Ganciclovir resistance as a result of oral ganciclovir in a heart transplant recipient with multiple human cytomegalovirus strains in blood

The etiologic spectrum of acute encephalitis syndrome (AES) has not been well defined in Vietnam. Cohort and case-control studies were performed on all adult and pediatric AES patients admitted to the Neurology Service of Bach Mai Hospital between June 5 and August 3, 1995. Among pediatric AES patients, 31 (67%) of 46 had acute Japanese encephalitis (JE), compared with only two (6%) of 33 adult AES patients (P < 0.0001). For confirmed JE cases, serum specimens obtained 15-21 days after symptom onset had the highest mean anti-JE IgM signal-to-noise (P/N) ratios (8.08 + 1.09 SE). A serosurvey of adult household members did not reveal any cases of recent subclinical JE infection, although 26% had evidence of past JE infection. The use of bed netting was nearly universal but did not appear to reduce the risk of AES or JE. Given the high incidence of JE, particularly among children, Vietnam seems well suited for the development of a targeted JE vaccination strategy.     

Duration of hospitalization for acute bacterial meningitis at Boston City Hospital during 12 selected years, 1935-1972

An analysis is presented of the duration of hospitalization of the patients with acute bacterial (purulent) meningitis which occurred at Boston City Hospital during 12 selected years between 1935 and 1972. Considerable differences in the length of stay in the hospital were noted depending on the bacterial etiology, whether the infection was present on admission or acquired within the hospital, and, of course, whether the patient survived or died. Most of the deaths occurred within the first few days after admission or after the diagnosis was first established, but even among fatal cases, the survival time differed depending on the etiology and site of acquisition of the infection. During the years after effective antibiotics became available the hospital stay of patients who survived after admission for meningococcal, influenzal, or pneumococcal meningitis was shorter than before. The same has not been true for meningitis caused by other gram-positive cocci, gram-negative rods, or mixed infections, probably reflecting the relative ineffectiveness of antimicrobial therapy in such patients.     

The cost-effectiveness of the diagnosis of renal artery stenosis

Variables were studied which predict at the acute stage the functional and occupational long-term outcome for patients with traumatic brain injury (TBI). Glasgow Coma Scale (GCS) score on hospital admission, length of coma (LOC) and duration of post-traumatic amnesia (PTA) were studied in a group of 508 TBI rehabilitation patients, age 0.8-71, mean age 19, followed up between five and over 20 years, mean of 12 years. Information from hospital charts and all data available before and after the injury were gathered and reviewed. The study was carried out among a consecutive sample of Finnish patients with TBI referred to a rehabilitation programme at the out-patient neurological clinic of Kauniala Hospital, which specializes in brain injuries in Finland. The patients came from various hospital districts in the country for an evaluation of their educational and vocational problems. Main outcome measures were functional outcome, as measured by the Glasgow Outcome Scale (GOS) at the end of follow-up, and post-injury occupational outcome. The patients' reemployment on the open job marklet, subsidized employment or inability to work was noted. The GCS score on hospital admission correlated clearly with the functional outcome of the patients at the end of follow-up. Length of coma and duration of post-traumatic amnesia correlated specifically with the patient's work history after the brain injury and with functional outcome measured by the GOS. Outcomes varied among age groups and seemed to be affected by age at injury. Accordingly, the extent of recovery and quality of life for rehabilitation patients with TBI can be estimated early on by prognostic factors reflecting injury severity in the acute phase. The results suggest that the GCS score, LOC and duration of PTA all have a strong predictive value in assessing functional or occupational outcome for TBI patients.     

Timing of surgery in patients with aneurysmal subarachnoid haemorrhage: rebleeding is still the major cause of poor outcome in neurosurgical units that aim at early surgery

