Elderly patients with non-cardiac admissions and elevated high-sensitivity troponin: the prognostic value of renal function

BACKGROUND High-sensitivity cardiac troponin(hs-cTn) levels are frequently elevated in elderly patients presenting to the emergency department for non-cardiac events. However, most studies on the role of elevated hs-cTn in elderly populations have investigated the prognostic value of hs-cTn in patients with a specific diagnosis or have assessed the relationship between hs-cTn and comorbidities.AIM To investigate the in-hospital prognosis of consecutive elderly patients admitted to the Internal Medicine Department with acute non-cardiac events and increased hs-cTnI levels.METHODS In this retrospective study, we selected patients who were aged ≥ 65 years and admitted to the Internal Medicine Department of our hospital between January 2019 and December 2019 for non-cardiac reasons. Eligible patients were those who had hs-cTnI concentrations ≥ 100 ng/L. We investigated the independent predictors of in-hospital mortality by multivariable logistic regression analysis.RESULTS One hundred and forty-six patients(59% female) were selected with an age range from 65 to 100(mean ± SD: 85.4 ± 7.61) years. The median hs-cTnI value was 284.2 ng/L. For 72(49%) patients the diagnosis of hospitalization was an infectious disease. The overall in-hospital mortality was 32%(47 patients). Individuals who died did not have higher hs-cTnI levels compared with those who were discharged alive(median: 314.8 vs 282.5 ng/L; P = 0.565). There was no difference in mortality in patients with infectious vs non-infectious disease(29% vs 35%). Multivariable analysis showed that age(OR 1.062 per 1 year increase, 95%CI: 1.000-1.127; P = 0.048) and creatinine levels(OR 2.065 per 1 mg/dL increase, 95%CI: 1.383-3.085; P 0.001) were the only independent predictors of death. Mortality was 49% in patients with eGFR 30 mL/min/1.73 m2.CONCLUSION Myocardial injury is a malignant condition in elderly patients admitted to the hospital for non-cardiac reasons. The presence of severe renal impairment is a marker of extremely high in-hospital mortality.     

Clinical analysis of liver transplantation in autoimmune liver diseases

Background: Autoimmune liver diseases(ALDs) consist of autoimmune hepatitis(AIH), primary biliary cirrhosis(PBC), primary sclerosing cholangitis(PSC), Ig G4-associated cholangitis and overlap syndromes.Patients with these diseases may gradually progress to end-stage liver diseases and need liver transplantation. The present study aimed to explore the prognosis of patients with ALDs after liver transplantation.Methods: The clinical data of 80 patients with ALD(24 cases of AIH, 35 of PBC, 15 of PSC and 6 of AIHPBC overlap syndromes) who underwent liver transplantation in Renji Hospital, Shanghai Jiao Tong University School of Medicine from June 2004 to September 2016 were collected retrospectively. The causes of death were analyzed and the postoperative cumulative survival rate was estimated by the Kaplan–Meier method. Recurrence and other complications were also analyzed.Results: Of the 80 patients, 18 were males and 62 were females. The average age was 50.5 years and the average Model for End-stage Liver Disease(MELD) score was 14.1. After a median follow-up of 19.8 months, 8 patients died. The 1-, 3-and 5-year cumulative survival rates were all 89.0%. Three cases of recurrent ALDs were diagnosed(3.8%) but they were not totally consistent with primary diseases. Biliary tract complication occurred in 10 patients(12.5%). The new onset of tumor was observed in 1 patient(1.3%). De novo HBV/CMV/EBV infection was found in 3, 8 and 3 patients, respectively.Conclusion: Liver transplantation is an effective and safe treatment for end-stage ALD.     

