Consecutive Episodes Research Articles

Predictors of mortality and adverse events in patients with infective endocarditis: a retrospective real world study in a surgical centre

PurposeMortality in infective endocarditis (IE) is still high, and the long term prognosis remains uncertain. This study aimed to identify predictors of long-term mortality for any cause, adverse event rate, relapse rate, valvular and ventricular dysfunction at follow-up, in a real-world surgical centre.MethodsWe retrospectively analyzed 363 consecutive episodes of IE (123 women, 34%) admitted to our department with a definite diagnosis of non-device-related IE. Median follow-up duration was 2.9 years. Primary endpoints were predictors of mortality, recurrent endocarditis, and major non-fatal adverse events (hospitalization for any cardiovascular cause, pace-maker implantation, new onset of atrial fibrillation, sternal dehiscence), and ventricular and valvular dysfunction at follow-up.ResultsMultivariate analysis independent predictors of mortality showed age (HR per unit 1.031, p < 0.003), drug abuse (HR 3.5, p < 0.002), EUROSCORE II (HR per unit 1.017, p < 0.0006) and double valve infection (HR 2.3, p < 0.001) to be independent predictors of mortality, while streptococcal infection remained associated with a better prognosis (HR 0.5, p < 0.04). Major non-fatal adverse events were associated with age (HR 1.4, p < 0.022). New episodes of infection were correlated with S aureus infection (HR 4.8, p < 0.001), right-sided endocarditis (HR 7.4, p < 0.001), spondylodiscitis (HR 6.8, p < 0.004) and intravenous drug abuse (HR 10.3, p < 0.001). After multivariate analysis, only drug abuse was an independent predictor of new episodes of endocarditis (HR 8.5, p < 0.001). Echocardiographic follow-up, available in 95 cases, showed a worsening of left ventricular systolic function (p < 0.007); severe valvular dysfunction at follow-up was reported only in 4 patients, all of them had mitral IE (p < 0.03).ConclusionsThe present study highlights some clinical, readily available factors that can be useful to stratify the prognosis of patients with IE.

Surgery modifies the prognosis of infectious endocarditis: The importance of post surgery clinical evolution in hospital Ibn Rochd Casablanca

Left-sided infectious endocarditis (LSIE) has a poor prognosis and surgery is required in more than half of the patients to improve survival. Our hypothesis was that clinical complications develop after prognosis for the impact of surgery. Among 99 consecutive episodes of LSIE, 26 (26.3%) had heart surgery. Among them, 41 patients (6.3%) died on the same day of surgery, 112 (17.2%) died after the first day of surgery during their hospital stay and 500 (76.5%) were successfully unloaded. We compared the latter two groups and performed a multivariate analysis of hospital mortality. Age (OR 1.02, 95% CI 1.01 to 1.04), perianular complications (OR 1.9, 95% CI 1.2 to 3.2), renal failure after surgery (OR 2, 4, 95% CI 1.3–4.4) but not before surgery, and septic shock after surgery (OR 9.6, 95% CI5.4–17.1), but not before surgery, do not predict death in hospital for LSIE patients who have undergone heart disease surgery. A thorough clinical evaluation for prognostic purposes in infectious endocarditis after surgery is mandatory. Hospital mortality of patients with infectious endocarditis and operated depends mainly on clinical course after surgery.

Validation of a simplified risk prediction model using a cloud based critical care registry in a lower-middle income country.