OBJECTIVE: To investigate prospectively the proportion of patients actually operated on early in units that aim at surgery in the acute phase of aneurysmal subarachnoid haemorrhage (SAH) and what is the main current determinant of poor outcome. METHODS: A prospective analysis of all SAH patients admitted during a one year period at three neurosurgical units that aim at early surgery. The following clinical details were recorded: age, sex, date of SAH, date of admission to the neurosurgical centre, whether a patient was referred by a regional hospital or a general practitioner, Glasgow coma scale and grade of SAH (World Federation of Neurological Surgeons (WFNS) score) on admission at the neurosurgical unit, results of CT and CSF examination, the presence of an aneurysm on angiography, details of treatment with nimodipine or antifibrinolytic agents, and the date of surgery to clip the aneurysm. At follow up at three months, the patients' clinical outcome was determined with the Glasgow outcome scale and in cases of poor outcome the cause for this was recorded. RESULTS: The proportion of patients that was operated on early--that is, within three days after SAH--was 55%. Thirty seven of all 102 admitted patients had a poor outcome. Rebleeding and the initial bleeding were the main causes of this in 35% and 32% respectively of all patients with poor outcome. CONCLUSIONS: In neurosurgical units with what has been termed "modern management" including early surgery, about half of the patients are operated on early. Rebleeding is still the major cause of poor outcome.     

Prognostic value of electrocardiographic monitoring of patients with severe diphtheria

The clinical, the 12-lead, and the 24-hour electrocardiographic findings in 15 consecutively studied Vietnamese children (aged 7 months to 16 years) with severe diphtheria were documented. Five patients died, three from respiratory arrest and two from cardiogenic shock; one of these two patients had complete heart block that necessitated insertion of a pacemaker. Electrocardiographic abnormalities were detected by 24-hour monitoring in all 15 cases, even though most patients had no clinical signs of myocarditis. Rates of supraventricular and ventricular ectopy were elevated and remained high long after other clinical manifestations were no longer noted. The degree of ventricular ectopy at the time of presentation was significantly associated with fatal outcome. In this series, more than two ventricular ectopic beats on a recording upon admission to the hospital predicted fatal outcome with 100% sensitivity and 100% specificity. A variety of nonsustained bradyarrhythmias and tachyarrhythmias were also observed up until discharge from the hospital. The time course of recovery from diphtheritic myocarditis is longer than has been appreciated previously.     

Single-photon emission CT findings in acute Japanese encephalitis

PURPOSE: To determine the usefulness of single-photon emission CT (SPECT) in the diagnosis of acute Japanese encephalitis (JE). METHODS: We examined 10 patients (six men and four women; mean age, 69 years) with viral encephalitis. We divided the cases into two groups: the JE group (n = 4) and the non-JE group (n = 6; two with herpes simplex encephalitis and four with encephalitis of unknown origin). All cases were investigated with 99mTc-hexamethylpropyleneamine oxime (HMPAO) SPECT within 15 days after the onset of symptoms. Two patients in the JE group were also examinated by SPECT at a later stage. In all cases MR imaging was performed after the SPECT study. RESULTS: In the acute stage, all patients in the JE group showed a marked increase of HMPAO uptake that matched the hyperintense area observed on MR images in the thalami and putamina bilaterally. Follow-up SPECT studies of two patients with JE revealed a decrease of HMPAO deposition in the areas of high uptake. None of the patients in the non-JE group had an increased accumulation of HMPAO in the thalami or the putamina. CONCLUSIONS: SPECT is helpful in differentiating JE from herpes simplex encephalitis and other types of encephalitis. SPECT may be useful as a diagnostic tool in the early stages of JE.     

Acute community-acquired pneumonia due to Aspergillus in presumably immunocompetent hosts: clues for recognition of a rare but fatal disease

This article reports a case of acute community-acquired pneumonia due to Aspergillus fumigatus in a healthy patient and reviews 11 previously reported cases occurring in presumably immunocompetent hosts. The diagnosis was delayed for all patients; mortality was 100%. Clues that might suggest Aspergillus as a pathogen in community-acquired pneumonia include a chest radiograph revealing diffuse infiltrates or new cavitation; lack of bacterial or viral cause; a preceding influenza A infection; and respiratory secretion cultures positive for Aspergillus. When these clues are present, the physician should consider an early biopsy of lung tissue. Increased recognition and more timely diagnosis in future cases will improve the outcome of this rare but fatal infection.     

