Latest Admission Research Articles

Recurrent Fatal Cryptococcal Meningitis in a Patient with Liver Transplant: A Case Report and Review of Literature

Introduction: Cryptococcal meningitis is a significant leading cause of death among individuals with HIV worldwide. It is caused by Cryptococcus neoformans and the C. gattii species complex. The primary predisposing factor is HIV, but it can also be observed in conditions such as immunodeficiency, sarcoidosis, liver disease, solid organ transplantation, and steroid treatment. Case Presentation: This report discusses a 61-year-old man with a medical history of liver transplantation, open-heart surgery, diabetes, hypertension, and previous cryptococcal meningitis. He had been receiving antifungals and was discharged in good condition to continue maintenance treatment at home. During his latest admission, he was hospitalized to investigate weakness and suspicious ulcerated skin lesions refractory to glucantime through biopsy. Two days after hospitalization and before receiving the biopsy result, the patient gradually developed lethargy, headache, and nausea. Laboratory examinations of cerebrospinal fluid (CSF) and skin biopsies revealed encapsulated yeast cells identified as C. neoformans using culture media and the PCR method. The patient died shortly after receiving liposomal amphotericin B and oral fluconazole. Conclusions: This case emphasizes the importance of follow-up visits for high-risk patients, early screening for fungal infections, and long-term antifungal treatment, especially in immunocompromised patients, to reduce unfavorable outcomes.

Optimized diagnosis-based comorbidity measures for all-cause mortality prediction in a national population-based ICU population

BackgroundWe aimed to optimize prediction of long-term all-cause mortality of intensive care unit (ICU) patients, using quantitative register-based comorbidity information assessed from hospital discharge diagnoses prior to intensive care treatment.Material and methodsAdult ICU admissions during 2006 to 2012 in the Swedish intensive care register were followed for at least 4 years. The performance of quantitative comorbidity measures based on the 5-year history of number of hospital admissions, length of stay, and time since latest admission in 36 comorbidity categories was compared in time-to-event analyses with the Charlson comorbidity index (CCI) and the Simplified Acute Physiology Score (SAPS3).ResultsDuring a 7-year period, there were 230,056 ICU admissions and 62,225 deaths among 188,965 unique individuals. The time interval from the most recent hospital stays and total length of stay within each comorbidity category optimized mortality prediction and provided clear separation of risk categories also within strata of age and CCI, with hazard ratios (HRs) comparing lowest to highest quartile ranging from 1.17 (95% CI: 0.52–2.64) to 6.41 (95% CI: 5.19–7.92). Risk separation was also observed within SAPS deciles with HR ranging from 1.07 (95% CI: 0.83–1.38) to 3.58 (95% CI: 2.12–6.03).ConclusionBaseline comorbidity measures that included the time interval from the most recent hospital stay in 36 different comorbidity categories substantially improved long-term mortality prediction after ICU admission compared to the Charlson index and the SAPS score.Trial registration ClinicalTrials.gov ID NCT04109001, date of registration 2019-09-26 retrospectively.

Recurrent acute coronary syndrome in a patient with right coronary artery ectasia: a case report

BackgroundCoronary artery ectasia is characterized by an abnormal dilatation of the coronary arteries. Coronary artery ectasia is observed in 3–8% of patients undergoing coronary angiography and sometimes leads to acute coronary syndrome regardless of the presence or absence of coronary stenosis or atrial fibrillation.Case presentationA 61-year-old Indonesian man presented with typical angina that began 1 week before admission and had worsened 3 hours prior to admission. Accompanying symptoms included dyspnea, nausea, and sweating. He was hemodynamically stable and had a history of tobacco smoking and dyslipidemia. An electrocardiogram showed ST-segment depression and T inversion. Laboratory results showed an international normalized ratio of 1.28. Dual antiplatelet therapy was administered along with fondaparinux, and symptoms were alleviated. Coronary angiography showed an ectatic and turbulent mid-distal right coronary artery and slow flow at the first presentation. There was a patent stent in the proximal-mid left anterior descending coronary artery. This patient had previously presented with recurrent acute coronary syndrome and received two coronary stents for the stenotic vessels.DiscussionHe had right coronary artery ectasia and experienced recurrent acute coronary syndrome. He received dual antiplatelet therapy along with warfarin after stenting of his left anterior descending coronary artery. However, he presented with unstable angina pectoris 7 months before the latest admission and at the latest admission despite a patent stent and no other significant obstructive lesion. The unstable angina pectoris might have been caused by slow flow, microvascular angina caused by small thrombi and/or vasospasm, or epicardial thrombosis at the ectatic coronary artery that dissolved after anticoagulation therapy prior to coronary angiography. Anticoagulant therapy may have a greater benefit than antiplatelet therapy in this patient due to the turbulence and stasis of blood in the ectatic vessel, although coexisting coronary conditions mandated antiplatelet therapy. His international normalized ratio was suboptimal and needed to be improved.ConclusionCoronary ectasia may play a role in recurrent acute coronary syndrome, and administration of an anticoagulant to prevent acute coronary syndrome in this patient was in accordance with the varying hemodynamic property of coronary artery ectasia.