The use of severity of illness scoring systems such as the Acute Physiology and Chronic Health Evaluation in lower-middle income settings comes with important limitations, primarily due to data burden, missingness of key variables and lack of resources. To overcome these challenges, in Asia, a simplified model, designated as e-TropICS was previously developed. We sought to externally validate this model using data from a multi-centre critical care registry in India. Seven ICUs from the Indian Registry of IntenSive care(IRIS) contributed data to this study. Patients > 18 years of age with an ICU length of stay > 6 hours were included. Data including age, gender, co-morbidity, diagnostic category, type of admission, vital signs, laboratory measurements and outcomes were collected for all admissions. e-TropICS was calculated as per original methods. The area under the receiver operator characteristic curve was used to express the model's power to discriminate between survivors and non-survivors. For all tests of significance, a 2-sided P less than or equal to 0.05 was considered to be significant. AUROC values were considered poor when ≤ to 0.70, adequate between 0.71 to 0.80, good between 0.81 to 0.90, and excellent at 0.91 or higher. Calibration was assessed using Hosmer-Lemeshow C -statistic. We included data from 2062 consecutive patient episodes. The median age of the cohort was 60 and predominantly male (n = 1350, 65.47%). Mechanical Ventilation and vasopressors were administered at admission in 504 (24.44%) and 423 (20.51%) patients respectively. Overall, mortality at ICU discharge was 10.28% (n = 212). Discrimination (AUC) for the e-TropICS model was 0.83 (95% CI 0.812-0.839) with an HL C statistic p value of < 0.05. The best sensitivity and specificity (84% and 72% respectively) were achieved with the model at an optimal cut-off for probability of 0.29. e-TropICS has utility in the care of critically unwell patients in the South Asia region with good discriminative capacity. Further refinement of calibration in larger datasets from India and across the South-East Asia region will help in improving model performance.

Standard treatment approaches for relapsed/refractory chronic lymphocytic leukemia after frontline chemoimmunotherapy.

Despite the effectiveness of chemoimmunotherapy (CIT), in most cases the clinical course of chronic lymphocytic leukemia (CLL) is characterized by consecutive episodes of disease progression and need for therapy. Treatment possibilities for patients with CLL in whom CIT fails whose disease progresses after initial CIT include pathway inhibitors (PIs) and, for selected patients, cellular therapy (ie, allogeneic stem cell transplant, chimeric antigen receptor T cells). PIs (ie, Bruton tyrosine kinase inhibitors, phosphatidylinositol 3-kinase inhibitors, and BCL2 inhibitors) are revolutionizing the treatment of CLL. PIs have proved to be more effective than CIT, both as upfront therapy and for relapsed/refractory disease, largely because they may overcome the negative impact of adverse biomarkers (eg, TP53 aberrations, unmutated IGHV) on outcomes and because of their acceptable toxicity. In this article, the management of patients with relapsed/refractory CLL is discussed, with a particular emphasis on the role of PIs.

Clinical Features and Mortality of Nosocomial Candidemia in Very Old Patients: A Multicentre Italian Study

Introduction: Being elderly is a well-known risk factor for candidemia, but few data are available on the prognostic impact of candidemia in the very old (VO) subjects, as defined as people aged ≥75 years. Objective: The aim of this study was to assess risk factors for nosocomial candidemia in two groups of candidemia patients, consisting of VO patients (≥75 years) and adult and old (AO) patients (18–74 years). In addition, risk factors for death (30-day mortality) were analysed separately in the two groups. Methods: We included all consecutive candidemia episodes from January 2011 to December 2013 occurring in six referral hospitals in north-eastern Italy. Results: A total of 683 nosocomial candidemia episodes occurred. Of those, 293 (42.9%) episodes were in VO and 390 (57.1%) in AO patients. Hospitalization in medical wards, chronic renal failure, urinary catheter, and peripheral parenteral nutrition (PPN) were more common in VO than in AO patients. In the former patient group, adequate antifungal therapy (73.2%) and central venous catheter (CVC) removal (67.6%) occurred less frequently than in AO patients (82.5 and 80%, p < 0.002 and p < 0.004, respectively). Thirty-day mortality was higher in VO compared to AO patients (47.8 vs. 23.6%, p < 0.0001). In AO patients, independent risk factors for death were age (OR 1.04, 95% CI 1.00–1.09, p = 0.038), recent history of chemotherapy (OR 22.01, 95% CI 3.12–155.20, p = 0.002), and severity of sepsis (OR 40.68, 95% CI 7.42–223.10, p < 0.001); CVC removal was associated with higher probability of survival (OR 0.10, 95% CI 0.03–0.33, p < 0.001). In VO patients, independent risk factors for death were PPN (OR 3.5, 95% CI 1.17–10.47, p = 0.025) and hospitalization in medical wards (OR 2.58, 95% CI 1.02–6.53, p = 0.046), while CVC removal was associated with improved survival (OR 0.40, 95% CI 0.16–1.00, p = 0.050). Conclusion: Thirty-day mortality was high among VO patients and was associated with inadequate management of candidemia, especially in medical wards.