Importance of outside hospital mortality as a first acute ischemic heart event: the Quebec Cardiovascular Study

Among 4371 men aged 35 to 64 in 1973 who were randomly selected, living in Quebec City suburbs, without clinical evidence of ischemic heart disease (IHD) at entry and followed for 16 years, 426 had a first acute IHD event; of these, 296 had a nonfatal myocardial infarction (MI), 50 a fatal MI (death within four weeks of the acute event) and 80 an early death, ie, they died before the diagnosis of MI was made. Among these 80 early deaths attributed to IHD in the absence of any other apparent cause, 55 men died within 1 h from the onset of symptoms or were found dead in their bed (group A) while 25 died more than 1 h after the onset of symptoms (group B). In this population, a first acute IHD event carried a 31% (130 of 426) case fatality within the first four weeks. Groups A and B accounted for 42% (55 of 130) and 19% (25 of 130) of the total acute ischemic mortality, respectively. As expected, fatal events increased with age, but the proportion of early deaths over the total IHD mortality was as frequent in younger men as in older men. Smoking, increased systolic and diastolic blood pressure and serum cholesterol were associated with increased nonfatal events. A similar association, except for serum cholesterol, was observed for all fatal events. No significant risk factor profile differentiated early from late fatal events. In conclusion, in this population, nearly a third of men with a first IHD event died, most of them outside the hospital. None of the main established risk factors differentiated men with a fatal MI from those with an early death.     

Practical estimation of the actual laboratory diagnostics of cholera

A series of 116 nonselected and consecutive patients with acute pancreatitis with a fatal outcome underwent necropsy and have been analyzed with special attention paid to hepatic findings and the cause of death. This series includes the total fatalities caused by the disease during a 15 year period from 1956 to 1970. All but two patients died in the first attack of acute pancreatitis. The patients were divided into four etiologic groups: gallstone disease, 43 per cent; alcoholism, 25 per cent; idiopathic origin, 18 per cent, and postoperative origin, following abdominal operations, 14 per cent. Over the three five-year periods, the frequency of alcohol abuse as a predisposing factor increased, while gallstone disease showed a corresponding decrease. About 75 per cent of the patients had hyperbilirubinemia. Half of these showed signs of cholestasis. Macroscopic steatosis of the liver was recorded in 62 per cent of the alcohol addicts and in about 25 per cent of the patients in the other etiologic groups. Shock and late sequelae of shock were the dominating immediate causes of death in 72 per cent. About 50 per cent of the fatalities occurred within the first week. Most of these early deaths were caused by intractable circulatory failure. Early death was most commonly caused by alcoholism, followed in frequency by gallstone disease. It is possible that impaired hepatic function contributes to the fatal outcome in both early and late phases of the disease.     

Clinical features of Crimean-Congo haemorrhagic fever in the United Arab Emirates

Crimean-Congo haemorrhagic fever (C-CHF) re-emerged recently in the United Arab Emirates. The clinical outcome of 11 cases of viral haemorrhagic fever patients admitted to hospital between June 1994 and January 1995 is described. Four cases were laboratory confirmed retrospectively as C-CHF, the other patients were diagnosed likely to have the same disease on epidemiological and clinical grounds. In 72.7% of the patients, infection was fatal. Symptoms started 3.5 days before hospitalization. On admission, 81.8% of patients had high fever, 45.5% were vomiting, 63.6% had diarrhoea, 45.5% had haemorrhagic signs, and 18.2% had throat pain. Fatalities occurred 6.8 days after admission. Survivors were hospitalized for 9.3 days. Nosocomial transmission was not observed.     

Causes, management and morbidity of acute hypoglycaemia in adults requiring hospital admission

In the community, acute hypoglycaemia is commonly caused by therapies for diabetes mellitus or the excessive consumption of alcohol. Although most episodes do not require admission to hospital, little information is available on the causes and outcome of those that do. We retrospectively surveyed adult patients admitted to a large urban teaching hospital with acute hypoglycaemia in a 12-month period, identifying 56 admissions of 51 patients. Forty-one had diabetes mellitus, 33 (80%) of whom were receiving treatment with insulin. The others had hypoglycaemia induced by excessive consumption of alcohol or by deliberate self-poisoning with insulin. A history of psychiatric illness and/or chronic alcoholism was common. Neurological manifestations of hypoglycaemia were the principal reason for admission, observed on 50 occasions (89%), and 11 events (20%) had precipitated convulsions. Although many patients (59%) had received treatment for hypoglycaemia before admission, hypoglycaemia recurred in 16% of patients in hospital. Four patients (7%) died following admission, but in only one case was this the direct result of hypoglycaemia. However, within 15 months of the index hypoglycaemia event, a further six patients (11%) had died, mostly of causes unrelated to hypoglycaemia. Patients who require hospital admission for treatment of hypoglycaemia have a high incidence of neurological manifestations, a high rate of mental illness and other medical disorders, and may represent a high-risk subgroup with a poor long-term prognosis.     

