Leptospirosis: prognostic factors associated with mortality

To determine the prognostic factors for leptospirosis, we conducted a retrospective study of data collected in the emergency department of our hospital between 1989 and 1993. Sixty-eight patients, for whom the diagnosis of leptospirosis was based on pertinent clinical and epidemiological data and positive serology, were included in this study. Fifty-six patients (82%) were discharged from the hospital, and 12 (18%) died. Multivariate logistic regression demonstrated that five factors were independently associated with mortality: dyspnea (odds ratio [OR], 11.7; 95% confidence interval [CI], 2.8-48.5; P < .05), oliguria (OR, 9; CI, 2.1-37.9; P < .05); white blood cell count, >12,900/mm3 (OR, 2.5; CI, 1.8-3.5; P < or = .01), repolarization abnormalities on electrocardiograms (OR, 5.9; CI, 1.4-24.8; P < or = .01), and alveolar infiltrates on chest radiographs (OR, 7.3; CI, 1.7-31.7; P < or = .01). Identification of these factors on admission might provide useful selection criteria for patients who need early transfer to the intensive care unit.     

An echocardiographic study of the interventricular septum in constrictive pericarditis

Ten patients with constrictive pericarditis were studied echocardiographically with specific reference to inter-ventricular septal dynamics. Abnormal movement of the interventricular septum was present in 8 patients and consisted of flattening in systole and unusual posterior motion in diastole. The aetiology of this type of movement is at present unknown but may be related to restriction of normal cardiac rotational dynamics. The interventricular septum also showed diminished degree of thickening (mean 21-2%). The amplitude of excursion was generally at the upper limit of or greater than normal. Left ventricular posterior wall amplitude of excursion was normal. Flattening of left ventricular posterior wall diastolic movement was seen in 4 patients. Right ventricular end-diastolic dimension was slightly increased (1-2 to 1-7 cm/m2) in 5 of 8 patients with abnormal septal motion, but no haemodynamic evidence of diastolic volume overload was found. Posterior pericardial thickening was noted echocardiographically when posterior calcification was present. We conclude that the most common though non-specific feature of the echocardiogram in patients with constrictive pericarditis is abnormal septal motion. Flattening of left ventricular posterior wall diastolic movement, posterior pericardial thickening, and epicardial-pericardial separation may also occur.     

Aneurysm of sinus of Valsalva dissecting into interventricular septum

PURPOSE: We developed an algorithm using unenhanced computerized tomography (CT) for the management of acute flank pain and suspected ureteral obstruction. MATERIALS AND METHODS: During a 25-month interval 417 patients with acute flank pain underwent unenhanced helical CT. The final diagnosis was confirmed by additional imaging or clinical followup. For all patients who underwent additional imaging studies the official dictated radiology reports were used to determine whether the studies were recommended based on CT findings. Cases requiring intervention were evaluated to determine whether additional imaging was performed before the procedure. Medical records were reviewed and/or patients were interviewed to document the course of therapy and long-term outcome. RESULTS: Unenhanced helical CT diagnosed ureteral stone disease with 95% sensitivity, 98% specificity and 97% accuracy. Of the 38 patients requiring intervention, including nephrostomy catheters in 18, lithotripsy in 3 and ureteroscopic stone extraction in 7, additional imaging (excretory urography) was performed in only 1. Additional imaging studies generated by CT were done in 3 cases in which the dictated reports were indeterminate for ureteral stones, including negative excretory urography in 2 and retrograde urography in 1. In 1 patient in whom CT misdiagnosed a ureteral stone unnecessary retrograde urography revealed the calcification to be a gonadal vein phlebolith. Seven patients with false-negative examinations reported spontaneous stone passage with no complications. CONCLUSIONS: Unenhanced helical CT accurately determines the presence or absence of ureterolithiasis in patients with acute flank pain. CT precisely identifies stone size and location. When ureterolithiasis is absent, other causes of acute flank pain can be identified. In most cases additional imaging is not required.     

Hydatid cyst of the interventricular septum in a 3.5-year-old child

An asymptomatic cardiac cyst located in the interventricular septum was diagnosed in a 3.5-year-old child by echocardiographic findings. Surgical ablation was done and histopathologic analysis confirmed a hydatid cyst. The patient was discharged without symptoms.     