Pulmonary artery sling

Abstract Introduction Pulmonary artery sling is a rare congenital vascular anomaly in which the left pulmonary artery originates from the right pulmonary artery, encircles the distal trachea and right main stem bronchus, and requiring early surgical interventions. Case presentation We report a 8-month old girl who presented with 3 consecutive episodes within 2 months of recurrent respiratory symptoms and signs masquerading pneumonia. CT thorax and echocardiography showed an anomalous origin of the left pulmonary artery from the right pulmonary artery passing behind the trachea. A left pulmonary artery reimplantation without tracheoplasty was performed. The child recovered slowly but uneventfully after surgery, and was discharged home in good health after 2-month-stay in the hospital. Conclusion Although rare, pulmonary artery sling should not be overlooked in the differential diagnosis of children with recurrent respiratory symptoms. Prognosis after surgical repair without tracheoplasty seems to be good, and follow-up needs to be done routinely to identify the long-term consequences.

SPONTANEOUS PNEUMOMEDIASTINUM IN AN ADULT ASTHMATIC MALE

SESSION TITLE: Medical Student/Resident Disorders of the Mediastinum Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Pneumomediastinum is a condition usually caused by trauma where air escapes from the lung, airway, or bowel into the chest cavity. CASE PRESENTATION: A 29-year-old male with a history of asthma, active marijuana use, and prior incarceration presented with 4 days of productive cough, wheezing, and pleuritic chest pain. Prior to arrival, he had several consecutive episodes of clear emesis. He was febrile to 101°F and was breathing at 22 breaths/minute with mild accessory muscle usage. Bilateral diffuse rhonchi were noted on auscultation and palpation of his supraclavicular neck revealed crepitus. He had no preceding trauma. CXR displayed subcutaneous gas in the right supraclavicular region. Contrast CT imaging revealed extensive pneumomediastinum in the anterior neck (right>left) without any extravasation of oral contrast or esophageal perforation. There were findings of aspiration in the bilateral lower lobes. He was treated for aspiration pneumonia, asthma exacerbation, and spontaneous pneumomediastinum. An oral challenge was recommended by Thoracic Surgery. His respiratory status improved after antibiotics and nebulizer treatments. Though his crepitus persisted on exam, he tolerated a full diet well. He was discharged home with amoxicillin-clavulanic acid and nebulizers. A repeat CXR 5 days later revealed complete resolution of the pneumomediastinum and subcutaneous gas seen on the previous study. DISCUSSION: Spontaneous pneumomediastinum (SPM) is defined by the presence of air or gas in the mediastinum occurring without a traumatic cause. It is usually seen in young adolescent males, and is rarely seen in adults or children. Air from ruptured alveoli moves towards the mediastinum via the bronchovascular sheath. The most common causes are asthma exacerbation and lower respiratory tract infections, followed by Valsalva maneuvers and vomiting. A clinical triad of chest pain, dyspnea, and subcutaneous emphysema (present in this case) may be seen. Diagnosis is confirmed by chest radiography, and contrast esophagography is indicated when suspicion for esophageal rupture is present; it was necessary here given the patient’s clinical status and vomiting prior to arrival. The disease process is usually self-limited, and treatment aims at addressing underlying causes. The most likely triggers for this patient were asthma exacerbation, vomiting, and pneumonia; his marijuana use (found to be an underappreciated risk factor for developing SPM) may have also played a role. Rare, severe complications include tension pneumothorax/pneumomediastinum or pneumopericardium. CONCLUSIONS: SPM is a rare occurrence of air or gas in the mediastinum without a traumatic cause. The most common triggers are asthma exacerbation and pneumonia; marijuana use is an underappreciated risk factor. Treatment aims at addressing underlying causes. Reference #1: Johnson JN, Jones R, Wills BK. Spontaneous pneumomediastinum. West J Emerg Med 2008;9:217–8 Reference #2: Cicak B, Verona E, Mihatov-Stefanovic I, Vrsalovic R. Spontaneous pneumomediastinum in a healthy adolescent. Acta Clin Croat 2009;48:461–467 Reference #3: Weiss ZF, Gore S, Foderaro A. Pneumomediastinum in marijuana users: a retrospective review of 14 cases. BMJ Open Respir Res 2019 DISCLOSURES: No relevant relationships by Christopher Chu, source=Web Response no disclosure on file for MARUTI KUMARAN; No relevant relationships by Ali Noory, source=Web Response

Changing understanding, perceptions, pain relief of and preference for generic medicines with patient education: An experimental intervention study.

