Abstract Background Group A Streptococcal (GAS) necrotizing fasciitis is a critical emergency. Patients with necrotizing fasciitis principally present to emergency departments (EDs), but most studies ...are focused on hospitalized patients. Objective An ED patient-based retrospective study was conducted to investigate the clinical characteristics, associated factors, and outcomes of GAS necrotizing fasciitis in the ED. Methods Patients visiting the ED from January 2005 through December 2011 with the diagnosis of GAS necrotizing fasciitis were enrolled. All patients with the diagnosis of noninvasive skin and soft-tissue infections caused by GAS were included as the control group. Results During the study period, 75 patients with GAS necrotizing fasciitis were identified. Males accounted for 84% of patients. The most prevalent underlying disease was diabetes mellitus (45.3%). Bullae were recognized in 37.3% of patients. One third of cases were complicated by bacteremia. Polymicrobial infections were found in 30.7% of patients. Overall mortality rate for GAS necrotizing fasciitis was 16%. Patients aged >60 years with diabetes mellitus, liver cirrhosis, and gout were considerably more likely to have GAS necrotizing fasciitis than noninvasive infections. Patients presenting with bacteremia, shock, duration of symptoms/signs <5 days, low white blood cell count, low platelet count, and prolonged prothrombin time were associated with increased mortality. Surgery is a significantly negative factor for mortality of patients with GAS necrotizing fasciitis (odds ratio = 0.16; 95% confidence interval 0.002−0.16; p < 0.001). Conclusions A better understanding of the associated factors and initiation of adequate treatments will allow for improved survival after GAS necrotizing fasciitis.
Summary Background The association between enterovirus infections in children and risk of leukaemia is unclear. We aimed to assess the risk of leukaemia after enterovirus infection in children. ...Methods We did a nationwide retrospective cohort study by analysing data from the National Health Insurance Research Database (NHIRD) in Taiwan. Children with enterovirus infections aged younger than 18 years were identified. With use of computer-generated random numbers, children not infected with enterovirus were randomly selected and frequency matched (1:1) with children infected with enterovirus by sex, age, urbanisation level, parental occupation, and index year of enterovirus infection. We only included children with complete baseline data for age and sex and who had at least three clinic visits with the diagnosis of enterovirus infection. The diagnosis date of the first clinic visit for the enterovirus infection was defined as the index date for initiation of follow-up person-year measurement and participants. All study patients were followed up until they developed leukaemia, were lost to follow-up, withdrew from the NHI programme, or until the end of the study without leukaemia (censored). Our primary endpoint was a diagnosis of leukaemia during follow-up. Findings Insurance claims data for 3 054 336 children younger than 18 years were randomly selected from all insured children in the NHIRD. We identified 282 360 children infected with enterovirus and 282 355 children not infected with enterovirus between Jan 1, 2000, and Dec 31, 2007. The incidence density rates of leukaemia were 3·26 per 100 000 person-years for the enterovirus-infected and 5·84 per 100 000 person-years for the non-enterovirus-infected cohorts. The risk of leukaemia was significantly lower in the enterovirus-infected cohort than in the non-enterovirus-infected cohort (adjusted subhazard ratio SHR 0·44, 95% CI 0·31–0·60; p<0·0001). Children infected with enterovirus have a reduced risk of both lymphocytic leukaemia (adjusted SHR 0·44, 0·30–0·65; p<0·0001) and acute myeloid leukaemia (adjusted SHR 0·40, 0·17–0·97; p=0·04). Herpangina and hand-foot-and-mouth disease were the main diseases associated with the reduced risk of leukaemia. Interpretation The association between enterovirus infection and the reduced risk of developing leukaemia supports Greaves' delayed infection hypothesis for the cause of childhood leukaemia. Funding Taiwan Ministry of Health and Welfare, Academia Sinica, NRPB Stroke Clinical Trial Consortium, Tseng-Lien Lin Foundation, Taiwan Brain Disease Foundation, Katsuzo and Kiyo Aoshima Memorial Funds, China Medical University Hospital, and Taiwan Ministry of Education.
Other risk factors that could be associated with STSS include previous surgery, viral infections (varicella and influenza), and nonsteroid anti-inflammatory drugs use 10. Besides fever and shock, the ...clinical manifestations of STSS include nausea, vomiting, diarrhea, abdominal pain, and flu-like symptoms 10,11. Because STSS usually displays diverse manifestations, ED physicians should take this catastrophic disease into consideration in patients who present with shock and have a history of trauma, even if trivial, before admission.
