Time Of Patient Presentation Research Articles

Outcomes and Clinical Features Predictive of Fungal Endophthalmitis

To analyze intravitreal antifungal injections performed at a tertiary center to determine (1) risk factors increasing fungal endophthalmitis likelihood at the time of patient presentation, (2) prognostic factors at presentation, and (3) validity of American Academy of Ophthalmology (Academy) ophthalmologic Candida septicemia (candidemia) screening guidelines. Single-center, retrospective clinical case-control study. Clinical course, visual outcome, and final diagnosis were analyzed for 75 patients (81 eyes) receiving intravitreal antifungal injections between 2014 and 2021. Features were compared between fungal endophthalmitis and clinically similar diseases (masquerades). Fungal endophthalmitis was more likely than masquerade based on injection in emergency department or inpatient setting (P=.0002) vs outpatient, greater visual acuity (P=.049), artificial indwelling line present (P=.0004), sepsis within past 6 months (P=.0002), prior/current hepatitis C diagnosis (P=.044), total parenteral nutrition (P=.0028), complicated diabetes mellitus (P=.035), actively treated cancer (P=.021), immunosuppressive medication within past year (P=.035), immunocompromising condition number (P=.031), and delayed pain (P=.0094) and vision loss (P=.020) onset. Visual acuity at presentation correlated with visual outcome (R2=0.3524, P=8.5×10-7). No patients with fungal endophthalmitis were asymptomatic or identified by screening. Many conditions can mimic fungal endophthalmitis, but certain risk factors should raise its suspicion. Regardless of diagnosis, presenting vision correlates with final vision. Lastly, no patients with fungal endophthalmitis were asymptomatic or identified by screening, further supporting current Academy candidemia screening guidelines.

Overcoming barriers to immediate penile implant salvage surgery: a narrative review.

Since immediate salvage (IS) surgery for infected penile prosthesis (PP) was introduced nearly 30 years ago, an abundance of evidence has emerged in support of its use. IS remains underutilized by the modern urologist despite its distinct advantages. While some medical literature proposes reasons for the underuse of IS, no comprehensive review attempts to address the numerous factors limiting its implementation. Our objective is to analyze the barriers to IS surgery for infected PP with the goal of expanding utilization of this technique through a practical and standardized approach for treating urologists. A narrative review of available English, peer-reviewed, medical literature relevant to the barriers to IS was completed. Searches were expanded to include literature from surgical specialties in general if hypothesized barriers were incompletely described in available PP publications. The major barriers that are likely contributing to the low rates of IS for PP surgery can be broadly classified into three major categories: institutional/systemic, medical/surgical, and patient preference. Institutional/systemically driven barriers include surgeon comfort with PP surgery, low national availability of urologists, inaccessibility of prosthetics or critical ancillary staff at the time of patient presentation and limited operating room (OR) access. Medical/surgical barriers primarily relate to reinfection fears, perceived contraindications to IS, and overall patient stability at the time of presentation. Patient preference factors inhibiting IS involve loss of trust in the medical team, psychosocial distress, dissatisfaction with the initial device prior to infection and anxiety regarding postoperative recovery. Many of the identified barriers can be overcome with increased surgical training, improved patient and surgeon understanding of PP infection, or precautionary planning. Of the factors that contribute to low utilization of IS, many are misunderstood or unknown. Recognition of these barriers may equip urologists to provide better care to patients with prosthesis infection.

Should Primary Stroke Centers Perform Advanced Imaging?

Should Primary Stroke Centers Perform Advanced Imaging?

Quantification of Vasoactive Medications and the "Pharmaco-Mechanical Continuum" in Cardiogenic Shock.

Quantification of Vasoactive Medications and the "Pharmaco-Mechanical Continuum" in Cardiogenic Shock.