Generic medicines have been associated with less perceived efficacy and more side effects compared to brand name drugs. Educational interventions to improve individuals' negative perceptions of generic medicines show contradictory effects. This study investigated whether an interventional video that informs about the approval process of releasing medicines has better effects on outcomes related to perceptions and effectiveness of generic medicines in participants with headaches, in comparison with another interventional video that addresses bioequivalence between brand name and generic drugs or a control video. Participants with frequent tension headaches were randomized to one of three groups (one of two interventional videos or the control video). One of the interventional videos explained the process of approval of generic medicines (n=34), the other one explained the bioequivalence between brand name and generic drugs (n=35). The control video informed participants about the epidemiology and etiology of headaches (n=34). After watching the video, participants treated their next two consecutive episodes of headache with a brand name and a generic analgesic in randomized order. Self-report measures of understanding and perceptions of and preference for medicines, pain severity and side effects. Linear mixed models showed that both interventional videos improved participants' understanding of generic medicines. The generic drug approval process video enhanced the perceived effectiveness, safety and quality of generic drugs. The bioequivalence video positively influenced the preference for generic drugs. The brand name and generic drug were equally effective in relieving pain in participants who watched either the generic drug approval process or the bioequivalence video. Information about both, approving a switch from brand name medicines to generic counterparts and bioequivalence, can be important and should be addressed in future educational interventions.

A novel, injury-free rodent model of vulnerability for assessment of acute and preventive therapies reveals temporal contributions of CGRP-receptor activation in migraine-like pain.

Development and characterization of a novel injury-free preclinical model of migraine-like pain allowing mechanistic assessment of both acute and preventive treatments. A "two-hit" hyperalgesic priming strategy was used to induce vulnerability to a normally subthreshold challenge with umbellulone, a transient receptor potential ankyrin 1 (TRPA1) activator, in uninjured female and male C57BL/6 mice. Priming (i.e. the first hit) was induced by three consecutive daily episodes of restraint stress; repeated umbellulone was also evaluated for potential priming effects. Sixteen days after the first restraint stress, mice received inhalational umbellulone (i.e. the second hit) to elicit migraine-like pain. Medications currently used for acute or preventive migraine therapy including propranolol (a beta blocker) and sumatriptan (5HT1B/D agonist), as well as olcegepant, an experimental calcitonin gene related peptide (CGRP) receptor antagonist and nor-Binaltorphimine (nor-BNI), an experimental long-acting kappa opioid receptor (KOR) antagonist, were investigated for their efficacy to block priming and prevent or reverse umbellulone-induced allodynia in primed animals. To assess migraine-like pain, cutaneous allodynia was determined by responses to periorbital or hindpaw probing with von Frey filaments. Repeated restraint stress, but not umbellulone exposure, produced transient cutaneous allodynia that resolved within 16 d. Restraint stress produced long-lasting priming that persisted beyond 16 d, as demonstrated by reinstatement of cutaneous allodynia following inhalational umbellulone challenge. Pretreatment with propranolol or nor-BNI prior to restraint stress prevented both transient cutaneous allodynia and priming, demonstrated by a lack of umbellulone-induced cutaneous allodynia. Following establishment of restraint stress priming, olcegepant, but not propranolol or nor-BNI, prevented umbellulone-induced cutaneous allodynia. When administered 1 h after umbellulone, sumatriptan, but not olcegepant, reversed umbellulone-induced cutaneous allodynia in restraint stress-primed rats. We have developed a novel injury-free model with translational relevance that can be used to study mechanisms relevant to migraine-like pain and to evaluate novel acute or preventive treatments. Restraint stress priming induced a state of vulnerability to a subthreshold stimulus that has been referred to as "latent sensitization". The development of latent sensitization could be prevented by blockade of stress pathways with propranolol or with a kappa opioid receptor antagonist. Following establishment of latent sensitization, subthreshold stimulation with umbellulone reinstated cutaneous allodynia, likely from activation of meningeal TRPA1-expressing nociceptors. Accordingly, in restraint stress-primed animals, sumatriptan reversed umbellulone-induced cutaneous allodynia, supporting peripheral sites of action, while propranolol and nor-BNI were not effective. Surprisingly, olcegepant was effective in mice with latent sensitization when given prior to, but not after, umbellulone challenge, suggesting time-dependent contributions of calcitonin gene-related peptide receptor signaling in promoting migraine-like pain in this model. Activation of the calcitonin gene-related peptide receptor participates in initiating, but has a more limited role in maintaining, pain responses, supporting the efficacy of small molecule calcitonin gene-related peptide antagonists as preventive medications. Additionally, the effectiveness of sumatriptan in reversal of established pain thus suggests modulation of additional, non-calcitonin gene-related peptide receptor-mediated nociceptive mechanisms. Kappa opioid receptor antagonists may represent a novel preventive therapy for stress-related migraine.

