Drug associated acute interstitial nephritis: clinical and pathological features and the response to high dose steroid therapy

Nine episodes of drug associated acute interstitial nephritis, in seven patients, were treated between 1972 and 1980. The drugs implicated were cotrimoxazole (three times), ampicillin, Magnapen (ampicillin and flucloxacillin), penicillin, gentamicin, paracetamol and bendrofluazide. The time from exposure to the onset of symptoms ranged from one to 30 days. Presentation was with acute renal failure, which was non-oliguric in five cases, accompanied by rash (four), fever (four), and loin pain (two). Renal biopsy was carried out in all cases, and showed a characteristic interstitial infiltrate comprising substantial numbers of lymphocytes and plasma cells, with a variable number of neutrophils, eosinophils and histiocytes. Immunofluorescence was negative in all four cases studied in the acute phase, and showed scattered deposits of IgG, IgM, IgA and C3 on the tubular basement membrane in one patient during recovery. Significant proteinuria and an abnormal urine deposit were present in all cases, and seven of nine had radiological evidence of enlarged kidneys. Seven episodes were treated with high doses of methyl prednisolone and in all there was a response with a diuresis or spontaneous fall in serum creatinine within 72 hrs, and recovery of virtually normal renal function. Of two cases who did not initially receive steroids, one improved more slowly and one developed chronic renal impairment.     

Changing Pattern of Acute Renal Failure

During the four-year period 1981–1984, 250 patients withsevere acute renal failure were treated at one centre. Therewere seven obstetric cases (2.8 per cent) 118 ‘surgical’cases (47.2 per cent) and 125 medical cases (50 per cent). Thisis a different pattern from that seen in the majority of earlierreports. In 60 of the 125 medical patients the aetiology ofthe acute renal failure could only be determined by renal biopsy.This series suggests that with changing medical practice (particularlythe improvement in resuscitation) and an ageing population,the pattern of causes of acute renal failure is altering. Italso highlights the value of renal histology as a guide to diagnosisand treatment in patients with unexplained acute renal failure. ^* Present address: The General Infirmary at Leeds, Great GeorgeStreet, Leeds LSI 3EX. Present address: Royal Victoria Infirmary, queen Victoria Road,Newcastle upon Tyne NE1 4LP     

The utility of hyperbaric oxygen therapy to treat recurrent acute bowel obstruction after previous pelvic radiotherapy: a case series

Background and objective

Repeated episodes of acute bowel obstruction is a potential complication following pelvic radiation therapy. It has been previously thought that hyperbaric oxygen therapy (HBOT) may not be useful for treatment of such obstructive episodes. We report our experience with the use of HBOT for recurrent radiation-induced acute bowel obstruction.

Methods

This is a retrospective case series. Radiological imaging had excluded the presence of recurrent or new cancer. Possible predisposing causes for acute obstruction had been treated and had not led to resolution of symptoms or had been excluded.

Results

During 2007–2010, five patients with recurrent episodes of acute obstructive bowel symptoms following previous therapeutic pelvic irradiation were referred for HBOT (four females and one male; median age 56; range 48–72). The primary tumours sites were the endometrium (n?=?2), ovary, cervix and prostate (n?=?1 each), and patients were treated 2–17 (median 9)?years previously with radiotherapy. Before HBOT, patients were experiencing acute obstructive bowel symptoms at 1–6 weekly intervals. Four patients had progressive weight loss. Patients received 100 % oxygen in a multiplace hyperbaric chamber at a pressure of 2.4 atm absolute for up to 90 min once a day, 5 to 7 days weekly. All patients were initially referred for 40 sessions of HBOT. Three patients required a further extra 20 sessions for complete resolution of bowel symptoms. HBOT was well tolerated with no side effects. Patients have remained well after 6–24 months of follow-up.

Conclusions

HBOT may be an effective treatment of radiation-induced bowel obstruction and deserves prospective evaluation.     

