, cramps, and fatigue, are present in the majority of the patients with symptomatic hypothyroidism, but rhabdomyolysis, the rapid breakdown of skeletal muscle, is a rare manifestation. In most patients with hypothyroidism who develop rhabdomyolysis, precipitating factors, such as strenuous exercise or use of lipid-lowering drugs, can be identified. CASE REPORT We report a case of a 52-year-old Hispanic woman with a history of hypothyroidism, hypertension, and type 2 diabetes mellitus who presented with fatigue, severe generalized weakness, bilateral leg pain, and recurrent falls. She reported poor medication compliance for the preceding month. Initial laboratory testing showed elevated thyroid stimulating hormone (TSH) and creatine kinase (CK) levels, indicating uncontrolled hypothyroidism with associated rhabdomyolysis. Supportive treatment with intravenous fluids and intravenous levothyroxine were initiated and resulted in dramatic clinical improvement. CONCLUSIONS We report a case of rhabdomyolysis, which is a rare but potentially serious complication of hypothyroidism. Screening for hypothyroidism in patients with elevated muscle enzymes should be considered, since an early diagnosis and prompt treatment of hypothyroidism is essential to prevent rhabdomyolysis and its consequences.

Treating Refractory Cardiogenic Shock With the TandemHeart and Impella Devices: A Single Center Experience

PubMed Central

Schwartz, Bryan G.; Ludeman, Daniel J.; Mayeda, Guy S.; Kloner, Robert A.; Economides, Christina; Burstein, Steven

2012-01-01

Background Patients with cardiogenic shock (CS) are routinely treated with intra-aortic balloon pumps (IABPs). The utility of 2 new percutaneous left ventricular assist devices (PLVADs), the Impella and TandemHeart, is unknown. The objective of this study was to describe the use of PLVADs for patients with CS at our institution. Methods All cases involving PLVADs in patients with CS between between January 1, 2008 and June 30, 2010 at a private, tertiary referral hospital were reviewed retrospectively. Results All 76 cases were identified (50 IABP only, 7 Impella, 19 TandemHeart). Most Impella (5/7) and TandemHeart (10/19) patients were initially treated with an IABP before "upgrading" for increased hemodynamic support. All 76 devices (100%) were initiated successfully. Percutaneous revascularization was attempted in 63 patients with angiographic success in 57 (90%). The incidences of major complications were similar between groups, except bleeding occurred less frequently with the IABP. Mean ejection fraction on presentation was 30.4±16.5% and increased by a mean of 6.6±11.4% (P < 0.001). With the institutional approach of treating patients with CS initially with vasopressors and IABPs, then upgrading to an Impella or TandemHeart device for patients refractory to IABP therapy, the overall mortality rate was 40%. Conclusion The Impella and TandemHeart devices can be initiated successfully in patients with CS, are associated with high rates of angiographic success during high risk percutaneous interventions and may benefit the myocardium during myocardial infarction. Randomized trials are warranted investigating use of the Impella and TandemHeart devices in patients with CS and in patients refractory to conventional IABP therapy. PMID:28348673

Paracoccidioidomycosis: an unusual presentation in a young girl disclosing an unnoted HIV-infection.

PubMed

Marques, Silvio Alencar; Camargo, Rosangela M P; Abbade, Luciana P F; Fortaleza, Carlos Magno C B; Marques, Mariangela E A

2010-02-01

The association of paracoccidioidomycosis with AIDS is apparently less frequent than expected. The authors present an unusual case of paracoccidioidomycosis in a 13-year-old female student which was later found to be the first opportunistic infection in the course of the patient's HIV-infection. The clinical presentation followed an accidental incised wound on the palmar region initially described as a 'sporotrichotic-chancre'. After good response under sulfamethoxazole-trimethoprin, the patient relapsed and presented an associated oral candidiasis. HIV-infection was documented and additional investigation showed CD4(+) T-cells=22/mm(3), CD8(+)=280 cell/mm(3) and viral load=4,043 log. This case report presents an uncommon dermatological-clinical picture in the youngest patient in which such association has been reported to date.

Clinical predictors of vestibulo-ocular dysfunction in pediatric sports-related concussion.

PubMed

Ellis, Michael J; Cordingley, Dean M; Vis, Sara; Reimer, Karen M; Leiter, Jeff; Russell, Kelly

2017-01-01

OBJECTIVE There were 2 objectives of this study. The first objective was to identify clinical variables associated with vestibulo-ocular dysfunction (VOD) detected at initial consultation among pediatric patients with acute sports-related concussion (SRC) and postconcussion syndrome (PCS). The second objective was to reexamine the prevalence of VOD in this clinical cohort and evaluate the effect of VOD on length of recovery and the development of PCS. METHODS A retrospective review was conducted for all patients with acute SRC and PCS who were evaluated at a pediatric multidisciplinary concussion program from September 2013 to May 2015. Acute SRS was defined as presenting < 30 days postinjury, and PCS was defined according to the International Classification of Diseases, 10th Revision criteria and included being symptomatic 30 days or longer postinjury. The initial assessment included clinical history and physical examination performed by 1 neurosurgeon. Patients were assessed for VOD, defined as the presence of more than 1 subjective vestibular and oculomotor complaint (dizziness, diplopia, blurred vision, etc.) and more than 1 objective physical examination finding (abnormal near point of convergence, smooth pursuits, saccades, or vestibulo-ocular reflex testing). Poisson regression analysis was used to identify factors that increased the risk of VOD at initial presentation and the development of PCS. RESULTS Three hundred ninety-nine children, including 306 patients with acute SRC and 93 with PCS, were included. Of these patients, 30.1% of those with acute SRC (65.0% male, mean age 13.9 years) and 43.0% of those with PCS (41.9% male, mean age 15.4 years) met the criteria for VOD at initial consultation. Independent predictors of VOD at initial consultation included female sex, preinjury history of depression, posttraumatic amnesia, and presence of dizziness, blurred vision, or difficulty focusing at the time of injury. Independent predictors of PCS among patients with acute SRC included the presence of VOD at initial consultation, preinjury history of depression, and posttraumatic amnesia at the time of injury. CONCLUSIONS This study identified important potential risk factors for the development of VOD following pediatric SRC. These results provide confirmatory evidence that VOD at initial consultation is associated with prolonged recovery and is an independent predictor for the development of PCS. Future studies examining clinical prediction rules in pediatric concussion should include VOD. Additional research is needed to elucidate the natural history of VOD following SRC and establish evidence-based indications for targeted vestibular rehabilitation.

Predictors of hospitalization of tuberculosis patients in Montreal, Canada: a retrospective cohort study.

PubMed

Ronald, Lisa A; FitzGerald, J Mark; Benedetti, Andrea; Boivin, Jean-François; Schwartzman, Kevin; Bartlett-Esquilant, Gillian; Menzies, Dick

2016-11-15

Hospitalization is the most costly health system component of tuberculosis (TB) control programs. Our objectives were to identify how frequently patients are hospitalized, and the factors associated with hospitalizations and length-of-stay (LOS) of TB patients in a large Canadian city. We extracted data from the Montreal TB Resource database, a retrospective cohort of all active TB cases reported to the Montreal Public Health Department between January 1996 and May 2007. Data included patient demographics, clinical characteristics, and dates of treatment and hospitalization. Predictors of hospitalization and LOS were estimated using logistic regression and Cox proportional hazards regression, respectively. There were 1852 active TB patients. Of these, 51% were hospitalized initially during the period of diagnosis and/or treatment initiation (median LOS 17.5 days), and 9.0% hospitalized later during treatment (median LOS 13 days). In adjusted models, patients were more likely to be hospitalized initially if they were children, had co-morbidities, smear-positive symptomatic pulmonary TB, cavitary or miliary TB, and multi- or poly-TB drug resistance. Factors predictive of longer initial LOS included having HIV, renal disease, symptomatic pulmonary smear-positive TB, multi- or poly-TB drug resistance, and being in a teaching hospital. We found a high hospitalization rate during diagnosis and treatment of patients with TB. Diagnostic delay due to low index of suspicion may result in patients presenting with more severe disease at the time of diagnosis. Earlier identification and treatment, through interventions to increase TB awareness and more targeted prevention programs, might reduce costly TB-related hospital use.

Management of Primary Tectal Plate Low-Grade Glioma in Pediatric Patients: Results of the Multicenter Treatment Study SIOP-LGG 2004.

PubMed

Kaufmann, Ariane; Gerber, Nicolas U; Kandels, Daniela; Azizi, Amedeo A; Schmidt, Rene; Warmuth-Metz, Monika; Pietsch, Torsten; Kortmann, Rolf-Dieter; Gnekow, Astrid K; Grotzer, Michael A

2018-06-11

 Tectal plate low-grade gliomas (LGGs) most often present with increased intracranial pressure and sometimes as incidental findings from brain imaging. Prognostic factors predicting outcome are largely unknown.  From 2004 until 2012, 71 patients with tectal plate LGG from Germany and Switzerland were followed within the SIOP-LGG 2004 study. Median age at diagnosis was 9.7 (range: 0.1-17.5) years, and median follow-up time of surviving patients was 6.3 (interquartile range: 4.9-8.3) years.  A total of 41 out of 71 patients received no tumor treatment (12 with and 29 without biopsy). The 10-year event-free survival (EFS) rate (± standard error ) for patients with an initial tumor volume of ≤3 cm 3 was 56% (±7%), as opposed to 12% (±8%) for those with tumors >3 cm 3 ( p  < 0.001). The 10-year EFS for patients without contrast enhancement on initial magnetic resonance imaging (MRI) was 52% (±9%), and for those with enhancement, it was 23% (±9%) ( p  = 0.003). The 10-year overall survival rate was 96% (±3%) (death due to disease, 1; ventriculoperitoneal shunt infection, 1). Sixty-three (89%) patients had at least one cerebrospinal fluid diversion procedure.  More than half of patients were managed without tumor treatment. Favorable prognostic factors for EFS were small initial tumor volume (≤3cm 3 ) and the absence of initial contrast enhancement on MRI. Overall survival was excellent. Georg Thieme Verlag KG Stuttgart · New York.

Missed injuries during the initial assessment in a cohort of 1124 level-1 trauma patients.

PubMed

Giannakopoulos, G F; Saltzherr, T P; Beenen, L F M; Reitsma, J B; Bloemers, F W; Goslings, J C; Bakker, F C

2012-09-01

Despite the presence of diagnostic guidelines for the initial evaluation in trauma, the reported incidence of missed injuries is considerable. The aim of this study was to assess the missed injuries in a large cohort of trauma patients originating from two European Level-1 trauma centres. We analysed the 1124 patients included in the randomised REACT trial. Missed injuries were defined as injuries not diagnosed or suspected during initial clinical and radiological evaluation in the trauma room. We assessed the frequency, type, consequences and the phase in which the missed injuries were diagnosed and used univariate analysis to identify potential contributing factors. Eight hundred and three patients were male, median age was 38 years and 1079 patients sustained blunt trauma. Overall, 122 injuries were missed in 92 patients (8.2%). Most injuries concerned the extremities. Sixteen injuries had an AIS grade of ≥ 3. Patients with missed injuries had significantly higher injury severity scores (ISSs) (median of 15 versus 5, p<0.001). Factors associated with missed injuries were severe traumatic brain injury (GCS ≤ 8) and multitrauma (ISS ≥ 16). Seventy-two missed injuries remained undetected during tertiary survey (59%). In total, 31 operations were required for 26 initially missed injuries. Despite guidelines to avoid missed injuries, this problem is hard to prevent, especially in the severely injured. The present study showed that the rate of missed injuries was comparable with the literature and their consequences not severe. A high index of suspicion remains warranted, especially in multitrauma patients. Copyright © 2011 Elsevier Ltd. All rights reserved.

Electromyographic and neuromuscular analysis in patients with post-polio syndrome.

PubMed

Corrêa, J C F; Rocco, C Chiusoli de Miranda; de Andrade, D Ventura; Peres, J Augusto; Corrêa, F Ishida

2008-01-01

Proceed to a comparative analysis of the electromyographic (EMG) activity of the muscles rectus femoris, vastus medialis and vastus lateralis, and to assess muscle strength and fatigue after maximal isometric contraction during knee extension. Eighteen patients with post-polio syndrome, age and weight matched, were utilized in this study. The signal acquisition system utilized consisted of three pairs of surface electrodes positioned on the motor point of the analyzed muscles. It was possible to observe with the results of this study a decreased endurance on initial muscle contraction and during contraction after 15 minutes of the initial maximal voluntary contraction, along with a muscle fatigue that was assessed through linear regression executed with Pearson's test. There were significant differences among the comparative analysis of EMG activity of the muscles rectus femoris, vastus medialis and vastus lateralis after maximal isometric contraction during knee extension. Initial muscle contraction and contraction after a 15 minute-rest from initial contraction decreased considerably, indicating a decreased endurance on muscle contraction, concluding that a lower limb muscle fatigue was present on the analyzed PPS patients.

Clinical presentation and outcome of children with central diabetes insipidus associated with a self-limited or transient pituitary stalk thickening, diagnosed as infundibuloneurohypophysitis.

PubMed

Schaefers, J; Cools, M; De Waele, K; Gies, I; Beauloye, V; Lysy, P; Francois, I; Beckers, D; De Schepper, J

2017-08-01

Despite lymphocytic or autoimmune infundibuloneurohypophysitis (INH) is an increasingly recognized aetiology in children with central diabetes insipidus (CDI); clinical data on epidemiology (clinical evolution, predisposing factors, complications), diagnosis and management of this entity are limited and mostly based on published case reports. The aim of this study was to gain a broader insight in the natural history of this disease by analysing the clinical presentation, radiological pituitary stalk changes, associated autoimmunity and hormonal deficiencies in children with CDI and a self-limiting or transient stalk thickening (ST), diagnosed as autoimmune infundibuloneurohypophysitis, during the last 15 years in four Belgian university hospitals. The medical files of nine CDI patients with a ST at initial presentation and no signs of Langerhans cell histiocytosis or germinoma at presentation and/or during follow-up of more than 1.5 years were reviewed. Age at presentation ranged from 3 to 14 years. Two patients had a positive family history of autoimmunity. Three children presented with associated growth failure, two with nausea and one with long-standing headache. Median maximal diameter of the stalk was 4.6 mm (2.7-10 mm). Four patients had extra-pituitary brain anomalies, such as cysts. One patient had central hypothyroidism, and another had a partial growth hormone deficiency at diagnosis. Within a mean follow-up of 5.4 (1.5-15) years, stalk thickening remained unchanged in two patients, regressed in one and normalized in six children. CDI remained in all, while additional pituitary hormone deficiencies developed in only one patient. In this series of children INH with CDI as initial presentation, CDI was permanent and infrequently associated with anterior pituitary hormone deficiencies, despite a frequent association with nonstalk cerebral lesions. © 2017 The Authors. Clinical Endocrinology Published by John Wiley & Sons Ltd.

A highly accurate method for monitoring histological recovery in patients with celiac disease on a gluten-free diet using an endoscopic approach that avoids the need for biopsy: a double-center study.

PubMed

Cammarota, G; Cuoco, L; Cesaro, P; Santoro, L; Cazzato, A; Montalto, M; La Mura, R; Larocca, L M; Vecchio, F M; Gasbarrini, A; Salvagnini, M; Gasbarrini, G

2007-01-01

Endoscopy with duodenal biopsy is often performed in order to assess histological recovery in patients with celiac disease who are on a gluten-free diet. Use of the "immersion" technique during upper endoscopy allows visualization of duodenal villi or detection of total villous atrophy. In this two-center study, we investigated the accuracy of the immersion technique in predicting histological recovery in patients on a gluten-free diet whose initial diagnosis of celiac disease had been made on the basis of total villous atrophy. The immersion technique was performed in 62 patients with celiac disease who were being treated and who had been referred for follow-up (26 patients at the Rome center and 36 patients at the Vicenza center). All these patients had an initial diagnosis based on positive antibodies and biopsy-proved duodenal total villous atrophy. At the follow-up examination, the duodenal villi were re-evaluated as present or absent by one endoscopist at each center, and the results were compared with the histology. At the follow-up endoscopy, the duodenal villi were found to be present in 51 patients and absent in 11. The sensitivity, specificity, positive predictive value, and negative predictive value of the immersion technique for detecting the presence or absence of villi were all 100 %. This study demonstrated the feasibility and the high level of accuracy of the immersion technique in predicting the histological recovery of duodenal villi in patients with celiac disease who are following a gluten-free diet. An endoscopy-based approach that avoids the need for biopsy could be useful for monitoring the dietary adherence and/or response of patients with an initial diagnosis of celiac disease based on total villous atrophy.

Long-term behavior of aortic intramural hematomas and penetrating ulcers.