Phaeohyphomycosis of the central nervous system is rare but typically associated with high mortality. Treatment has not been standardized, but the combination of antifungal chemotherapy with surgical ...debridement is recommended. We report a 73-year-old, retired, male timber merchant with acute meningitis caused by Cladosporium sphaerospermum. The patient, who had well-controlled type 2 diabetes mellitus, presented with fever and weakness of the lower limbs. No brain abscess was apparent by cranial computed tomography. C. sphaerospermum was isolated from the cerebral spinal fluid and identified based on both morphology and DNA sequencing. He was treated with combination antifungal chemotherapy with amphotericin B and voriconazole for 28 days, followed by voriconazole monotherapy for 46 days. To date, the patient has recovered without significant sequelae. This patient represents the first reported case of cerebral phaeohyphomycosis caused by C. sphaerospermum. Moreover, the therapy was successful for totally less than 3 months of treatment duration.
Summary Rac GTPase activating protein 1 (RACGAP1) plays a regulatory role in initiation of cytokinesis, control of cell growth and differentiation, and tumor malignancy, making it a potential ...prognostic biomarker. RACGAP1 is present in the nucleus, but a diffuse distribution in the cytoplasm also occurs. The aim of this study was to determine the impact of nuclear and cytoplasmic expression of RACGAP1 on clinical outcome to provide further evidence of a role in colorectal cancer. RACGAP1 expression was analyzed by immunohistochemistry in 166 cancer specimens from primary colorectal cancer patients. The mean follow-up time after surgery was 5.4 years (range, 0.01-13.10 years). The prognostic value of RACGAP1 on overall survival was validated by Kaplan-Meier analysis and Cox regression models. RACGAP1 is expressed in colorectal specimen and is present in both the nucleus and cytoplasm in different amounts. Colorectal cancer patients had opposite prognoses depending on the site of RACGAP1 expression. Patients with high nuclear RACGAP1 expression had poor outcomes, whereas those with high cytoplasmic RACGAP1 expression had favorable prognosis ( P = .003 and P = .001, respectively). Patients with low nuclear but high cytoplasmic RACGAP1 expression had better survival compared with those with other combinations ( P < .001). We suggest that RACGAP1 expression levels in the nucleus and cytoplasm, determined by immunohistochemical staining, predict opposite clinical outcomes and that both could be independent prognostic markers for colorectal cancer.
Endometriosis Presenting as Bloody Ascites and Shock Lin, Jiun-Nong, MD; Lin, Hsing-Lin, MD; Huang, Chun-Kai, MD ...
The Journal of emergency medicine,
2010, 2010-Jan, 2010-01-00, 20100101, Letnik:
38, Številka:
1
Journal Article
Recenzirano
Abstract Endometriosis is defined as the presence of ectopic foci of endometrial tissue outside the uterine cavity. Many patients are asymptomatic, but others present protean symptoms, including ...headache, cyclic hemoptysis, pleural effusion, and ascites depending on the endometrial implantation sites. Although massive ascites has been reported as a manifestation of endometriosis, hypovolemic shock is unusual. We report a case of endometriosis presenting as shock and bloody ascites to show that endometriosis can result in acute abdomen with shock. A 29-year-old female presented to our Emergency Department (ED) complaining of light-headedness and palpitations. Examination suggested hypovolemic shock. Ultrasonography revealed massive ascites and paracentesis showed bloody ascites. Exploratory laparoscopy showed endometriosis over the left broad ligament. After fluid resuscitation and electrocauterization of the endometriosis, the patient's condition stabilized, and she was discharged 5 days after admission. This case is presented to raise awareness that endometriosis can present with hypovolemic shock.
The 12-lead electrocardiogram (ECG) is a commonly used tool to access left atrial enlargement, which is a marker of left ventricular diastolic dysfunction (LVDD). The aim of this study was to ...evaluate any association of the P-wave measurements in ECG with left atrial volume (LAV) index and LVDD.
This study enrolled 270 patients. In this study, 4 ECG P-wave parameters corrected by heart rate, that is, corrected P-wave maximum duration (PWdurMaxC), corrected P-wave dispersion (PWdisperC), corrected P-wave area (PWareaC) and corrected mean P-wave duration (meanPWdurC), were measured. LAV and left ventricular diastolic parameters were measured from echocardiography. LVDD was defined as a pseudonormal or restrictive mitral inflow pattern.