Cushing's Disease: TREATMENT BY PITUITARY IMPLANTATION OF RADIOACTIVE GOLD OR YTTRIUM SEEDS

Fifty-seven patients with Cushing's disease (pituitary-dependentCushing's syndrome), and four with Nelson's syndrome followingadrenalectomy, have been treated by implantation of ¹⁹⁸Au or⁹⁰Y seeds into the pituitary gland. Fifty-five of the Cushing'sdisease patients have been fully followed up with steroid testsfor 1 to 12 years after implant. They have been categorizedaccording to the X-ray appearance of the fossa before implant,which was the most important factor in predicting the outcome.The results were as follows: 1. Cushing's disease without evidence of pituitary tumour onX-ray (31 patients). One year after implant, 65 per cent ofthese patients were in complete remission and a further 16 percent in partial remission—a total of 81 per cent improved,without any other treatment. Only 34 per cent required replacementcorticosteroids, and 30 per cent replacement thyroxine. 52 percent needed no replacement hormone treatment. Only one patienthad relapsed more than 2 years after implant. 2. Cushing's disease with possible pituitary tumour on X-ray(10 patients). One year after implant, five of these were incomplete and one in partial remission. These remissions weremaintained. 60 per cent required replacement steroids or thyroxine. 3. Cushing's disease with definite X-ray evidence of pituitarytumour (14 cases). In only two of these was permanent remissionobtained by implant alone, despite the use of higher radiationdoses in most of them. In four the tumour showed X-ray or clinicalevidence of local invasion after implant, and three subsequentlyneeded surgical hypophysectomy. A combination of implant, adrenalectomy,hypophysectomy, or external irradiation was needed to controlthe disease in most of these patients; 10 required surgery ofpituitary or adrenals. Some degree of hypopituitarism occurredin them all and 64 per cent required replacement hormones asa result of pituitary or adrenal ablation. In the whole series of 61 patients implanted for either Cushing'sor Nelson's syndrome, there were six who developed serious problemsfrom local invasion by pituitary tumours despite various formsof treatment of the pituitary. This invasion contributed tothe deaths of four. 4. In all four cases of Nelson's syndrome, clinical remissionof pigmentation was evident within a year of implant. One patientlater required external pituitary irradiation and craniotomyto control his pituitary tumour, but survived 13 years. Theothers have been followed for three, four, and nine years withoutrecurrence. 5. Pituitary implant for Cushing's disease appears to be atleast as effective in producing remission as other treatmentsdirected at the pituitary, and is as effective in restraininggrowth of pituitary tumours. It is much more effective thanexternal irradiation. Though the cure of the Cushing's syndromeis not as certain as with adrenalectomy, the proportion of patientsrequiring replacement hormone therapy is approximately half,and the procedure of implant is a smaller surgical undertaking.The technical complications of implants, particularly cerebrospinalfluid rhinorrhoea, are minimal (5 per cent) and readily treatable.     

Follow-up after acute poisoning by substances of abuse: a prospective observational cohort study

Objective: To chart follow-up of patients after acute poisoning by substances of abuse, register whether patients referred to specialist health services attended, and whether patients contacted a general practitioner (GP) after the poisoning episode.

Design: Observational cohort study.

Setting: A primary care emergency outpatient clinic in Oslo, Norway.

Subjects: Patients?≥12 years treated for acute poisoning by substances of abuse were included consecutively from October 2011 to September 2012.

Main outcome measures: Follow-up initiated at discharge, proportion of cases in which referred patients attended within three months, and proportion of cases in which the patient consulted a GP the first month following discharge.

Results: There were 2343 episodes of acute poisoning by substances of abuse. In 391 (17%) cases the patient was hospitalised, including 49 (2%) in psychiatric wards. In 235 (10%) cases the patient was referred to specialist health services, in 91 (4%) advised to see their GP, in 82 (3%) to contact social services, in 74 (3%) allotted place in a homeless shelter, and in 93 (4%) other follow-up was initiated. In 1096 (47%) cases, the patient was discharged without follow-up, and in a further 324 (14%), the patient self-discharged. When referred to specialist health services, in 200/235 (85%) cases the patient attended within three months. Among all discharges, in 527/1952 (27%) cases the patient consulted a GP within one month. When advised to see their GP, in 45/91 (49%) cases the patient did.