Predicting Malaria Transmission Dynamics in Dangassa, Mali: A Novel Approach Using Functional Generalized Additive Models.

Mali aims to reach the pre-elimination stage of malaria by the next decade. This study used functional regression models to predict the incidence of malaria as a function of past meteorological patterns to better prevent and to act proactively against impending malaria outbreaks. All data were collected over a five-year period (2012–2017) from 1400 persons who sought treatment at Dangassa’s community health center. Rainfall, temperature, humidity, and wind speed variables were collected. Functional Generalized Spectral Additive Model (FGSAM), Functional Generalized Linear Model (FGLM), and Functional Generalized Kernel Additive Model (FGKAM) were used to predict malaria incidence as a function of the pattern of meteorological indicators over a continuum of the 18 weeks preceding the week of interest. Their respective outcomes were compared in terms of predictive abilities. The results showed that (1) the highest malaria incidence rate occurred in the village 10 to 12 weeks after we observed a pattern of air humidity levels >65%, combined with two or more consecutive rain episodes and a mean wind speed <1.8 m/s; (2) among the three models, the FGLM obtained the best results in terms of prediction; and (3) FGSAM was shown to be a good compromise between FGLM and FGKAM in terms of flexibility and simplicity. The models showed that some meteorological conditions may provide a basis for detection of future outbreaks of malaria. The models developed in this paper are useful for implementing preventive strategies using past meteorological and past malaria incidence.

Derivation of age-adjusted LACE index thresholds in the prediction of mortality and frequent hospital readmissions in adults

The LACE index has been shown to predict hospital readmissions and death with variable accuracy. A LACE index ≥ 10 is considered as high risk in the existing literature. We aimed to derive age-specific LACE index thresholds in the prediction of mortality and frequent readmissions. Analysis of prospectively collected data of consecutive alive-discharge episodes between 01/04/2017 and 31/03/2019 to a single hospital was conducted. The derivation of LACE index thresholds for predicting all-cause mortality within 6 months of hospital discharge or frequent readmissions (≥ 2 times within 28 days) was examined by receiver operating characteristics (ROC) in 32270 patients (14878 men, 17392 women) aged 18–107 year (mean = 64.0 years, SD = 20.5). For all patients with a LACE index ≥ 10, the area under the curve (AUC) for predicting mortality was 80.5% (95% CI 79.7–81.3) and for frequent readmissions was 84.0% (83.0–85.1). Two-graph ROC plots showed that the LACE index threshold where sensitivity equates specificity was 9.5 (95% intermediate range = 5.6–13.5) for predicting mortality and 10.3 (95% intermediate range = 6.6–13.6) for frequent readmissions. These thresholds were lowest among youngest individuals and rose progressively with age for mortality prediction: 18–49 years = 5.0, 50–59 years = 6.5, 60–69 years = 8.0, 70–79 years = 9.8 and ≥ 80 years = 11.6, and similarly for frequent readmissions: 18–49 years = 5.1, 50–59 years = 7.5, 60–69 years = 9.1, 70–79 years = 10.6 and ≥ 80 years = 12.0. Positive and negative likelihood ratios (LRs) ranged 1.5–3.3 and 0.4-0.6 for predicting mortality, and 2.5–4.4 and 0.3–0.6 for frequent readmissions, respectively, with stronger evidence in younger than in older individuals (LRs further from unity). In conclusion, the LACE index predicts mortality and frequent readmissions at lower thresholds and stronger in younger than in older individuals. Age should be taken into account when using the LACE index for identifying patients at high risk.

