Abnormal Laboratory Test Research Articles

Predicting the severity of dengue fever in children on admission based on clinical features and laboratory indicators: application of classification tree analysis

BackgroundDengue fever is a re-emerging viral disease commonly occurring in tropical and subtropical areas. The clinical features and abnormal laboratory test results of dengue infection are similar to those of other febrile illnesses; hence, its accurate and timely diagnosis for providing appropriate treatment is difficult. Delayed diagnosis may be associated with inappropriate treatment and higher risk of death. Early and correct diagnosis can help improve case management and optimise the use of resources such as hospital staff, beds, and intensive care equipment. The goal of this study was to develop a predictive model to characterise dengue severity based on early clinical and laboratory indicators using data mining and statistical tools.MethodsWe retrieved data from a study of febrile illness in children at Angkor Hospital for Children, Cambodia. Of 1225 febrile episodes recorded, 198 patients were confirmed to have dengue. A classification and regression tree (CART) was used to construct a predictive decision tree for severe dengue, while logistic regression analysis was used to independently quantify the significance of each parameter in the decision tree.ResultsA decision tree algorithm using haematocrit, Glasgow Coma Score, urine protein, creatinine, and platelet count predicted severe dengue with a sensitivity, specificity, and accuracy of 60.5%, 65% and 64.1%, respectively.ConclusionsThe decision tree we describe, using five simple clinical and laboratory indicators, can be used to predict severe cases of dengue among paediatric patients on admission. This algorithm is potentially useful for guiding a patient-monitoring plan and outpatient management of fever in resource-poor settings.

Laboratory Abnormalities in Polyneuropathy and Electrophysiological Correlations

To study the frequency of laboratory test abnormalities, and electrophysiological correlations, we performed a retrospective chart review of 226 patients with polyneuropathy. The frequency of laboratory test abnormalities, and correlations with electrophysiological findings were explored. Abnormal glucose handling tests were the most common findings (54%), followed by paraproteinemia (21%) and anemia (21%). The frequencies of paraproteinemia and anemia in our cohort were significantly higher than previously reported. In addition, several laboratory abnormalities correlated with electrophysiological findings of median neuropathy at the wrist, expanding current knowledge about the deleterious effects of various metabolic and hematologic derangements at this site.

Bainbridge-Ropers syndrome with ASXL3 gene variation in a child and literature review

Objective: To investigate the clinical manifestations and genetic features of a child with Bainbridge-Ropers syndrome caused by ASXL3 gene variation and review the literature. Methods: Clinical data and genetic features were collected and analyzed from a child with Bainbridge-Ropers syndrome who was diagnosed in Bao'an Maternity and Child Health Hospital in November 2016. "ASXL3" and "Bainbridge-Ropers" were used as key words to search at China National Knowledge Infrastructure, Wangfang Data Knowledge Service Platform, PubMed and Human Gene Mutation Database up to June 2017. Results: A 2(9/12) years old girl was presented with psychomotor retardation, feeding difficulty, hypotonia and specific craniofacial phenotype. She showed severe growth retardation (height: 84 cm, body weight: 8.0 kg (both were less than 3(rd) percentile rank of the children at the same age) and head circumference: 46 cm(=3rd percentile rank)), without obvious abnormalities in laboratory tests and neuroimaging tests. A de novo heterozygous nonsense variation: c.3349C>T(p.R1117*) in ASXL3 gene was identified by the whole exome sequencing, and the novel variation was classified into pathologic variant based on Standards and guidelines for the interpretation of sequence variants from ACMG. According to literature retrieval, no Chinese cases with ASXL3 variation had been reported. Totally 28 cases including the present girl harboring ASXL3 variations with detailed clinical information were reported. Thirty-one variations in ASXL3 gene were involved, including 1 missense variation and 30 loss of function variations, which were all de novo variations. Conclusions: The clinical features of Bainbridge-Ropers syndrome include severe psychomotor retardation, feeding difficulties, hypotonia and specific facial features. The heterozygous nonsense variation in ASXL3 gene is the cause of the patient. All the pathogenic variations in ASXL3 gene are de novo and loss of function variations.