PubMed

Chou, Alan S; Ziganshin, Bulat A; Charilaou, Paris; Tranquilli, Maryann; Rizzo, John A; Elefteriades, John A

2016-02-01

For intramural hematoma and penetrating atherosclerotic ulcer, long-term behavior and treatment are controversial. This study evaluates the long-term behavior of intramural hematoma and penetrating atherosclerotic ulcer, including radiologic follow-up and survival analysis. Between 1995 and 2014, 108 patients (mean age, 70.8 ± 10 years; 56% female) presented with intramural hematoma or penetrating atherosclerotic ulcer to Yale-New Haven Hospital (New Haven, Conn). We reviewed the medical records, radiology, and online mortality databases. Ten of 55 patients (18%) with intramural hematoma and 17 of 53 patients (32%) with penetrating atherosclerotic ulcer had rupture state symptoms on admission, both greater than type A (8%) or type B dissection (4%) (P < .001). No branch vascular occlusion occurred. For patients with intramural hematoma with follow-up imaging, 8 of 14 (57%) worsened (mean follow-up, 9.4 months) and 6 (43%) underwent late surgery. For patients with penetrating atherosclerotic ulcer with follow-up imaging, 6 of 20 (30%) worsened and underwent late surgery, and 11 (55%) showed no change (mean follow-up, 34.3 months). Overall survivals were 77%, 70%, 58%, and 33% at 1, 3, 5, and 10 years, respectively. No operative deaths occurred for patients with nonrupture state. Patients with penetrating atherosclerotic ulcer with initial surgical treatment had better long-term survival than patients treated medically (P = .037). In the intramural hematoma group, no such difference was observed (P = .10). At presentation, the incidence of early rupture of intramural hematoma and penetrating atherosclerotic ulcer was higher than for typical dissection. For branch vessels, intramural hematoma never occludes branch arteries. On imaging follow-up, patients with intramural hematoma and penetrating atherosclerotic ulcer rarely improved, with late surgery commonly needed. Better survival was observed for the initial surgical management of patients with penetrating atherosclerotic ulcer compared with initial medical management. Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

To participate or not in the physician quality reporting initiative (PQRI); that is the question.

PubMed

Elliott, Brett

2007-05-01

The Tax Relief and Health Care Act of 2006 authorized the establishment of a physician quality reporting system which would tie a reimbursement incentive to compliance with benchmarks that are considered proxies of quality patient care. The Centers for Medicare and Medicare Services (CMS) has called this the Physician Quality Reporting Initiative (PQRI). A brief historical background about how this program evolved, how one participates in this initiative, and the strengths and weaknesses of current and new benchmarks is presented.

Cervical Spondylotic Myelopathy presenting as mechanical neck pain: a case report.

PubMed

Smith, Benjamin E; Diver, Claire J; Taylor, Alan J

2014-08-01

Cervical Spondylotic Myelopathy (CSM) is the most common type of myelopathy in adults over 55 years of age. In the early stages symptoms may include local neck pain and stiffness that might mimic the presentation of non-specific mechanical neck pain (NSMNP). The patient was a 79 year old male, who complained of eight weeks of neck pain. He had been referred for physiotherapy by his family physician with a diagnosis of NSMNP. Initial presentation was consistent with the referral, but further assessment by the physiotherapist revealed findings suggestive of CSM. He was referred for an urgent cervical MRI scan, which revealed myelomalacic changes at C3/4 due to spondylotic changes. The patient was unsuitable for manual therapy intervention and was referred to a spinal orthopaedic surgeon who performed a posterior decompression and stabilisation at C3-C5, 2 months after the initial presentation. This case report highlights the importance of considering CSM in adults over 55 years of age presenting with NSMNP, particularly as the prevalence of both increases with age. It demonstrates the need for health professionals to carry out detailed examination where CSM may be a potential differential diagnosis. Outcomes are less favourable for patients over the age of 70, therefore an urgent surgical opinion was required for this patient. Deterioration of symptoms whilst he awaited surgery demonstrates how missed diagnosis may lead to possible long term spinal cord damage, with potential medico-legal concerns for the therapist. Copyright © 2014 Elsevier Ltd. All rights reserved.

Delayed Presentation of Ureteropelvic Junction Obstruction and Loss of Renal Function After Initially Mild (SFU Grade 1-2) Hydronephrosis.

PubMed

Bowen, Diana K; Yerkes, Elizabeth B; Lindgren, Bruce W; Gong, Edward M; Faasse, Mark A

2015-07-01

We report 4 pediatric cases of ureteropelvic junction obstruction involving delayed progression of initially mild postnatal hydronephrosis. All 4 children became symptomatic; however, 3 already had a substantial decrement of ipsilateral kidney function by the time of diagnosis. Two of these 3 patients had previous renal scintigraphy demonstrating normal differential function. We caution that counseling regarding hydronephrosis should emphasize the importance of prompt re-evaluation for any symptoms potentially referable to delayed presentation of ureteropelvic junction obstruction, irrespective of initial hydronephrosis grade. Future studies are needed to determine the optimal follow-up regimen for conservative management of hydronephrosis. Copyright © 2015 Elsevier Inc. All rights reserved.

Radiofrequency thermo-ablation of PVNS in the knee: initial results.

PubMed

Lalam, Radhesh K; Cribb, Gillian L; Cassar-Pullicino, Victor N; Cool, Wim P; Singh, Jaspreet; Tyrrell, Prudencia N M; Tins, Bernhard J; Winn, Naomi

2015-12-01

Pigmented villonodular synovitis (PVNS) is normally treated by arthroscopic or open surgical excision. We present our initial experience with radiofrequency thermo-ablation (RF ablation) of PVNS located in an inaccessible location in the knee. Review of all patients with histologically proven PVNS treated with RF ablation and with at least 2-year follow-up. Three patients met inclusion criteria and were treated with RF ablation. Two of the patients were treated successfully by one ablation procedure. One of the three patients had a recurrence which was also treated successfully by repeat RF ablation. There were no complications and all patients returned to their previous occupations following RF ablation. In this study we demonstrated the feasibility of performing RF ablation to treat PVNS in relatively inaccessible locations with curative intent. We have also discussed various post-ablation imaging appearances which can confound the assessment for residual/recurrent disease.

Factors associated with comprehensive dental care following an initial emergency dental visit.

PubMed

Johnson, Jeffrey T; Turner, Erwin G; Novak, Karen F; Kaplan, Alan L

2005-01-01

The purpose of this study was to characterize the patient population utilization of a dental home as grouped by: (1) age; (2) sex; and (3) payment method. A retrospective chart review of 1,020 patients, who initially presented for an emergency visit, was performed. From the original data pool, 2 groups were delineated: (1) those patients who returned for comprehensive dental care; and (2) those who did not return for comprehensive dental care. Patients with private dental insurance or Medicaid dental benefits were statistically more likely to return for comprehensive oral health care than those with no form of dental insurance. Younger patients (< or =3 years of age) were least likely to return for comprehensive dental care. Socioeconomic factors play a crucial role in care-seeking behaviors. These obstacles are often a barrier to preventive and comprehensive oral health care.

Management of acute ischemic stroke. What is the role of tPA and antithrombotic agents?

PubMed

Meschia, J F

2000-05-15

Every patient with acute stroke who presents to a medical center that has appropriate resources should undergo evaluation for intravenous tPA therapy. Such therapy should not be given unless the patient meets strict eligibility criteria based on clinical, radiographic, and laboratory data. Intra-arterial thrombolysis may be a promising alternative to intravenous tPA therapy, but it should still be regarded as experimental. Daily aspirin therapy should be initiated immediately in most patients who do not receive intravenous tPA therapy and after 24 hours in most patients who receive this treatment. Measures should be taken to prevent medical complications, such as aspiration pneumonia, deep vein thrombosis, contractures, and pressure sores. Early initiation of rehabilitation can maximize stroke recovery. Whenever feasible, institutions should have stroke teams or units to streamline care and provide expertise for patients with acute stroke.

Management and surgical treatment of parathyroid crisis secondary to parathyroid tumors: report of four cases.

PubMed

Ameerudden, Shakil; He, Xianghui

2011-01-01

Parathyroid crisis, also known as a parathyroid storm, is a rare and serious complication of primary hyperparathyroidism. Four cases are reported here in which patients presented to hospital with general complaints due to hypercalcemia secondary to hyperparathyroidism. Blood test results upon admission showed high levels of serum calcium and parathyroid hormone, and medical treatment initiated to lower the calcium level was ineffective. After relevant investigations, each patient underwent surgical exploration of the parathyroid glands, followed by excision of a pathological parathyroid tumor. There was a prompt decrease in parathyroid hormone level immediately after surgery. Histology reports revealed that patients had parathyroid adenoma. All patients recovered after surgery, with serum calcium levels restored back to normal and with resolution of all symptoms of hypercalcemia. This report illustrates how often this disease is initially misdiagnosed, and how prompt appropriate surgical treatment provides the best outcome for the patient.

Initial experience of coiling cerebral aneurysms using the new Comaneci device

PubMed Central

Lawson, Aimee Louise Deborah; Chandran, Arun; Puthuran, Mani; Goddard, Tony; Nahser, Hans; Patankar, Tufail

2015-01-01

We present our initial patient experience with an innovative temporary bridging device, the Comaneci (Rapid Medical, Israel), to assist in the coiling of cerebral aneurysms. The Comaneci device confers the same benefits as balloon remodeling but without the risks of parent artery occlusion. This alleviates time pressure on the clinician, and could reduce the risk of parent artery thrombosis. Three patients were treated with the Comaneci device. Two patients had acute ruptured posterior communicating aneurysms and one patient was treated electively for a carotico-ophthalmic aneurysm. Excellent occlusion of all three aneurysms was obtained. One patient developed a distal middle cerebral artery clot, that was treated with intravenous aspirin, with minor neurological consequences. These early results show that the Comaneci device can be used to achieve good cerebral aneurysm occlusion. Vessel patency is maintained throughout the procedure with potential advantages over conventional balloon assisted coiling. PMID:26123460

Cohort study of oncologic emergencies in patients with head and neck cancer.

PubMed

Reyes-Gibby, Cielito C; Melkonian, Stephanie C; Hanna, Ehab Y; Yeung, Sai-Ching J; Lu, Charles; Chambers, Mark S; Banala, Srinivas R; Gunn, Gary B; Shete, Sanjay S

2017-06-01

Treatments for head and neck squamous cell carcinoma (HNSCC) are associated with toxicities that lead to emergency department presentation. We utilized data from an ongoing prospective cohort of newly diagnosed, previously untreated patients (N = 298) with HNSCC to evaluate the association between clinical and epidemiologic factors and risk for and frequency of emergency department presentation. Time to event was calculated from the date of treatment initiation to emergency department presentation, date of death, or current date. Frequency of emergency department presentation was the sum of emergency department visits during the follow-up time. History of hypertension, normal/underweight body mass index (BMI), and probable depression predicted increased risk for emergency department presentation. BMI and severe pain were associated with higher frequency of emergency department presentations. Clinical and epidemiologic factors can help predict patients with HNSCC who will present to the emergency department. Such knowledge may improve treatment-related patient outcomes and quality of life. © 2017 Wiley Periodicals, Inc. Head Neck 39: 1195-1204, 2017. © 2017 Wiley Periodicals, Inc.

Phrenic Nerve Palsy as Initial Presentation of Large Retrosternal Goitre.

PubMed

Hakeem, Arsheed Hussain; Hakeem, Imtiyaz Hussain; Wani, Fozia Jeelani

2016-12-01

Unilateral phrenic nerve palsy as initial presentation of the retrosternal goitre is extremely rare event. This is a case report of a 57-year-old woman with history of cough and breathlessness of 3 months duration, unaware of the thyroid mass. She had large cervico-mediastinal goiter and chest radiograph revealed raised left sided hemidiaphragm. Chest CT scan did not reveal any lung parenchymal or mediastinal pathology. The patient underwent a total thyroidectomy through a cervical approach. The final pathology was in favor of multinodular goitre. Even after 1 year of follow up, phrenic nerve palsy did not improve indicating permanent damage. Phrenic nerve palsy as initial presentation of the retrosternal goitre is unusual event. This case is reported not only because of the rare nature of presentation, but also to make clinicians aware of the entity so that early intervention may prevent attendant morbidity.

[Transcatheter aortic valve implantation for aortic stenosis. Initial experience].

PubMed

Careaga-Reyna, Guillermo; Lázaro-Castillo, José Luis; Lezama-Urtecho, Carlos Alberto; Macías-Miranda, Enriqueta; Dosta-Herrera, Juan José; Galván Díaz, José

Aortic stenosis is a frequent disease in the elderly, and is associated with other systemic pathologies that may contraindicate the surgical procedure. Another option for these patients is percutaneous aortic valve implantation, which is less invasive. We present our initial experience with this procedure. Patients with aortic stenosis were included once selection criteria were accomplished. Under general anaesthesia and echocardiographic and fluosocopic control, a transcatheter aortic valve was implanted following s valvuloplasty. Once concluded the procedure, angiographic and pressure control was realized in order to confirm the valve function. Between November 2014 and May 2015, 6 patients were treated (4 males and 2 females), with a mean age of 78.83±5.66 years-old. The preoperative transvalvular gradient was 90.16±28.53mmHg and posterior to valve implant was 3.33±2.92mmHg (P<.05). Two patients had concomitant coronary artery disease which had been treated previously. One patient presented with acute right coronary artery occlusion which was immediately treated. However due to previous renal failure, postoperative sepsis and respiratory failure, the patient died one month later. It was concluded that our preliminary results showed that in selected patients percutaneous aortic valve implantation is a safe procedure with clinical improvement for treated patients. Copyright © 2016 Academia Mexicana de Cirugía A.C. Publicado por Masson Doyma México S.A. All rights reserved.

Rheumatoid arthritis phenotype at presentation differs depending on the number of autoantibodies present.

PubMed

Derksen, V F A M; Ajeganova, S; Trouw, L A; van der Helm-van Mil, A H M; Hafström, I; Huizinga, T W J; Toes, R E M; Svensson, B; van der Woude, D

2017-04-01

In rheumatoid arthritis (RA), seropositive and seronegative disease may be two entities with different underlying pathophysiological mechanisms, long-term outcomes and disease presentations. However, the effect of the conjoint presence of multiple autoantibodies, as proxy for a more pronounced humoral autoimmune response, on clinical phenotype remains unclear. Therefore, this study investigates the association between the number of autoantibodies and initial clinical presentation in two independent cohorts of patients with early RA. Autoantibody status (rheumatoid factor, anticitrullinated protein antibodies and anticarbamylated protein antibodies) was determined at baseline in the Leiden Early Arthritis Cohort (n=828) and the Swedish BARFOT (Better Anti-Rheumatic Farmaco-Therapy, n=802) study. The association between the number of autoantibodies and baseline clinical characteristics was investigated using univariable and multivariable ordinal regression. In both cohorts, the following independent associations were found in multivariable analysis: patients with a higher number of RA-associated antibodies were younger, more often smokers, had a longer symptom duration and a higher erythrocyte sedimentation rate at presentation compared with patients with few autoantibodies. The number of autoantibodies, reflecting the breadth of the humoral autoimmune response, is associated with the clinical presentation of RA. Predisease pathophysiology is thus reflected by the initial clinical phenotype. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Orthodontic Consideration in Patients with Beta-Thalassemia Major: Case Report and Literature Review.

PubMed

Einy, Shmuel; Hazan-Molina, Hagai; Ben-Barak, Ayelet; Aizenbud, Dror

Beta Thalassemia (βT) patients present a unique facial appearance and specific craniofacial, jaw and dental patterns. Although this anomaly often requires orthodontic management, βT patients have received scant attention in the orthodontic and dental literature over the past 50 years. The aim of this article is to review the characteristic craniofacial and dental manifestation pattern of βT patients and to emphasize their preferred orthodontic management protocol by presenting a βT orthodontic treated patient. A 10 year old patient presented with a complaint of severe esthetic and functional disorders due to her diagnosis of βT. We initiated orthodontic treatment including a combined orthopedic and functional treatment modality to improve facial appearance. Maxillary restraint and increased mandibular size during treatment along with an increase in the vertical dimension were achieved. The patient presented with Angle class I molar relationship, with reduction of the excessive overjet and deep overbite. Orthodontic treatment comprised of maxillary orthopedic treatment directed especially toward premaxilla with light forces, and mandibular modification by functional appliance along with fixed orthodontic treatment is recommended in βT patients.

Evaluation of an imaging protocol using ultrasound as the primary diagnostic modality in pediatric patients with superficial soft tissue infections of the face and neck.