Conclusion: Attendance was high for follow-up initiated after acute poisoning by substances of abuse.

• KEY POINTS

• Despite poor long-term prognosis, patients treated for acute poisoning by substances of abuse are frequently not referred to follow-up.

• Nearly all patients referred to specialist health services attended, indicating the acute poisoning as an opportune moment for intervention.

• Advising patients to contact their GP was significantly associated with patients consulting the GP, but few patients were so advised.

• One out of three patients was discharged without follow-up, and there seems to be an unused potential for GP involvement.

     

Severe hypoglycemia and cardiovascular disease incidence in type 1 diabetes: the EURODIAB Prospective Complications Study

OBJECTIVE

Frequent episodes of severe hypoglycemia may increase the risk of cardiovascular disease (CVD) in people with diabetes. Our aim was to study the relationship between severe hypoglycemic episodes and CVD incidence in subjects with type 1 diabetes, and further, to assess if markers of inflammation/endothelial injury were enhanced in individuals who experienced hypoglycemic episodes.

RESEARCH DESIGN AND METHODS

The prospective study included 2,181 type 1 diabetic patients from the EURODIAB Prospective Complications Study. At baseline, frequency of self-reported severe hypoglycemia, defined as episodes serious enough to require the help of another person, was assessed based on responses to a patient questionnaire. Both fatal/nonfatal CVD was assessed 7.3 years after baseline examination. At the follow-up visit, data on both severe and nonsevere hypoglycemic episodes in the previous year were collected through a questionnaire and markers of inflammation/stress response/endothelial injury measured by enzyme-linked immunosorbent assays in the 531 subjects of the nested case-control study, including 363 case subjects with one or more complications of diabetes and 168 control subjects with no evidence of any complication.

RESULTS

During the follow-up period, 176 patients had incident CVD. Logistic regression analysis showed that severe hypoglycemia at the baseline examination was not associated with incidence of CVD (adjusted odds ratios [95% CI]: one to two episodes, 0.87 [0.55–1.37]; three or more episodes, 1.09 [0.68–1.75]). Furthermore, follow-up serum levels of markers of endothelial damage/inflammation were not cross-sectionally associated with the frequency of hypoglycemic episodes.

CONCLUSIONS

Taken together our data do not support the hypothesis that in type 1 diabetes, severe hypoglycemia increases the risk of CVD.Hypoglycemia is the most common side effect of glucose-lowering therapies in patients with diabetes, and intensive glucose control invariably increases the risk of severe hypoglycemia. Recent large randomized trials, looking at the effect of intensive glycemic control on macrovascular complications in type 2 diabetic patients, have individually shown either no benefit or increased mortality (1). Although the reason for this increased mortality is unclear and hypoglycemia has not been proven to be involved, these studies have fueled longstanding concerns that hypoglycemia itself may increase the risk of cardiovascular disease (CVD).Evidence linking hypoglycemia to CVD comes predominantly from studies in type 2 diabetic patients (2–8). However, the risk of hypoglycemia is even greater in type 1 diabetic patients, and in the Diabetes Control and Complications Trial (DCCT), severe hypoglycemic episodes requiring assistance affected nearly one-third of the intensively treated patients (9). The DCCT/Epidemiology of Diabetes Interventions and Complications (EDIC) study showed a reduction in CVD at later follow-up (10,11); however, the risk of cardiovascular (CV) events among the people who experienced severe hypoglycemia was not reported, and this issue has been scarcely explored in clinical and epidemiological studies.Recently, additional support for the hypothesis of a role of hypoglycemia in CVD in type 1 diabetic patients was offered by indirect evidence. First, repeated hypoglycemic episodes were associated with preclinical atherosclerosis (12). Second, physiological studies have shown that acute provoked hypoglycemia induces a rise in the circulating levels of markers of both inflammation and endothelial dysfunction (1,13–16). Most of these studies, however, are acute observations and the long-term effects of hypoglycemia on markers of inflammation/endothelial injury are largely unknown.The aim of the current study was to examine in a large, 7-year prospective cohort study of patients with type 1 diabetes if the frequency of severe hypoglycemic episodes predicts incident CVD at follow-up. Moreover, we tested if both severe and nonsevere hypoglycemic episodes were cross-sectionally associated with serum levels of markers of both inflammation and endothelial dysfunction.     