Postoperative changes in the coagulation and fibrinolytic systems in endoluminal stent-graft treatment of thoracic aortic aneurysms

Length of stay (LOS) predictions in acute pancreatitis could be used to stratify patients with severe acute pancreatitis, make treatment and resource allocation decisions, and for quality assurance. Artificial neural networks have been used to predict LOS in other conditions but not acute pancreatitis. The hypothesis of this study was that a neural network could predict LOS in patients with acute pancreatitis. The medical records of 195 patients admitted with acute pancreatitis were reviewed. A backpropagation neural network was developed to predict LOS >7 days. The network was trained on 156 randomly selected cases and tested on the remaining 39 cases. The neural network had the highest sensitivity (75%) for predicting LOS >7 days. Ranson criteria had the highest specificity (94%) for making this prediction. All methods incorrectly predicted LOS in two patients with severe acute pancreatitis who died early in their hospital course. An artificial neural network can predict LOS >7 days. The network and traditional prognostic indices were least accurate for predicting LOS in patients with severe acute pancreatitis who died early in their hospital course. The neural network has the advantage of making this prediction using admission data.     

Mitochondrial oxygen radical formation during reductive and oxidative stress to intact hepatocytes

BACKGROUND: Many processes behind the admission to hospital of elderly people can lead to a deterioration in their health at the time of discharge. The aims of the study are to assess the dependency on and need for socio-health care required by elderly people aged over 64 when discharged from a hospital for acute cases, the help that patients prefer and the help that they actually receive one month following their discharge. METHODS: A total of 193 patients aged over 64 and admitted to a hospital in Valencia between February and April 1994 were studied. Information on socio-demographic characteristics, self-care capacity, mental state, main diagnosis and co-morbidity was obtained by means of an interview at the time of admission and the medical record. A multidisciplinary team evaluated the socio-health care required in each case. A second interview, one month after discharge from hospital, gathered data on the actual care received. RESULTS: At the time of admission, 17% of the patients needed partial care and 21% full care. 23% were candidates for receiving home help, 9% to be treated as out-patients and 6% in a chronic illness hospital. Most of the patients asked to live at home. One month after discharge from hospital, only 2% of patients were receiving home help, none were being treated as out-patients or in a chronic illness hospital and 3% had once again admitted to a hospital for acute cases. 8% of the patients who were living at home alone before being admitted to hospital and 5% of those who were living with someone else had gone to live with relatives. CONCLUSIONS: The reality observed reflects the lack of socio-health resources. In many cases, this situation leads families to take on the care of the elderly themselves.     

Troponin T in patients with low grade or atypical angina. Identification of a high risk group for short- and long-term cardiovascular events

AIMS: Cardiac troponin T is an established marker of cardiovascular risk in patients with severe angina pectoris. Data are scarce on patients admitted to a coronary care unit with low grade or atypical angina pectoris to rule out myocardial infarction. METHODS AND RESULTS: We investigated 106 patients (57.4 SD 11.6 years) with low grade (Braunwald class I) or atypical symptoms out of 702 patients admitted to the coronary care unit with suspected acute myocardial infarction. Serum concentrations of troponin T were measured at admission and 4 h later. In hospital cardiovascular events including acute myocardial infarction, life threatening cardiac arrhythmias, congestive heart failure, and death were recorded. Patients were additionally observed after 3 and 6 months post-discharge regarding acute myocardial infarction, unstable angina, rehospitalization for cardiac causes and death. The patients were divided into a troponin T positive (> or =0.2 microg x 1(-1) at admission or 4 h later; n=11) and a troponin T negative group. The mean value of troponin T 4 h after admission in the positive group was 0.58 microg x 1(-1). Of the troponin T positive patients, 0.82 (0.95 CI: 0.48-0.98) had a cardiovascular event during their stay in hospital vs 0.41 (0.95 CI: 0.31-0.52) of troponin T negative patients (P<0.05). In the troponin T positive group 0.64 (0.95 CI: 0.31-0.89) developed myocardial infarction in hospital vs 0.07 (0.95 CI: 0.03-0.15) in the troponin T negative group (P<0.001). Troponin T predicts outcome after 3 and 6 months significantly (P<0.05). CONCLUSION: Troponin T identifies patients with low grade or atypical angina at risk of severe short- and long-term cardiovascular events. Therefore, troponin T adds substantial information in patients with ruled out acute myocardial infarction. Troponin T positive patients have to be observed carefully regardless of their symptom intensity and may have to receive early cardiac catheterization; troponin T negative patients could be released safely from the coronary care unit early.     