PubMed

Sethia, Rishabh; Mahida, Justin B; Subbarayan, Rahul A; Deans, Katherine J; Minneci, Peter C; Elmaraghy, Charles A; Essig, Garth F

2017-05-01

To determine the clinical impact of an initiative to use ultrasound (US) as the primary diagnostic modality for children with superficial face and neck infections versus use of computed tomography (CT). Children with a diagnosis of lymphadenitis, face or neck abscess, or face and neck cellulitis were retrospectively evaluated by the otolaryngology service. Patients were separated into two groups based on implementation of a departmental initiative to use US as the primary diagnostic modality. The pre-implementation cohort consisted of patients treated prior to the initiative (2006-2009) and the current protocol cohort consisted of patients treated after the initiative was started (2010-2013). Demographics, use of US or CT, necessity of surgical intervention, and failure of medical management were compared. Three hundred seventy three children were evaluated; 114 patients were included in the pre-implementation cohort and 259 patients were included in the current protocol cohort for comparison. Patients presenting during the current protocol period were more likely to undergo US (pre-implementation vs. current protocol, p-value) (12% vs. 49%, p < 0.0001) and less likely to undergo CT (66% vs. 41%, p < 0.0001) for their initial evaluation. There were no differences in the percentage of children who underwent prompt surgical drainage, prompt discharge without surgery, or trial inpatient observation. There were also no differences in the rate of treatment failure for patients undergoing prompt surgery or prompt discharge on antibiotics. For those patients who underwent repeat evaluation following trial medical management, US was used more frequently in the current protocol period (4% vs. 20%, p = 0.002) with no difference in CT use, selected treatment strategy, or treatment failure rates. Increased use of US on initial evaluation of children with superficial face and neck infections resulted in decreased CT utilization, without negatively impacting outcome. Decreasing pediatric radiation exposure and potential long-term effects is of primary importance. Copyright © 2017. Published by Elsevier B.V.

Prevalence and incidence of adults consulting for shoulder conditions in UK primary care; patterns of diagnosis and referral.

PubMed

Linsell, L; Dawson, J; Zondervan, K; Rose, P; Randall, T; Fitzpatrick, R; Carr, A

2006-02-01

To estimate the national prevalence and incidence of adults consulting for a shoulder condition and to investigate patterns of diagnosis, treatment, consultation and referral 3 yr after initial presentation. Prevalence and incidence rates were estimated for 658469 patients aged 18 and over in the year 2000 using a primary care database, the IMS Disease Analyzer-Mediplus UK. A cohort of 9215 incident cases was followed-up prospectively for 3 yr beyond the initial consultation. The annual prevalence and incidence of people consulting for a shoulder condition was 2.36% [95% confidence interval (CI) 2.32-2.40%] and 1.47% (95% CI 1.44-1.50%), respectively. Prevalence increased linearly with age whilst incidence peaked at around 50 yr then remained static at around 2%. Around half of the incident cases consulted once only, while 13.6% were still consulting with a shoulder problem during the third year of follow-up. During the 3 yr following initial presentation, 22.4% of patients were referred to secondary care, 30.8% were prescribed non-steroidal anti-inflammatory drugs and 10.6% were given an injection by their general practitioner (GP). GPs tended to use a limited number of generalized codes when recording a diagnosis; just five of 426 possible Read codes relating to shoulder conditions accounted for 74.6% of the diagnoses of new cases recorded by GPs. The prevalence of people consulting for shoulder problems in primary care is substantially lower than community-based estimates of shoulder pain. Most referrals occur within 3 months of initial presentation, but only a minority of patients are referred to orthopaedic specialists or rheumatologists. GPs may lack confidence in applying precise diagnoses to shoulder conditions.

A Retrospective Chart Review of Contraceptive Use among Adolescents with Opioid Use Disorder.

PubMed

Handy, Caitlin J; Lange, Hannah L H; Manos, Brittny E; Berlan, Elise D; Bonny, Andrea E

2018-04-01

To describe contraceptive use among female adolescents initiating outpatient treatment for opioid use disorder. Retrospective chart review. Outpatient clinic providing medication-assisted treatment for substance use disorders to adolescents and young adults. Nonpregnant female adolescents who presented for treatment from January 1, 2013 to January 31, 2016 (N = 123). None. Prescription contraceptive use at baseline and initiation of a new method within 90 days. Of 123 female adolescents who presented for treatment of opioid use disorder, 113 (91.9%) reported sexual activity and 80 (65.0%) were not using prescription contraception at intake. Previous pregnancy was reported by 43 (35.0%) and 20 (16.3%) were positive for a sexually transmitted infection. Contraceptive counseling was not documented for 73 (59.3%) patients. Among patients with no prescription contraception at baseline, 56 of 80 (70.0%) initiated a method within the study window. Significant predictors (odds ratio [OR]; 95% confidence interval) of contraceptive initiation included previous pregnancy (8.6; 1.39-52.99), education of less than a high school diploma/general equivalency diploma (7.4; 1.63-33.41), and return for follow-up visit (9.8; 2.18-43.69). Young women who presented for opioid use disorder treatment were at high risk of adverse reproductive health outcomes. Most were sexually active and not using prescription contraception. Findings underscore the need for contraceptive counseling in this patient population. Optimally, these services would be provided in conjunction with substance use treatment. Improved contraceptive counseling documentation will allow evaluation of effective contraceptive counseling strategies for adolescents with opioid use disorders and might serve to inform future interventions. Copyright © 2017 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.

Clinical presentation and treatment of septic arthritis in children.

PubMed

Moro-Lago, I; Talavera, G; Moraleda, L; González-Morán, G

The aim of this study is to determine the epidemiological features, clinical presentation, and treatment of children with septic arthritis. A retrospective review was conducted on a total of 141 children with septic arthritis treated in Hospital Universitario La Paz (Madrid) between the years 2000 to 2013. The patient data collected included, the joint affected, the clinical presentation, the laboratory results, the appearance, Gram stain result, and the joint fluid culture, as well as the imaging tests and the treatment. Most (94%) of the patients were less than 2 years-old. The most common location was the knee (52%), followed by the hip (21%). The septic arthritis was confirmed in 53%. No type of fever was initially observed in 49% of them, and 18% had an ESR (mm/h) or CRP (mg/l) less than 30 in the initial laboratory analysis. The joint fluid was purulent in 45% and turbid in 12%. The Gram stain showed bacteria in 4%. The fluid culture was positive in 17%. Staphylococcus aureus was the most common pathogen found, followed by Streptococcus agalactiae, Streptococcus pneumoniae, and Kingella kingae. Antibiotic treatment was intravenous administration for 7 days, followed by 21 days orally. Surgery was performed in 18% of cases. The diagnosis was only confirmed in 53% of the patients. Some of the confirmed septic arthritis did not present with the classical clinical/analytical signs, demonstrating that the traumatologist or paediatrician requires a high initial level of clinical suspicion of the disease. Copyright © 2017 SECOT. Publicado por Elsevier España, S.L.U. All rights reserved.

Diagnosis and initial management of cerebellar infarction.

PubMed

Edlow, Jonathan A; Newman-Toker, David E; Savitz, Sean I

2008-10-01

Cerebellar infarction is an important cause of stroke that often presents with common and non-specific symptoms such as dizziness, nausea and vomiting, unsteady gait, and headache. Accurate diagnosis frequently relies on careful attention to patients' coordination, gait, and eye movements--components of the neurological physical examination that are sometimes omitted or abridged if cerebellar stroke is not specifically being considered. The differential diagnosis is broad, and includes many common and benign causes. Furthermore, early-stage posterior fossa ischaemia is rarely seen with brain CT--the most commonly available initial imaging test that is used for stroke. Insufficient examination and imaging can result in misdiagnosis. However, early correct diagnosis is crucial to help prevent treatable but potentially fatal complications, such as brainstem compression and obstructive hydrocephalus. The identification and treatment of the underlying vascular lesions at an early stage can also prevent subsequent occurrences of stroke and improve patients' outcomes. Here, we review the clinical presentation of cerebellar infarction, from diagnosis and misdiagnosis to patients' monitoring, treatment, and potential complications.

Early detection and treatment of sexually transmitted disease in pregnant adolescents of low socioeconomic status.

PubMed

Matson, S C; Pomeranz, A J; Kamps, K A

1993-10-01

This study evaluated the prevalence of sexually transmitted disease (STD) in adolescents presenting to a primary pediatric care clinic (PPCC) for the diagnosis of pregnancy and our ability to eradicate identified infections. We followed 168 pregnant adolescents of low socioeconomic status from their original pregnancy diagnosis until their first prenatal clinic visit. We collected screening cervical cultures for Neisseria gonorrhoeae and Chlamydia trachomatis by completing a pelvic examination on 91 patients at our PPCC. At the PPCC visit, 29% were positive for gonorrhea, chlamydia, or both. Screening tests for these infections were collected on all patients at the initial prenatal clinic visit. The risk for presenting to the prenatal clinic with a STD was significantly greater in patients not screened and treated for STD at the PPCC. Average delay from diagnosis to first prenatal clinic visit was 35.7 days. Thus, in this adolescent population, primary care providers are missing an important therapeutic opportunity by failing to identify and treat STD at initial diagnosis of pregnancy.

Bilateral Proliferative Retinopathy as the Initial Presentation of Chronic Myeloid Leukemia

PubMed Central

Macedo, Mafalda S. F.; Figueiredo, Ana R. M.; Ferreira, Natália N.; Barbosa, Irene M. A.; Furtado, Maria João F. B. S.; Correia, Nuno F. C. B. A.; Gomes, Miguel P.; Lume, Miguel R. B.; Menéres, Maria João S.; Santos, Marinho M. N.; Meireles S., M. Angelina C.

2013-01-01

The authors report a rare case of a 48-year-old male with chronic myeloid leukemia (CML) who initially presented with a bilateral proliferative retinopathy. The patient complained of recent visual loss and floaters in both eyes (BE). Ophthalmologic evaluation revealed a best corrected visual acuity (BCVA) of 20/50 in the right eye and 20/200 in the left eye (LE). Fundoscopy showed the presence of bilateral peripheral capillary dropout with multiple retinal sea fan neovascularisations, which were confirmed on fluorescein angiography. Full blood count revealed hyperleukocytosis, thrombocytosis, anemia, and hyperuricemia. Bone marrow aspiration and biopsy showed the reciprocal chromosomal translocation t (9;22), diagnostic of CML. The patient was started on hydroxyurea, allopurinol and imatinib mesylate. He received bilateral panretinal laser photocoagulation and a vitrectomy was performed in the LE. The patient has been in complete hematologic, cytogenetic, and major molecular remission while on imatinib and his BCVA is 20/25 in BE. PMID:24339689

Hazardous materials accidents: initial scene assessment and patient care.

PubMed

Leonard, R B

1993-06-01

Hazardous materials, i.e., chemicals that are toxic, corrosive, flammable, or explosive, are a ubiquitous aspect of modern life. They are manufactured throughout the United States, shipped by truck, train, barge, and pipeline, and stored at a wide variety of locations, including factories, military bases, and warehouses. Accidents involving hazardous materials present an added dimension of danger to emergency personnel arriving first at the scene, and have the potential to produce chemically contaminated patients who require special medical treatment. Personnel arriving first at the scene must understand how to evaluate the scene for fast and safe mitigation without endangering themselves. Chemically contaminated patients require prompt treatment, which, for optimal outcome, must begin at the scene. Although frequently the identification of the hazardous materials involved is not known initially, emergency personnel may safely provide medical care to the victims by understanding and following the principles of hazardous materials accidents and the pathophysiology of chemical injuries as presented in this paper.

A Pilot Study Using a Web Survey to Identify Characteristics That Influence Hypogonadal Men to Initiate Testosterone Replacement Therapy.

PubMed

Rosen, Raymond C; Seftel, Allen D; Ruff, Dustin D; Muram, David

2018-05-01

Men with hypogonadism (HG) who choose testosterone replacement therapy (TRT) may have distinct characteristics that provide insight as to why they may/may not initiate therapy. The aim of the current study was to identify trends in patient characteristics and attitudes in men diagnosed with HG who initiated TRT (TRT+) compared with men who were diagnosed with HG but did not initiate TRT (TRT-). The market research-based online survey conducted between 2012 and 2013 included patients from a Federated Sample, a commercially available panel of patients with diverse medical conditions. The current analysis was composed of two groups: TRT+ ( n = 155) and TRT- ( n = 157). Patient demographics, clinical characteristics, and attitudes toward HG and TRT were examined as potential predictors of primary adherence in men with HG; cohorts were compared by using Fisher's exact test. Significant associations among sexual orientation, relationship status, educational level, presence of comorbid erectile dysfunction, area of residence, and TRT initiation were present ( p ≤ .05). College-educated, heterosexual, married men with comorbid erectile dysfunction living in suburban and urban areas were more likely to initiate treatment. The most bothersome symptoms reported were lack of energy (90% vs. 81%, p = .075), decreased strength and endurance (86% vs. 76%, p = .077), and deterioration in work performance (52% vs. 31%, p = .004); lack of energy prompted men to seek help. Patients (48%) in the TRT+ group were more knowledgeable regarding HG as compared with TRT- respondents (14%, p < .001), and most men obtained their information from a health care professional (89% vs. 82%, p = .074). The current analysis identified distinct demographic and clinical characteristics and attitudes among TRT users compared with men who were diagnosed with HG yet remained untreated.

Keratoconus presenting with bilateral simultaneous acute corneal hydrops.

PubMed

Bilgin, Burak; Unal, Betül; Unal, Mustafa; Doğan, Erkan; Cetinkaya, Aslı; Akyol, Mahmut; Yücel, Iclal; Akar, Yusuf; Apaydın, Cemil; Ilhan, Deniz

2013-04-01

To report a case of unknown keratoconus presenting with bilateral simultaneous acute corneal hydrops. Case report. A case of a 12-year-old male patient with Leber congenital amaurosis (LCA) presented with sudden whitening and lacrimation for 2 days in both eyes simultaneously. At the initial examination, there were bilateral acute corneal hydrops, enophthalmic eyes and roving nystagmus. Ultrasonography revealed clear crystalline lenses and attached retina. Initial management consisted of topical hypertonic solutions, steroids and artificial tears. Bilateral simultaneous acute corneal hydrops has not been reported before in the literature. It may be the presenting sign of keratoconus. Copyright © 2012 British Contact Lens Association. Published by Elsevier Ltd. All rights reserved.

Pseudotumor cerebri secondary to subacute sclerosing panencephalitis.

PubMed

Ayçiçek, Ali; Işcan, Akin; Ceçe, Hasan

2009-05-01

Unusual presentations are not rare in subacute sclerosing panencephalitis. Five patients initially diagnosed with pseudotumor cerebri were ultimately determined to have pseudotumor cerebri secondary to subacute sclerosing panencephalitis. The present study retrospectively reviewed 56 cases history, neurologic symptoms, and clinical and laboratory data, as well as the outcomes. On admission, five patients (group 1) presenting with pseudotumor cerebri exhibited bilateral papilledema, and in each of them cranial magnetic resonance imaging revealed small lateral ventricles, effacement of the subarachnoid space, and no mass lesion. On admission, 51 patients (group 2) had no pseudotumor cerebri findings. The year of original measles infection, the interval between measles and onset of subacute sclerosing panencephalitis, and initial neurologic symptoms were similar, but length of symptoms before diagnosis of subacute sclerosing panencephalitis was shorter in group 1, and the clinical stage of subacute sclerosing panencephalitis on admission was more advanced in group 2. Cerebrospinal fluid mean open pressure was 378 +/- 22 H(2)O in group 1 and 146 +/- 28 H(2)O in group 2; cerebrospinal fluid antibody was 2038 +/- 768 U/L in group 1 and was 664 +/- 214 U/L in group 2. Only three of the five patients with pseudotumor cerebri had typical periodic discharges on electroencephalographic examination. These findings suggest that subacute sclerosing panencephalitis can cause pseudotumor cerebri.

Prolonged disturbance of consciousness caused by severe hypophosphatemia: a report of two cases.

PubMed

Murakami, Takaaki; Yoshida, Masanori; Funazo, Tomoko; Matsuda, Yuki; Matsuo, Koji; Nambu, Takuo; Yonemitsu, Shin; Muro, Seiji; Oki, Shogo

2014-01-01

We herein describe two patients with a prolonged disturbance of consciousness due to severe hypophosphatemia. Case one presented with pneumococcal infection and acute exacerbation of chronic obstructive pulmonary disease and asthma. Case two presented with diabetic foot infections and diabetic ketoacidosis. Both patients responded to initial therapy for their primary diseases, but consciousness became worse in both cases. Their test results for impaired consciousness revealed severe hypophosphatemia; therefore, phosphate replacement therapy was administered, thus resulting in complete alertness. These cases demonstrate that we should consider the possibility of hypophosphatemia in critically ill patients with an altered consciousness.

[Nocardiosis in immunocompromised host presenting as cellulitis].

PubMed

Asgeirsson, Hilmar; Sigurdardottir, Bryndis

2010-06-01

Nocardia is a rare pathogen of mainly immunocomprised patients. Only two cases of nocardiosis have previously been identified in Iceland. A 92-year-old male on glucocorticoid therapy with metastatic bladder cancer presented with two weeks history of progressive swelling and erythema of the hand and deteriorating cognitive functioning. A brain lesion and pulmonary nodules were identified and Nocardia farcinia was cultured from a hand abscess. The patient was initially treated with trimethoprim/sulfamethoxazole but because of rapid deterioration and old age an end-of-life decision was made. This case of nocardiosis illustrates the importance of uncommon opportunistic infections in immunocompromised Icelandic patients.