Treatment of pancreatic pseudocysts in line with D＇Egidio＇s classification

AIM: To explore the implications of underlying diseases in treatment of pancreatic pseudocysts (PPC). METHODS: Clinical data of 73 cases of pancreatic pseudocyst treated in a 12-year period were reviewed comprehensively. Pancreatic pseudocysts were classified according to the etiological criteria proposed by D'Egidio. The correlation between the etiological classification, measure of treatment and clinical outcome of the patients was analyzed. RESULTS: According to the etiological criteria proposed by D'Egidio, 73 patients were divided into three groups. Group I was comprised of 37 patients with type I pseudocyst, percutaneous drainage was successful in the majority (9/11, 82%) while external or internal drainage was not satisfactory with a low success rate (8/16, 50%). Group II was comprised of 24 patients with type II pseudocyst, and internal drainage was curative for most of the cases (11/12, 92%), but the success rate of percutaneous or external drainage was unacceptably low (4/9, 44%). Group III consisted of 12 patients with type III pseudocyst. Internal drainage or pancreatic resection performed in 10 of these patients produced a curative rate of 80% (8/10) with the correction of the ductal pathology as a prerequisite. CONCLUSION: The classification of pancreatic pseudocyst based on its underlying diseases is meaningful for its management. Awareness of the underlying diseases of pancreatic pseudocyst and detection of the ductal pathology in type II and III pancreatic pseudocysts with endoscopic retrograde cholangiopancreatography may help make better decisions of treatment to reduce the rate of complications and recurrence.     

Epidemiological and clinical characteristics of inflammatory bowel diseases in Cairo,Egypt

AIM:To study the natural history,patterns and clinical characteristics of inflammatory bowel diseases(IBD)in Egypt.METHODS:We designed a case-series study in the gastroenterology centre of the Internal Medicine department of Cairo University,which is a tertiary care referral centre in Egypt.We included all patients in whom the diagnosis of ulcerative colitis(UC)or Crohn’s disease(CD)was confirmed by clinical,laboratory,endoscopic,histological and/or radiological criteria over the 15 year period from 1995 to 2009,and we studied their sociodemographic and clinical characteristics.Endoscopic examinations were performed by 2 senior experts.This hospital centre serves patients from Cairo,as well as patients referred from all other parts of Egypt.Our centre received 24156 patients over the described time period for gastro-intestinal consultations and/or interventions.RESULTS:A total of 157 patients with established IBD were included in this study.Of these,135 patients were diagnosed with UC(86%of the total),and 22patients,with CD(14%of the total).The mean ages at diagnosis were 27.3 and 29.7,respectively.Strikingly,we noticed a marked increase in the frequency of both UC and CD diagnoses during the most recent 10 years of the 15 year period studied.Regarding the gender distribution,the male:female ratio was 1:1.15 for UC and 2.6:1 for CD.The mean duration of follow up for patients with UC was 6.2±5.18 years,while the mean duration of follow up for patients with CD was 5.52±2.83 years.For patients with UC we found no correlation between the severity of the disease and the presence of extraintestinal manifestations.Eleven patients had surgical interventions during the studied years:4cases of total colectomy and 7 cases of anal surgery.CONCLUSION:We observed a ratio of 6:1 for UC to CD in our series.The incidence of IBD seems to be rising in Egypt.     

Utility of endoscopic retrograde cholangiopancreatography on biliopancreatic diseases in patients with Billroth Ⅱ-reconstructed stomach

AIM To examine the utility of endoscopic retrograde cholangiopancreatography(ERCP) on biliopancreatic diseases in the patients with Billroth II-reconstructed stomach.METHODS For 26 cases of biliopancreatic diseases in patients with Billroth Ⅱ-reconstructed stomach,ERCP was conducted using a straight-view scope or a retrograde obliqueviewing endoscope.All the cases were patients aiming at selective insertion into the bile duct.One patient aimed at diagnosis,and 25 patients aimed at treatment.The cases in which the endoscope reached the duodenal papilla and anastomosis,and insertion into the bile duct became possible,were considered successful.RESULTS The rate of reaching the duodenal papilla and anastomosis was 84.7%(22/26 patients).Among the cases without reaching the duodenal papilla and anastomosis,there were 2 in which the endoscope did not pass due to tumor-induced duodenal infiltration.In 1 case,the fiber did not reach the duodenal papilla due to long afferent loop.The success rate of insertion into the bile duct in patients in which the endoscope reached the duodenal papilla and anastomosis was 90.9%(20/22 patients),and the success rate of procedures including treatment was 86.3%(19/22 patients).After treatment,mild cholangitis was observed in 1 patient(4.5%,1/22 patients) but relieved conservatively.No other accidental symptom was observed.CONCLUSION It was considered that the ERCP for biliopancreatic diseases in patients with Billroth II-reconstructed stomach will become a less invasive,safe and useful examination and treatment approach.     