Multireader evaluation of radiologist performance for COVID-19 detection on emergency department chest radiographs

BackgroundChest radiographs (CXR) are frequently used as a screening tool for patients with suspected COVID-19 infection pending reverse transcriptase polymerase chain reaction (RT-PCR) results, despite recommendations against this. We evaluated radiologist performance for COVID-19 diagnosis on CXR at the time of patient presentation in the Emergency Department (ED). Materials and methodsWe extracted RT-PCR results, clinical history, and CXRs of all patients from a single institution between March and June 2020. 984 RT-PCR positive and 1043 RT-PCR negative radiographs were reviewed by 10 emergency radiologists from 4 academic centers. 100 cases were read by all radiologists and 1927 cases by 2 radiologists. Each radiologist chose the single best label per case: Normal, COVID-19, Other – Infectious, Other – Noninfectious, Non-diagnostic, and Endotracheal Tube. Cases labeled with endotracheal tube (246) or non-diagnostic (54) were excluded. Remaining cases were analyzed for label distribution, clinical history, and inter-reader agreement. Results1727 radiographs (732 RT-PCR positive, 995 RT-PCR negative) were included from 1594 patients (51.2% male, 48.8% female, age 59 ± 19 years). For 89 cases read by all readers, there was poor agreement for RT-PCR positive (Fleiss Score 0.36) and negative (Fleiss Score 0.46) exams. Agreement between two readers on 1638 cases was 54.2% (373/688) for RT-PCR positive cases and 71.4% (679/950) for negative cases. Agreement was highest for RT-PCR negative cases labeled as Normal (50.4%, n = 479). Reader performance did not improve with clinical history or time between CXR and RT-PCR result. ConclusionAt the time of presentation to the emergency department, emergency radiologist performance is non-specific for diagnosing COVID-19.

Racial Bias in Pulse Oximetry

Pulse oximetry is an important vital sign collected at the time of patient presentation and monitored throughout a patient’s stay in the hospital. Pulse oximetry is frequently needed especially now in the setting of the COVID-19 pandemic. Currently available devices for measuring pulse oxygenation were not developed in racially diverse populations. With this information in mind, previous studies have raised questions about the accuracy of these devices in measuring oxygen saturation in non-white patients.

S0020 The Effect of ER Crowding on Time to Fluid Initiation in Acute Pancreatitis

INTRODUCTION: Studies suggest that early fluid resuscitation in acute pancreatitis may improve outcomes. Thus, the timely diagnosis and treatment in the emergency room is vital. One factor consistently implicated in delay of care is ER crowding, which has been associated with increased inpatient mortality, longer hospital length of stay and higher healthcare costs. The primary aim of our study is to evaluate the effects of ER crowding on time to fluid initiation in patients who present to the emergency room with acute pancreatitis. METHODS: An observational cohort of consecutive unique patients who presented to the LAC + USC emergency room for acute pancreatitis between June 2015 and April 2017 were included. The time that the patient’s first set of vitals was recorded upon presentation to the emergency room triage was labeled as “time zero,” and the time that fluids were started was labeled as “time to fluid initiation.” The crowding level of the LAC + USC emergency room was determined by the National Emergency Department Overcrowding Scale (NEDOCS) at the time of patient presentation and was recorded on a scale from 1 to 4 (1 = normal, 2 = busy, 3 = overcrowded, 4 = severe). The primary endpoint was time to fluid initiation. Detailed demographic information, pancreatitis etiology, and medical history was recorded. Linear regression analysis to analyze the relationship between the crowding level to the time to fluid initiation. RESULTS: Overall, 42 patients presented when the ER had normal (level 1) crowding, 111 patients while it was busy (level 2), 119 patients while it was overcrowded (level 3) and 58 patients while it was (level 4) severely crowded. The features of the 330 patients stratified by crowding level was similar. Most of the patients in our study were of Hispanic ethnicity, 44% female, and 39% had comorbidities. Gallstone pancreatitis was the most common etiology. The time to fluid initiation was strongly correlated with ER crowding level and was significantly increased for each step increase in crowding (p < 0.001). It increased from 1.83 (±1.25 hours) in normal conditions to 2.78 (±2.5) hours when the ER was busy to 5.41 (±5) when overcrowded, and 7.1 (+6.8) when the condition was severe. CONCLUSION: ER overcrowding is strongly correlated with a delay in time to fluid initiation in patients with acute pancreatitis. Pathways to rapidly identify and trigger treatment are needed.Figure 1