Prospective evaluation of an artificial intelligence-enabled algorithm for automated diabetic retinopathy screening of 30 000 patients

Background/aimsHuman grading of digital images from diabetic retinopathy (DR) screening programmes represents a significant challenge, due to the increasing prevalence of diabetes. We evaluate the performance of an automated artificial...

Cystic echinococcosis: An attraction for fungal and bacterial pulmonary infections

Abstract Lung hydatidosis can remain latent for a long time, and symptoms may occur when the cysts grow to a certain size or when symptoms arise secondary to complications such as rupture or superinfection with bacterial organisms or fungi. A variety of signs denoting different appearances of complicated and/or uncomplicated pulmonary hydatid cysts have been described on chest radiographs and computed tomography scans. Aspergillosis is one of the most common fungal infections associated with pre-existing pulmonary cavities. The coexistence of aspergillosis and hydatid cyst is rare. Citrobacter infections usually occur in patients with underlying co-morbidities or immunosuppression. We presented a case of pulmonary echinococcosis with multiple bilateral cysts in which several consecutive episodes of cysts rupture and concomitant Aspergillus and Citrobacter pulmonary infections have been documented.

Early sepsis markers in patients admitted to intensive care unit with moderate-to-severe diabetic ketoacidosis

BackgroundBacterial infections are frequent triggers for diabetic ketoacidosis. In this context, delayed antibiotic treatment is associated with increased morbidity and mortality. Unnecessary administration of antimicrobial therapy might however, also negatively impact the prognosis. The usefulness of sepsis markers in diabetic ketoacidosis has not been assessed. Thus, we sought to investigate diagnostic performances of clinical and biological sepsis markers during diabetic ketoacidosis.MethodsIn this monocentric retrospective cohort study, all consecutive episodes of diabetic ketoacidosis (defined as pH ≤ 7.25, glycaemia > 300 mg/dL and presence of ketones) admitted in intensive care unit were included. A proven bacterial infection was defined as bacteriological documentation on any bacterial sample. Clinical (presence of fever: temperature > 38 °C and presence of hypothermia: temperature < 36 °C) and biological markers (whole blood count, neutrophils count, neutrophils-to-lymphocytes count ratio and procalcitonin), recorded at admission, were compared according to the presence or absence of a proven bacterial infection.ResultsBetween 2011 and 2018, among 134 episodes of diabetic ketoacidosis, 102 were included (91 patients). Twenty out of 102 were infected. At admission, procalcitonin (median: 3.58 ng/mL vs 0.52 ng/mL, p < 0.001) and presence of fever (25% vs 4%, p = 0.007) were different between episodes with and without proven bacterial infection in both univariate and multivariate analysis. Whole blood count, neutrophils count, neutrophils-to-lymphocytes count ratio and presence of hypothermia were not different between both groups. The diagnostic performance analysis for procalcitonin revealed an area under the curve of 0.87 with an optimal cutoff of 1.44 ng/mL leading to a sensitivity of 0.90 and a specificity of 0.76. Combining procalcitonin and presence of fever allowed to distinguish proven bacterial infection episodes from those without proven bacterial infection. Indeed, all patients with procalcitonin level of more than 1.44 ng/mL and fever had proven bacterial infection episodes. The presence of one of these 2 markers was associated with 46% of proven bacterial infection episodes. No afebrile patient with procalcitonin level less than 1.44 ng/mL had a proven bacterial infection.ConclusionAt admission, combining procalcitonin and presence of fever may be of value to distinguish ketoacidosis patients with and without proven bacterial infection, admitted in intensive care unit.

Clinical Usefulness of Bronchoalveolar Lavage in the Management of Pulmonary Infiltrates in Adults with Hematological Malignancies and Stem Cell Transplantation.