Late progression of neurological symptoms and MRI T2 hyperintensities in Parry-Romberg syndrome

We describe a case of a 50-year-old woman who developed drug-resistant status epilepticus with complex partial and secondary generalised seizures. She had suffered from Parry-Romberg syndrome (PRS) for more than...

Risk factors for sudden cardiac death among patients with schizophrenia

IntroductionPatients with schizophrenia suffer from excessive premature mortality, and sudden cardiac death (SCD) is receiving growing attention as a potential cause. AimThe present study investigated the incidence of SCD and its risk factors in a large schizophrenia cohort. MethodsWe enrolled a consecutive series of 8264 patients diagnosed with schizophrenia (according to DSM-III-R and DSM-IV criteria) who were admitted to a psychiatric center in northern Taiwan from January 1, 1985 through December 31, 2008. By linking with national mortality database, 64 cases of SCD were identified. The standardized mortality ratio (SMR) for SCD was estimated. The cases were matched with controls randomly selected using risk-set sampling in a 1:2 ratio. A standardized chart review process was used to collect socio-demographic and clinical characteristics and the prescribed drugs for each study subject. Multivariate conditional logistic regression analysis was used to identify correlates of SCD at the index admission and the latest admission. ResultsThe SMR for SCD was 4.5. For the clinical profiles at the index admission, physical disease (adjusted risk ratio [aRR]=2.91, P<.01) and aggressive behaviors (aRR=3.99, P<.01) were associated with the risk of SCD. Regarding the latest admission, electrocardiographic abnormalities (aRR=5.46, P<.05) and administration of first-generation antipsychotics (aRR=5.13, P<.01) elevated the risk for SCD. Consistently, aggressive behaviors (aRR=3.26, P<.05) were associated with increased risk as well. ConclusionsApart from cardiovascular profiles and antipsychotics, physical aggression is a crucial risk factor that deserves ongoing work for clarifying the mechanisms mediating SCD in schizophrenia.

On just-in-time control of timed event graphs with input constraints: a semimodule approach

Timed event graph (TEG) is a subclass of timed Petri nets that can be used to model discrete event systems subject to synchronization and time delay phenomena. Just-in-Time control in TEG can be defined as the determination of latest admission date of resources in order to respect a given demand profile. In this paper this kind of control problem is studied in situations in which the input dynamics are constrained to a given semimodule (a kind of linear vector space in a semiring context). We give necessary and sufficient conditions to solve the problem and present two computational methods to solve it. Application examples are presented to illustrate the applicability of the results.

Epicardial Scar in a Patient with no Apparent Heart Disease

A 35-year-old man, who had an episode of aborted sudden cardiac death due to ventricular fibrillation, suffered from multiple storms of ventricular tachycardia (VT). Conventional cardiac examinations did not reveal any structural heart diseases, and he had been treated by an implantable cardioverter defibrillator since 2007. At the latest admission, epicardial but not endocardial voltage mapping revealed a small area of low voltage at the left ventricular (LV) postero-lateral wall where a delayed potential was recorded during sinus rhythm. Excellent pacemapping with a prolonged stimulus to QRS interval was obtained from the area, and a mid-diastolic potential was recorded during the VT. Radiofrequency application terminated the VT and any VT became noninducible after the ablation. In some patients diagnosed as LV-VT with no apparent heart disease, arrhythmogenic substrate may exist on the epicardial surface of the ventricle.