REPORT OF A CASE AND REVIEW OF THE LITERATURE: AXILLARY LYMPH NODES METASTASIS IN PAPILLARY THYROID CANCER PATIENT

Introduction: thyroid cancer (ТС) is the most common endocrine malignancy. Typical and frequent type of TC is papillary carcinoma (PC). Metastases of papillary TC have more often cervical location in II-VI neck lymph nodes groups. Axillary metastasis is not a common finding in the classic type of PC. Adequate Surgery and radioiodine therapy, if necessary, provide the excellent prognosis for most papillary TC patients. Case presentation. 87-year-old woman was presented in our Center with metastatic axillary lymphadenopathy. She had a history of thyroidectomy with central neck dissection 31 years ago for papillary TC. Earlier she underwent right and left lateral neck dissection and 131-I therapy (3 times: after 6 months - 86 mCi, after 12 months- 92 mCi, after 24 months - 98 mCi). On the time of patient presentation in the Center we have found right axillary lymphadenopathy, occipital lymphadenopathy and multiple pulmonary metastases. In our clinic we have performed removal of occipital lymph node metastases and right axillary metastases dissection. Postoperative pathology report has shown infiltration of the cervical and axillary lymph nodes by metastatic papillary TC. After Surgery patient received 131-I therapy one more again (after 3 months - 110 mCi, after 9 months - 150 mCi). Unfortunately, she died after 18 months later. The reason of death was progression of distant metastases at lungs. Follow up period from the initial operation made 32.5 years. Conclusion and discussion. Papillary thyroid cancer patient’s progression free survival is more 10 years. As a rule a papillary TC patients has survived for many years after the initial surgery. Exclusively rarely TC metastases can emerge in different atypical places and in the axillary lymph nodes also (more than 31 years after initial Surgery) that maybe associated with a poor prognosis. Case report is unique, because there are 16 equal clinical cases in world literature.

Urethral Stricture is Frequently a Morbid Condition: Incidence and Factors Associated With Complications Related to Urethral Stricture

ObjectiveTo determine the frequency of complications related to urethral stricture and identify clinical factors associated with them. MethodsOf 1851 patients with a suspected diagnosis of urethral stricture referred to a single urologist from 2005 to 2016 were retrospectively reviewed. Clinical variables included complications directly related to urethral stricture at the time of patient presentation, associated signs/symptoms, patient age, stricture length, location, and etiology. Complications considered significant were acute urinary retention or difficult catheterization requiring emergent urologic intervention or renal failure, urosepsis, or urethral abscess directly related to stricture. Patients without complete data were excluded from study. The occurrence of complications was compared in relation to patient age, symptoms, stricture length, location, and etiology using binary logistic regression. ResultsOf 1023 patients meeting inclusion criteria, mean age was 48.0 years and mean stricture length was 5.0 cm (1-18). Of 40.6% (415) of patients experienced at least one complication directly related to urethral stricture including acute urinary retention (32.6%), difficult catheterization (16.0%), urethral abscess/urosepsis (5.0%), or renal failure (3.1%). On multivariate analysis, stricture length (cm) (odds ratio [OR] 1.1; 95% confidence interval [CI] 1.1-1.2, P = .01), lack of reported lower urinary tract symptoms (OR 3.8, 95%CI 1.9-7.3, P <.0001), posterior stenosis (OR 3.0, 95%CI 1.3-6.8, P = .01), and trauma-related strictures (OR 1.6, 95% CI 1.1-2.4, P = .02) were associated with complications. Lastly, 7.0% of patients experienced complications deemed to be life-threatening. ConclusionUrethral stricture is frequently a morbid condition. Patients with longer strictures, posterior stenoses, absence of preceding lower urinary tract symptoms and traumatic strictures are at highest risk for complications related to urethral stricture and should likely be directed toward more definitive treatment.