Treatment of opioid overdose in a physician-based prehospital EMS: frequency and long-term prognosis

Background

Prehospital treatment of opioid overdose accounts for a significant proportion of the workload of the emergency system in most major cities. Treatment consists of basic life support and administering naloxone. In our physician-manned mobile emergency care unit (MECU), most patients are released and not admitted to hospital. In this study, we aimed to assess the pattern in the number of episodes with opioid overdose treated by MECU in Copenhagen during a 10-year period and to investigate risk factors for mortality of these patients beyond the initial contact.

Methods

Data were collected prospectively in the MECU database covering all cases of opioid overdose in a 10-year period between 1994 and 2003. The pattern in the number of opioid overdose was analysed in Poisson regression models, and mortality was analysed in Kaplan-Meier plots and in Cox regression models.

Results

A total of 4762 episodes of opioid overdose were recorded. Patients were identified in 3245 of these episodes. The annual number of episodes decreased significantly over the data-collection period: from 639 overdoses out of 4520 (14.1%) patients treated in 1994 to 311 out of 7263 patients treated (4.3%) in 2003. A total of 352 patients had cardiac arrest at the scene. The MECU released 2246 patients (69.3%) after treatment, while 675 (20.8%) were admitted to hospital and 322 (9.9%) died. Long-term prognosis was poor with 14% mortality at 1 year. Long-term mortality was significantly related to increasing age, time of the year and if the patient had previous episodes of opioid overdose.

Conclusions

There has been a significant decrease in the number of opioid overdoses during this 10-year-period. Long-term mortality is high in these patients and highest in those with advanced age and numerous episodes of opioid overdose.     

Idiopathic Acute Fatty Liver of Pregnancy in 12 Patients

The clinical features, laboratory investigations and histopathologyof 12 patients with idiopathic acute fatty liver of pregnancyare presented. Repeated vomiting, starting in the last trimester,was the cardinal symptom. Seven patients had proteinuria, hypertensionand peripheral oedema before jaundice appeared. Caesarian section and induction of labour led to a lower thanexpected maternal mortality (33.3 per cent) and foetal mortality(66.7 per cent). There was a high incidence of twin and malebirths. Neutrophilia, thrombocytopenia and normoblasts were a uniformfeature and uric acid levels were universally high. These findingsmay be useful in diagnosis in conjunction with liver functiontests. Hepatic histology showed pathognomonic microvesicularfat in swollen hepatocytes with central nuclei and centrilobulardistribution. However, a diffuse pattern and the presence ofsignificant inflammation and fibrin deposits led to an initialmisdiagnosis in two patients. Histology of fetal livers andfive placentae was normal. Seven subsequent normal pregnancies occurred in four patients. Acute fatty liver of pregnancy may be confused with acute hepatitisor toxaemia on both clinical and histological grounds. Accuratediagnosis should lead to improved management and lessen maternaland fetal mortality. This justifies more intensive and urgentinvestigation of nausea, vomiting and jaundice in the last trimesterof pregnancy. ^*Present address: Department of Medicine III, Singapore GeneralHospital. Singapore. Presnt address: Nis,Jugoslavia     

Nephritis in Infectious Mononucleosis

Three patients are presented with acute nephritis associatedwith infectious mononucleosis. Renal biopsy in these patientsindicates that an interstitial nephritis or a focal mesangialglomerulonephritis can be present. The condition can be distinguishedfrom post-streptococcal glomerulonephritis, and should be consideredin all patients presenting with acute nephritis, particularlyif other features such as fever, skin rash ‘hepatitis’or thrombocytopaenia are present. ^*Senior Registrar, Renal Unit, Q.E.H. Senior Registrar, Renal Unit, Q.E.H. Director of Histopathology, Q.E.H. Director, Renal Unit, Q.E.H.     