Edema associated with quetiapine

PubMed Central

Koleva, Hristina K.; Erickson, Mark A.; Vanderlip, Erik R.; Tansey, Janeta; Mac, Joseph; Fiedorowicz, Jess G.

2010-01-01

Background Edema associated with quetiapine has been described in only one case report to date and represents a potentially serious adverse reaction. Methods We present a case series of three patients who developed bilateral leg edema following initiation of quetiapine. Results One of these patients had a recurrence of edema with subsequent rechallenge. Another patient developed quetiapine-induced edema following a prior episode of olanzapine-induced edema. All the cases present a compelling temporal relationship between the drug challenge and the adverse event. Conclusions Prompt recognition and intervention with discontinuation of the offending agent is important for this potentially serious, seemingly idiosyncratic, vascular complication. PMID:19439156

Chronic Granulomatous Disease Presenting as Aspergillus Fumigatus Pneumonia in a Previously Healthy Young Woman.

PubMed

Williams, David; Kadaria, Dipen; Sodhi, Amik; Fox, Roy; Williams, Glenn; Threlkeld, Stephen

2017-04-05

BACKGROUND Chronic Granulomatous Disease (CGD) is a rare immunodeficiency disease caused by a genetic defect in the NADPH (nicotinamide adenine dinucleotide phosphate) oxidase enzyme, resulting in increased susceptibility to bacterial and fungal infections. The inheritance can be X-linked or autosomal recessive. Patients usually present with repeated infections early in life. We present an unusual case of a 23-year-old patient diagnosed with CGD. CASE REPORT A 23-year-old white woman with no previous history of recurrent infections presented with complaints of fever, shortness of breath, and diffuse myalgia. She had been treated twice for similar complaints recently, but without resolution. She was febrile, tachypneic, tachycardic, and hypoxic at presentation. Physical examination revealed diffuse inspiratory rales. Laboratory results showed leukocytosis. Her initial chest X-ray and CT chest showed reticular nodular interstitial lung disease pattern. Despite being on broad-spectrum antibiotics for 5 days, she continued to require supplemental oxygen and continued to be tachypneic, with minimal activity. Initial diagnostic tests, including bronchoscopy with biopsy and lavage, did not reveal a diagnosis. She then underwent a video-assisted thoracoscopic surgery (VATS) lung biopsy. The biopsy slides showed suppurative granulomatous inflammation affecting greater than 50% of the parenchymal lung surface. Fungal hyphae consistent with Aspergillus were present in those granulomas. A diagnosis of CGD was made and she was started on Voriconazole. She improved with treatment. Her neutrophil burst test showed negative burst on stimulation, indicating phagocytic dysfunction consistent with CGD. Autosomal recessive CGD was confirmed by genetic testing. CONCLUSIONS CGD can present in adulthood without any previous symptoms and signs. Clinicians should consider this disease in patients presenting with recurrent or non-resolving infections. Timely treatment and prophylaxis has been shown to reduce serious infections as well as mortality in these patients.

An agent-based model identifies MRI regions of probable tumor invasion in a patient with glioblastoma

NASA Astrophysics Data System (ADS)

Chen, L. Leon; Ulmer, Stephan; Deisboeck, Thomas S.

2010-01-01

We present an application of a previously developed agent-based glioma model (Chen et al 2009 Biosystems 95 234-42) for predicting spatio-temporal tumor progression using a patient-specific MRI lattice derived from apparent diffusion coefficient (ADC) data. Agents representing collections of migrating glioma cells are initialized based upon voxels at the outer border of the tumor identified on T1-weighted (Gd+) MRI at an initial time point. These simulated migratory cells exhibit a specific biologically inspired spatial search paradigm, representing a weighting of the differential contribution from haptotactic permission and biomechanical resistance on the migration decision process. ADC data from 9 months after the initial tumor resection were used to select the best search paradigm for the simulation, which was initiated using data from 6 months after the initial operation. Using this search paradigm, 100 simulations were performed to derive a probabilistic map of tumor invasion locations. The simulation was able to successfully predict a recurrence in the dorsal/posterior aspect long before it was depicted on T1-weighted MRI, 18 months after the initial operation.

An agent-based model identifies MRI regions of probable tumor invasion in a patient with glioblastoma.

PubMed

Chen, L Leon; Ulmer, Stephan; Deisboeck, Thomas S

2010-01-21

We present an application of a previously developed agent-based glioma model (Chen et al 2009 Biosystems 95 234-42) for predicting spatio-temporal tumor progression using a patient-specific MRI lattice derived from apparent diffusion coefficient (ADC) data. Agents representing collections of migrating glioma cells are initialized based upon voxels at the outer border of the tumor identified on T1-weighted (Gd+) MRI at an initial time point. These simulated migratory cells exhibit a specific biologically inspired spatial search paradigm, representing a weighting of the differential contribution from haptotactic permission and biomechanical resistance on the migration decision process. ADC data from 9 months after the initial tumor resection were used to select the best search paradigm for the simulation, which was initiated using data from 6 months after the initial operation. Using this search paradigm, 100 simulations were performed to derive a probabilistic map of tumor invasion locations. The simulation was able to successfully predict a recurrence in the dorsal/posterior aspect long before it was depicted on T1-weighted MRI, 18 months after the initial operation.

[Acute myocardial infarction as Eosinophilic granulomatosis with polyangiitis (formerly Churg Strauss syndrome) initial presentation].

PubMed

Sulaiman, Wahinuddin; Seung, Ong Ping; Noor, Sabariah Mohd

2014-01-01

Eosinophilic granulomatosis with polyangiitis is a rare primary vasculitic disease characterized by hypereosinophilia, late onset asthma and extravascular eosinophil granulomas. We report a case presented initially with acute myocardial infarction which later only proceed with asthma, skin manifestations and peripheral neuropathy. Laboratory parameters showed hypereosinohpilia with negative perinuclear pattern of antineutrophil cytoplasmic autoantibodies (p-ANCA). Skin biopsy showed leucocytoclastic vasculitis with eosinophilic infiltration while coronary angiography was normal. The patient's symptoms improved with IV methylprednisolone, pulse cyclophosphamide and azathioprine. Copyright © 2014 Elsevier Editora Ltda. All rights reserved.

Managing hypopituitarism in emergency departments.

PubMed

Welsh, Jeanette

2015-10-01

Healthcare professionals manage patients with a vast range of conditions, but often specialise and acquire expertise in specific disease processes. Emergency and pre-hospital clinicians care for patients with various conditions for short periods of time, so have less opportunity to become familiar with more unusual conditions, yet it is vital that they have some knowledge and understanding of these. Patients with rare conditions can present at emergency departments with common complaints, but the effect of their original diagnosis on the presenting complaint may be overlooked or underestimated. This article uses a case study to describe the experience of one patient who presented with vomiting, but who also had hypopituitarism and therefore required specific management she did not at first receive. The article describes hypopituitarism and the initial management of patients with this condition who become unwell, and discusses how the trust responded to the patient's complaint to improve patient safety and care. It has been written with the full participation and consent of the patient and her husband.

Silibinin administration improves hepatic failure due to extensive liver infiltration in a breast cancer patient.

PubMed

Bosch-Barrera, Joaquim; Corominas-Faja, Bruna; Cuyàs, Elisabet; Martin-Castillo, Begoña; Brunet, Joan; Menendez, Javier A

2014-08-01

Silibinin exerts hepatoprotective, anti-inflammatory and anti-fibrotic effects. Several pre-clinical studies have shown anti-tumoral activity of silibinin in breast cancer cell lines. We present the case of a heavily pre-treated breast cancer patient with extensive liver infiltration. The patient presented with progressive liver failure despite several chemotherapy treatments, including paclitaxel, capecitabine and vinorelbine. After four cycles of a fourth-line chemotherapy treatment consisting of carboplatin and gemcitabine, the patient's liver blood test results deteriorated to life-threatening levels. The compassionate use of Legasil®, a new commercially available nutraceutical product containing a new silibinin formulation, was offered to the patient according to article 37 of the 2013 Declaration of Helsinki. After treatment initiation, the patient presented clinical and liver improvement, which permitted the patient to continue palliative chemotherapy. This is the first case report of a clinical benefit of silibinin administration in a breast cancer patient. Copyright© 2014 International Institute of Anticancer Research (Dr. John G. Delinassios), All rights reserved.

Hard tissue pediatric facial trauma: a review.

PubMed

Hogg, Nicholas J V; Horswell, Bruce B

2006-01-01

Although hard tissue injuries are uncommon in the pediatric patient, dentists may be involved in the initial assessment of these patients. In this paper, we review fractures of the facial skeleton with a focus on dentoalveolar injuries. Minimally displaced fractures in pediatric patients can be managed conservatively, while displaced fractures may require open approaches and rigid fixation. New fixation stratagems are presented, and possible facial growth disturbances resulting from trauma are discussed.

Exercise capacity before and after an 8-week multidisciplinary inpatient rehabilitation program in lung cancer patients: a pilot study.

PubMed

Spruit, Martijn A; Janssen, Paul P; Willemsen, Sonja C P; Hochstenbag, Monique M H; Wouters, Emiel F M

2006-05-01

Although lung cancer is a highly prevalent type of cancer, the effects of an inpatient multidisciplinary rehabilitation program on pulmonary function and exercise capacity have never been studied in these patients. Pulmonary function, 6-min walking distance and peak exercise capacity of 10 patients with a severely impaired pulmonary function following treatment of lung cancer were assessed in this pilot study before and after an 8-week inpatient multidisciplinary rehabilitation program. At baseline, patients had a restrictive pulmonary function and an apparent exercise intolerance (median 6-min walking distance: 63.6% predicted; median peak cycling load: 58.5% predicted). Despite the lack of change in median pulmonary function [FEV1: -0.01L, p = 0.5469], functional exercise capacity [145 m; 43.2% of the initial values, p=0.0020] and peak exercise capacity [26 W; 34.4% of the initial values, p = 0.0078] improved significantly compared to baseline. Future trials have to corroborate the present findings. Nevertheless, patients with lung cancer have a clear indication to start a comprehensive rehabilitation program following intensive treatment of their disease. In fact, based on the results of the present pilot study it appears that these patients are good candidates for pulmonary rehabilitation programs.

Time-courses of plasma IL-6 and HMGB-1 reflect initial severity of clinical presentation but do not predict poor neurologic outcome following subarachnoid hemorrhage.

PubMed

Kiiski, Heikki; Långsjö, Jaakko; Tenhunen, Jyrki; Ala-Peijari, Marika; Huhtala, Heini; Hämäläinen, Mari; Moilanen, Eeva; Öhman, Juha; Peltola, Jukka

2017-03-01

Patients with aneurysmal subarachnoid hemorrhage (aSAH) experience high mortality and morbidity. Neuroinflammation causes brain damage expansion after aSAH. Due to the complexity of the inflammatory response multiple biomarkers are needed to evaluate its' progression. We studied inflammatory process after aSAH by measuring two inflammatory biomarkers, interleukin-6 (IL-6) and high-mobility group box 1 (HMGB1) at simultaneous time-points after aSAH. In this prospective population-based study, IL-6 and HMGB1 were measured in aSAH patients (n = 47) for up to five days. Plasma concentrations of IL-6 and HMGB1 were measured at 0, 12 and 24 h after hospital admission, and thereafter daily for up to five days or until the patient was transferred from the intensive care unit (ICU). The patients' neurological outcomes were evaluated with the modified Rankin Scale at six months after aSAH. A high IL-6 level during the first day after aSAH was associated with a severe initial clinical presentation (p = 0.002) and infection during follow-up (p = 0.031). The HMGB1 level did not associate with these parameters. There was no correlation between IL-6 and HMGB1 levels at any time point during the follow-up. The concentrations of IL-6 and HMGB1 were not associated with neurological outcome. High initial IL-6 values seem to reflect the intensity of the inflammatory response but not the brain damage per se. An early inflammatory response might even be beneficial since although elevated IL-6 levels were observed in patients with a more severe initial clinical presentation, they were not associated with neurological outcome. The lack of correlation between IL-6 and HMGB1 questions the role of macrophages in the process of the secretion of these inflammatory markers after aSAH, instead pointing to the activation of alternative pro-inflammatory pathways.

Prospective validation of a clinical decision rule to identify patients presenting to the emergency department with chest pain who can safely be removed from cardiac monitoring

PubMed Central

Syed, Shahbaz; Gatien, Mathieu; Perry, Jeffrey J.; Chaudry, Hina; Kim, Soo-Min; Kwong, Kenneth; Mukarram, Muhammad; Thiruganasambandamoorthy, Venkatesh

2017-01-01

BACKGROUND: Most patients with chest pain in the emergency department are assigned to cardiac monitoring for several hours, blocking access for patients in greater need. We sought to validate a previously derived decision rule for safe removal of patients from cardiac monitoring after initial evaluation in the emergency department. METHODS: We prospectively enrolled adults (age ≥ 18 yr) who presented with chest pain and were assigned to cardiac monitoring at 2 academic emergency departments over 18 months. We collected standardized baseline characteristics, findings from clinical evaluations and predictors for the Ottawa Chest Pain Cardiac Monitoring Rule: whether the patient is currently free of chest pain, and whether the electrocardiogram is normal or shows only nonspecific changes. The outcome was an arrhythmia requiring intervention in the emergency department or within 8 hours of presentation to the emergency department. We calculated diagnostic characteristics for the clinical prediction rule. RESULTS: We included 796 patients (mean age 63.8 yr, 55.8% male, 8.9% admitted to hospital). Fifteen patients (1.9%) had an arrhythmia, and the rule performed with the following characteristics: sensitivity 100% (95% confidence interval [CI] 78.2%–100%) and specificity 36.4% (95% CI 33.0%–39.6%). Application of the Ottawa Chest Pain Cardiac Monitoring Rule would have allowed 284 out of 796 patients (35.7%) to be safely removed from cardiac monitoring. INTERPRETATION: We successfully validated the decision rule for safe removal of a large subset of patients with chest pain from cardiac monitoring after initial evaluation in the emergency department. Implementation of this simple yet highly sensitive rule will allow for improved use of health care resources. PMID:28246315

Health Ethics Education for Health Administration Chaplains

ERIC Educational Resources Information Center

Porter, Russell; Broussard, Amelia; Duckett, Todd

2008-01-01

It is imperative for divinity and health administration programs to improve their level of ethics education for their graduates who work as health administration chaplains. With an initial presentation of the variation of ethical dilemmas presented in health care facilities covering social, organizational, and patient levels, we indicate the need…

Randomized clinical trial of an intravenous hydromorphone titration protocol versus usual care for management of acute pain in older emergency department patients.

PubMed

Chang, Andrew K; Bijur, Polly E; Davitt, Michelle; Gallagher, E John

2013-09-01

Opioid titration is an effective strategy for treating pain; however, titration is generally impractical in the busy emergency department (ED) setting. Our objective was to test a rapid, two-step, hydromorphone titration protocol against usual care in older patients presenting to the ED with acute severe pain. This was a prospective, randomized clinical trial of patients 65 years of age and older presenting to an adult, urban, academic ED with acute severe pain. The study was registered at http://www.clinicaltrials.gov (NCT01429285). Patients randomized to the hydromorphone titration protocol initially received 0.5 mg intravenous hydromorphone. Patients randomized to usual care received any dose of any intravenous opioid. At 15 min, patients in both groups were asked, 'Do you want more pain medication?' Patients in the hydromorphone titration group who answered 'yes' received a second dose of 0.5 mg intravenous hydromorphone. Patients in the usual care group who answered 'yes' had their ED attending physician notified, who then could administer any (or no) additional medication. The primary efficacy outcome was satisfactory analgesia defined a priori as the patient declining additional analgesia at least once when asked at 15 or 60 min after administration of the initial opioid. Dose was calculated in morphine equivalent units (MEU: 1 mg hydromorphone = 7 mg morphine). The need for naloxone to reverse adverse opioid effects was the primary safety outcome. 83.0 % of 153 patients in the hydromorphone titration group achieved satisfactory analgesia compared with 82.5 % of 166 patients in the usual care group (p = 0.91). Patients in the hydromorphone titration group received lower mean initial doses of opioids at baseline than patients in the usual care group (3.5 MEU vs. 4.7 MEU, respectively; p ≤ 0.001) and lower total opioids through 60 min (5.3 MEU vs. 6.0 MEU; p = 0.03). No patient needed naloxone. Low-dose titration of intravenous hydromorphone in increments of 0.5 mg provides comparable analgesia to usual care with less opioid over 60 min.