Abstract WP396: Simultaneous Patient Presentation for Endovascular Thrombectomy

Introduction: Increased demand for endovascular thrombectomy has increased the likelihood of simultaneous patient presentation leading to competing demand for time-sensitive treatment. The occurrence of simultaneous demand has not been well studied. In this work, we quantified the occurrence of simultaneous patient presentation at different patient volumes. Methods: Distributions for time of patient presentation and case duration were derived from local data. These distributions were used to probabilistically generate arrival time and case duration for annual patient volumes ranging from 5 to 500 cases per year, with 8000 independent trials at each volume. Time series were generated for each trial to represent the number of concurrent cases at each minute of the year. Time series were used to calculate the occurrence of simultaneous demand. Results: Annual simultaneous demand by two or more patients was far lower than annual demand by a single patient at all tested volumes. The median patient volume at which there was at least one occurrence per year of simultaneous demand by two patients was 45 (IQR 30-65). The median patient volume at which there was at least one occurrence per year of simultaneous demand by three patients was 220 (IQR 160-275). Conclusions: The occurrence of simultaneous presentation for endovascular thrombectomy varies with patient volume. Understanding these trends can inform intelligent strategies for optimizing patient care within real-world financial and operational constraints. Figure: Annual duration of concurrent demand by (A) one patient, (B) two patients, and (C) three patients. Solid line = median, dark gray = 50% confidence bound, light gray = 95% confidence bound.

Initial clinical and laboratory profiles to predict pediatric dengue infection severity

Background. In dengue infection, it is difficult to differentiate mild and severe dengue prior to its critical phase. Ability to identify risk factors for severe dengue form patients’ initial presentation would help decrease the need of hospitalization, increase physicians’ awareness, and improve outcome.Objective. To predict pediatric dengue infection severity based on initial patient characteristics, routine clinical and laboratory profiles. Methods. This was a cross-sectional study based on medical records of children with dengue infection in Atma Jaya Hospital, Jakarta. Inclusion criteria were children aged 1 – 18 years old with proven dengue infection, hospitalized in Atma Jaya Hospital during January – December 2016. Clinical profiles and laboratory parameters at the time of patient presentation were extracted and analyzed in relationship with dengue severity. Result. Data collected was 110 patients with mean age 9.5 years old. Initial clinical profiles that significantly related to severe dengue were: age ≤5 years old (OR = 0.113, p = 0.001), hepatomegaly (OR = 2.643, p = 0.035), pleural effusion (OR = 9.545, p = 0.000), platelet ≤125,000/uL (OR = 0.201, p = 0.025), hyponatremia (OR = 10.139, p = 0.000) and AST &gt;135 u/L (OR = 5.112, p = 0.014). Gender, duration of fever, additional symptoms, spontaneous bleeding, blood pressure, pulse pressure, hematocrit, leucocyte, random blood glucose, calcium, and ALT were not related significantly to dengue severity.Conclusion. Physician should be cautious in pediatric dengue patients presented in age younger than 5 years old, with hepatomegaly and/or pleural effusion, platelet below 125,000/uL, hyponatremia, and AST more than three times upper normal limit. These patients have higher risk of severe dengue than patients without those findings.