Infections in a pediatric patient cohort with acute lymphoblastic leukemia during the entire course of treatment

Goals To assess the type, frequency, severity, and outcome of all infectious episodes in a pediatric patient cohort with acute lymphoblastic leukemia (ALL) from a single institution during the entire length of leukemia treatment.Patients and methods Eighty-six patients were treated according to a modified ALL Berlin–Frankfurt–Munster protocol. Retrospective analysis of all types of infections according to the treatment phase and the degree of neutropenia is presented.Results A total of 610 infectious episodes were recorded. Most infections were documented during maintenance (57%), followed by the induction phase (20.3%). During maintenance, 347 episodes were encountered, with nonspecific viral upper respiratory tract infections (URIs) being the commonest diagnosis (40.0%). Additionally, 38 of 58 total specific viral infections occurred during maintenance: 16 herpes simplex, 7 varicella, 10 herpes zoster infections [varicella–zoster virus (VZV), 45%]. The majority of bacteremia and fever of unknown origin occurred during induction (20%). The number of Gram-negative bacteremia was 50% of the total (26 of 52). The majority of the infections (59.5%) occurred without neutropenia [absolute neutrophil count (ANC) >1,000 l^–1]. Fewer infections (9.3%) were recorded with concurrent very severe neutropenia (ANC <100 l^–1), although 38.5% of positive blood cultures were documented with severe neutropenia. No infection-related fatality occurred.Conclusions Most of the severe infections occurred during induction. Gram-positive bacteremia and Gram-negative bacteremia were almost equal. URIs were the commonest infections during the entire treatment and during maintenance. Specific viral infections represented a smaller percentage of the total (VZV was the commonest pathogen). Infectious complications represented a significant morbidity factor, but notably, mortality was negligible.     

Delayed cerebral thrombosis in bacterial meningitis: a prospective cohort study

Purpose

To study the incidence and clinical characteristics of delayed cerebral thrombosis in bacterial meningitis patients.

Methods

We assessed the incidence and clinical characteristics of delayed cerebral thrombosis in adults with cerebrospinal fluid (CSF) culture-proven community-acquired bacterial meningitis included in a prospective nationwide study in The Netherlands performed from 2006 to 2012.

Results

Delayed cerebral thrombosis occurred in 11 of 1,032 episodes (1.1 %). CSF culture yielded Streptococcus pneumoniae in ten patients and Listeria monocytogenes in one. Adjunctive dexamethasone therapy was administered before or with the first dose of antibiotics in 9 of 11 patients; two patients were initially not treated with dexamethasone. All patients made good initial recovery, followed by sudden deterioration after 7–42 days. Cranial imaging studies showed multiple cerebral infarctions in all patients. The outcome was unfavorable in all but one patient. In an explorative analysis, patients with delayed cerebral thrombosis had eightfold higher complement C5a CSF concentrations on the diagnostic lumbar puncture as compared in those without delayed cerebral thrombosis (p = 0.04).

Conclusion

Delayed cerebral thrombosis is a rare but devastating complication of bacterial meningitis. Adjunctive dexamethasone therapy seems to predispose patients with bacterial meningitis to this complication. We found some evidence that this thrombotic complication is associated with activation of the complement system.     

The Heart Disease of Friedreich's Ataxia: a Clinical and Electrocardiographic Study of 115 Patients, with an Analysis of Serial Electrocardiographic Changes in 30 Cases

