Abnormal movements associated with severe hyponatraemia.

An elderly woman with severe hyponatraemia manifested transient choreoathetoid movements of the upper extremities and dyskinetic movements of the face and mouth. She showed more than one type of hyponatraemia and a precise diagnosis was not possible. The movements were abolished with treatment of the hyponatraemia with no recurrence or sequelae.     

The treatment of advanced cardiac allograft rejection

Severe cardiac allograft rejection remains a serious problem despite the advances of cyclosporine-based immunosuppression. This study analyzes our experience with 202 recipients of cardiac allografts who were treated primarily with cyclosporine and prednisone. Failure of such therapy in 86 patients (43%) resulted in 105 episodes of advanced cardiac allograft rejection as diagnosed by endomyocardial biopsy. Of 101 rejection episodes that were initially treated with intravenous pulse therapy, 48 (48%) were successfully resolved, yet 60% of these successes were associated with major infections. Patients in whom steroid therapy failed or was contra-indicated received intravenous antithymocyte globulin (ATG) or intravenous monoclonal antibody (OKT3). ATG and OKT3 successfully reversed severe rejection in 26 (81%) of 32 and in 13 (93%) of 14 episodes, respectively. Infectious complication rates were 54% and 21%, respectively. Because the majority (87%) of these rejection episodes occurred within the first 30 days after treatment, many of them may have resulted from inadequate immunosuppressive induction therapy. Based on our results, we believe that advanced cardiac allograft rejection may be managed best by individualizing immunosuppressive therapy, thus enhancing prevention, and by adding OKT3 to the regimen when rejection occurs.     

Duodenal and jejunal atresia with agenesis of the dorsal mesentery: "apple peel" small bowel.

Two newborn infants with duodenal and jejunal atresia and agenesis of the dorsal mesentery represent our surgical experience with "apple peel" small bowel or "christmas tree" demormity. The first patient had the typical appearance of this condition. The postoperative course was complicated by hyperbilirubinemia, septicemia, and disseminated intravascular coagulation. The infant is in satisfactory condition 1.5 years after operation. The second patient had agenesis of the dorsal mesentery without spiraling of the bowel around its vascular stalk. The child died after 1 month, with complete absence of extrahepatic bile ducts as seen at a second laparotomy. Neither child had been subjected to gastrostomy.     

Osteoplastische Behandlung der Osteomyelitis

Zusammenfassung Nach kurzer Einführung folgt die Begriffsbestimmung der osteoplastischen Behandlung der Osteomyelitis, bei der die Knochentransplantation nicht nur Knochenersatz leistet, sondern darüber hinaus ein wesentlicher Faktor der Heilung des osteomyelitischen Prozesses ist. Der Autor geht auf die Fragen der Indikationen, Eigenschaften des Knochenlagers, Wesen, Struktur und Konservierungsart des Transplantates, immunologische Probleme, Anwendungsmethoden, Dynamik des Umbaues des Transplantates und Ergebnisse ein. Er schlägt eine Skala für eine Qualifizierung des Empfängerlagers vor. Der Autor hat die osteoplastische Behandlung der Osteomyelitis im breiten Rahmen der verschiedenen Anwendungsmethoden entwickelt. Es wird zur Analyse und Diskussion ein Krankengut von 602 Fällen vorgeführt. Das Krankengut ist nach Kriterien, Alter, Lokalisation, Morphologie, Infektion und Operationsverfahren untersucht. Weiterhin ist die Charakteristik des Transplantates, Entnahmestellen und seine Konservierungsart aufgezeigt. Der Autor hat die Ausfüllung der Defekte an der Entnahmestelle des Autotransplantates (Spongiosa, Span) durch Allospongiosa eingeführt.Bei Ausfüllungen von 285 Entnahmestellen hat er keinerlei Komplikationen beobachtet.Die Beurteilung der Ergebnisse werden im Zusammenhang mit den Komplikationen bzw. Erkrankungen des Transplantates analysiert. Andererseits werden die Ergebnisse und die Komplikationen im Zusammenhang mit dem Alter, dem Wesen und der Struktur des Transplantates sowie in Beziehung zum Operationsverfahren beurteilt. Gesondert sind die Reoperationen aufgestellt. Es haben sich bei 436 Kranken mit hämatogener Osteomyelitis 58 und bei 166 Kranken mit traumatischer eitriger Ostitis 34 Reoperationen als notwendig erwiesen. Die Heilungsquote nach der osteoplastischen Behandlung ist für die hämatogene Osteomyelitis 86%, für die traumatische Ostitis 79%. Einschließlich der Reoperationen steigt die Heilungsquote auf entsprechend 97% und 98%.Der Autor führt eine neue Stadienskala für den Umbau des Transplantates ein, die 6 Stadien enthält und die den Verhältnissen bei der Osteomyelitis entspricht.