Ambulatory blood pressure monitoring in school children with a history of extreme prematurity.

Extremely premature children have a higher incidence of High Blood Pressure (HBP) and risk of renal damage due to decreased glomerular count with consequent hyperfiltration of the remnants. To assess the prevalence of altered blood pressure values in outpatient measurement and ambulatory blood pressure monitoring (ABPM) in preterm infants ≤ 32 weeks and/ or ≤ 1,500 g birth weight between 5 and 7 years of age, as well as the presence of early renal damage markers. An isolated measurement of blood pressure, ABPM and laboratory tests (microalbuminuria/creatininuria ratio in an isolated urine sample, serum creatinine, blood urea nitrogen and urinalysis) were performed. 30 patients were recruited, of whom valid measu rements of ABPM were obtained in 19 cases, of which nine (47,4%) presented some abnormalities, principally nocturnal day/night difference or DIP absent. No abnormal laboratory tests were found. Our study detected a high prevalence of abnormalities in ABPM principally DIP absence, which has been related to an increased risk of progression to hypertension. The importance of per forming ABPM in the study is emphasized in patients with risk factors for developing hypertension in order to detect early alterations and close management and follow-up.

Disseminated intravascular coagulation scoring in children with newly diagnosed acute leukemia

Background Patients with acute leukemia (AL) commonly present with abnormalities in laboratory tests of blood coagulation. Coagulation abnormalities and disseminated intravascular coagulation (DIC) have been extensively studied in acute promyelocytic leukemia, but only a limited number of studies addressed this issue in children with other types of AL. Objective The aim of this study was to detect DIC by using the International Society of Thrombosis and Haemostasis scoring system, for both nonovert and overt DIC, among newly diagnosed children with AL. Participants and methods The study was a diagnostic test accuracy study including 25 children presenting with newly diagnosed AL (lymphoblastic and myeloid) and admitted to the Hematology–Oncology Unit at Alexandria University Children’s Hospital. They were consecutively recruited between October 2016 and March 2017. Coagulation studies including prothrombin time, D-dimer, fibrinogen, antithrombin III, and protein C levels were assessed, and the International Society of Thrombosis and Haemostasis scoring system was used for defining nonovert and overt DIC. Results The age of patients included in the present study ranged from 17 to 149 months, with a median of 48 months; males and females were almost equally represented. At baseline assessment, 10 (40%) of 25 patients had a positive overt DIC score and only seven (28%) of 25 had a positive nonovert DIC score. Bleeding manifestations were a common problem in the present study, as 16 (64%) patients presented with bleeding symptoms, being more frequently in patients with an overt DIC positive score (P=0.040). The median platelet count (P=0.023), D-dimer level (P=0.000), and fibrinogen level (P=0.010) showed a significant statistical difference between patients with either positive or negative overt DIC score, whereas neither white blood cells count, absolute blasts count, hemoglobin, prothrombin time, antithrombin III nor protein C levels did. Conclusion Our data confirm that children with AL have some hemostatic derangement at baseline. A positive overt or nonovert DIC score was not statistically related to a worse end of induction remission status or a significantly higher 28-day mortality rate. Larger multicenter studies are needed to determine the most clinically relevant hemostatic abnormalities and adapt more sensitive and specific scoring system for DIC in children with hematological malignancies.

Routine Screening Laboratory Studies for Nonheat Stroke Field Heat Injuries Are Unnecessary: A Retrospective Review.