Metastatic Pheochromocytoma/Paraganglioma Related to Primary Tumor Development in Childhood or Adolescence: Significant Link to SDHB Mutations

PubMed Central

King, Kathryn S.; Prodanov, Tamara; Kantorovich, Vitaly; Fojo, Tito; Hewitt, Jacqueline K.; Zacharin, Margaret; Wesley, Robert; Lodish, Maya; Raygada, Margarita; Gimenez-Roqueplo, Anne-Paule; McCormack, Shana; Eisenhofer, Graeme; Milosevic, Dragana; Kebebew, Electron; Stratakis, Constantine A.; Pacak, Karel

2011-01-01

Purpose To present data on the high rate of SDHB mutations in patients with metastatic pheochromocytoma/paraganglioma whose initial tumor presentation began in childhood or adolescence. Patients and Methods From 2000 to 2010, 263 patients with pheochromocytoma/paraganglioma were evaluated through the National Institutes of Health (NIH), Bethesda, MD. Of the 263 patients, 125 patients were found to have metastatic disease; of these 125 patients, 32 patients presented with a tumor before 20 years of age. An additional 17 patients presented with a tumor before 20 years of age but demonstrated no development of metastatic disease. Genetic testing for mutations in the VHL, MEN, and SDHB/C/D genes was performed on patients without previously identified genetic mutations. Results Of the 32 patients who presented with metastatic disease and had their primary tumor in childhood or adolescence, sequence analysis of germline DNA showed SDHB mutations in 23 patients (71.9%), SDHD mutations in three patients (9.4%), VHL mutations in two patients (6.3%), and an absence of a known mutation in four patients (12.5%). The majority of these 32 patients (78.1%) presented with primary tumors in an extra-adrenal location. Conclusion The majority of patients with metastatic pheochromocytoma/paraganglioma who presented with a primary tumor in childhood/adolescence had primary extra-adrenal tumors and harbored SDHB mutations. Except for primary tumors located in the head and neck where SDHD genetic testing is advised, we recommend that patients who present with metastatic pheochromocytoma/paraganglioma with primary tumor development in childhood or adolescence undergo SDHB genetic testing before they undergo testing for other gene mutations, unless clinical presentation or family history suggests a different mutation. PMID:21969497

Reversible lesions in the brain parenchyma in Wilson's disease confirmed by magnetic resonance imaging: earlier administration of chelating therapy can reduce the damage to the brain.

PubMed

Kozić, Duško B; Petrović, Igor; Svetel, Marina; Pekmezović, Tatjana; Ragaji, Aleksandar; Kostić, Vladimir S

2014-11-01

The aim of this study was to evaluate the resolution of brain lesions in patients with Wilson's disease during the long-term chelating therapy using magnetic resonance imaging and a possible significance of the time latency between the initial symptoms of the disease and the introduction of this therapy. Initial magnetic resonance examination was performed in 37 patients with proven neurological form of Wilson's disease with cerebellar, parkinsonian and dystonic presentation. Magnetic resonance reexamination was done 5.7 ± 1.3 years later in 14 patients. Patients were divided into: group A, where chelating therapy was initiated < 24 months from the first symptoms and group B, where the therapy started ≥ 24 months after the initial symptoms. Symmetry of the lesions was seen in 100% of patients. There was a significant difference between groups A and B regarding complete resolution of brain stem and putaminal lesions (P = 0.005 and P = 0.024, respectively). If the correct diagnosis and adequate treatment are not established less than 24 months after onset of the symptoms, irreversible lesions in the brain parenchyma could be expected. Signal abnormalities on magnetic resonance imaging might therefore, at least in the early stages, represent reversible myelinolisis or cytotoxic edema associated with copper toxicity.

Quantification of the impact of multifaceted initiatives intended to improve operational efficiency and the safety culture: a case study from an academic medical center radiation oncology department.

PubMed

Chera, Bhishamjit S; Mazur, Lukasz; Jackson, Marianne; Taylor, Kinely; Mosaly, Prithima; Chang, Sha; Deschesne, Kathy; LaChapelle, Dana; Hoyle, Lesley; Saponaro, Patricia; Rockwell, John; Adams, Robert; Marks, Lawrence B

2014-01-01

We have systematically been incorporating several operational efficiency and safety initiatives into our academic radiation oncology clinic. We herein quantify the impact of these initiatives on prospectively collected, clinically meaningful, metrics. The data from 5 quality improvement initiatives, each focused on a specific safety/process concern in our clinic, are presented. Data was collected prospectively: operational metrics recorded before and after implementation of the initiative were compared using statistical analysis. Results from the Agency for Health Care Research and Quality (AHRQ) patient safety culture surveys administered during and after many of these initiatives were similarly compared. (1) Workload levels for nurses assisting with brachytherapy were high (National Aeronautics and Space Administration Task Load Index (NASA-TLX) scores >55-60, suggesting, "overwork"). Changes in work flow and procedure room layout reduced workload to more acceptable levels (NASA-TLX <55; P < .01). (2) The rate of treatment therapists being interrupted was reduced from a mean of 4 (range, 1-11) times per patient treatment to a mean <1 (range, 0-3; P < .001) after implementing standards for electronic communication and placement of monitors informing patients and staff of the treatment machine status (ie, delayed, on time). (3) The rates of replans by dosimetrists was reduced from 11% to 6% (P < .01) through a more systematic pretreatment peer review process. (4) Standardizing nursing and resident functions reduced patient wait times by ≈ 45% (14 min; P < .01). (5) Standardizing presimulation instructions from the physician reduced the number of patients experiencing delays on the simulator (>50% to <10%; P < .01). To assess the overall changes in "patient safety culture," we conducted a pre- and postanalysis using the AHRQ survey. Improvements in all measured dimensions were noted. Quality improvement initiatives can be successfully implemented in an academic radiation oncology department to yield measurable improvements in operations resulting in improvement in patient safety culture. Copyright © 2014 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.

Pathways to multidrug-resistant tuberculosis diagnosis and treatment initiation: a qualitative comparison of patients' experiences in the era of rapid molecular diagnostic tests.

PubMed

Naidoo, Pren; van Niekerk, Margaret; du Toit, Elizabeth; Beyers, Nulda; Leon, Natalie

2015-10-28

Although new molecular diagnostic tests such as GenoType MTBDRplus and Xpert® MTB/RIF have reduced multidrug-resistant tuberculosis (MDR-TB) treatment initiation times, patients' experiences of diagnosis and treatment initiation are not known. This study aimed to explore and compare MDR-TB patients' experiences of their diagnostic and treatment initiation pathway in GenoType MTBDRplus and Xpert® MTB/RIF-based diagnostic algorithms. The study was undertaken in Cape Town, South Africa where primary health-care services provided free TB diagnosis and treatment. A smear, culture and GenoType MTBDRplus diagnostic algorithm was used in 2010, with Xpert® MTB/RIF phased in from 2011-2013. Participants diagnosed in each algorithm at four facilities were purposively sampled, stratifying by age, gender and MDR-TB risk profiles. We conducted in-depth qualitative interviews using a semi-structured interview guide. Through constant comparative analysis we induced common and divergent themes related to symptom recognition, health-care access, testing for MDR-TB and treatment initiation within and between groups. Data were triangulated with clinical information and health visit data from a structured questionnaire. We identified both enablers and barriers to early MDR-TB diagnosis and treatment. Half the patients had previously been treated for TB; most recognised recurring symptoms and reported early health-seeking. Those who attributed symptoms to other causes delayed health-seeking. Perceptions of poor public sector services were prevalent and may have contributed both to deferred health-seeking and to patient's use of the private sector, contributing to delays. However, once on treatment, most patients expressed satisfaction with public sector care. Two patients in the Xpert® MTB/RIF-based algorithm exemplified its potential to reduce delays, commencing MDR-TB treatment within a week of their first health contact. However, most patients in both algorithms experienced substantial delays. Avoidable health system delays resulted from providers not testing for TB at initial health contact, non-adherence to testing algorithms, results not being available and failure to promptly recall patients with positive results. Whilst the introduction of rapid tests such as Xpert® MTB/RIF can expedite MDR-TB diagnosis and treatment initiation, the full benefits are unlikely to be realised without reducing delays in health-seeking and addressing the structural barriers present in the health-care system.

In-flight automated external defibrillator use and consultation patterns

PubMed Central

Brown, AM; Rittenberger, JC; Ammon, CM; Harrington, S; Guyette, FX

2010-01-01

Background Limited information exists about the in-flight use and outcomes associated with automatic external defibrillators (AED) on commercial airlines. Methods We collected self-reported cases of AED use to an airline consultation service from three US airlines between May 2004 and March 2009. We reviewed all available data files, related consult forms, and recordings. For each case, demographics, initial rhythm, shock delivery/success, survival to admission, and ground medical consultation use were obtained. Success was defined as the return of a perfusing rhythm. Initial rhythms were classified as: sinus, heart block, SVT, atrial fibrillation/flutter, asystole, PEA and VF/VT. Results There were a total of 169 AED applications with 40 cardiac arrests. The mean ages were 58 years (SD 15) and 63 years (SD 12) respectively; both populations were 64% male. AEDs were applied for monitoring in 129 (76%) cases with initial rhythms of: sinus 114 (88%); atrial fibrillation/flutter 7 (5%); complete heart block 4 (3%); and SVT 4 (3%). Presenting rhythms among the cardiac arrest population were: asystole 16 (40%); ventricular fibrillation/ventricular tachycardia 10 (25%); and PEA 14 (35%). Fourteen patients were defibrillated including nine of the 10 patients with initial VF/VT and five for the presence of VF/VT after resuscitation for initial PEA/asystole. Defibrillation was advised but not performed in the remaining case of initial VF/VT and no medical consult was obtained. All five successful defibrillations occurred in patients with initial VF/VT. There were 6 (15%; 95% CI 3–27%) survivors with 5 occurring after successful defibrillation for initial VF/VT and one with return of a perfusing rhythm after CPR for a junctional rhythm. Survival in those with VF/VT was 5/10 (50%; 95% CI 14–86%). Medications were delivered twice. The median time to first shock was 19 (IQR 12–24) seconds from AED application. Medical consultation was obtained in 56 (33%) of the 169 AED cases and 14 (35%) of the cardiac arrests. Conclusion AEDs resulted in 50% survival among those with VT/VF in-flight and 14% overall survival for cardiac arrest. Survival is poor among patients presenting with non-shockable rhythms. AEDs are used extensively for in-flight monitoring with significant rhythms identified. Ground medical consultation is sought in only one-third of AED uses and cardiac arrests. PMID:20128705

Anterior cruciate ligament injury: A persistently difficult diagnosis.

PubMed

Parwaiz, Hammad; Teo, Alex Q A; Servant, Christopher

2016-01-01

Historically anterior cruciate ligament (ACL) injuries have been diagnosed poorly. A paper published in Injury in 1996 showed that less than 10% of patients with an ACL injury had the diagnosis made by the first physician to see them and that the average delay from first presentation to diagnosis was 21 months. The aim of our study was to investigate whether an improvement has been made over the last two decades in diagnosing ACL injuries. We identified 160 patients who had an ACL reconstruction performed by a single surgeon between October 2004 and December 2011 and for whom a complete data set was available. Data was extracted retrospectively from the hospital notes and a dedicated patient database. We performed a sub-group analysis comparing patients seen prior to the introduction of an acute knee injury clinic in April 2007 and patients seen after the introduction of the clinic. 75.1% (120/160) of patients presented first to an emergency department (ED) or to their general practitioner (GP), but only 14.4% (23/160) were diagnosed on initial presentation. The median number of healthcare professionals a patient saw prior to a diagnosis of ACL injury was 3. The median delay from injury to presentation was 0 weeks (range 0-885), injury to diagnosis 13 weeks (0-926), presentation to diagnosis 10 weeks (0-924), presentation to a specialist knee clinic 24 weeks (0-1006), and specialist knee clinic to surgery 13 weeks (0-102). The median total time from injury to surgery was 42 weeks (0-1047). Following the implementation of an acute knee injury clinic in 2007, the median delay from presentation to surgery dropped from 59 weeks to 36 weeks (p = 0.050) and there was a significant decrease in the median delay from specialist knee clinic to surgery from 23 to 11 weeks (p=0.002). Over the past two decades there appears to have been little improvement in the early diagnosis of ACL injuries, with only 14.4% of patients being diagnosed correctly at initial presentation. We recommend further education of emergency and primary care clinicians in the diagnosis of ACL injuries, emphasising the importance of the typical history of an ACL injury. The implementation of an acute knee injury clinic may help minimise delays to surgery, which should result in better patient outcomes. Copyright © 2015 Elsevier B.V. All rights reserved.

Preoperative Surgical Discussion and Information Retention by Patients.

PubMed

Feiner, David E; Rayan, Ghazi M

2016-10-01

To assess how much information communicated to patients is understood and retained after preoperative discussion of upper extremity procedures. A prospective study was designed by recruiting patients prior to undergoing upper extremity surgical procedures after a detailed discussion of their operative technique, postoperative care and treatment outcomes. Patients were given the same 20-item questionnaire to fill out twice, at two pre operative visits. An independent evaluator filled out a third questionnaire as a control. Various discussion points of the survey were compared among the 3 questionnaires and retained information and perceived comprehension were evaluated. The average patients' age was 50.3 (27-75) years The average time between the two surveys preoperative 1 and preoperative 2 was 40.7 (7-75) days,. The average patient had approximately 2 years of college or an associate's degree. Patients initially retained 73% (52-90%) of discussion points presented during preoperative 1 and 61% (36-85%) of the information at preoperative 2 p = .002. 50% of patients felt they understood 100% of the discussion, this dropped to only 10% at their preoperative 2 visit. 15% of our patients did not know what type of anesthesia they were having at preoperative 2. A communication barrier between patients and physicians exists when patients are informed about their preoperative surgical discussion. The retention of information presented is worsened with elapsing time from the initial preoperative discussion to the second preoperative visit immediately prior to surgery. Methods to enhance patients' retention of information prior to surgery must be sought and implemented which will improve patients' treatment outcome.

Effect of 24-h continuous rotigotine treatment on stationary and non-stationary locomotion in de novo patients with Parkinson disease in an open-label uncontrolled study.

PubMed

Serrao, Mariano; Ranavolo, Alberto; Conte, Carmela; Davassi, Chiara; Mari, Silvia; Fasano, Alfonso; Chini, Giorgia; Coppola, Gianluca; Draicchio, Francesco; Pierelli, Francesco

2015-11-01

The aim of this study was to investigate the effect of a rotigotine transdermal patch on stationary and non-stationary locomotion in de novo Parkinson disease (PD) patients in an open-label uncontrolled study. A 3-D gait analysis system was used to investigate four different locomotor tasks: steady-state linear walking, gait initiation, gait termination and 180°-turning. A series of gait variables were measured for each locomotor task. PD patients who received rotigotine treatment (4-8 mg) displayed: (1) increased step length, gait speed, cadence and arm oscillations, and reduced double support duration and step asymmetry during steady-state linear gait; (2) increased initial step length during gait initiation; (3) increased final step length and gait speed, and decreased stability index during gait termination; (4) decreased duration of turning and head-pelvis delays during 180°-turning. The main finding that emerges from the present study is that the dopamine agonist rotigotine can improve various aspects of gait in de novo PD patients.

Endoscopic third ventriculostomy for treatment of adult hydrocephalus: long-term follow-up of 163 patients.

PubMed

Isaacs, Albert M; Bezchlibnyk, Yarema B; Yong, Heather; Koshy, Dilip; Urbaneja, Geberth; Hader, Walter J; Hamilton, Mark G

2016-09-01

OBJECTIVE The efficacy of endoscopic third ventriculostomy (ETV) for the treatment of pediatric hydrocephalus has been extensively reported in the literature. However, ETV-related long-term outcome data are lacking for the adult hydrocephalus population. The objective of the present study was to assess the role of ETV as a primary or secondary treatment for hydrocephalus in adults. METHODS The authors performed a retrospective chart review of all adult patients (age ≥ 18 years) with symptomatic hydrocephalus treated with ETV in Calgary, Canada, over a span of 20 years (1994-2014). Patients were dichotomized into a primary or secondary ETV cohort based on whether ETV was the initial treatment modality for the hydrocephalus or if other CSF diversion procedures had been previously attempted respectively. Primary outcomes were subjective patient-reported clinical improvement within 12 weeks of surgery and the need for any CSF diversion procedures after the initial ETV during the span of the study. Categorical and actuarial data analysis was done to compare the outcomes of the primary versus secondary ETV cohorts. RESULTS A total of 163 adult patients with symptomatic hydrocephalus treated with ETV were identified and followed over an average of 98.6 months (range 0.1-230.4 months). All patients presented with signs of intracranial hypertension or other neurological symptoms. The primary ETV group consisted of 112 patients, and the secondary ETV consisted of 51 patients who presented with failed ventriculoperitoneal (VP) shunts. After the initial ETV procedure, clinical improvement was reported more frequently by patients in the primary cohort (87%) relative to those in the secondary ETV cohort (65%, p = 0.001). Additionally, patients in the primary ETV group required fewer reoperations (p < 0.001), with cumulative ETV survival time favoring this primary ETV cohort over the course of the follow-up period (p < 0.001). Fifteen patients required repeat ETV, with all but one experiencing successful relief of symptoms. Patients in the secondary ETV cohort also had a higher incidence of complications, with one occurring in 8 patients (16%) compared with 2 in the primary ETV group (2%; p = 0.010), although most complications were minor. CONCLUSIONS ETV is an effective long-term treatment for selected adult patients with hydrocephalus. The overall ETV success rate when it was the primary treatment modality for adult hydrocephalus was approximately 87%, and 99% of patients experience symptomatic improvement after 2 ETVs. Patients in whom VP shunt surgery fails prior to an ETV have a 22% relative risk of ETV failure and an almost eightfold complication rate, although mostly minor, when compared with patients who undergo a primary ETV. Most ETV failures occur within the first 7 months of surgery in patients treated with primary ETV, but the time to failure is more prolonged in patients who present with failed previous shunts.