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Osteoplastic treatment of the osteomyelitis

Summary After a short introduction, a definition of the nature of the osteoplastic treatment is given, in which the bone grafting assures not only a bonesubstitution, but it is the motive factor for the treatment of the osteomyelitis.The author gives a discussion on the problems of indications, properties of the bone-bed, structure and methods of conservation of the graft, the immunological problems, methods of application, the dynamics of the graft's reorganization and the results. He proposes a scale for the properties of the bed-recipient. Osteoplastic treatment of the osteomyelitis is developed by the author in a large plan of different surgical-operative methods. A clinical material of 602 patients is included for analysis and discussion. Criteria for the clinical material are as follows: age, localization, morphology, infection and method of conservation are given. The author starts using allografting to replace the donor's damage, when the auto-bone is taken. There are any complications after 285 such substitutions. The results are analysed in connection with the complications, typical of the bone grafting add of the diseases of the grafts respectively. On other hand the results are analysed in connection with the age of the patient, nature and structure of the graft and the type of operation. The reoperations are analysed separately. In 436 patients with haematogenic osteomyelitis the reoperations are 58, and in 166 patients with traumatic purulent ostitis they are 34. With the osteoplastic treatment of the haematogenic osteomyelitis the curability is 86 per cent, and in the traumatic purulent ostitis is 79 per cent. After the reoperations these percentages ware corrected to 97 for the haematogenic osteomyelitis and 98 per cent for the traumatic purulent ostitis, respectively. The author introduces a new scale for the stages of reorganization of the graft, including 6 stages with good correspondation to the conditions of the osteomyelitis.

     

How do I manage a patient with enterococcal bacteraemia?

BackgroundEnterococcal bacteraemia (EB) is common, particularly in the nosocomial setting, and its management poses a challenge for clinicians and microbiologists.ObjectivesThe aim was to summarize the more relevant features of EB and to provide a practical state-of-the-art on the topics that more directly affect its management.SourcesPubmed articles from inception to 31 May 2020.ContentThe following topics are covered: epidemiological, clinical and microbiological characteristics and factors associated with prognosis of EB; diagnosis and work-up, including the use of echocardiography to rule out endocarditis; antibiotic management with special focus on antimicrobial resistance and complicated EB; and the role of infectious disease consultation and the use of bundles in EB. In addition, three clinical vignettes are presented to illustrate the practical application of the guidance provided, and major gaps in the current evidence supporting EB management are discussed.ImplicationsEB is associated with large burdens of morbidity and mortality, particularly among fragile and immunosuppressed patients presenting complicated bacteraemia due to multidrug-resistant enterococci. Most cases of EB are caused by Enterococcus faecalis, followed by E. faecium. EB often presents as polymicrobial bacteraemia. Rapidly identifying patients at risk of EB is crucial for timely application of diagnostic techniques and empiric therapy. Early alert systems and rapid diagnostic techniques, such as matrix-assisted desorption ionization–time of flight mass spectrometry, especially if used together with infectious disease consultation within bundles, appear to improve management and prognosis of EB. Echocardiography is also key in the work-up of EB and should probably be more extensively used, although its exact indications in EB are still debated. Multidisciplinary approaches are warranted due to the complexity and severity of EB.     