One hundred and fifteen patients with carefully defined Friedreich'sataxia were assessed clinically and electrocardiographicallyfor evidence of heart disease. Cardiac symptoms, of which dyspnoeaand palpitations were the most frequent, occurred in less than30 per cent. Abnormalities on clinical examination were presentin a similar proportion; harsh systolic murmurs, ventricularhypertrophy and added heart sounds were the commonest of these.Cardiac failure and persistent arrhythmias were rare and occurredlate in the evolution of the neurological disease. Two patientspresented with heart disease before developing neurologicalsymptoms. Cardiac signs and symptoms were uncommon in patientswithout electrocardiographic abnormalities. About two-thirdsof the cases had definitely abnormal ECG recordings. The characteristicfinding was of widespread T-wave inversion with ventricularhypertrophy. Serial ECGs, recorded over periods of up to 32 years, were availablein 30 cases and showed that abnormalities may develop in patientswith Friedreich's ataxia at any time up until 20 years afterthe onset of neurological symptoms. In four patients initialECG abnormalities had either improved or disappeared subsequently. Present address: The National Hospital for Nervous Diseases,Queen Square, London WC1 3BG.     

Frequency and severity of aggressive incidents in acute psychiatric wards in Switzerland

Background

Aggression and violence and negative consequences thereof are a major concern in acute psychiatric inpatient care globally. Variations in study designs, settings, populations, and data collection methods render comparisons of the incidence of aggressive behaviour in high risk settings difficult.

Objective

To describe the frequency and severity of aggressive incidents in acute psychiatric wards in the German speaking part of Switzerland.

Methods

We conducted a prospective multicentre study on 24 acute admission wards in 12 psychiatric hospitals in the German speaking part of Switzerland. Aggressive incidents were recorded by the revised Staff Observation Aggression Scale (SOAS-R) and we checked the data collection for underreporting. Our sample comprised 2344 treatment episodes of 2017 patients and a total of 41'560 treatment days.

Results

A total of 760 aggressive incidents were registered. We found incidence rates per 100 treatment days between 0.60 (95% CI 0.10–1.78) for physical attacks and 1.83 (1.70–1.97) for all aggressive incidents (including purely verbal aggression). The mean severity was 8.80 ± 4.88 points on the 22-point SOAS-R-severity measure; 46% of the purely verbally aggression was classified as severe (≥ 9 pts.). 53% of the aggressive incidents were followed by a coercive measure, mostly seclusion or seclusion accompanied by medication. In 13% of the patients, one ore more incidents were registered, and 6.9% of the patients were involved in one ore more physical attack. Involuntary admission (OR 2.2; 1.6–2.9), longer length of stay (OR 2.7; 2.0–3.8), and a diagnosis of schizophrenia (ICH-10 F2) (OR 2.1; 1.5–2.9) was associated with a higher risk for aggressive incidents, but no such association was found for age and gender. 38% of the incidents were registered within the first 7 days after admission.

Conclusion

Aggressive incidents in acute admission wards are a frequent and serious problem. Due to the study design we consider the incidence rates as robust and representative for acute wards in German speaking Switzerland, and thus useful as reference for comparative and interventional research. Implications for clinical practice include the recommendation to extend the systematic risk assessment beyond the first days after admission. The study confirms the necessity to differentiate between types of aggressive behaviour when reporting and comparing incidence-data.

     

Chemotherapy-induced nausea and vomiting in routine practice: a European perspective

Goals of work The aim of this study was to evaluate the occurrence of chemotherapy-induced nausea and vomiting (CINV) and its effect on patients ability to carry out daily life activities following moderately to highly emetogenic, first-cycle chemotherapy in routine practice in cancer centers of four different European countries.Patients and methods This was a prospective, cross-sectional, nonrandomized, self-assessment study in 249 patients enrolled from cancer centers in Spain, Austria, Germany, and Switzerland. The study population consisted of 78% women, with a mean age of 54. Breast, lung, and ovarian cancers made up 75% of all cancers in the study. Patients received a mean of 2.0 chemotherapy agents and 2.5 antiemetic drugs.Main results A total of 450 emetic episodes experienced by 243 patients was recorded over 5 days following chemotherapy, with an average of 1.8 episodes per patient (range: 0–28). A higher percentage of patients (38%) suffered from delayed compared to acute emesis (13%). Between 42% and 52% of all patients suffered from nausea (visual analogue scale 5 mm) on any one day, peaking at day 3. Using the Functional Living Index for Emesis (FLIE) questionnaire, 75% of patients with nausea and 50% with vomiting reported a negative impact of these conditions on performance of daily living.Conclusions CINV remains a significant problem in routine practice, particularly in the delayed phase posttreatment. Overall, CINV had a negative impact on patients daily life.     