Initial clinical and laboratory profiles to predict pediatric dengue infection severity

Background. In dengue infection, it is difficult to differentiate mild and severe dengue prior to its critical phase. Ability to identify risk factors for severe dengue form patients’ initial presentation would help decrease the need of hospitalization, increase physicians’ awareness, and improve outcome.Objective. To predict pediatric dengue infection severity based on initial patient characteristics, routine clinical and laboratory profiles. Methods. This was a cross-sectional study based on medical records of children with dengue infection in Atma Jaya Hospital, Jakarta. Inclusion criteria were children aged 1 – 18 years old with proven dengue infection, hospitalized in Atma Jaya Hospital during January – December 2016. Clinical profiles and laboratory parameters at the time of patient presentation were extracted and analyzed in relationship with dengue severity. Result. Data collected was 110 patients with mean age 9.5 years old. Initial clinical profiles that significantly related to severe dengue were: age ≤5 years old (OR = 0.113, p = 0.001), hepatomegaly (OR = 2.643, p = 0.035), pleural effusion (OR = 9.545, p = 0.000), platelet ≤125,000/uL (OR = 0.201, p = 0.025), hyponatremia (OR = 10.139, p = 0.000) and AST &gt;135 u/L (OR = 5.112, p = 0.014). Gender, duration of fever, additional symptoms, spontaneous bleeding, blood pressure, pulse pressure, hematocrit, leucocyte, random blood glucose, calcium, and ALT were not related significantly to dengue severity.Conclusion. Physician should be cautious in pediatric dengue patients presented in age younger than 5 years old, with hepatomegaly and/or pleural effusion, platelet below 125,000/uL, hyponatremia, and AST more than three times upper normal limit. These patients have higher risk of severe dengue than patients without those findings.

Increased levels of soluble forms of E-selectin and ICAM-1 adhesion molecules during human leptospirosis.

Leptospirosis is a multisystemic zoonotic disease with infiltration of visceral organs by Leptospira. The capacity of the vascular endothelium to grant immune cell recruitment and activation in target organs during the disease course remains poorly characterized. We ascertained the levels of expression of several soluble cell adhesion molecules (CAM) notably expressed by endothelial cells in human leptospirosis. We prospectively enrolled 20 hospitalized patients and compared them to 10 healthy controls. Disease severity was defined by one or more organ failures, or death. Plasmatic concentrations of soluble CAM were assessed by multiplex bead assay at the time of patient presentation (M0) and 1 month after hospital discharge. The levels of soluble E-selectin (sCD62E) and soluble intercellular adhesion molecule 1 (sICAM-1, sCD53) were significantly increased in patients compared to controls (p<0.0001) and at 1 month (p<0.0001) with median values at 978 ng/ml (interquartile ranges 787–1164; sCD62E) and 1021 ng/ml (690–1428; sCD53). At M0, Soluble P-selectin level (sCD62P) was found to be decreased with levels at 60 ng/ml (0–631) versus 711 ng/ml (343–1113) for healthy controls (p<0.05). Levels of sICAM-3 (sCD50), sVCAM-1 (vascular cell adhesion molecule, sCD106) and sPECAM-1 (platelet endothelial cell adhesion molecule, sCD31) were not different from healthy subjects at M0. This study shows that two adhesion molecules, shed as soluble forms, are elevated during the acute phase of leptospirosis: E-selectin and s-ICAM1. These molecules may interfere with the process of immune cell recruitment to clear Leptospira at tissue levels.

Patient Perception and Emotional Disturbance in Out-of-Hour Ophthalmic Emergency Care

ABSTRACTPurpose: To investigate patient’s perception of the severity of their symptoms, reasons for attending an ophthalmic emergency department (ED) out of hours, and to review the prevalence of anxiety and depression. Methods: We carried out a prospective analysis of the cases presenting out of hours (8:30 PM to 8:30 AM) over a four-month period. We also conducted two questionnaire studies. First, patient’s perception of the severity of their symptoms (graded from 1–10). A score of 7 or above was defined as significant. A second questionnaire study used the Hospital Anxiety and Depression Scale (HADS), with a maximum score of 21. Patients who scored between 7–10 points on either anxiety or depression scales are defined as borderline; above 10 as pathological. Results: A total of 1,531 patients attended the out-of-hours service. The most common diagnoses were trauma (22.8%), infective conjunctivitis (10.2%), and contact-lens-related problems (6.6%). Of 175 completed questionnaires, worry about sight impairment and pain were the most common concerns for attendance. A total of 91% of patients believed their conditions were emergencies that require medical review within 24 hours. 127 HADS questionnaires were completed, showing that 18.9% and 15.0% of patients were suffering from borderline and pathological anxiety, respectively, with a mean HADS-A score of 6.5, SD=3.9. The prevalence of possible and pathological depression was 14.2% and 6.3%, mean=4.9 (SD=3.6). There was no statistical significance difference of score with the time of patient presentation. Conclusion: The prevalence of anxiety and depression is relatively high in patients who attended the ophthalmic ED and awareness of psychological impact should be raised amongst healthcare professionals.