Guillain-Barré Syndrome presenting as unilateral hip pain in a child.

PubMed

Neocleous, Charalambos; Diakolios, Konstandinos; Adramerina, Alkistis; Varveris, Evangelos; Tsioni, Vasiliki; Machairidou, Konstandina

2015-01-01

The aim of this report is to highlight the importance of close observation and follow-up in children who present with an acutely irritable hip. This is because hip pain is a symptom of not only benign but also severe conditions. Thus, at the time of the initial presentation, hip pain can be misdiagnosed. This report serves as an example for a wide range of doctors such as orthopaedic surgeons, paediatricians, emergency room physicians or primary care physicians, because these are the first-line doctors who treat patients with a painful hip. We herein present a three-year-old child who was admitted to our hospital with pain in the right leg and initially diagnosed with transient synovitis of the hip. An additional examination two days later, after severe deterioration of the clinical picture, revealed that our patient was actually suffering from Guillain-Barré syndrome. Failure to diagnose Guillain-Barré syndrome and initiating prompt treatment is potentially life-threatening. Clinicians should be aware that hip pain could be the presenting complaint of Guillain-Barré syndrome, a syndrome that has many clinical features. Even when all the clinical and laboratory findings indicate a benign condition, Guillain- Barré syndrome should still be considered. Therefore, close observation and follow-up in children who present with an acutely irritable hip is highly recommended. In this way, the potentially catastrophic consequences of more severe conditions can be avoided. Copyright © 2015 by Academy of Sciences and Arts of Bosnia and Herzegovina.

Pacemakers and implantable cardioverter defibrillators: device longevity is more important than smaller size: the patient's viewpoint.

PubMed

Wild, David M; Fisher, John D; Kim, Soo G; Ferrick, Kevin J; Gross, Jay N; Palma, Eugen C

2004-11-01

The size of pacemakers and implantable cardioverter defibrillators (ICDs) has been diminishing progressively. If two devices are otherwise identical in components, features and technology, the one with a larger battery should have a longer service life. Therefore, patients who receive smaller devices may require more frequent surgery to replace the devices. It is uncertain whether this tradeoff for smaller size is desired by patients. We surveyed 156 patients to determine whether patients prefer a larger, longer-lasting device, or a smaller device that is less noticeable but requires more frequent surgery. The effects of subgroups were evaluated; these included body habitus, age, gender, and patients seen at time of pulse generator replacement (PGR), initial implant, or follow-up. Among 156 patients surveyed, 151 expressed a preference. Of these, 90.1% preferred the larger device and 9.9% the smaller device (P <0.0001). Among thin patients, 79.5% preferred a larger device. Ninety percent of males and 89.2% of females selected the larger device. Among younger patients (< or =72 years), 89.6% preferred the larger device, as did 90.5% of older patients (>72 years). Of patients undergoing PGR or initial implants, 95% favored the larger device, as did 86% of patients presenting for follow-up. The vast majority of patients prefer a larger device to reduce the number of potential replacement operations. This preference crosses the spectrum of those with a previously implanted device, those undergoing initial implants, those returning for routine follow-up, and patients of various ages, gender, and habitus.

Clinical initiatives linking Japanese and Swedish healthcare resources on cancer studies utilizing Biobank Repositories.

PubMed

Nishimura, Toshihide; Kawamura, Takeshi; Sugihara, Yutaka; Bando, Yasuhiko; Sakamoto, Shigeru; Nomura, Masaharu; Ikeda, Norihiko; Ohira, Tatsuo; Fujimoto, Junichiro; Tojo, Hiromasa; Hamakubo, Takao; Kodama, Tatsuhiko; Andersson, Roland; Fehniger, Thomas E; Kato, Harubumi; Marko-Varga, György

2014-12-01

The Tokyo Medical University Hospital in Japan and the Lund University hospital in Sweden have recently initiated a research program with the objective to impact on patient treatment by clinical disease stage characterization (phenotyping), utilizing proteomics sequencing platforms. By sharing clinical experiences, patient treatment principles, and biobank strategies, our respective clinical teams in Japan and Sweden will aid in the development of predictive and drug related protein biomarkers. Data from joint lung cancer studies are presented where protein expression from Neuro- Endocrine lung cancer (LCNEC) phenotype patients can be separated from Small cell- (SCLC) and Large Cell lung cancer (LCC) patients by deep sequencing and spectral counting analysis. LCNEC, a subtype of large cell carcinoma (LCC), is characterized by neuroendocrine differentiation that small cell lung carcinoma (SCLC) shares. Pre-therapeutic histological distinction between LCNEC and SCLC has so far been problematic, leading to adverse clinical outcome. An establishment of protein targets characteristic of LCNEC is quite helpful for decision of optimal therapeutic strategy by diagnosing individual patients. Proteoform annotation and clinical biobanking is part of the HUPO initiative (http://www.hupo.org) within chromosome 10 and chromosome 19 consortia.

Emergent Start Peritoneal Dialysis for End-Stage Renal Disease: Outcomes and Advantages.

PubMed

Nayak, K Shivanand; Subhramanyam, Sreepada V; Pavankumar, Navva; Antony, Sinoj; Sarfaraz Khan, M A

2018-01-01

Initiating renal replacement therapy in late referred patients with central venous catheter (CVC) hemodialysis (HD) causes serious complications. In urgent start peritoneal dialysis, initiating peritoneal dialysis (PD) within 14 days of catheter insertion still needs HD with CVC. We initiated Emergent start PD (ESPD) with Automated PD (APD) at our center within 48 h from the time of presentation. A prospective, case-controlled, intention-to-treat study with 56 patients was conducted between March 2016 and August 2017. Group A (24 patients) underwent conventional PD 14 days after catheter insertion. Group B (32 patients), underwent ESPD with APD. Exit site leak (ESL), catheter blockage, and peritonitis at 90 days were primary outcomes. Technique survival was secondary outcome. Baseline characteristics were similar with 3 episodes of ESLs (9.4%) in the study group and none in the control group (p = 0.123). Catheter blockage (16.7%-Group A, 25%-Group B) and peritonitis (none vs. 9.4% in study group) were similar in terms of statistical details just as technique survival (95%-Group A, 88.2%-Group B at 90 days). ESPD with APD in the unplanned patient is an appropriate approach. © 2018 S. Karger AG, Basel.

Description and management of cutaneous side effects during erlotinib and cetuximab treatment in lung and colorectal cancer patients: a prospective and descriptive study of 19 patients.

PubMed

de Noronha e Menezes, Nuno Miguel Bouças Vasconcelos; Lima, Ricardo; Moreira, Ana; Varela, Paulo; Barroso, Ana; Baptista, Armando; Parente, Bárbara

2009-01-01

Erlotinib and cetuximab are human epidermal growth factor receptor inhibitors (EGFRI) that are approved in monotherapy for the treatment of patients with locally advanced or metastatic non-small cell lung cancer after failure of at least one prior chemotherapy regimen. Papulopustular eruptions are the most frequent adverse effect, their occurrence being associated with increased survival in some studies. We describe 19 patients who presented with a rash located mainly to the face and trunk, without presence of comedones, shortly after initiation of EGFRI therapy. We present our algorithm to manage these patients and their respective responses. We also report other therapeutic options and cutaneous alterations that may be seen.

Initial Misdiagnosis of Proximal Pancreatic Adenocarcinoma Is Associated with Delay in Diagnosis and Advanced Stage at Presentation.

PubMed

Swords, Douglas S; Mone, Mary C; Zhang, Chong; Presson, Angela P; Mulvihill, Sean J; Scaife, Courtney L

2015-10-01

Delay in diagnosis of pancreatic ductal adenocarcinoma (PDAC) is associated with decreased survival. The effect of an initial misdiagnosis on delay in diagnosis and stage of PDAC is unknown. This study is a retrospective review (2000-2010) from a University-based cancer center of new diagnoses of proximal PDAC. Of 313 patients, 98 (31.3 %) had an initial misdiagnosis. Misdiagnosed patients were younger, 62.8 ± 12.6 vs. 68.0 ± 10.1 (p < 0.001). The most common initial misdiagnoses were: gallbladder disease, gastroesophageal reflux disease, and peptic ulcer disease. After excluding patients with prior cholecystectomy, 14.2 % were misdiagnosed with gallbladder disease and underwent cholecystectomy before PDAC diagnosis. Misdiagnosed patients had higher rates of abdominal pain (p < 0.001), weight loss (p = 0.04), and acute pancreatitis (p < 0.001) and lower rate of jaundice (p < 0.001). Median time between symptoms to PDAC diagnosis was longer in misdiagnosed: 4.2 months vs. 1.4 (p < 0.001). Median time from contact with medical provider to axial imaging was longer in misdiagnosed (p < 0.001). Rate of stages III-IV disease at diagnosis was higher in misdiagnosed: 61.2 vs. 43.7 % (p = 0.004), with a 1.4 (95 % confidence interval (CI), 1.12-1.74) higher risk of stages III-IV disease at diagnosis; however, there was no difference in median overall survival in misdiagnosed patients (9.6 months in misdiagnosed vs. 10.3 months in correctly diagnosed, p = 0.69). Initial misdiagnosis of patients with proximal PDAC is associated with delay in diagnosis and higher risk of locally advanced or advanced disease at time of PDAC diagnosis.

Gynaecomastia: an endocrine manifestation of testicular cancer.

PubMed

Hassan, H C; Cullen, I M; Casey, R G; Rogers, E

2008-06-01

Testicular cancer is the most common malignancy affecting young men in their third or fourth decade with an incidence of three to six new cases per 100,000 males each year. When diagnosed and treated in its early stages, it has an excellent cure rate. 7-11% of patients with testicular cancer present initially with gynaecomastia. This may precede the presence of a palpable testicular tumour or hormonal abnormalities. This article evaluates the association between gynaecomastia and testicular cancer and recommends appropriate management for patients presenting with gynaecomastia.

Abdominal Sarcoidosis Mimicking Peritoneal Carcinomatosis.

PubMed

Roh, Won Seok; Lee, Seungho; Park, Ji Hyun; Kang, Jeonghyun

2018-04-01

We present a patient diagnosed with skin sarcoidosis, breast cancer, pulmonary tuberculosis, and peritoneal sarcoidosis with a past history of colorectal cancer. During stage work up for breast cancer, suspicious lesions on peritoneum were observed in imaging studies. Considering our patient's history and imaging findings, we initially suspected peritoneal carcinomatosis. However, the peritoneal lesion was diagnosed as sarcoidosis in laparoscopic biopsy. This case demonstrates that abdominal sarcoidosis might be considered as a differential diagnosis when there is a lesion suspected of being peritoneal carcinomatosis with nontypical clinical presentations.

Safety of once-daily insulin detemir in patients with type 2 diabetes treated with oral hypoglycemic agents in routine clinical practice.

PubMed

Ross, Stuart; Dzida, Grzegorz; Ji, Qiuhe; Kaiser, Marcel; Ligthelm, Robert; Meneghini, Luigi; Nazeri, Avideh; Orozco-Beltran, Domingo; Pan, Changyu; Svendsen, Anne Louise

2014-05-01

The aim of the present study was to identify demographic and treatment factors that were predictive of hypoglycemia in a large cohort of type 2 diabetic patients initiating insulin detemir. The present 24-week observational study of insulin initiation included 17 374 participants from 10 countries. Severe hypoglycemia was defined as an event requiring third party assistance; minor hypoglycemia was defined as a daytime or nocturnal glucose measurement <3.1 mmol/L. Prior to initiating insulin therapy, 4.9% of the cohort reported hypoglycemia (pre-insulin hypoglycemia), with most (94.2%) reporting minor events and 9.6% reporting severe events. Compared with patients without pre-insulin hypoglycemia, those with pre-insulin hypoglycemia had a higher incidence of events of minor hypoglycemia (1.72 vs 4.46 events per patient-year [ppy], respectively), nocturnal hypoglycemia (0.25 vs 1.09 events ppy, respectively), and severe hypoglycemia (<0.01 vs 0.04 events ppy, respectively) at final visit. Age (P < 0.047), body mass index (P < 0.001), a prior history of microvascular disease (P < 0.001), pre-insulin hypoglycemia (P < 0.001), increased number of oral hypoglycemic agents (OHAs; P < 0.001), OHA intensification (P < 0.001), and the use of glinides (P = 0.004) were all found to be independently associated with the occurrence of hypoglycemia during the study. Once-daily insulin detemir therapy was safe and effective, and rates of hypoglycemia were low. Concerns about hypoglycemia should not deter the initiation of basal insulin analogs. © 2013 Ruijin Hospital, Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd.

Bilateral paracoccidioidomycotic iliopsoas abscess associated with ileo-colonic lesion.

PubMed

Duani, Helena; Nunes, Vinícius Rodrigues Taranto; Assumpção, Anísio Borges; Saraiva, Isadora Sofia Borges; Rosa, Rodrigo Macedo; Neiva, Augusto Motta; Pedroso, Enio Roberto Pietra

2012-10-01

This case report shows the clinical development of a patient with systemic paracoccidioidomycosis presenting with lymphatic-intestinalmanifestation. The patient initially had a substantial clinical improvement but had a recrudescence after six months of sulfamethoxazoletrimethoprim oral treatment, with the emergence of feverish syndrome, lumbar pain, and intermittent claudication, characterizing a bilateral iliopsoas muscle abscess, necessitating clinicosurgical therapeutics.

Three-Dimensional Spinal Morphology Can Differentiate Between Progressive and Nonprogressive Patients With Adolescent Idiopathic Scoliosis at the Initial Presentation

PubMed Central

Nault, Marie-Lyne; Mac-Thiong, Jean-Marc; Roy-Beaudry, Marjolaine; Turgeon, Isabelle; deGuise, Jacques; Labelle, Hubert

2014-01-01

Study Design. This is a prospective case-control study. Objective. The objective of this study was to compare 3-dimensional (3D) morphological parameters of the spine at the first visit between a nonprogressive (NP) and a progressive (P) group of immature adolescent idiopathic scoliosis (AIS). Summary of Background Data. Prediction of curve progression remains challenging in AIS at the first visit. Prediction of progression is based on curve type, curve magnitude, and skeletal or chronological age. Methods. A prospective cohort of 133 AIS was followed from skeletal immaturity to maturity (mean, 37 mo). The first group was made up of patients with AIS with a minimum 6-degree progression of the major curve between the first and last follow-up (P) (n = 53) and the second group was composed of patients with NP who reached maturity with less than 6-degree progression (n = 81). Computerized measurements were taken on reconstructed 3-dimensional (3D) spine radiographs of the first visit. There were 6 categories of measurements: angle of plane of maximum curvature, Cobb angles (kyphosis, lordosis), 3D wedging (apical vertebra, apical disks), rotation (upper and lower junctional vertebra, apical vertebra, and thoracolumbar junction), torsion, and slenderness (height/width ratio). t tests were also conducted. Results. There was no statistical difference between the 2 groups for age and initial Cobb angle. P presented significant hypokyphosis, and parameters related to rotation presented significant statistical differences between NP and P (plane of maximal curvature, torsion, and apical axial rotation). Depth slenderness also presented statistical differences. Conclusion. This study confirms that even at the initial visit, 3D morphological differences exist between P and NP AIS. It supports the use of 3D reconstructions of the spine in the initial evaluation of AIS to help predict outcome. Level of Evidence: 3 PMID:24776699

Evaluation of children with lymphatic malformations of the head and neck using the Cologne Disease Score.

PubMed

Wiegand, Susanne; Eivazi, Behfar; Zimmermann, Annette P; Sesterhenn, Andreas M; Werner, Jochen A

2009-07-01

To assess the disease-related impairments of children with lymphatic malformations of the head and neck and their changes after therapy using the Cologne Disease Score (CDS). 29 children with lymphatic malformations of the head and neck were evaluated regarding their symptoms before and after therapy using the CDS. The Wilcoxon test for dependent groups was used to compare the CDS at initial visit before treatment and last visit after treatment. The CDS of patients belonging to the moderate (initial CDS: more than eight points) and advanced disease group (initial CDS: five, six or seven points) significantly increased after therapy while the patients in the severe disease group (initial CDS: lower than four points) showed no significant improvement of CDS. Patients with stage IV and especially stage V lymphatic malformations according to de Serres showed considerably lower pre- and posttherapeutic CDS levels than those of stage I and II. The visual impairment is not mapped by the CDS, therefore item vision should be added to the CDS to make an evaluation of all lymphatic malformations of the head and neck possible. The present series could show that especially patients with a moderate or advanced disease according to the CDS may profit from therapeutic interventions.