Heat injuries are common in the military training environment. Base policies often mandate that heat causalities require evaluation at a higher level of care, which comes at significant use of resources. Laboratory studies are often ordered routinely, but their utility is unclear at this time. This project evaluated the use of screening laboratory studies for heat casualties brought to Bayne-Jones Army Community Hospital, Fort Polk, Louisiana. Casualties brought from the field directly to the emergency department (ED) were included. Abnormalities in laboratory study findings, admission/discharge rates, and length of stay were documented. From May through September 2014, 104 casualties were seen in the ED because of heat injury. Laboratory tests were ordered for 101 patients. Of these, 11 patients were admitted to the hospital because of laboratory, history, and/or physical examination abnormalities. Nine were discharged in less than 24 hours. The remaining two were discharged within 48 hours; both had documented altered mental status on arrival to the ED. Laboratory test abnormalities were seen in most of the patients and appeared to have no impact on the decision to admit. Routine laboratory studies appeared to have low clinical utility in this patient population. A more targeted approach based on the history and physical examination may reduce military resource use.

Study of Related Biochemical Tests and PTH in End Stage Renal Disease Patients in Iran

Introduction: End-stage renal disease (ESRD) patients usually have abnormalities in various laboratory tests. The aim of this study is evaluating of the rate of various laboratory tests in ESRD patient to reduce the risk of mortality and prevent them of other diseases.Methods: In this cross-sectional study a total of 300 patients who had ESRD and had been on hemodialysis treatment for at least 6 months were selected. The laboratory tests consisted of measurement of high density lipoprotein, triglyceride, cholesterol, fasting blood sugar, parathyroid hormone, alanine transferase, aspartate transferase, alkaline phosphatase, creatinine, blood urea nitrogen, calcium, phosphorous, sodium, potassium, and albumin.Results: The study population included 52.3% males and 47.7% females with average age of 41.5 ± 14.3 years. The high serum level of Chol (˃200 mg/dL) and TG (˃160 mg/dL) are 48.7%, 32.3%, respectively. About 98% were in high risk of range HDL (˂45 mg/dL). All of participants had over normal range of BUN and about 96% of them were over normal range of Cr. Rate of high serum level of Na, K, P, and Ca were 3.7%, 52%, 54.3%, and 14.6%, respectively.Discussion: Depend the result of this study, can understand that great group of patients with ESRD have high risk serum level of lipid indexes. Recent studies showed that there is a clear correlation between HDL cholesterol and cardiovascular risk in ESRD patients and there is correlation between level of triglyceride level and CKD progression. The important risk factors for involving in ESRD are hyperphosphatemia, hypercalcemia, dyslipidemia, and hypoalbuminemia which impact on CVD morbidity directly.Conclusion: In this study observed that most of patient with ESRD have abnormality in their lipid profiles factors, mineral electrolytes factors, and PTH. Regular laboratory checkup can control renal failure (especially ESRD patients) patients. Proper care of body, balanced diet intake, plenty water intake during the day can help them to control these diseases.

Adult-Onset Still's Disease: Persistent Pruritic Erythematous Plaques and Papules

We present a case of a 24 year-old woman with high fever, pruritic erythematous plaques and papules on the trunk and extremities, inflammatory peripheral joint symptoms and sore throat for two weeks. The patient had neutrophilic leucocytosis, elevated acute phase proteins (erythrocyte sedimentation rate, C-reactive protein and ferritin) and increased liver enzymes. Abdominal ultrasonography revealed mild splenomegaly. After the exclusion of infection, malignancy and other rheumatic inflammatory diseases, the patient was diagnosed with adult-onset Still's disease (AOSD) meeting to Yamaguchi criteria. Clinical symptoms and abnormal laboratory tests rapidly improved within days of starting glucocorticoid treatment. The presence of typical evanescent skin rash (salmon-pink) is one of the major criteria of disease, however different skin lesions such as persistent pruritic erythematous plaques and papules have been occasionally reported in association with AOSD on trunk and extremities, which may be confused with other diseases. Therefore, the recognition of the atypical skin lesions with AOSD is necessary for diagnosis and choice treatment of disease.