Infective endocarditis in adolescents. Analysis of risk factors for hospital mortality

PURPOSE: To study the epidemiological, clinical, therapeutic and evolutive aspects of endocarditis in a group of patients aging 12 to 20 years-old (mean 15.5). METHODS: Thirty-three consecutive patients (14 males, 19 females) admitted with infective endocarditis were retrospectively studied. RESULTS: Infective endocarditis mortality was 42%. Rheumatic heart disease was the predominant underlying condition in 63% of patients. Congenital heart disease (24%) and cardiac prosthesis (12%) were the other affections involved. The majority of patients (78%) were in functional class III and IV, with more deaths than the 22% who were in functional class I and II (p = 0.01). Staphylococcus aureus was the most frequently isolated agent (42% of the positive blood cultures, followed by Staphylococcus viridans, 21%). Multivariate analysis identified total leukocyte count above 10,000/mm3 and functional class, both at admission (p = 0.01 and p = 0.004, respectively), and the occurrence of embolic complications (p = 0.03) as independent predictors of in-hospital mortality. CONCLUSION: Rheumatic heart disease remains, as in adults, the main predisposing factor for infective endocarditis in adolescents, and S. aureus is, like in children, the leading agent. Mortality is high and functional class at hospital admission, embolic complications and leukocytosis are independent predictors of in-hospital mortality.     

Appearance of the interventricular septum in obstructive lesions of the left ventricular outflow tract

Measurements of the thickness of the septum were made in 26 cardiac specimens and in 13 patients. There were 10 normal specimens, five with aortic stenosis, two with asymmetric septal hypertrophy, four with hypertensive cardiovascular disease, and five with idiopathic cardiomyopathy. Patient measurements were obtained by visualizing the septum during simultaneous left and right ventriculography on angiograms obtained in the left anterior oblique projection. Four patients were normal, five had aortic stenosis, and four had a symmetric septal hypertrophy. Measurements derived from normal cardiac specimens and angiographic appearance suggested that the normal septum is a smooth-walled structure with right and left ventricular surfaces parallel, diverging only slightly at the apex of the ventricle. In aortic stenosis and idiopathic cardiomyopathy, the septum tends to be biconvex with maximal thickening in its middle third. Hypertensive cardiovascular disease produces uniform septal thickening, resembling an exaggeration of normal. However, in asymmetric septal hypertrophy no consistent patterns of hypertrophy or septal thickening are evident; bulging can be present at any point along the left ventricular surface of the septum.     

Rupture of a presumed hydatid cyst of the interventricular septum diagnosed by transoesophageal echocardiography

In a sample of 34 study subjects, Cook and Jamshidi intraosseous (IO) needles were compared for ease of insertion into turkey bones. The averaged lapsed time of insertion was significantly shorter using the Jamshidi needle (25.5 v 56.2 seconds, P < .0001). The mean difficulty of insertion score was lower using the Jamshidi needle (3.0 v 7.1 on a 10-cm visual analog scale, P < .0001). The less costly Jamshidi needle is easier to use in IO insertion in this turkey bone model.     

Hemangioma of the interventricular septum simulating right obstructive cardiomyopathy. Apropos of a case and review of the literature

The authors report a case of haemangioma of the interventricular septum, a rare cardiac tumour (2.8% of all primary cardiac tumours) simulating right obstructive cardiomyopathy. Based on a review of the literature, they emphasize the diversity of the clinical expression of this disease and the uncertain medium and long-term outcome of operated and nonoperated tumours.     

Outcome and prognostic factors of achilles rupture repair using a new scoring method

A new clinical scoring system, including subjective assessment of symptoms and evaluation of ankle range of motion and isokinetic measurement of ankle plantar flexion and dorsiflexion strengths, is presented in 101 patients (86 men, 15 women) who had repair of a closed Achilles tendon rupture. Twenty-one patients were competitive athletes and 70 were recreational athletes. Eighty-one percent of the ruptures were related to sports, and 32% occurred while playing volleyball. Twenty-six patients had previous Achilles tendon symptoms. At followup, an average of 3.1 years after repair, the overall result scores were excellent in 34 cases, good in 46, fair in 17, and poor in four. Only age was a predictor of overall results. The isokinetic strength scores were excellent or good in 72 cases, fair in 18, and poor in 11. Presence of systemic diseases, activity level, previous Achilles tendon symptoms, and later return to physical exercise were predictors of strength results. Gender, body weight, height, period between rupture and operation, surgeon, rupture site, operative method, complications, and thickness, width, and area of the Achilles tendon at followup were not related significantly to the outcome.     

Mortality in psychiatric hospital patients: a cohort analysis of prognostic factors