Free wall rupture (FWR) in patients with acute ST-elevation myocardial infarction (STEMI) receiving fibrinolytic therapy (FT): a 7-year prospective study

Previous studies have shown a paradoxical increase in early mortality in older patients (>70 years) with acute STEMI treated with fibrinolytic therapy (FT), which has been attributed to the development of free wall rupture (FWR). Our aim was to assess occurrence of FWR in STEMI patients receiving FT. In this 7-year prospective study, data from 1701 consecutive patients were obtained. We analyzed predictors of the in-hospital mortality in patients > 70 years old. The independent contribution of several variables to overall mortality and FWR development was assessed using multiple logistic regression analyses. The mortality of entire cohort was 18% (306/1701). Diabetes mellitus, anterior infarction, smoking, female gender and hypercholesterolemia were independent predictors of in-hospital mortality. FT was given to 18% of all patients (304/1701) of which 13% died (39/304). FWR was 18.4-times more often in patients who received FT. Among patients younger than 70 years who received FT there was no FWR, while in patients ≥70 years of age FWR was found in almost half of the deceased (30/68; 44%). Application of FT in STEMI patients is not associated with higher mortality, but significantly increases number of FWR, especially in patients over 70 years of age.     

Influence of multisystemic affection on health-related quality of life in patients with myotonic dystrophy type 1

Aim

To assess health-related quality of life (HRQoL) in patients with DM1, to identify muscular, multisystemic, central and social factors that may affect QoL and to define a DM1 patient in risk of poor QoL.

Patients and method

This cross-sectional study comprised 120 DM1 consecutive patients. The following scales were used: Multidimensional Scale of Perceived Social Support (MSPSS), Muscular Impairment Rating Scale (MIRS), battery of neuropsychological tests, acceptance of illness scale (AIS), Hamilton rating scale for depression (Ham-D), Krupp's Fatigue Severity Scale (FSS), Daytime Sleepiness Scale (DSS) and SF-36 questionnaire.

Results

HRQoL was impaired in DM1 patients in both physical and mental domains (PCS was 41.8 ± 23.5, MCS 47.0 ± 24.3 and total SF-36 score 45.6 ± 24.0). The most significant factors correlating with better SF-36 total score were younger age (β = −0.45, p < 0.001), shorter duration of disease (β = −0.27, p = 0.001), higher education (β = 0.20, p = 0.009), less severe muscular weakness (β = −0.52, p < 0.001), normal swallowing (β = 0.22, p = 0.005), absence of fainting (β = 0.31, p = 0.002), absence of snoring (β = 0.21, p = 0.036), better acceptance of disease (β = −0.17, p = 0.036), lower depressiveness (β = −0.46, p = 0.001), lower fatigue (β = −0.32, p = 0.001), absence of cataract (β = −0.21, p = 0.034), absence of kyphosis (β = 0.31, p = 0.004) and absence of constipation (β = 0.24, p = 0.016). Second linear regression analysis revealed that depressed (β = −0.38, p < 0.001) and elder patients (β = −0.27, p = 0.007) and as well as those with poor acceptance of illness (β = −0.21, p = 0.006) were in especially higher risk of having poor HRQoL (R² = 0.68).

Conclusion

We identified different central, social, muscular, cardiorespiratory and other factors correlating with HRQoL. It is of great importance that most of these factors are amenable to treatment.     

Cardiologic predictors of sudden death in patients with myotonic dystrophy type 1

The aim of this study was to analyze survival, causes of death and cardiologic predictors of sudden death in a large cohort of patients with myotonic dystrophy type 1 (DM1). The study was comprised of 171 adult DM1 patients hospitalized at the Neurology Clinic in a 20-year period. Severe electrocardiographic (ECG) abnormality included at least one of the following: rhythm other than sinus, PR interval of ?240 ms, QRS complex duration of 120 ms or more, and second-degree or third-degree atrioventricular (AV) block. Survival data were analyzed by the Kaplan–Meier test, log–rank test and Cox regression analysis. During the mean follow-up period of 9.4 ± 5.4 years, a pacemaker was implanted in 5.8% of DM1 patients and 14% of patients died. The mean age at death was 55.6 ± 12.5 years. The most common causes of death in our cohort were sudden death (41.7%) and respiratory failure (29.2%). The presence of palpitations (hazard ratio [HR] = 4.7, p < 0.05) and increased systolic blood pressure (HR = 9.8, p < 0.05) were significant predictors of sudden death. Among ECG parameters, severe ECG abnormality (HR = 4.7, p < 0.05), right bundle branch block (RBBB; HR = 3.9, p < 0.05) and bifascicular block (HR = 5.8, p < 0.05) were significant predictors of sudden death.