IntroductionPulmonary complications are frequent in patients with hematologic malignancies and stem cell transplantation. Regardless of the microbiological usefulness of bronchoalveolar lavage (BAL), little information exists on both its benefits as a guide for therapeutic decisions and its impact on patients’ clinical outcome.MethodsA prospective observational single-center study was performed between July 2011 and July 2016. Consecutive episodes of pulmonary infiltrates were analyzed in subjects over 18 years of age who presented hematologic malignancies and underwent chemotherapy or stem cell transplantation.ResultsNinety-six episodes of pulmonary infiltrates were analyzed. Acute leukemia was the most frequent underlying condition. Thirty-seven patients (38.5%) received a stem cell transplant. Sixty-one (62.9%) were neutropenic at the moment of inclusion in the study. A definitive etiologic diagnosis was obtained in 41 cases (42.7%), where infection accounted for the vast majority of cases (33 cases, 80.5%). Definitive diagnosis was reached by non-invasive methods in 13 cases (13.5%). BAL was performed in 47 cases and led to a diagnosis in 40.4% of the cases. BAL results led to therapeutic changes in 27 cases (57.4%), including the addition of new antimicrobials to empiric treatments in 10. Regarding BAL’s safety, two patients experienced minor adverse events and one a severe adverse event; no procedure-related deaths were observed.ConclusionsInfection was the leading cause of pulmonary infiltrates in patients with hematologic malignancies and stem cell transplantation. BAL was a useful decision-making diagnostic tool, with minor adverse events.

Two Consecutive Episodes of Severe Delayed Hemolytic Transfusion Reaction in a Sickle Cell Disease Patient

Patients with sickle cell disease (SCD) suffer from anemia and painful vaso-occlusive crisis (VOC) and sometimes need blood transfusions. Delayed hemolytic transfusion reaction (DHTR) is a rare life-threatening complication observed in SCD and mimics VOC. We describe a female SCD patient undergoing three surgical procedures during which DHTR developed following the first two. Prior to a planned tonsillectomy, she received transfusion and three days after surgery developed severe hemolysis as well as pain and respiratory symptoms. On suspicion of VOC, she received additional transfusions and became hemodynamically unstable, and her hemolytic anemia worsened. Gradually, she recovered and could be discharged after two weeks; DHTR was not suspected. Sixteen months later, an arthroplasty was performed due to avascular necrosis, and again she was transfused preoperatively. Similar to the initial surgery, she developed symptoms and signs of VOC after three days, but this time, DHTR was suspected and further transfusions were withheld. Although immunosuppressive medication did not alleviate the condition, she improved on combined treatment with darbepoietin, rituximab, and eculizumab. Six months later, a second arthroplasty was performed uneventfully after prophylaxis with rituximab and without transfusion. DHTR should be considered in the presence of severe, unexplained hemolysis following a recent transfusion, and additional transfusions in this setting should be given only on vital indication.

Tendencias en las hospitalizaciones psiquiátricas de personas mayores de 65 años

BackgroundThe aim of this study was to analyse the trend in the percentages of elderly patients admitted to hospital for psychiatric reasons. An additional aim was to analyse the characteristics of the elderly population admitted to a psychiatric hospitalisation unit. Material an MethodsAn analysis was made of the trends in the percentages of discharges in elderly population at the national level and in the Mental Health Hospitalisation Unit (MHHU) of the Regional University Hospital of Malaga for a period of at least 18years using segmented regression. For the study of the characteristics of the elderly population, all patients (N=5,925) and consecutive episodes of admission (N=15,418) were compared between 1999 and 2017 in the MHHU. ResultsAt the national level, there was an increase in hospital discharges in elderly patients with a significant mean annual percent change of 2.0%. In the study unit, the elderly population were more frequently female, involuntarily admitted, and had a longer hospital stay. They had been diagnosed more frequently with organic and depressive mental disorders, and less frequently with schizophrenia, substance use, and personality disorders. ConclusionsThere was a growing trend in the percentage of elderly psychiatric patients admitted to hospitals during the study period. These results point to the increase in elderly psychiatric admissions and thus the need to adapt psychiatric units to the characteristics of this population.

Clinical outcomes and treatments effectiveness in status epilepticus resolved by antiepileptic drugs: A five-year observational study.