Reference intervals for hematology test parameters from apparently healthy individuals in southwest Ethiopia.

Background:Clinical laboratory reference intervals are an important tool to identify abnormal laboratory test results. The generating of hematological parameters reference intervals for local population is very crucial to improve quality of health care, which otherwise may lead to unnecessary expenditure or denying care for the needy. There are no well-established reference intervals for hematological parameters in southwest Ethiopia.Objective:To generate hematological parameters reference intervals for apparently healthy individuals in southwest Ethiopia.Methods:A community-based cross-sectional study was conducted involving 883 individuals from March to May 2017. Four milliliter of blood sample was collected and transported to Jimma University Medical Center Laboratory for hematological analysis and screening tests. A hematological parameters were measured by Sysmex XS-500i hematology analyzer (Sysmex Corporation Kobe, Japan). The data were analyzed by SPSS version 20 statistical software. The non-parametric independent Kruskal–Wallis test and Wilcoxon rank-sum test (Mann–Whitney U test) were used to compare the parameters between age groups and genders. The 97.5 percentile and 2.5 percentile were the upper and lower reference limit for the population.Results:The reference interval of red blood cell, white blood cell, and platelet count in children were 4.99 × 1012/L (4.26–5.99 × 1012/L), 7.04 × 109/L (4.00–11.67 × 109/L), and 324.00 × 109/L (188.00–463.50 × 109/L), respectively. The reference interval of red blood cell, white blood cell, and platelet count in adults was 5.19 × 1012/L (4.08–6.33 × 1012/L), 6.35 × 109/L (3.28–11.22 × 109/L), and 282.00 × 109/L (172.50–415.25 × 109/L), respectively. The reference interval of red blood cell, white blood cell, and platelet count in geriatrics were 5.02 × 1012/L (4.21–5.87 × 1012/L), 6.21 × 109/L (3.33–10.03 × 109/L), and 265.50 × 109/L (165.53–418.80 × 109/L), respectively. Most of the hematological parameters showed significant differences across all age groups.Conclusion:Most of the hematological parameters in this study showed differences from similar studies done in the country. This study provided population-specific hematological reference interval for southwest Ethiopians. Reference intervals should also be established in the other regions of the country.

Risk Factors Affecting Adverse Effects of Cyclosporine A in a Real-World Psoriasis Treatment.

BackgroundNo study to date has focused on the changes in laboratory test results and related risk factors in patients with psoriasis treated with prolonged Cyclosporine A (CsA) therapy.ObjectiveThe objective of this study was to investigate the changes of laboratory values and related risk factors in patients with psoriasis treated with CsA in a real-world setting.MethodsRecords of patients with psoriasis treated with CsA at an outpatient clinic were collected, and a Cox proportional hazards regression model was used.ResultsOf the 128 patients included in this study, 28 patients (21.9%) showed laboratory test abnormalities over a mean medication period of 11.6 months. Older age (hazard ratio [HR], 1.174; 95% confidence interval [CI], 1.068~1.370; p=0.007) and pre-existing kidney disease (HR, 0.008; 95% CI, 0~0.205; p=0.001) significantly increased the risk of renal dysfunction. Male sex was the only significant risk factor for liver enzyme elevation (HR, 0.284; 95% CI, 0.081~0.784; p=0.026) and uric acid abnormality (HR, 0.048; 95% CI, 0~0.372; p=0.046).ConclusionThis is an in-depth analysis of laboratory changes and related risk factors in patients with psoriasis treated with CsA. Liver is the most commonly affected organ of CsA toxicity. Older age, male sex, and presence of kidney disease were risk factors associated with laboratory abnormality during CsA treatment.