The 4 P-wave parameters were significantly correlated with the LAV index after adjusting for age, sex, diabetes, hypertension, coronary artery disease, body mass index and diastolic blood pressure in multivariate analysis. The standardized β coefficients of PWdurMaxC, PWdisperC, meanPWdurC and PWareaC were 0.338, 0.298, 0.215 and 0.296, respectively. The 4 P-wave parameters were also significantly correlated with LVDD after multivariate logistic regression analysis. The odds ratios (95% confidence intervals) of PWdurMaxC, PWdisperC, meanPWdurC and PWareaC were 1.03 (1.01-1.04), 1.02 (1.04-1.04), 1.04 (1.02-1.07) and 1.01 (1.00-1.02), respectively.
This study demonstrated that PWdurMaxC, PWdisperC, meanPWdurC and PWareaC were important determinants of the LAV index and LVDD. Therefore, screening patients by means of the 12-lead ECG may be helpful in identifying a high-risk group of increased LAV index and LVDD.
Background Endoscopic epinephrine injection is the conventional means of treating bleeding ulcers. However, recurrent bleeding still occurs in 10% to 30% of cases. In such cases, the role of ...endoscopic combination therapy (endoscopic hemoclip plus dilute epinephrine injection) is unclear. Objective This prospective study compares the efficacies of epinephrine injection alone and epinephrine injection combined with hemoclip therapy in treating high-risk bleeding ulcers. Methods This study enrolled 105 patients hospitalized for hematemesis, melena, or hematochezia. Endoscopy was performed within 24 hours of admission, and those patients with active spurting, oozing, nonbleeding visible vessels, or adherent clots were enrolled. Each patient was randomly assigned either endoscopic combination therapy (N = 52) or diluted epinephrine injection alone (N = 53). Results Initial hemostasis was achieved in 51 patients treated with combination therapy and 49 patients with epinephrine injection therapy (98% vs 92%, P = .18). Bleeding recurred in 2 patients in the combination therapy group and 11 patients in the epinephrine injection group (3.8% vs 21%, P = .008). Among the patients with recurrent bleeding, repeated combination therapy was more effective than repeated injection therapy in achieving permanent hemostasis (100% vs 33%, P = .02). No patient required an emergency operation in the combination therapy group. However, 5 patients in the epinephrine injection group underwent emergency surgery to arrest bleeding (0% vs 9%, P = .023). Conclusions Endoscopic combination therapy is also useful in achieving permanent hemostasis and reducing the rate of recurrent bleeding and a need for emergency surgery in patients with high-risk bleeding ulcers.
Abstract Background The roadmap concept provides a strategy to maximize hepatitis B virus suppression and minimize drug resistance by add-on or switching therapy in patients with a suboptimal ...response at Week 24. The efficacy of this strategy in routine clinical practice remains to be validated. Objective The aim of our study was to validate the roadmap concept in the treatment of chronic hepatitis B, and to investigate the virologic efficacy and kinetics of quantitative hepatitis B surface antigen (qHBsAg) during telbivudine therapy in a real-world setting. Methods A prospective, cohort study enrolled 96 consecutive, treatment-naïve patients with chronic hepatitis B receiving telbivudine therapy. At Week 24, only 17 of 42 (40%) partial or inadequate responders (hepatitis B virus DNA 60–2000 and >2000 IU/mL, respectively) followed the roadmap model and consented to adefovir add-on therapy. The remaining patients continued to receive telbivudine monotherapy. Results At Week 96, none of the patients receiving adefovir add-on therapy, and 28% of patients receiving telbivudine monotherapy, either partial or inadequate responders, developed genotypic resistance ( P = 0.03). Poor early qHBsAg kinetics (an increase in qHBsAg >0.4 log IU/mL at Week 12) was the only significant predictor of genotypic resistance (adjusted hazard ratio = 13.83; 95% CI, 1.79–106.76; P = 0.01). Telbivudine monotherapy was efficacious in 94% of partial responders who did not have poor early qHBsAg kinetics, remaining free of drug resistance after 2 years. Conclusions The application of the roadmap model with add-on adefovir therapy prevented genotypic resistance. However, telbivudine monotherapy achieved a good response in the majority of partial responders who did not have poor early qHBsAg kinetics. Poor early qHBsAg kinetics was an early predictor of genotypic resistance at Week 96. Modification of the roadmap model to incorporate early qHBsAg kinetics may further optimize the efficacy of the treatment strategy of hepatitis B virus.