Predictors of inhospital mortality following out-of-hospital cardiac arrest: Insights from a single-centre consecutive case series

Purpose of the studyOut-of-hospital cardiac arrest (OHCA) has a poor prognosis despite bystander resuscitation and rapid transfer to hospital. Optimal management of patients after arrival to hospital continues to be...

Necrotizing soft tissue infections: The role of the LRINEC score

Necrotizing fasciitis is a life-threatening soft tissue infection which requires prompt diagnosis and early debridement. This study was conducted to validate whether the LRINEC score can help in the management of Necrotizing Soft Tissue Infections (NSTI). This was a retrospective, observational study of patients admitted to our hospital with a diagnosis of NSTI. The LRINEC score was calculated for each case based on points assigned for each of the six laboratory variables at the time of patient presentation, including C-reactive protein, total white cell count, haemoglobin, serum sodium, serum creatinine and blood glucose. The study included 57 males and three females. Their ages ranged from 27-75 years, the mean age being 48.72 ± 10.16 years. The mean age among diabetic patients was slightly higher. In 37 patients, the condition was of unknown aetiology. Diabetes was the most common comorbid condition found in 19 (31.67%) patients. The wound culture was polymicrobial in all patients. Four patients died, giving a mortality of 6.67% in this study. The LRINEC score was calculated for each patient and according to the score, the patients were categorized into low-, intermediate- and high-risk groups. Notably, amputations were required only in the high-risk group. The four patients who died also belonged to the high-risk category. It was also noted in this study that patients with scrotal NSTI had a low LRINEC score compared to those with trunk and lower extremity NSTI. The LRINEC score is helpful in predicting the clinical course of NSTI and helps in taking necessary precautions to reduce the mortality of the disease.

Erratum to: Bilateral Clubfeet Are Highly Correlated: A Cautionary Tale for Researchers

The article ‘‘Bilateral Clubfeet Are Highly Correlated: A Cautionary Tale for Researchers’’ (Clin Orthop Relat Res 2014, epub ahead of print, DOI 10.1007/s11999-014-3776-6) contained important areas of overlap with the article ‘‘Unilateral Versus Bilateral Clubfoot: An Analysis of Severity and Correlation,’’ which was published in a volume of the Journal of Pediatric Orthopaedics (British) (2014, 23:397–399). This was not made clear in the CORR article. In particular, 26 of the 33 patients whose data were included in the study published in CORR were included in the earlier work published in Journal of Pediatric Orthopaedics (British). This is particularly relevant to the question of clubfoot severity at the time of patient presentation, which was studied in both papers. The authors regret that they did not make this clear in the later publication in CORR.