Risk and Protective Factors for Suicide Among Patients With Methamphetamine Dependence

Methamphetamine as a recreational drug has undergone cycles of popularity, with a recent surge worldwide since the 1990s. This study aimed to identify clinical characteristics associated with suicide mortality in patients with methamphetamine dependence by means of a nested case-control design. In a consecutive series of 1,480 inpatients with methamphetamine dependence (diagnosed according to DSM-III-R and DSM-IV criteria) admitted to a psychiatric center in northern Taiwan from January 1, 1990, through December 31, 2006, 38 deaths due to suicide were identified as cases via record linkage, and 76 controls were randomly selected using risk-set density sampling in a 2:1 ratio, matched for age, sex, and the year of index admission. A standardized chart review process was adopted to collate sociodemographic and clinical information for each study subject. Multivariate conditional logistic regression analysis was used to identify correlates of suicide among these patients. For the sociodemographic and symptom profiles at the latest admission, financial independence lowered the risk for suicide (adjusted risk ratio [ARR] = 0.33, P < .05), whereas visual hallucinations elevated the risk (ARR = 2.57, P < .05) for suicide. For the profiles during the postdischarge period, financial independence (ARR = 0.11, P < .05) remained associated with reduced risk for suicide, whereas suicide attempt (ARR = 8.78, P < .05) and depressive syndrome (ARR = 3.28, P = .059) were associated with increased risk of suicide. Both protective and risk factors for suicide mortality were found among inpatients with methamphetamine dependence, and the findings have implications for clinical intervention and prevention.

Gliomatosis Cerebri Presenting as a Parkinsonian Syndrome

We report a 70-year-old man who was hospitalized after a left-sided partial seizure progressed to grand mal seizures. Three years before, the patient had presented with the main symptoms of bradykinesia and gait disturbance and was diagnosed with parkinsonism resistant to L-dopa. At the latest admission, extensive diffuse white matter high-intensity areas were present on T2-weighted magnetic resonance imaging images, and stereotactic brain biopsy showed that these lesions were gliomatosis cerebri (GC). This is the first reported case in which extensive lesions in the bilateral white matter have been associated with parkinsonism as the main clinical feature; only one other case has been reported in which GC presented as parkinsonism, and this differed from the current case with respect to localization and symptoms. We speculate that damage to the thalamocortical projections and functional impairment due to demyelination could have caused parkinsonism in our patient, and we discuss the differential diagnosis.

Psychotic symptoms, epilepsy, mental retardation, and brain malformation in a patient with 45,XO/46,XX mosaicism: Detection of mutation of ARX molecule

45,XO/46,XX mosaicism is associated with Turner syndrome and is rarely associated with serious abnormalities of brain structure or malformation of cortical development.1,2 In addition, individuals with Turner syndrome are reported to display less mental illness.3,4 We report herein a case of 45,XO/46′XX mosaicism without typical Turner syndrome symptoms but with psychotic symptoms, epilepsy, mental retardation, and brain malformation resembling lissencephaly. Ms A is a 63-year-old woman with a history of intractable epilepsy, psychotic symptoms, and mental retardation. She had her first seizure at the age of 10. From the age of 14 years onwards, she had repeated complex partial seizures. At the age of 20, she experienced her first psychotic symptoms. She was hospitalized 11 times because of her refractory psychotic symptoms and repeated seizures, and responded poorly to antipsychotic and anticonvulsant medication. She had a normal reproductive lifespan and delivered a daughter. During the latest admission, magnetic resonance imaging of the brain revealed noticeable frontal and temporal lobe atrophy and an asymmetric irregular gyral pattern. An absence of gyri, which is suggestive of lissencephaly, was noted dominantly in the left frontal and temporal lobe. Several interictal electroencephalogram recordings showed spikes localized on the bilateral fronto-temporal region, especially F3 and T5. Peripheral blood cells were analyzed using standardized cytogenetic methods. Of 30 peripheral blood mononuclear cells examined, eight were of the karyotype 45,XO and 22 were 46XX. We hypothesize that this chromosomal abnormality could explain the brain abnormality. Early this year, X chromosome-linked, aristaless-related, homeobox gene (ARX) was found to be associated with X-linked mental retardation, epilepsy and lissencephaly.5 We then investigated a mutation of ARX molecule in the present case. Mutation of ARX, however, was not detected in the present patient. For analysis of ARX, we obtained written informed consent. This study was approved by the Ethical Cornmittee of Shizuoka Prefectural Mental Care ard Rehabilitation Center. There have been very few reports that mention the relationship between Turner syndrome and psychiatric symptoms.4 Two reports have mentioned a case resembling the present one.1,2 Both of those patients had epilepsy, mental retardation, and lissencephaly. Neither of those patients, however, was reported to present psychotic symptoms. Further cases resembling the present one should provide insight into these types of patients.