Creutzfeldt-Jakob Disease Presenting With Dizziness and Gaze-Evoked Nystagmus: A Case Report.

PubMed

Choi, Yun-Ju; Kang, Kyung-Wook; Lee, Sae-Young; Kang, Seung-Ho; Lee, Seung-Han; Kim, Byeong C

2016-02-01

Sporadic Creutzfeldt-Jakob disease (CJD) is clinically characterized by rapidly progressive dementia combined with other cardinal symptoms, such as myoclonus, visual or cerebellar disturbances, extrapyramidal or pyramidal disturbance, and akinetic mutism. However, as an initial manifestation, focal neurologic deficits other than the aforementioned or nonspecific generalized symptoms may lead to a misdiagnosis or a delayed diagnosis. The authors report a case of 66-year-old male patient with sporadic CJD who had dizziness, gaze-evoked nystagmus (GEN), and other central eye signs (impaired smooth pursuit, saccadic dysmetria) as an initial manifestation without dementia. The central eye signs led us to perform brain magnetic resonance images, which showed abnormal cortical high-signal intensity in both the cerebral and cerebellar hemispheres including the vestibulocerebellum. We reached a presumptive diagnosis of CJD, but the findings did not meet diagnostic criteria for probable CJD at that time. Three weeks after the initial work-ups, the patient presented with typical neurological findings of CJD: rapidly progressive dementia, akinetic mutism, and myoclonus of the left arm. Cerebrospinal fluid was positive for 14-3-3 protein, and electroencephalography showed periodic sharp wave complexes. In this patient, GEN and other central eye signs provided diagnostic clues for CJD. These unusual neurological manifestations may help physicians have a thorough knowledge of early deficits of CJD.

Late recovery in cerebral fat embolism

PubMed Central

Srikanth, KP; Sundararajan, SR; Rajasekaran, S

2014-01-01

Fat embolism syndrome presenting primarily with cerebral manifestations is rarely reported. We report here two such patients who showed complete recovery following initial deterioration. The aim of these reports is to highlight that prolonged intensive care and good rehabilitation can lead to normal neurologic recovery despite poor clinical picture initially. The importance of adequate oxygenation to prevent secondary brain damage is emphasized during prolonged recovery. PMID:24600071

High-resolution axial MR imaging of tibial stress injuries

PubMed Central

2012-01-01

Purpose To evaluate the relative involvement of tibial stress injuries using high-resolution axial MR imaging and the correlation with MR and radiographic images. Methods A total of 33 patients with exercise-induced tibial pain were evaluated. All patients underwent radiograph and high-resolution axial MR imaging. Radiographs were taken at initial presentation and 4 weeks later. High-resolution MR axial images were obtained using a microscopy surface coil with 60 × 60 mm field of view on a 1.5T MR unit. All images were evaluated for abnormal signals of the periosteum, cortex and bone marrow. Results Nineteen patients showed no periosteal reaction at initial and follow-up radiographs. MR imaging showed abnormal signals in the periosteal tissue and partially abnormal signals in the bone marrow. In 7 patients, periosteal reaction was not seen at initial radiograph, but was detected at follow-up radiograph. MR imaging showed abnormal signals in the periosteal tissue and entire bone marrow. Abnormal signals in the cortex were found in 6 patients. The remaining 7 showed periosteal reactions at initial radiograph. MR imaging showed abnormal signals in the periosteal tissue in 6 patients. Abnormal signals were seen in the partial and entire bone marrow in 4 and 3 patients, respectively. Conclusions Bone marrow abnormalities in high-resolution axial MR imaging were related to periosteal reactions at follow-up radiograph. Bone marrow abnormalities might predict later periosteal reactions, suggesting shin splints or stress fractures. High-resolution axial MR imaging is useful in early discrimination of tibial stress injuries. PMID:22574840

Ineffective initiation contributes to deficient verbal and non-verbal fluency in patients with schizophrenia.

PubMed

Krukow, Paweł; Harciarek, Michał; Morylowska-Topolska, Justyna; Karakuła-Juchnowicz, Hanna; Jonak, Kamil

2017-09-01

Patients with schizophrenia (SCH) show impaired verbal and non-verbal fluency. However, these individuals' fluctuations in words or designs generation efficiency over time, a phenomenon that may significantly affect fluency, have never been studied. Thus, the aim of this research was to investigate if individuals with SCH may present with alternations in the dynamics of the information production and its control as well as to test if the potential abnormalities in this regard might affect these patients' overall performance on both verbal and non-verbal fluency tasks. Forty-four patients with SCH and 40 healthy controls (HC) completed both verbal (phonological, semantic) and non-verbal fluency tests. To analyse processing efficiency changes over time, the period in which subjects had to generate words or designs (60 s) has been divided into 15-s sections. In comparison to HCs, individuals with SCH obtained significantly lower total scores for all fluency measures. Furthermore, group differences in the dynamics of the test performance also emerged, with SCH patients having a significantly worse production during the initial 15 s of each fluency task. Additionally, the initial production deficiency seen in patients with SCH has accounted for these individuals' total performance. Moreover, comparisons of errors distribution over time during the phonemic and figural fluency performance also revealed differences, suggesting there was a rapid depletion in maintaining of cognitive control in the SCH sample. Inefficient fluency in SCH may arise from a more general initiation deficits that may partly account for these patients' cognitive problems.

Characterizing the pain score trajectories of hospitalized adult medical and surgical patients: a retrospective cohort study.

PubMed

Kannampallil, Thomas; Galanter, William L; Falck, Suzanne; Gaunt, Michael J; Gibbons, Robert D; McNutt, Robert; Odwazny, Richard; Schiff, Gordon; Vaida, Allen J; Wilkie, Diana J; Lambert, Bruce L

2016-12-01

Pain care for hospitalized patients is often suboptimal. Representing pain scores as a graphical trajectory may provide insights into the understanding and treatment of pain. We describe a 1-year, retrospective, observational study to characterize pain trajectories of hospitalized adults during the first 48 hours after admission at an urban academic medical center. Using a subgroup of patients who presented with significant pain (pain score >4; n = 7762 encounters), we characterized pain trajectories and measured area under the curve, slope of the trajectory for the first 2 hours after admission, and pain intensity at plateau. We used mixed-effects regression to assess the association between pain score and sociodemographics (age, race, and gender), pain medication orders (opioids, nonopioids, and no medications), and medical service (obstetrics, psychiatry, surgery, sickle cell, intensive care unit, and medicine). K-means clustering was used to identify patient subgroups with similar trajectories. Trajectories showed differences based on race, gender, service, and initial pain score. Patients presumed to have dissimilar pain experiences (eg, sickle vs obstetrical) had markedly different pain trajectories. Patients with higher initial pain had a more rapid reduction during their first 2 hours of treatment. Pain reduction achieved in the 48 hours after admission was approximately 50% of the initial pain, regardless of the initial pain. Most patients' pain failed to fully resolve, plateauing at a pain score of 4 or greater. Visualizing pain scores as graphical trajectories illustrates the dynamic variability in pain, highlighting pain responses over a period of observation, and may yield new insights for quality improvement and research.

Chronic Granulomatous Disease Presenting as Aspergillus Fumigatus Pneumonia in a Previously Healthy Young Woman

PubMed Central

Williams, David; Kadaria, Dipen; Sodhi, Amik; Fox, Roy; Williams, Glenn; Threlkeld, Stephen

2017-01-01

Patient: Female, 23 Final Diagnosis: Chronic granulomatous disease Symptoms: Fever • shortness of breath Medication: — Clinical Procedure: Bronchoscopy Specialty: Pulmonology Objective: Unusual clinical course Background: Chronic Granulomatous Disease (CGD) is a rare immunodeficiency disease caused by a genetic defect in the NADPH (nicotinamide adenine dinucleotide phosphate) oxidase enzyme, resulting in increased susceptibility to bacterial and fungal infections. The inheritance can be X-linked or autosomal recessive. Patients usually present with repeated infections early in life. We present an unusual case of a 23-year-old patient diagnosed with CGD. Case Report: A 23-year-old white woman with no previous history of recurrent infections presented with complaints of fever, shortness of breath, and diffuse myalgia. She had been treated twice for similar complaints recently, but without resolution. She was febrile, tachypneic, tachycardic, and hypoxic at presentation. Physical examination revealed diffuse inspiratory rales. Laboratory results showed leukocytosis. Her initial chest X-ray and CT chest showed reticular nodular interstitial lung disease pattern. Despite being on broad-spectrum antibiotics for 5 days, she continued to require supplemental oxygen and continued to be tachypneic, with minimal activity. Initial diagnostic tests, including bronchoscopy with biopsy and lavage, did not reveal a diagnosis. She then underwent a video-assisted thoracoscopic surgery (VATS) lung biopsy. The biopsy slides showed suppurative granulomatous inflammation affecting greater than 50% of the parenchymal lung surface. Fungal hyphae consistent with Aspergillus were present in those granulomas. A diagnosis of CGD was made and she was started on Voriconazole. She improved with treatment. Her neutrophil burst test showed negative burst on stimulation, indicating phagocytic dysfunction consistent with CGD. Autosomal recessive CGD was confirmed by genetic testing. Conclusions: CGD can present in adulthood without any previous symptoms and signs. Clinicians should consider this disease in patients presenting with recurrent or non-resolving infections. Timely treatment and prophylaxis has been shown to reduce serious infections as well as mortality in these patients. PMID:28377567

Altered mental status in a U.S. Army Special Forces Soldier.

PubMed

Brandon, Jonathan; Hill, Guyon J

2011-01-01

Special Operations medical provider must be familiar with the differential diagnosis for a patient with altered mental status since it includes multiple life-threatening illnesses. Potential diagnoses include meningitis, encephalitis, malaria and many others. While preparing to evacuate to definitive care from an austere location, they must also be prepared to initiate empiric therapy that is specific to the patient and the area of operations. We present a case of a U.S. Army Special Forces Soldier that developed limbic encephalitis of presumed Herpes Simplex Virus (HSV) origin. We will review the key differential diagnoses for this presentation with a focus on infectious etiologies. We will also summarize current diagnostic and therapeutic strategies. Our recommendation is to initiate oral acyclovir when IV acyclovir is not available and this diagnosis cannot be excluded. 2011.

Association of low non-invasive near-infrared spectroscopic measurements during initial trauma resuscitation with future development of multiple organ dysfunction.

PubMed

Nicks, Bret A; Campons, Kevin M; Bozeman, William P

2015-01-01

Near-infrared spectroscopy (NIRS) non-invasively monitors muscle tissue oxygen saturation (StO2). It may provide a continuous noninvasive measurement to identify occult hypoperfusion, guide resuscitation, and predict the development of multiple organ dysfunction (MOD) after severe trauma. We evaluated the correlation between initial StO2 and the development of MOD in multi-trauma patients. Patients presenting to our urban, academic, Level I Trauma Center/Emergency Department and meeting standardized trauma-team activation criteria were enrolled in this prospective trial. NIRS monitoring was initiated immediately on arrival with collection of StO2 at the thenar eminence and continued up to 24 hours for those admitted to the Trauma Intensive Care Unit (TICU). Standardized resuscitation laboratory measures and clinical evaluation tools were collected. The primary outcome was the association between initial StO2 and the development of MOD within the first 24 hours based on a MOD score of 6 or greater. Descriptive statistical analyses were performed; numeric means, multivariate regression and rank sum comparisons were utilized. Clinicians were blinded from the StO2 values. Over a 14 month period, 78 patients were enrolled. Mean age was 40.9 years (SD 18.2), 84.4% were male, 76.9% had a blunt trauma mechanism and mean injury severity score (ISS) was 18.5 (SD 12.9). Of the 78 patients, 26 (33.3%) developed MOD within the first 24 hours. The MOD patients had mean initial StO2 values of 53.3 (SD 10.3), significantly lower than those of non-MOD patients 61.1 (SD 10.0); P=0.002. The mean ISS among MOD patients was 29.9 (SD 11.5), significantly higher than that of non-MODS patients, 12.1 (SD 9.1) (P<0.0001). The mean shock index (SI) among MOD patients was 0.92 (SD 0.28), also significantly higher than that of non-MODS patients, 0.73 (SD 0.19) (P=0.0007). Lactate values were not significantly different between groups. Non-invasive, continuous StO2 near-infrared spectroscopy values during initial trauma resuscitation correlate with the later development of multiple organ dysfunction in this patient population.

XP11.2 translocation renal cell carcinoma: clinical experience of Taipei Veterans General Hospital.

PubMed

Hung, Chia-Chen; Pan, Chin-Chen; Lin, Chih-Chieh; Lin, Alex T L; Chen, Kuang-Kuo; Chang, Yen-Hwa

2011-11-01

Xp11.2 translocation renal cell carcinoma (RCC), a recently recognized distinct subtype of RCC, is characterized by various translocations, all involving the TFE3 transcription factor gene. These rare cancers occur predominantly in children and young adults and comprise about one-third of pediatric RCCs. In the present study, we review the clinical course of Xp11.2 translocation renal cell carcinoma in our institution. We identified eight cases with Xp11.2 translocation RCC between 2007 and 2010 from the pathological archives of the Taipei Veterans General Hospital. We retrospectively analyzed the patients' characteristics, clinical manifestations, and specific pathological features for definitive diagnosis, surgical and systemic treatment and clinical outcome of these rare cancers. Patients were aged 20 years to 49 years (mean age 28 years) with female predominance (6 females, 2 males). One patient presented with asymptomatic renal mass detected incidentally during abdominal sonography. Four patients complained of flank or abdominal pain, and the other three complained of gross hematuria at initial presentation. The mean tumor size was 9.2 cm (range, 4 cm-17 cm). Seven patients underwent radical nephrectomy for the primary tumor, while one presented with multiple metastases. All cases were confirmed by TFE3 immunohistochemistry, a sensitive and specific marker of tumors with TFE3 gene fusion, which showed positive nuclear staining. Three patients presented initially with metastatic diseases, and another three patients progressed to lung, liver and bone metastases at eight, seven and nine months postoperatively. Although RT-PCR and DNA sequencing are the final diagnoses of the molecular identity of Xp11.2 translocation RCC, experienced pathologists could confirm the histologic diagnosis based on the distinctive morphologic features with positive TFE3 immunochemical nuclear stain. Surgical resection is the only treatment. The role of systemic therapy for local recurrence and metastasis remains to be determined. Copyright © 2011. Published by Elsevier B.V.

Gender Differences in Presentation, Management, and In-Hospital Outcomes for Patients with AMI in a Lower-Middle Income Country: Evidence from Egypt

PubMed Central

Butala, Neel M.; Desai, Mayur M.; Linnander, Erika L.; Wong, Y. Rex; Mikhail, Daoud G.; Ott, Lesli S.; Spertus, John A.; Bradley, Elizabeth H.; Aaty, Ahmed Abdel; Abdelfattah, Alia; Gamal, Ayman; Kholeif, Hatem; Baz, Mohamed El; Allam, A. H.; Krumholz, Harlan M.

2011-01-01

Background Many studies in high-income countries have investigated gender differences in the care and outcomes of patients hospitalized with acute myocardial infarction (AMI). However, little evidence exists on gender differences among patients with AMI in lower-middle-income countries, where the proportion deaths stemming from cardiovascular disease is projected to increase dramatically. This study examines gender differences in patients in the lower-middle-income country of Egypt to determine if female patients with AMI have a different presentation, management, or outcome compared with men. Methods and Findings Using registry data collected over 18 months from 5 Egyptian hospitals, we considered 1204 patients (253 females, 951 males) with a confirmed diagnosis of AMI. We examined gender differences in initial presentation, clinical management, and in-hospital outcomes using t-tests and χ2 tests. Additionally, we explored gender differences in in-hospital death using multivariate logistic regression to adjust for age and other differences in initial presentation. We found that women were older than men, had higher BMI, and were more likely to have hypertension, diabetes mellitus, dyslipidemia, heart failure, and atrial fibrillation. Women were less likely to receive aspirin upon admission (p<0.01) or aspirin or statins at discharge (p = 0.001 and p<0.05, respectively), although the magnitude of these differences was small. While unadjusted in-hospital mortality was significantly higher for women (OR: 2.10; 95% CI: 1.54 to 2.87), this difference did not persist in the fully adjusted model (OR: 1.18; 95% CI: 0.55 to 2.55). Conclusions We found that female patients had a different profile than men at the time of presentation. Clinical management of men and women with AMI was similar, though there are small but significant differences in some areas. These gender differences did not translate into differences in in-hospital outcome, but highlight differences in quality of care and represent important opportunities for improvement. PMID:22022463

Clinical problem solving: monster on the hook--case problems in neurosurgery.