Impact of Physician Awareness on Diagnosis of Fetomaternal Hemorrhage

Background: Fetomaternal hemorrhage (FMH) is a poorly understood condition in which the placenta allows transmission of fetal whole blood to the mother. FMH can cause fetal anemia resulting in critical illness, death or lifelong disability. Ascertainment of the incidence of FMH is limited by reliance on retrospective studies that are dependent on a diagnosis of FMH being made at the time of patient presentation. Objective: To determine whether the diagnosis of FMH is made more frequently after an educational intervention to increase physician awareness of the condition. Methods: This is a retrospective cohort study of all neonates born at our institution from 1988 through 2010. The medical records of all neonates diagnosed with anemia in the first 24 h of life were reviewed. The incidence of FMH as a documented etiology of anemia was compared between infants born before and after our educational intervention. Results: Of 124,738 births during the study period, 572 neonates with neonatal anemia were identified. A total of 23 cases of FMH demonstrated by positive Kleihauer-Betke testing occurred in our cohort. The incidence of diagnosed FMH prior to our intervention was 22 per 1,000 anemic neonates compared to 182 per 1,000 afterwards (p < 0.001), while the incidence of neonatal anemia remained unchanged (p = 0.377). Conclusions: FMH may be a significant cause of neonatal anemia. Diagnosis of FMH is highly dependent on physician awareness of the condition. Incorrect or absent diagnosis of the etiology of neonatal anemia has significant implications for our understanding of the epidemiology of FMH.

Cytokine response signatures in disease progression and development of severe clinical outcomes for leptospirosis.

BackgroundThe role of the immune response in influencing leptospirosis clinical outcomes is not yet well understood. We hypothesized that acute-phase serum cytokine responses may play a role in disease progression, risk for death, and severe pulmonary hemorrhage syndrome (SPHS).Methodology/Principal FindingsWe performed a case-control study design to compare cytokine profiles in patients with mild and severe forms of leptospirosis. Among patients hospitalized with severe disease, we compared those with fatal and nonfatal outcomes. During active outpatient and hospital-based surveillance we prospectively enrolled 172 patients, 23 with mild disease (outpatient) and 149 with severe leptospirosis (hospitalized). Circulating concentrations of pro- and anti-inflammatory cytokines at the time of patient presentation were measured using a multiplex bead array assay. Concentrations of IL-1β, IL-2, IL-4, IL-6, IL-8, IL-10, IL-17A, and TNF-α were significantly higher (P<0.05) in severe disease compared to mild disease. Among severe patients, levels of IL-6 (P<0.001), IL-8 (P = 0.0049) and IL-10 (P<0.001), were higher in fatal compared to non-fatal cases. High levels of IL-6 and IL-10 were independently associated (P<0.05) with case fatality after adjustment for age and days of symptoms. IL-6 levels were higher (P = 0.0519) among fatal cases who developed SPHS than among who did not.Conclusion/SignificanceThis study shows that severe cases of leptospirosis are differentiated from mild disease by a “cytokine storm” process, and that IL-6 and IL-10 may play an immunopathogenic role in the development of life-threatening outcomes in human leptospirosis.

Joint-preserving osteotomy of malunited ankle and pilon fractures

Malunion and nonunion after ankle and pilon fractures regularly lead to the development of painful functional impairment even in cases of only mild axial deviation or residual joint incongruity. Involvement of the tibial pilon results in rapid progression of posttraumatic ankle arthritis. Corrective osteotomy with joint preservation aims at secondary anatomical reconstruction with functional rehabilitation. This requires a careful preoperative analysis and will be possible in carefully selected cases only. Prerequisites for successful reconstruction are intact cartilage, sufficient bone quality, residual joint function and good patient compliance. Since the works of B. G. Weber, joint-sparing osteotomy is an established treatment option for malunited malleolar fractures with reliable long-term results and low rates of complications and secondary fusions. Key to success is the re-establishment of the length of the distal fibula and repositioning into the tibial incisura in cases of syndesmotic instability. Corrections of the medial malleolus and posterior tibial fragment are less frequent. Corrective intra-articular osteotomies for malunited pilon fractures are rarely feasible because of manifest arthritis at the time of patient presentation in most cases. Besides case reports there is only one series of 14 patients available in the literature. At 5-year follow-up, a good to excellent result was seen in 10 cases and secondary ankle fusion was done in 2 patients with a poor result. Anatomical reconstruction of malunited tibial pilon fractures appears to be a viable treatment option besides arthroplasty and fusion in carefully selected patients.