Extremitätenerhalt für den diabetischen Fuß

Lower-extremity amputation (LEA) is a common complication among patients with diabetes. This study tests the effects of a structured disease management program for the diabetic foot (DF) aiming to reduce the number of LEA. DESIGN, METHODS: In a prospective study design we investigate patients with DF in a system of outpatient treatment, acute in-patient care and rehabilitative treatment. Subjects were recruited since January 1(st), 2000, with the latest admission being December 31, 2004. All study participants undergo a five-year follow-up observation period. The University of Texas Wound Classification System (UT) of foot ulcers serves as basis of the documentation and analysis. We evaluated numbers of LEA, rates of ulcer healing and underlying forms of peripheral vascular disease. We report the results of the first patient group completing the two-year follow-up examination. In 2000, 102 subjects with new foot ulcers were consecutively included into the study. 68.6% were men, the mean age of the study population was 68.1 +/- 11.4 years and the mean diabetes duration was 19.4 +/- 10.3 years. After two years, 68 patients can still be examined. Altogether, 22 patients (21.6%) died, and 12 (11.8%) dropped out for various reasons. At the point of discharge from the clinics 35.3% of the ulcers had healed and another 44.1% were in UT grade 1. After two years, a complete healing could still be determined with 51 patients (50.0% of the cohort of the original 102 patients, or 75.0% of the subjects reaching the two-year follow-up). 10 subjects (9.8% or 14.5%) were in the UT grade 1. Eight diabetics underwent major amputation (MA) during the two-year examination period (amputation rate 7.8%). The primary objective of the study, a significant reduction of MA with DF patients, has been achieved. The ulcer healing rates are comparable to the reports of leading centers.

Cystic duct dilatation after cholecystectomy in fibropolycystic liver disease

A 50 year-old woman presented with fevers, rigors and right hypochondrial pain. On examination she was pyrexial (38.5 8C) and there was some right hypochondrial tenderness. A cholecystectomy scar was noted on the abdominal wall. A clinical diagnosis of cholangitis was made by the admitting physician. The patient had a complicated past medical history and initially presented 30 years previously at another hospital with jaundice. A liver biopsy at that time suggested a diagnosis of congenital hepatic fibrosis [1]. Over the intervening years, her history was complicated by infrequent episodes of cholangitis, but with time these episodes became more frequent. Subsequent renal imaging was consistent with medullary sponge kidneys, while hepatic imaging performed over 20 years after initial diagnosis showed a cyst in the right lobe of the liver (on ultrasound) with intrahepatic duct dilatation (at ERCP), suggestive of coexisting Caroli’s disease [2]. A further liver biopsy at that time confirmed the diagnosis of congenital hepatic fibrosis. The patient subsequently developed several episodes of cholecystitis and an interval cholecystectomy was performed 3 years prior to the current presentation. On the latest admission, a MRCP (left panel) was performed which revealed multiple small intrahepatic biliary cysts, consistent with Caroli’s disease (left panel, white arrows) with saccular dilatation of the extrahepatic biliary tree. In addition, there was a saccular cystic lesion resembling a gallbladder within the gall bladder fossa (left panel, black arrow). This called into question whether the patient had actually had a previous cholecystectomy, despite the abdominal wall scar. A subsequent multidisciplinary histopathology meeting highlighted the complete removal of the gallbladder, beyond all doubt. A review of the imaging showed that this cystic lesion, reported initially as a gallbladder, on axial T2-weighted MRI (middle panel, arrow) was indeed smaller and in a different position when compared to the pre-cholecystectomy CT scan, where the gallbladder was dilated (right panel, arrow). This saccular cyst within the gallbladder fossa on MRCP most likely represents extrahepatic biliary dilatation of the cystic duct remnant following cholecystectomy, as a consequence of Caroli’s disease. To our knowledge, this is the first case of fibropolycystic disease, where a cystic duct remnant has dilated sufficiently to be mistaken for a gallbladder, even by experienced hepatobiliary radiologists.

Hypoglycaemia secondary to the secretion of pro-insulin like growth factor ii by a metastatic neuroendocrine tumour with sarcomatous differentiation

A patient presented with frequent episodes of spontaneous hypoglycaemia due to a disseminated neuroendocrine tumour with sarcomatous differentiation, secreting incompletely processed pro-insulin-like growth factor II (pro-IGF-II). Although the combination of GH and glucocorticoid therapy initially controlled the hypoglycaemia, there was a later escape necessitating frequent re-admissions to hospital. The patient deceased two weeks following her latest admission.