Characteristics of patients with myelomatous pleural effusion. A systematic review

BackgroundMyelomatous pleural effusion (MPE) is rare in multiple myeloma, and therefore its characteristics are not well defined. MethodsA systematic review (4 online databases) was conducted of articles describing the clinical characteristics of patients with MPE, pleural effusion's biochemical characteristics and treatment efficacy. We analyzed isolated cases and small retrospective series. ResultsWe included 98 articles with a total of 153 patients with MPE. The median age was 62 years, and the ratio of males to females was 1.7:1. The most common symptoms were dyspnea (98.8%), bone pain (100%) and chest pain (95.3%), and the most relevant abnormal laboratory test results were anemia (90.1%) and renal failure (53.8%). MPE was predominantly unilateral (63.9%) and covered more than two-thirds of the hemithorax (54.5%). The pleural fluid (PF) had a haematologic/serohaematologic appearance (87%) and met the criteria for lymphocytic (78.6%) exudate (94.7%). The most cost-effective diagnostic procedures were pleural cytology (95.9%) and the observation of a monoclonal peak in the PF (94.7%). In a significant proportion of patients (54.7%), the MPE did not respond to treatment, and the best response was achieved when chemotherapy (with/without corticosteroids) was combined with therapeutic thoracentesis, chest drainage or pleurodesis. ConclusionsMPE predominates in middle to older age men, is symptomatic and is usually unilateral. PF is an exudate with a hemorrhagic appearance, and the most cost-effective diagnostic procedure is pleural cytology. Treatment response is unfavorable in more than half of patients.

Características de los pacientes con derrame pleural mielomatoso. Revisión sistemática

BackgroundMyelomatous pleural effusion (MPE) is rare in multiple myeloma, and therefore its characteristics are not well defined. MethodsA systematic review (4 online databases) was conducted of articles describing the clinical characteristics of patients with MPE, pleural effusion's biochemical characteristics and treatment efficacy. We analysed isolated cases and small retrospective series. ResultsWe included 98 articles with a total of 153 patients with MPE. The median age was 62years, and the ratio of males to females was 1.7:1. The most common symptoms were dyspnoea (98.8%), bone pain (100%) and chest pain (95.3%), and the most relevant abnormal laboratory test results were anaemia (90.1%) and renal failure (53.8%). MPE was predominantly unilateral (63.9%) and covered more than two-thirds of the hemithorax (54.5%). The pleural fluid (PF) had a haematologic/serohaematologic appearance (87%) and met the criteria for lymphocytic (78.6%) exudate (94.7%). The most cost-effective diagnostic procedures were pleural cytology (95.9%) and the observation of a monoclonal peak in the PF (94.7%). In a significant proportion of patients (54.7%), the MPE did not respond to treatment, and the best response was achieved when chemotherapy (with/without corticosteroids) was combined with therapeutic thoracentesis, chest drainage or pleurodesis. ConclusionsMPE predominates in middle to older age men, is symptomatic and is usually unilateral. PF is an exudate with a haemorrhagic appearance, and the most cost-effective diagnostic procedure is pleural cytology. Treatment response is unfavourable in more than half of patients.

Identification and Characterization of Fenofibrate-Induced Liver Injury.

Fenofibrate is a commonly used hypolipidemic associated with rare instances of hepatotoxicity, and routine liver biochemistry monitoring is recommended. The aim of this study is to describe the presenting clinical features, liver histopathology, and outcomes of 7 cases of acute liver injury associated with fenofibrate. All cases of definite, very likely, and probable drug-induced liver injury (DILI) attributed to fenofibrate enrolled in the DILI Network study between 2004 and 2015 were reviewed. Among 1229 patients with confirmed DILI, 7 cases (0.6%) were attributed to fenofibrate. The median age was 43 (range 37-61) years, and latency to onset was short (5-8weeks) in 4 patients but more prolonged (18-56weeks) in the rest. Laboratory results at presentation showed hepatocellular, mixed, and cholestatic injury, but 6 cases presented with jaundice. No patient had undergone routine monitoring. Four patients required hospitalization and 2 in whom drug discontinuation was delayed had a severe outcome, 1 undergoing liver transplantation, and 1 developing chronic injury and death. Liver biopsy was available in 4 patients and showed diverse injury patterns. Genetic studies showed the presence of the rare HLA-A*33:01 in 3 patients (43 vs. 1% in control populations). The causality scores were highly likely in 5 and probable in 2. Liver injury after fenofibrate exposure occurs with variable latency, enzyme elevation, and histology. Although most cases are self-limited, severe injury and mortality can occur, particularly if drug withdrawal is delayed. Jaundice or abnormal laboratory tests during fenofibrate therapy should trigger prompt discontinuation.