ObjectiveTo evaluate clinical outcomes and treatment effectiveness of status epilepticus finally resolved by nonbenzodiazepine antiepileptic drugs (AEDs).MethodsAll consecutive SE episodes observed from September 1, 2013, to September 1, 2018, and resolved by AEDs were considered. Diagnosis and classification of SE followed the 2015 ILAE proposal. Nonconvulsive status (NCSE) diagnosis was confirmed according to the Salzburg EEG criteria. The modified Rankin Scale and deaths at 30 days from onset were used to evaluate outcomes.ResultsA total of 277 status episodes (mean age 71 years; 61% female) were treated and resolved by antiepileptic drugs after 382 treatment trials. 68% of the SE resolved after AED use as first/second treatment line, while subsequent trials with AEDs gave an additional 32% resolution. A return to baseline conditions was observed in 48% of the patients, while overall mortality was 19% without significant changes across the study years. Mortality was higher in NCSE than in convulsive SE (22.5% vs 12.9%; P < .05), while mortality did not differ in SE episodes resolved by a first/second AED trial (17.2%) versus SE resolved by successive treatment trials (18.9%). The resolution rate of intravenous AEDs was 82% for valproate, 77% for lacosamide, 71% for phenytoin, and 62% for levetiracetam. No significant differences were found in head‐to‐head comparison, but for the valproate‐levetiracetam one that was related to NCSE episodes in which valproate resulted to be effective in 86% of the trials while levetiracetam in 62% (P < .002).SignificanceA high short‐term mortality, stable over time, was observed in SE despite resolution of seizures, especially in SE with nonconvulsive semiology. Comparative AED efficacy showed no significant differences except for higher resolution rate for valproate versus levetiracetam in NCSE.

Shakespeare's Notation: Writing Sound inMuch Ado about Nothing

In Act 5 ofMuch Ado About Nothing, Shakespeare Dramatizes Two Consecutive Episodes in Which Writing Poetry is Mixed suggestively with singing, recalling, or imitating music. The first comes when Benedick sings or speaks several lines from the popular ballad “The God of Love.” The second is Claudio's musical rite of contrition for slandering Hero and (he believes) causing her death. In both cases, poetry is produced through writing practices that are interwoven with song. Indeed, Shakespeare yokes literacy and aurality together in the same keyword,noting, which referred both to writing and to musical notes, and which (as scholars have long observed) is hownothingwas pronounced in early modern English. Benedick seeks poetic inspiration from the notes of balladry, then bemoans his inability to versify in rhyme. Claudio not only sees that his epitaph is notated, read aloud, and hung on the tomb; he calls for a corresponding hymn to be sung. Taken together, the scenes attune us to forms of poetic making that are irreducible to writing or language—those overdetermined categories in literary studies that have enabled our neglect of the role that nonverbal sound has played in poetic composition.

Predictive factors of death associated with infective endocarditis in adult patients with congenital heart disease.

Infective endocarditis is a severe infection which can occur in adult patients with congenital heart disease. We aimed to determine outcomes and risk factors of death in adult congenital heart disease and to investigate differences with infective endocarditis in non-congenital heart disease. Between March 2000 and June 2018, 671 consecutive episodes of infective endocarditis in adult patients were retrospectively recorded. Cases were classified according to the modified Duke classification. All adult congenital heart disease cases were managed by infectious disease specialists and adult congenital heart disease cardiologists. During this period, 142 infective endocarditis episodes (21%) occurred in adult congenital heart disease patients with simple (46.5%), moderate (21.1%), or complex (32.4%) congenital heart disease. In-hospital mortality was 12.7%. The strongest predictive factors of in-hospital death in multivariate analysis were complexity of congenital heart disease (odds ratio (OR) 8.02, 95% confidence interval (CI) 1.53-42.07), age (OR 1.05, 95% CI 1.00-1.19) and white blood cell count 12 g/L or greater (OR 8.72, 95% CI 2.42-31.43). Patients with congenital heart disease were significantly younger (median age 36 vs. 67 years, P<0.001), had undergone more redo cardiac surgeries (35.7% vs. 11.3%, P<0.01) and presented with more right-sided infective endocarditis (39.4% vs. 7.9%, P<0.01) than patients without congenital heart disease. Congenital heart disease was associated with two-fold lower in-hospital mortality rates (OR 0.37, 95% CI 0.19-0.74), independently of age, gender, obesity, renal function and side of infective endocarditis. Although mortality associated with infective endocarditis is lower in adult patients with congenital heart disease than patients without congenital heart disease, infective endocarditis mortality is particularly high in patients with complex congenital heart disease. Education and prevention about the risk of infective endocarditis is essential, especially in this group.