Recurrent Pancreatitis Secondary to Hypercalcemia Following Vitamin D Poisoning

A 66-year-old patient had been admitted four times for recurrent episodes of acute pancreatitis. At each time, elevated serum calcium levels, between 13.5-14.5 mg/dl, were found. Surgical drainage of necrotic pancreatic tissue had to be done on one occasion. Extensive investigations failed to disclose any conventional hypercalcemic disease. At his latest admission, the serum calcium level was 13.4 mg/dl, and the serum amylase level was 440 IU/L (N, less than 85). This time, the serum 25-OH vitamin D levels were investigated using radioimmunology and proved to be raised to 330 micrograms/L (normal, 16-74 micrograms/L). Specific questioning of the patient revealed that he had been taking regularly excessive quantities of vitamin supplements as a self medication. After stopping vitamin intake, his serum amylase levels returned to normal, and he had no more episodes of pancreatitis. This case illustrates vitamin D intoxication as a cause of recurrent pancreatitis. Measuring serum 25-OH vitamin D levels is advocated in pancreatitis associated with hypercalcemia of unclear origin.

Insulin-induced hypoglycaemia in an accident and emergency department: the tip of an iceberg?

In one year a prospective survey in a large accident and emergency department identified 204 admissions of adults with severe hypoglycaemia, 200 in insulin-treated patients. Ninety-six had one admission while 34 others were admitted on 104 occasions. Of the 130 patients, 111 attended diabetic clinics in Nottingham, forming 9% of a known clinic population of 1229 on insulin treatment. Since many other episodes of hypoglycaemia were presumably treated outside hospital, 9% a year is a minimum estimate of the incidence of severe hypoglycaemia in our area. The mean insulin dose was 1.2 units/kilogram/day for those admitted twice or more and 0.9 U/kg/day for those admitted once; these doses were significantly higher than those of an age-matched clinic population. A year after the latest admission with hypoglycaemia, the mean insulin dose in the group with two or more admissions had fallen to 0.8 U/kg/day, suggesting that over-treatment had been an important causal factor. A similarly high incidence has been reported in other studies, and we believe that it is due mainly to the inadequacy of conventional subcutaneous insulin treatment.

An exercise in radiologic-pathologic correlation.

If one wished to illustrate the value of the triangulation method in the everyday approach to radiographic interpretation, it would be difficult to choose a better example than the current Case of the Month. Few examinations in diagnostic radiology challenge the patience of the radiologist more than those involving the small bowel. When a nondescript filling defect is seen on a small bowel series the radiologist often despairs of making an accurate diagnosis and usually offers only a long list of differential possibilities. A careful analysis of all the parameters in the current case, however—beginning with an accurate evaluation of all the intrinsic data on the roentgenograms, followed by placement of the disturbed morphologic picture into a range of possibilities, and finally invoking a pertinent clinical fact—would lead to the correct label or diagnosis. This is the essence of the triangulation method. Radiographic Findings The upper gastrointestinal radiograph of a 57-year-old woman hospitalized with chronic hypochromic anemia in August 1966 shows a 3-cm circumscribed intraluminal filling defect at the level of the ligament of Treitz (Fig. 1). The barium column is dispersed about this lesion, and there is no evidence of ulceration or local invasion. At the time of a small bowel series performed Nov. 15, 1967, on the patient's latest admission because of massive gastrointestinal bleeding, a 10-cm segment of proximal jejunum, at and beyond the ligament of Treitz, was noted to be involved with an intussusception (Fig. 2). This portion of the jejunum exhibits considerable localized dilatation, and there is the typical coiled-spring appearance of stretched valvulae conniventes produced by intussusception of the large intraluminal filling defect at the ligament of Treitz into the lumen of the proximal jejunum. The lack of significant dilatation of the duodenal loop suggests that the intussusception is transient and intermittent in nature, although a two-hour follow-up film still shows the intussuscepted segment (Fig. 3). An admission chest film demonstrates only slight scattered interstitial fibrotic changes within the apices and lower lung fields as well as outlines of multiple cutaneous nodules overlying the chest wall (Fig. 4). In the evaluation of any patient with gastrointestinal bleeding, the most frequently overlooked source of the blood loss is the small bowel. This oversight occurs partly because the stomach, duodenum, and colon are statistically much more common offenders. In addition, the discovery of small bowel lesions is virtually limited to a radiographic evaluation, and they may not be revealed even by a carefully performed small bowel series with multiple spot-films. When a lesion is detected, however, it is of paramount importance to ascertain whether it is solitary or multiple and by careful spot-filming and compression studies to try to determine if it is a mucosal, an intramural, or an extrinsic filling defect.