BACKGROUND: This work followed a group of patients living in a psychiatric hospital in Central Italy in 1978 at the time of enforcement of the Italian reform law (No. 180) for closing down mental hospitals. The study had the following aims: a) to compare in terms of mortality patients discharged into the community with patients who did not experience deinstitutionalization; b) to determine the survival of the cohort of patients and to analyse prognostic risk factors for death; c) to analyse differences in mortality rates between psychiatric patients and the general population. METHODS: The study was designed as an historical follow-up investigation. Univariate (product limit) and multivariate (proportional hazards model) methods were used to estimate prognostic variables and related death risks. Mortality was assessed using standardized mortality ratios (SMR) on the entire cohort as well as after stratification according to age, sex, cause of death and discharge status, assuming the Abruzzo Region's population as standard. RESULTS: Length of hospitalization and discharge from hospital are prognostic variables for death risk, with relative risks respectively of 4.22 (95% confidence interval [CI]: 2.41-7.40) for a length of hospitalization of 10-25 years, and 8.13 (95% CI: 4.73-13.88) for non-discharge. The global SMR of the cohort was 2.68 (95% CI: 2.42-3.07). Non-discharged patients showed higher SMR than discharged. Excess mortality was found both in males and females for circulatory, respiratory and undefined diseases. A significantly lower mortality for cancer was observed in male patients. A strong excess mortality was observed in younger patients (20-29 years: SMRmales = 43.57; SMRfemales = 97.52). CONCLUSIONS: Longer periods of hospitalization and non-discharge from hospital are the main risk factors for death in psychiatric patients, who globally experience higher death rates than the general population for a wide spectrum of causes of death, whatever their diagnosis or gender. These findings strongly suggest positive actions in order to overcome the effects of institutionalization.     

Function of the residual myocardium after infarct and prognostic significance

Changes of the left ventricle after myocardial infarction are characterized by geometric, structural, and vascular alterations, which have been summarized under the term "remodeling". This process takes place in the infarct region as well as in the surviving myocardium. Depending on to the size of infarction and the degree of neurohumoral activation, the left ventricle demonstrates diastolic dysfunction which may finally lead to systolic failure. The residual myocardium develops progressive myocyte hypertrophy and interstitial fibrosis. These structural alterations are due to changes in loading conditions and stimulation of the neurohumoral system with an activation of local paracrine and autocrine factors. Myocardial function can be assessed by different non-invasive (echocardiography, radionuclide ventriculography, magnetic resonance imaging, etc.) or invasive methods (e.g., simultaneous pressure-volume measurements). "Myocardial tagging" based on magnetic resonance imaging allows the assessment of 3D-motion of the left ventricle by labelling specific myocardial regions with a rectangular grid. A systolic "wringing" motion with clock-wise rotation at the base and counter-clockwise rotation at the apex has been described in normal subjects. In the ischemic myocardium, delayed relaxation with a prolonged back-rotation (untwisting) has been reported during early diastole, whereas decreased systolic contraction with delayed diastolic rotation has been observed in non-Q-wave infarction. In patients with anterolateral aneurysms, a complete loss of systolic rotation has been demonstrated. The prognostic significance of LV "remodeling" has been emphasized by several authors: The size of infarction, LV volume, LV ejection fraction, as well as the degree of neurohumoral activation have been identified as being associated with an unfavorable clinical outcome. Yearly mortality rates have been reported to range between 15 and 17% in patients with large infarcts and marked LV dilatation and between 3 and 7% in patients with small to medium-sized infarcts.     

The prognostic factors for early mortality and for total or partial gammagraphic resolution in venous thromboembolic disease

Our objective was to investigate possible factors implicated in either early death from or scintigraphic resolution of pulmonary embolism. To that end we conducted a retrospective study of 116 patients with either a high likelihood of pulmonary thromboembolism (PTE) diagnosed by scintiscan or with a fair probability of PTE by scintiscan accompanied by a positive phlebograph. The images were taken upon admission, at 7 days, 10 days and 6 months. The factors analyzed were age, sex, trauma, immobility, surgery, obesity, hemiplegia, venous insufficiency, cardiopulmonary disease, neoplasia, chest X-ray and ECG alterations, D(A-a)O2 and size of perfusion defects upon admission and 7 to 10 days later. We performed single-variable analyses and multiple logical regression analyses using perfusion defect at 6 months as the dependent variable. The early mortality rate (13%) was higher in patients with neoplasms, a larger alveolar-arterial index and greater perfusion defects upon admission. Scintiscans became normal in 28%. Multivariate analysis to predict total or partial resolution at 6 months showed that size of perfusion defects at 7 to 10 days was the best predictive factor. A cutoff point was calculated by analyzing the ROC for this factor. Thus, when the defect at 7 to 10 days was equal to or greater than 1 segment, the probability of residual defects remaining after 6 months was twice as great (sensitivity 83%, specificity 57%). In conclusion, early death was more likely in PTE patients with neoplasms, larger defects upon admission and greater alveolar-arterial difference. Scintigrams showed resolution 6 months after admission in 28%. The size of perfusion defects 7 to 10 days after admission was the factor that best predicted total of partial resolution at 6 months.     

The prognostic factors of arterialized bypass veins in the lower extremities

Two children with cystitis presented with multiple filling defects in the urinary bladder. They were proven to be cases of cystitis glandularis with proliferative changes of the bladder epithelium. The radiographic findings are described and the differential diagnosis from neoplasms is outlined.