PubMed

Muh, Carrie R; Boulis, Nicholas M; Chandler, William F; Barkan, Ariel L; Mosunjac, Marina B; Oyesiku, Nelson M

2011-03-01

Nonfunctioning and functioning pituitary tumors can present in numerous ways. They may be difficult to diagnose correctly and, even with proper treatment, may lead to complications. We present the case of a patient who presented with a large, invasive sellar mass and underwent both medical and surgical treatment for this lesion. The patient's course did not progress as was expected from his initial workup. The patient's history, physical examination, laboratory values, pathologic specimens, and radiologic findings are discussed. His management before, during, and after medical therapy and surgery is reviewed by pituitary experts from 2 different institutions. Aspects of diagnosis and management of sellar lesions are presented and reviewed in the literature. Neurosurgeons frequently treat patients with sellar lesions and should remember that despite modern laboratory, pathologic, and radiologic techniques, the diagnosis and treatment of these lesions is not always clear.

Preemptive warfarin dose reduction after initiation of sulfamethoxazole-trimethoprim or metronidazole.

PubMed

Powers, Anna; Loesch, Erin B; Weiland, Anthony; Fioravanti, Nicole; Lucius, David

2017-07-01

To evaluate the utility of a preemptive warfarin dose reduction at the time of initiation of either sulfamethoxazole-trimethoprim or metronidazole, a retrospective chart review of patients who received an outpatient prescription for warfarin and either sulfamethoxazole-trimethoprim and/or metronidazole from July 1, 2011 to July 1, 2015 was conducted. Clinical outcomes compared Veterans who had a warfarin dose reduction and those who did not within 120 h (5 days) of antibiotic initiation. The primary outcome compared the pre-and post-antibiotic International Normalized Ratio (INR) of patients in the intervention group (warfarin dose reduction) with those in the control group (no intervention). Secondary outcomes assessed incidence of thromboembolic and major bleeding events within 30 days of antibiotic completion. Fifty patients were assessed. Forty-nine patients had at least one follow-up appointment; 126 follow-up visits were evaluated. There was a statistically significant difference for the change in therapeutic INR at the first follow-up appointment (p = 0.029) for those patients in the control group. On average, the patients in the intervention group required fewer follow-up visits (p = 0.019). There were no statistically significant differences for the overall rate of therapeutic INR values between groups, as well as no instances of a thromboembolic or major bleeding events during the follow-up period. Clinically significant differences were observed for patients who received a preemptive warfarin dose reduction upon initiation of sulfamethoxazole-trimethoprim or metronidazole. Patients in the intervention group required fewer follow-up appointments and were more likely maintain a therapeutic INR within the 30 days following the antibiotic course. Results of this study will be presented the at Pharmacy and Therapeutics committee in an effort to seek approval for policy development to initiate a local preemptive warfarin dose adjustment as a standard of practice.

Predictive factors for rebleeding and death in alcoholic cirrhotic patients with acute variceal bleeding: a multivariate analysis.

PubMed

Krige, Jake E J; Kotze, Urda K; Distiller, Greg; Shaw, John M; Bornman, Philippus C

2009-10-01

Bleeding from esophageal varices is a leading cause of death in alcoholic cirrhotic patients. The aim of the present single-center study was to identify risk factors predictive of variceal rebleeding and death within 6 weeks of initial treatment. Univariate and multivariate analyses were performed on 310 prospectively documented alcoholic cirrhotic patients with acute variceal hemorrhage (AVH) who underwent 786 endoscopic variceal injection treatments between January 1984 and December 2006. All injections were administered during the first 6 weeks after the patients were treated for their first variceal bleed. Seventy-five (24.2%) patients experienced a rebleed, 38 within 5 days of the initial treatment and 37 within 6 weeks of their initial treatment. Of the 15 variables studied and included in a multivariate analysis using a logistic regression model, a bilirubin level >51 mmol/l and transfusion of >6 units of blood during the initial hospital admission were predictors of variceal rebleeding within the first 6 weeks. Seventy-seven (24.8%) patients died, 29 (9.3%) within 5 days and 48 (15.4%) between 6 and 42 days after the initial treatment. Stepwise multivariate logistic regression analysis showed that six variables were predictors of death within the first 6 weeks: encephalopathy, ascites, bilirubin level >51 mmol/l, international normalized ratio (INR) >2.3, albumin <25 g/l, and the need for balloon tube tamponade. Survival was influenced by the severity of liver failure, with most deaths occurring in Child-Pugh grade C patients. Patients with AVH and encephalopathy, ascites, bilirubin levels >51 mmol/l, INR >2.3, albumin <25 g/l and who require balloon tube tamponade are at increased risk of dying within the first 6 weeks. Bilirubin levels >51 mmol/l and transfusion of >6 units of blood were predictors of variceal rebleeding.

Armored brain: A case report and review of the literature.

PubMed

Petraglia, Anthony L; Moravan, Michael J; Jahromi, Babak S

2011-01-01

Calcified chronic subdural hematomas occur infrequently. When the calcifications are extensive and bilateral, the condition is termed "armored brain". We describe a case of "armored brain" incidentally discovered in an adult presenting with abdominal pain and mild headaches, long after initial placement of a ventriculo-peritoneal (VP) shunt. A 38-year-old woman, treated at infancy with a VP shunt, presented with a 2-month history of abdominal pain associated with nausea and chills. She was neurologically intact on exam. An abdominal computed tomography (CT) scan demonstrated a rim-enhancing loculated fluid collection surrounding the patient's distal VP shunt catheter tip. As a part of her initial work-up, she received a head CT to evaluate the proximal VP shunt, which demonstrated large bilateral chronic subdural hematomas with heavily calcified walls. She was eventually taken to the operating room (OR) for replacement of the distal catheter. It was felt that her acute clinical presentation was unrelated to the bilateral, calcified subdural hematomas and thus the decision was made to manage them conservatively. This rare complication of chronic shunting for hydrocephalus is sometimes referred to as armored brain. Surgery for armored brain is infrequently indicated and beneficial in only small subgroup of patients, with management guided by clinical presentation. Our patient fully recovered after shunt revision alone.

Non-Small Cell Lung Carcinoma: Clinical Reasoning in the Management of a Patient Referred to Physical Therapy for Costochondritis.

PubMed

Hensley, Craig P; Emerson, Alicia J

2018-06-01

Chest pain, a frequent complaint for seeking medical care, is often attributed to musculoskeletal pathology. Costochondritis is a common disorder presenting as chest pain. Initial physical therapist examination emphasizes red flag screening. Reexamination throughout the episode of care is critical, particularly when patients are not progressing and/or in the presence of complex pain presentations. The purpose of this case report is to describe the clinical reasoning process in the management of a patient referred to physical therapy with a medical diagnosis of costochondritis. A 59-year-old woman presented with a 5-month history of left-sided chest pain that had progressed to include the cervical and shoulder regions. She reported multiple psychosocial stressors; a depression screen was positive. She reported a history of asthma and smoking and improvement in recent fatigue, coughing, dyspnea, and sweating. At the initial visit, shoulder, cervical, and thoracic active and passive range of motion and joint mobility testing reproduced her pain. Allodynia was present throughout the painful areas in the left upper quarter. The patient demonstrated improvement over 30 days (4 visits). On her fifth visit (day 35), she reported an exacerbation of her chest and upper extremity pain and noted increased fatigue, sweating, dyspnea, and loss of appetite. Even though her pain was again reproduced with musculoskeletal testing, the physical therapist contacted the patient's physician regarding the change in presentation. A subsequent chest computed tomography scan revealed a non-small cell lung adenocarcinoma. Cancer can masquerade as a musculoskeletal condition. This case highlights the importance of screening, clinical reasoning, and communication throughout the episode of care, particularly in the presence of chronic pain and psychosocial stressors.

Bilateral Central Retinal Vein Occlusion as Presenting Feature of Chronic Myeloid Leukemia

PubMed Central

Narang, Subina; Gupta, Panchmi; Sharma, Anuj; Sood, Sunandan; Palta, Anshu; Goyal, Shilpa

2016-01-01

Central retinal vein occlusion (CRVO) is a common pathology of the retinal vasculature. Patients with CRVO usually present with a drop in visual acuity. The condition bears no specific therapy; treatment is aimed at the management of potentially blinding complications, of which there are many. With majority of cases being unilateral, bilateral CRVO is usually associated with an underlying systemic illness such as a hyperviscosity syndrome. Here, we present a case of a patient, who presented with a bilateral drop in vision diagnosed as bilateral CRVO on ophthalmic evaluation. Systemic workup revealed the presence of an underlying undiagnosed chronic myeloid leukemia. An initial presentation to the ophthalmologist is a rare occurrence in leukemic patients. This case report highlights the role of the ophthalmologist in diagnosing a potentially life-threatening hematological illness. PMID:27555710

Do patient expectations about arthroplasty at initial presentation for hip or knee pain differ by sex and ethnicity?

PubMed

Lavernia, Carlos J; Contreras, Juan S; Parvizi, Javad; Sharkey, Peter F; Barrack, Robert; Rossi, Mark D

2012-10-01

Many studies show gender and ethnic differences in healthcare utilization and outcomes. Patients' presurgical cognitions regarding surgical outcomes also may vary by gender and ethnicity and play a role in explaining utilization and outcome differences. However, it is unclear whether and to what extent gender and ethnicity play a role in patients' presurgical cognitions. Do gender and ethnicity influence outcome expectations? Is arthroplasty-related knowledge affected by gender and ethnicity? Do gender and ethnicity influence willingness to pay for surgery? In a prospective, multicenter study we gave 765 patients an anonymous questionnaire on expectations, arthroplasty knowledge, and preferences before their consultation for hip and/or knee pain, from March 2005 to July 2007. Six hundred seventy-two of the 765 patients (88%) completed questionnaires. Non-Hispanics and men were more likely to indicate they would be able to engage in more activities. Non-Hispanics and men had greater arthroplasty knowledge. Hispanics and women were more likely to report they would not pay for a total joint arthroplasty (TJA) relative to non-Hispanics and men. Sex and ethnic differences in patients presenting for their initial visit to the orthopaedists for hip or knee pain influence expectations, knowledge, and preferences concerning TJAs. Longitudinal study of relationships between patients' perceptions and utilization or outcomes regarding TJA is warranted.

Ventricular Arrhythmic Storm after Initiating Sacubitril/Valsartan.

PubMed

Vicent, Lourdes; Juárez, Miriam; Martín, Irene; García, Jorge; González-Saldívar, Hugo; Bruña, Vanesa; Devesa, Carolina; Sousa-Casasnovas, Iago; Fernández-Avilés, Francisco; Martínez-Sellés, Manuel

Sacubitril/valsartan was approved recently for the treatment of patients with heart failure and reduced ejection fraction. We present 6 cases of ventricular arrhythmia, that occurred shortly after sacubitril/valsartan initiation, that required drug withdrawal. Other potential triggering factors of electrical storm were ruled out and, from the arrhythmic perspective, all of the patients were stable in the previous year. Our aim is to describe the possible association of sacubitril/valsartan with arrhythmic storm. This was an observational monocentric study performed in the first 7 months of sacubitril/valsartan commercialization in Spain (October 2016). All patients were included in the SUMA (Sacubitril/Varsartan Usado Ambulatoriamente en Madrid [Sacubitril/Valsartan Used in Outpatients in Madrid]) registry. Patients were consecutively enrolled on the day they started the drug. Ventricular arrhythmic storm was defined as ≥2 episodes of sustained ventricular arrhythmia or defibrillator therapy application in 24 h. From 108 patients who received the drug, 6 presented with ventricular arrhythmic storm (5.6%). Baseline characteristics were similar in the patients with and without ventricular arrhythmic storm. The total number of days that sacubitril/valsartan was administered to each patient was 5, 6, 44 (8 since titration), 84, 93, and 136 (105 since titration), respectively. Our data are not enough to infer a cause-and-effect relationship. Further investigations regarding a potential proarrhythmic effect of sacubitril/valsartan are probably needed. © 2018 S. Karger AG, Basel.

Does treatment of paradoxical vocal fold movement disorder decrease asthma medication use?

PubMed

Kramer, Scott; deSilva, Brad; Forrest, L Arick; Matrka, Laura

2017-07-01

To determine whether diagnosis and treatment of paradoxical vocal fold movement disorder (PVFMD) leads to decreased asthma medication use. Secondary objectives include determining initial rate of asthma medication use, characterizing symptom improvement, and correlating with pulmonary function testing (PFT). Prospective observational study. Patients newly diagnosed with PVFMD at a single institution were recruited to participate. Medication questionnaires were completed at the initial visit, at the first return visit for therapy, and at 6 months. PFTs were reviewed when available. Sixty-six patients were recruited; the study was closed early because findings reached significance. Fifty-six patients (85%) were taking asthma medication at presentation. Forty-four patients presented with PFTs, and two-thirds were normal. Forty-two patients completed follow-up questionnaires; 79% decreased asthma medication use (P < .001), and 82% reported symptom improvement. Seventy-seven percent of patients participated in therapy and 23% did not, with equal rates of decrease in asthma medication use between these groups. Outcomes did not vary based on PFT pattern (i.e., obstructive vs. nonobstructive, P = .75). Diagnosis and treatment of PVFMD lead to a decline in asthma medication use. This decrease occurred alongside symptom improvement and irrespective of PFT findings. Use of asthma medication in this patient population is high, at 85%. 4. Laryngoscope, 127:1531-1537, 2017. © 2016 The American Laryngological, Rhinological and Otological Society, Inc.

Ocular morbidities of juvenile idiopathic arthritis-associated uveitis in adulthood: results from a tertiary center study.

PubMed

Oray, Merih; Khachatryan, Naira; Ebrahimiadib, Nazanin; Abu Samra, Khawla; Lee, Stacey; Foster, C Stephen

2016-09-01

To describe the clinical and visual outcomes of juvenile idiopathic arthritis (JIA)-associated uveitis in adults and to examine risk factors for ongoing inflammation in adulthood. Medical records were reviewed for patients with JIA-associated uveitis who were >16 years old at the final visit (the last visit prior to data collection). In total, 135 eyes of 77 patients (70 female, 7 male) were included. The mean age of patients at the final visit was 29.72 ± 11.27 years. The number of eyes with visual acuity of ≤20/50 and ≤20/200 at the final visit was 37 (28 %) and 20 (15 %), respectively; at least one ocular complication was present in 72 % of eyes. Band keratopathy was the most frequent complication (42 %), followed by cataract (25 %), posterior synechiae (22 %), maculopathy (22 %), ocular hypertension (13 %), and hypotony (5 %). At the final visit, patients who were >16 years of age at presentation to the Massachusetts Eye Research and Surgery Institution had more ocular complications and a greater degree of vision loss than patients who were ≤16 years of age. Ongoing inflammation at the final visit was noted in 40 patients (52 %). The presence of posterior synechiae, hypotony, cataract at presentation, and a history of cataract surgery prior to presentation were predictive of ongoing inflammation in adulthood in univariate analysis. The presence of hypotony and posterior synechiae at the initial visit were predictive factors in multivariate analysis. JIA-associated uveitis may be associated with ongoing inflammation, ocular complications, and severe visual impairment in adulthood. The presence of posterior synechiae and hypotony at the initial visit is predictive of ongoing inflammation.

Methicillin-Resistant Staphylococcus aureus in Foot Osteomyelitis.

PubMed

Ashong, Chester N; Raheem, Shazia A; Hunter, Andrew S; Mindru, Cezarina; Barshes, Neal R

Conflicting studies exist regarding the impact of methicillin-resistant Staphylococcus aureus (MRSA) on increased time to wound healing, future need for surgical procedures, and likelihood of treatment failure in patients with diabetic foot osteomyelitis. The purpose of this study is to determine the overall significance of MRSA in predicting treatment failure in bone infections of the foot and to determine an appropriate pre-operative and empiric post-operative antibiotic regimen. Patients presenting with an initial episode of "probable" or "definite" foot osteomyelitis were included for review and analysis if the following criteria were met: (1) Osteomyelitis occurred in the foot (i.e., distal to the malleoli of the ankle); episodes occurring above the ankle were excluded. (2) Patients received either no antibiotics or only oral antibiotics for long-term treatment; episodes managed with long-term parenteral antibiotics were excluded. (3) The infection was managed initially with medical therapy or conservative surgical therapy; episodes managed with major (above-ankle) amputation as the initial treatment were excluded. The primary objective of this study was to assess whether episodes of foot osteomyelitis associated with MRSA resulted in treatment failure more frequently than not. Of 178 episodes included in the study, 50 (28.1%) episodes had treatment failure. Median time-to-treatment failure was 60 days (range 7-598 days). In 28.1% (9/32 episodes) in which treatment failure occurred and 39.0% (41/105) episodes in which no treatment failure occurred, MRSA was present. The presence of MRSA was not significantly associated with treatment failure (p = 0.99). The presence of MRSA in bone culture and whether antibiotic use had anti-MRSA activity was not associated with increased treatment failure of diabetic foot osteomyelitis in our institution. Empiric antibiotic coverage of MRSA may not be necessary for many patients presenting with foot osteomyelitis.