Clinical and laboratory findings of rhabdomyolysis in opioid overdose patients in the intensive care unit of a poisoning center in 2014 in Iran.

OBJECTIVESThe aim of this study was to investigate the clinical and demographic characteristics and some laboratory findings of hospitalized patients with acute opioid toxicity and rhabdomyolysis.METHODSThis cross-sectional study investigated 354 patients hospitalized at Baharloo Hospital in Tehran in 2014 with acute illicit drug toxicity. Data were collected using an investigator-made checklist. The collected data (such as mortality rate, demographic data, and renal function tests, as well as serum biochemical findings) were analyzed by descriptive statistics and the chi-square test.RESULTSA total of 354 patients were admitted to the hospital in 2014 with acute illicit drug toxicity, including 291 males and 63 females. The total number of patients with rhabdomyolysis was 76 (21.5% of the total), of whom 69 (90.8%) were male and 7 (9.2%) were female. Most cases of rhabdomyolysis were associated with methadone abuse, followed by opium abuse. Rhabdomyolysis was most common in those 20-29 and 30-39 years old, with methadone and opium the most commonly abused illicit drugs. The mean blood urea level was 3.8±1.0 mg/dL, and the mean serum potassium and sodium levels were 3.8±0.3 mg/dL and 140.4±4.0 mg/dL, respectively. Five patients, all of whom were male, passed away due to severe renal failure (6.5%).CONCLUSIONSToxicity caused by opioids is associated with clinical complications and laboratory disorders, such as electrolyte disorders, which can lead to lethal or life-threatening results in some cases. Abnormal laboratory test findings should be identified in patients with opioid toxicity in order to initiate efficient treatment.

Clinical characteristics of acute fatty liver of pregnancy in a tertiary Indonesian hospital

Acute fatty liver of pregnancy (AFLP) is a rare, often autosomal recessive disorder with a major risk for maternal and perinatal mortality and morbidity. In order to achieve a more favorable outcome, awareness of its clinical signs and symptoms and early recognition are of pivotal importance. Over a 5-year period, 18 patients were diagnosed with AFLP (one twin, 19 babies). The most common sign and symptoms were jaundice, hypoglycemia, nausea and vomiting, encephalopathy, and hypertension. Abnormal laboratory test results included elevated total/conjugated (direct) bilirubin, AST, ALT, PT, APTT, creatinine, leukocyte count, and hypoalbuminemia. Maternal and fetal mortality rate was high: 66.7% resulted in a maternal death and 57.9% in an intrauterine fetal demise (IUFD). The number of complications was found to correlate with maternal death (p = .042). Surviving AFLP patients had ≤3 complications, while patients with >3 complications on presentation had a high risk of maternal death (OR = 5.0; 95% CI: 0.55–45.4). The presence of hypertension significantly increased the risk of maternal death (OR: 24.5; 95% CI: 1.1–542.8; p = .01). The risk of IUFD was primarily related to gestational age at delivery and birth weight. The high rate of jaundice as presenting symptom of AFLP suggests that Indonesian primary maternity care providers may often miss its important earlier signs and symptoms, in particular de novo onset of nausea and vomiting in late pregnancy.