The Degree of Conversion of {alpha}-Keto Acids to Valine and Phenylalanine in Health and Uraemia

¹³C-labelled -keto acid analogues of valine and phenylalaninewere given by mouth and by intravenous route to three healthyand four uraemic individuals who were used as their own controls.The excretion of ¹³CO₂ in expired air and of ¹³C-lebelled ketoacid in urine was measured together with plasma and, in somecases, intramuscular concentrations of total and ¹³C-labelledfree valine and phenylalanine. A minimum and maximum limit ofdegree of conversion of these two -keto acids to essential aminoacids was calculated and was of the order of 25–50 percent for both keto acids given by either route in health anduraemia.     

Acute Renal Failure Due to Leptospirosis: Clinical Features and Outcome in Six Cases

Six cases of severe leptospiral infection with renal failureare described. Five of the six patients had acute oliguric renalfailure requiring dialysis. Renal function recovered over threeweeks and by two months all patients had plasma creatinine levels< 200 µmol/litre. The initial diagnosis of leptospirosisdepended on clinical and epidemiological features because serologicalconfirmation was not possible during the first week of the illness.All the patients had either high risk occupations or a historyof exposure to external sources of infection. All had fever,myalgia, jaundice and muscle tenderness. Although biirubin levelswere high (> 350 µmol/litre in five) the elevationsof aspartate transaminase and alkaline phosphatase levels, andprolonga tions of prothrombin times were relatively slight.Thrombocytopenia occurred in five of the six cases. Leptospiracomplement fixation tests were weakly positive or negative onadmission in five cases but rose to significant levels subsequently.Penicillin treathient resulted in Jarisch-Herxheimer reactionsin three cases. The important complications were: upper gastro-intestinalhaemorrhage (five cases), thrombocytopenia <30000 platelets/mm³(four cases), atrial fibrilla tion (three cases), drowsinesswith asterixis (four cases). All six patients were seriouslyill and required intensive supportive therapy. All survived.     

Comparison of Three Oral Rehydration Strategies in the Treatment of Acute Diarrhea in a Tropical Country

Background: The administration of hydrating solutions and early refeeding improve recovery for infants and children with diarrhea.Objective: The aim of this study was to assess the efficacy of a low-osmolarity (30 mEq/L Na⁺) solution administered after the standard, high-osmolarity (90 mEq/L Na⁺) solution via a nasogastric tube (NGT) and followed by early refeeding to achieve more rapid body weight recovery in infants and children with acute diarrhea.Methods: Infants and children aged <5 years with acute diarrhea and dehydration (body weight loss of ≥10%) observed from January to August 2001 at Saint Camille Medical Center, Ouagadougou, Burkina Faso, were enrolled. Patients were randomized to 1 of 3 treatment protocols. Patients in group A received, via NGT, rehydration with a high-osmolarity solution for 3 hours, followed by a low-osmolarity solution for at least 3 additional hours. Patients in group B were given only a low-osmolarity solution via NGT. In group C, rehydration was carried out using a high-osmolarity solution via NGT.Results: Four thousand consecutively treated infants and children (2010 boys, 1990 girls; mean [SD] age, 3.5 [2.7] years) were enrolled. After the first 6 hours of infusion, 90% of the patients who had received the combined rehydration (group A) showed significant body weight recovery, versus 80% and 79% of the patients in groups B and C, respectively. Stool output significantly decreased for group A compared with groups B and C (114 vs 125 and 120 g/kg, respectively). Only 7% of the patients in group A required prolonged rehydration (>6 hours) with the low-osmolarity solution, versus 10% and 12% in groups B and C, respectively. A total of 3% of patients treated with combined rehydration required hospitalization, compared with 10% and 9% in groups B and C, respectively. At the end of infusion, 25% of the patients rehydrated only with a low-osmolarity solution showed poor body weight recovery and appeared lethargic, versus 10% in group A and 15% in group C. Patients who were rehydrated with a high-osmolarity solution showed symptoms of hypernatremia (serum Na⁺ concentration >140 mEq/L). At the end of rehydration (≥6 hours), all patients recovered their previous body weight, partially or totally, and refeeding was begun. Rehydration and diet were continued at home, or in neighboring areas for those living far away.Conclusions: In this study population, the administration of a high-osmolarity solution followed by a low-osmolarity solution and early refeeding was effective in the treatment of acute diarrhea and was well tolerated.     