Reye''s syndrome: relapses and neurological sequelae

Twenty-two children aged 2 months to 11 years were seen at our institution from January 1970 to March 1975 with clinical, laboratory, and/or histological features consistent with the diagnosis of Reye's syndrome. There were three pairs of siblings. Severity of the illness ranged from relatively benign to rapidly fatal forms. Five received live attenuated vaccines within the three weeks prior to admission. Four relapsed 1 to 21 months after the initial episode, and in one there were multiple recurrences. Six developed major neurological sequelae. All patients graded levels IV and V by EEGs on admission subsequently died in contrast to none from grades 1 and 2. Peritoneal dialysis was carried out in the more severely affected patients. The procedure did not influence final outcome as predicted by the first EEG and is thought to be of limited value.     

Cognitive sequelae following rupture of aneurysms of the anterior communicating artery and the anterior cerebral artery. Retrospective study of 56 cases

The neuropsychological records of 56 patients operated for clipping were studied. Almost every patient remained autonomous and without invalidating motor defect. The present study was aimed at specifying the type and frequency of neuropsychological sequelae and, to a lesser extent, the role of various pathophysiological factors. A main concern was to examine to what extent and at what post-operative interval the neuropsychological assessment can predict the intellectual and socioprofessional outcome of each individual patient. The neuropsychological assessment performed beyond the acute phase showed evidence of intellectual sequelae in about two thirds of the patients. Only one case of permanent anterograde amnesia was observed, probably due to unavoidable inclusion of a hypothalamic artery in the clip during surgery. Transient anterograde amnesia and confabulations were occasionally observed, generally for less than three weeks. A common finding was impaired performance on memory and/or executive tests. In a minority of patients, language disorders, visuoperceptive and visuoconstructive disabilities were found, probably in relation with hemodynamic changes at distance from the aneurysm. Global impairment of intellectual function was not uncommon in the acute post-operative phase but it evolved in most cases towards a more selective impairment, for instance restricted to executive and memory functions, in the chronic phase. The neuropsychological investigation carried out 4 to 15 weeks post-operatively provided satisfactory information about possible long-lasting intellectual disturbances and professional resumption. In particular, persistent global intellectual impairment, persistent amnesia and confabulations 4-15 weeks post-operative were associated with cessation of professional activity; executive and memory impairment, behavioral disturbances such as those encountered in patients with frontal lobe damage were associated with a decreased probability of full-time employment. Pre- and post-operative angiography were not good predictors of long-term cognitive outcome: normal angiography was not necessarily followed by normal neuropsychological outcome, conversely abnormal angiography could be found together with normal neuropsychological outcome. By contrast, there was a relationship between left-lateralised abnormalities on post-operative angiography and occurrence of language disorders; similarly, there was a relationship between side of craniotomy and type of deficits, that is language disorders versus visuoperceptive-visuoconstructive impairments.     

A case of paraquat poisoning and subsequent fatality presenting to an emergency department

Paraquat (1,1'-dimethyl-4,4'-dipyridylium) is an herbicide associated with both accidental and intentional ingestion, leading to severe and often fatal toxicity. Prognosis is largely dependent on the amount of paraquat absorbed. Rapid identification of the symptoms of paraquat toxicity (burns or ulceration at the site of ingestion or injection, acute respiratory distress, and renal failure) can facilitate early treatment intervention to limit absorption. We report a case of a 71-year-old man with a suicidal ingestion of paraquat 2 days prior to presentation. Serum paraquat levels, time elapsed since ingestion, and clinical symptoms all indicated poor prognosis. The patient developed severe respiratory distress and progressive renal failure, and died 6 days after admission to the hospital.     