Rational approach to transfusion in liver transplantation

For over 50 years patients with liver cirrhosis were considered to be at markedly increased risk of bleeding. This dogma was seemingly supported by abnormalities in standard laboratory tests (SLTs), such as the prothrombin time, that were interpreted as indicating a bleeding diathesis. However, publications from the last decade have revealed SLTs to be poor predictors of bleeding and it is now understood that stable patients with cirrhosis have a rebalanced haemostatic system and preserved thrombin generation. Viscoelastic tests (VETs), such as ROTEM® or TEG™ allow dynamic assessment of the entire coagulation process and provide a better illustration of the interactions between pro- and anticoagulants as well as platelets. Despite their documented success in reducing transfusion rates in liver transplantation more than 30 years ago, the adoption of VETs has been met with some resistance and has only recently gained significant momentum. Bleeding risk should be assessed in every patient undergoing invasive intervention and must consider markers of disease severity, underlying coagulation incompetence, anaemia and surgical factors. The recognition that bleeding in this patient cohort is predominantly linked to mechanistic factors such as portal hypertension, rather than primary coagulopathy, has led to a paradigm shift in their perioperative management. Cognizant of their detrimental effect, the use of large volumes of fresh frozen plasma to correct derangements in SLTs has given way to more refined haemostatic management with specific factor concentrates guided by VETs, coupled with measures to minimize portal venous pressure and meticulous surgical hemostasis.

Acute abdomen and septic shock in young lady treated conservatively

Introduction Septic shock is a life-threatening condition that is accompanied by high mortality rates. It is defined as sepsis- induced hypotension that persists despite adequate fluid resuscitation and is associated with hypoperfusion abnormalities and organ dysfunction. Blood cultures are positive in only 40% to 60% of patients with clinical manifestations of septic shock. Aggressive treatment with broad-spectrum regimens and vasopressors is mandatory to increase survival. Case description A 37-year-old lady presented to the emergency unit with an intense, sudden onset periumbilical pain with fever (39oC) and rigor, the last five hours. On physical examination, she was haemodynamically stable with rebound tenderness at palpation of right iliac fossa and right lateral ventricle. Abnormal laboratory tests were leukocytosis (WBC=19.500/µL, neutrophils=96.5%), hypoalbuminemia (3.4gr/dL) and elevated LDH (579U/L). She underwent abdominal CT scan with edema and inflammation of terminal ileum loops, high turbidity of mesenteric fat and high amount of free fluid. She was surgically evaluated and admitted in internal medicine department with triple antibiotic therapy and hydration. Results and conclusions Just after admission, she had recurrent episodes of loss of consciousness and hypotension, refractory in administering fluids. She was treated, according to guidelines, as septic shock with vasopressors (noradrenaline) and broad-spectrum antibiotics (imipenem). She was informed of necessitation for urgent surgical intervention in case of response failure, however, she was gradually improved with postponement of surgery. Despite laboratory deterioration (WBC=44.000/µL, hypoalbuminemia=2.9gr/dL), she remained afebrile after the 2nd day with gradual symptoms' resolution and feeding the 5th day. She was discharged, free of symptoms, 7 days later. Blood cultures were negative. Abdominal MRI, upper and lower endoscopy were normal. Take-home message Early diagnosis and treatment of septic shock is mandatory for rapid and effective treatment of this potentially fatal situation. Aggressive administration of vasopressors and antibiotics are life-saving and may avoid complications or painful therapeutic interventions, such as surgery.