Rapid response systems: a prospective study of response times

Purpose

The purpose of the study was to evaluate the time taken for delivery of each component of care following patient deterioration and to assess the effect on response times of strategies implemented to improve the system.

Methods

A model identifying the sequence of organizational responses following a patient's unexpected clinical deterioration was developed. The time to key events and interventions from initial deterioration was measured for 3 months in 2005 and again in 2006 at a tertiary care hospital with a rapid response team (RRT) in place. Strategies to improve compliance with the RRT system were introduced between the 2 periods.

Results

The number of acute deterioration episodes identified increased (61 episodes in 2005; 154 episodes in 2006), but there was no improvement in response times. The 2 components contributing most frequently to delays were the time for nursing staff to call for assistance and, where needed, for physicians to call for higher-level care. Overall, 26% of episodes in 2006 and 30% in 2005 did not receive medical attention within 30 minutes of acute deterioration.

Conclusions

Significant delays in responding to acute deterioration persist despite strategies to facilitate the functioning of the RRT system. Simple strategies such as policy directives are not sufficient to effect change in complex health care systems.     

A novel prospective descriptive analysis of nausea and vomiting among patients receiving gastrointestinal radiation therapy

Purpose

Nausea and vomiting are common side effects from radiotherapy that can interfere with gastrointestinal (GI) cancer patients’ quality of life (QOL). This study described the subjective experience of patients with radiation-induced nausea and vomiting (RINV) and its relation to QOL.

Methods

Forty-eight patients treated with abdominal radiotherapy alone or with concomitant chemoradiotherapy were followed in a prospective study. All episodes of nausea, vomiting, and antiemetic use were recorded daily for the treatment period and the week following completion of therapy. QOL was assessed weekly using the Functional Living Index—Emesis QOL Tool (FLIE) and the EORTC QLQ-C30 core questionnaire (C30).

Results

In total, 351 episodes of nausea severity, duration, onset time, and 154 outcomes of vomiting onset times and contents were documented. The median nausea severity experienced per episode was 5 (on a scale from 1 to 10), and the most common durations of nausea were 30 min or less and constant nausea all day and night. The most common location of nausea was the abdomen. Longer nausea duration, great nausea severities, and the location of nausea experienced had significant adverse relationships to multiple QOL items on both the FLIE and the C30. In addition, the onset timing and number of vomiting episodes were related to the majority of all FLIE and QOL scores.

Conclusion

Patient’s subjective experiences of RINV directly correlated to the worsening of QOL outcomes. The identification and amelioration of these RINV experiences could improve QOL.

     

Meningococcal Epiglottitis in a Diabetic Adult Patient: A Case Report

Background

After deployment of the Haemophilus influenzae vaccination, the range of pathogens causing acute epiglottitis has changed, as has the epidemiology from a primarily pediatric syndrome towards more frequent adult onset.

Objectives

We present a case of acute-onset meningococcal epiglottitis in an adult patient, to our knowledge one of a few reported cases in the medical literature. We review the historic changes and outcomes of similar episodes.

Case Report

A 37-year-old diabetic man presented to our Emergency Department in acute respiratory distress. Examination revealed epiglottitis; his airway subsequently closed rapidly and was secured by surgical cricothyroidotomy; blood cultures showed the primary pathogen to be Neisseria meningitidis type C.

Conclusion

Neisseria meningitidis has been found to be an emerging cause of acute epiglottitis in adult patients over the last decade, possibly having worsened outcomes compared to other etiologies.