Therapeutic strategies in acute myocardial infarction. Results of STIM 93 registry

A registry was set up by the national college of cardiologists practicing in general hospitals in February 1993. The data concerned mode of admission, demographic details, initial clinical and haemodynamic evaluation and hospital outcome. Special attention was given to the electrocardiographic changes before and, in patients receiving thrombolytic therapy, after treatment. An analysis of predictive factors for mortality was performed both in the group of patients "revascularised" and in the group treated conventionally. One thousand and twenty three cases from 327 centres were analysed. There were 1292 men and 531 women, with an average age of 67.9 years. The average time interval from onset of symptoms to hospital admission was 5 h 30 min, 56.8% of patients arriving within 6 hours. 36.4% of the population underwent thrombolysis or angioplasty, 75% of patients under 75 years of age admitted before the 5th hours underwent a procedure of myocardial revascularisation. The hospital mortality was 14%, 8.7% in those revascularised and 17% in patients treated conventionally. Factors predictive of mortality were age, female gender, Killip Classes III or IV, systolic blood pressure of less than 100 mmHg, heart rate of more than 100/min and contraindications of thrombolysis. The maximum ST depression, the sum of ST depression, the sum of ST elevation and depression, were also significant predictive factors of a fatal hospital outcome in the whole population group and in patients treated conventionally. In the reperfused group, only the initial sum of ST elevation and depression was predictive of mortality: 120 minutes after the beginning of thrombolysis, the sum of ST elevations and of elevations and depressions was predictive of twice the mortality when the values exceeded 0.6 mv and 1.4 mv respectively.     

Priapism: diagnosis and management

A 32-year-old female patient with a primary adenohypophyseal neoplasm that rapidly progressed to a fatal outcome is presented. The time interval between her admission to the hospital and her death was 3 months. Despite dopamine agonist therapy, local invasion as well as frontal and spinal cord metastases at Th 10-12 region developed, and four surgical resections were performed. The serum prolactin levels were high. Both the primary pituitary tumour and all the metastatic tumours had the same histological findings and immunohistochemical reactions. Each was composed of pleomorphic chromophobic cells with enlarged nuclei. Mitoses and necroses were frequent. Immunostains revealed prolactin in the tumour cells. A literature review revealed that in most of the pituitary carcinomas as in our case hyperprolactinaemia did not respond to medical therapy and the histopathological appearance of the tumour has not correlated with the aggressive behaviour of the tumour. It may therefore be considered that at least some of the cases with metastases in prolactin secreting pituitary carcinomas could be the result of hyperprolactinaemia itself.     

Acute bacterial meningitis in adults: a clinical and developmental analysis of 100 cases

BACKGROUND: Characterize clinical findings and outcome of acute bacterial meningitis (ABM) in adults, with special emphasis on nosocomial meningitis and meningitis in the elderly. METHODS: We reviewed the charts of all persons 14 years of age or older in whom ABM was diagnosed in our hospital during a 12 and a half-year period. RESULTS: Ninety-seven patients were treated for 100 episodes of ABM, of which 23 percent were nosocomial and 27 percent occurred in elderly persons. Predisposing factors were present in 59 percent of the episodes. Fifty-four percent had the classic triad of fever, nuchal rigidity, and change in mental status. Cerebrospinal fluid pleocytosis with a neutrophilic predominance, hypoglycorrhachia, and elevated protein levels were present in 62 percent of the episodes. A pathogen was identified in 62 percent of the cases, in a higher frequency in elderly persons (p < 0.05) and in patients who had not received antibiotics before the lumbar puncture (p < 0.05). Causal agents more frequently identified were: Streptococcus pneumoniae (27 percent) in community-acquired meningitis, coagulase-negative Staphylococci (35 percent) in nosocomial meningitis, and Strep. pneumoniae (33 percent) in elderly persons. Central nervous system (CNS) complications occurred in 18 percent of episodes, and 15 percent developed systemic complications. The overall mortality rate was 9 percent, higher among patients in whom CNS complications began within 24 hours of admission (p < 0.05). CONCLUSIONS: A high proportion of cases of ABM in adults are nosocomial, or affect elderly persons. The fatality rate is high, particularly among those who develop CNS complications at the onset of the disease.