Congenital syphilis in neonates with nonreactive nontreponemal test results

Infants whose mothers had syphilis during pregnancy were studied to determine how often exposed newborns with normal physical examinations and nonreactive nontreponemal serologic tests had abnormal laboratory or radiographic studies. Retrospective analysis of prospectively collected data from infants born to mothers with syphilis and had a normal examination and a nonreactive nontreponemal test. Some infants had IgM immunoblotting, PCR testing or rabbit infectivity testing (RIT) performed. From 1984 to 2002, 115 infants had a nonreactive serum Venereal Disease Research Laboratory (VDRL)/rapid plasma reagin (RPR) test and a normal physical examination at birth. Among 87 infants born to mothers who had untreated syphilis, 4 had a positive serum IgM immunoblot or PCR test, but none had spirochetes recovered by RIT. Two infants had anemia, one had an elevated serum alanine aminotransferase concentration and one with Down's syndrome had direct hyperbilirubinemia. Among 14 infants born to mothers treated <4 weeks before delivery, none had abnormal laboratory or radiographic tests, although 1 of 11 had a reactive serum IgM immunoblot. Among 14 infants born to mothers treated ⩾4 weeks before delivery, none had abnormal laboratory or radiographic tests. Newborns with normal physical examination and nonreactive nontreponemal test results are unlikely to have abnormalities detected on conventional laboratory and radiographic testing.

A community pharmacy-based cardiovascular risk screening service implemented in Iran.

Background:Cardiovascular disease is a major health concern around the world.Objective:To assess the outcomes and feasibility of a pharmacy-based cardiovascular screening in an urban referral community pharmacy in Iran.Methods:A cross sectional study was conducted in a referral community pharmacy. Subjects aged between 30-75 years without previous diagnose of cardiovascular disease or diabetes were screened. Measurement of all major cardiovascular risk factors, exercise habits, medical conditions, medications, and family history were investigated. Framingham risk score was calculated and high risk individuals were given a clinical summary sheet signed by a clinical pharmacist and were encouraged to follow up with their physician. Subjects were contacted one month after the recruitment period and their adherence to the follow up recommendation was recorded.Results:Data from 287 participants were analyzed and 146 were referred due to at least one abnormal laboratory test. The results showed 26 patients with cardiovascular disease risk greater than 20%, 32 high systolic blood pressure, 22 high diastolic blood pressures, 50 high total cholesterol levels, 108 low HDL-C levels, and 22 abnormal blood glucose levels. Approximately half of the individuals who received a follow up recommendation had made an appointment with their physician. Overall, 15.9% of the individuals received medications and 15.9% received appropriate advice for risk factor modification. Moreover, 7.5% were under evaluation by a physician.Conclusion:A screening program in a community pharmacy has the potential to identify patients with elevated cardiovascular risk factor. A plan for increased patient adherence to follow up recommendations is required.

A Collaborative Behavioral Model for Psychiatric Visits in a Pediatric Emergency Department.

Psychiatric pediatric emergency department (PED) visits are associated with extended length of stay (LOS) compared with nonpsychiatric visits. To address delays in definitive care, our PED incorporated a Collaborative Behavioral Model for patients with a psychiatric complaint. We evaluated LOS and 6-month readmission by comparing patients who received a psychiatric consultation through the model with a control group of nonpsychiatric patients. In addition, we assessed the utilization of laboratory tests and imaging and the impact of testing on final patient disposition. A matched-pair retrospective chart review of psychiatric PED visits was conducted for visits from January 1, 2009, to December 31, 2013. Patients who received a psychiatric diagnosis and consultation through the Collaborative Behavioral Model were included. Participants were matched with a control group of similar patients who did not receive a psychiatric diagnosis. One hundred forty-seven patients met all the inclusion criteria. There was no statistical difference in median LOS for patients who received a psychiatric consultation versus nonpsychiatric visits (204 vs 200 minutes; P = 0.35). The 6-month PED readmission rate for psychiatric visits was significantly less than that in the control group (18% vs 32%; P = 0.003). Of the laboratory and imaging studies performed, 1 abnormal laboratory test (1%) and no imaging studies resulted in a change in patient management. Collaborative models, with specialized psychiatric components, can better coordinate the care of mental health visits by providing focused interventions that promote efficient disposition. In addition, laboratory and imaging studies resulted in few changes in management or final disposition.