Distribution of cagG gene in Helicobacter pylori isolates from Chinese patients with different gastroduodenal diseases and its clinical and pathological significance

AIM: To determine the distribution of cagG gene of Helicobacter pylori(Hpylori) isolates cultured from patients with various digestive diseases and its relationship with gastroduodenal diseases.METHODS: cagG was amplified by polymerase chain reaction in 145 H pylori isolates cultured from patients with chronic gastritis (n=72), duodenal ulcer (n=48), gastric ulcer (n=17), or gastric and duodenal ulcer (n=8), and the relationship between cagGstatus and the grade of gastric mucosal inflammation was determined.RESULTS: cagG was present in 91.7% of the 145 H pylori isolates, with the rates were 90.3%, 93.8%, 88.2% and 100.0%, respectively, in those from patients with chronic gastritis, duodenal ulcer, gastric ulcer, and gastric and duodenal ulcer. There was no significant difference among the four groups (P＞0.05). The average grade of gastric mucosal inflammation in the antrum and corpus was 1.819±0.325and 1.768±0.312, respectively in cagG positive patients,whereas the average inflammation grade was 1.649±0.297,1.598±0.278 respectively in cagG negative cases (P＞0.05).CONCLUSION: cagG gene of H pylori was quite conservative,and most H pylori strains in Chinese patients were cagG positive.cagG status was not related to clinical outcome or the degree of gastric mucosal inflammation. Therefore, cagG can notbe used as a single marker for discrimination of H pylori strains with respect to a specific digestive disease.     

自身免疫性胰腺炎误诊误治17例临床分析

Objective To summarize the reasons of mis-diagnosis and mis-treatment of autoimmune pancreatitis (AIP). Methods Clinical data of 17 patients with AIP,who were admitted to the hospital from May 2005 to July 2010 and experienced mis-diagnosis and mis-treatment, were retrospectively analyzed. Results The main clinical manifestations included epigastric pain (13 cases),progressive obstructive jaundice (12 cases), fever (6 cases) and weight loss (9 cases). Fifteen patients had extrapancreatic organ involvemnet, including allergic rhinitis, swelling of lymphoglandulae submaxillares, swelling of submaxillary gland, allergic asthma, rheumatoid arthritis, Sjogren syndrome, diabetes mellitus, primary sclerosing cholangitis and autoimmune hepatitis. Of these 17 cases, 11 cases presented with high serum globulin, 14 cases with high serum IgG, 13 cases with high serum γ-globulin, 13 cases with positive anti-nuclear antibody and 2 cases with positive anti-insulin IgG antibody. The abdominal imaging demonstrated that 15 patients had diffuse enlargement of the pancreas with diffuse or segmental narrowing of main pancreatic duct, narrowing of the intrapancreatic common bile duct, dilation of the proximal biliary duct and gallbladder enlargement. Focal enlargement of the pancreas was found in 2 cases. Thirteen cases were misdiagnosed as pancreatic carcinoma. Among them, 4 cases underwent pancreaticoduodenectomy and 7 cases underwent choledochojejunostomy. Two cases were misdiagnosed as end stage of cancer that lost therapeutic chance. Another 4 cases were misdiagnosed as chronic pancreatitis. Steroid therapy was administered in all patients with satisfactory response. All patients were followed-up for 15 months (ranged from 6 months to 45 months), and recurrence was found in 4 cases. Satisfactory response was found in patients treated with steroid for the second time. No pancreatic cancer was found in these patients in the follow up period. Conclusion The main causes of mis-diagnosis and mis-treatment of AIP may be contributed by difficulty in differentiating AIP from pancreatic carcinoma based on clinical manifestations and inadequate knowledge of AIP as well as insufficient attention to AIP in China.     

新型甲型H1N1流感危重症存活和死亡病例的临床特点分析

Objective To understand the clinical features of critically ill patients with pandemic 2009 influenza A(H1N1)and investigate the risk factors associated with death cases. Methods The clinical features of 55 critically ill patients with pandemic 2009 influenza A(H1N1)viral infection hospitalized at Beijing Ditan Hospital from October 3 to December 15,2009 were retrospectively analyzed,and a comparative analysis was performed on the manifestations of the survival and the death groups of patients. Results There were 31 males and 24 females.The age ranged from 10 months to 84 year old,and the mean(SD)was 38(20)year old.The critically ill cases were more in patients under age 65(48/55),with obesity(33/49),with underlying diseases(26/49),and pregnancy(6/24).Both the survivors and non-survivors of patients had high fever,cough,sputum(some sputum with blood),dyspnea,r(a)les of both lungs fields.and all further developed severe pneumonia.The patients also showed respiratory failure(54/55)and ARDS(26/55).All of them received oseltamivir therapy,and 38 patients received mechanical ventilation and 30 were giyen steroid therapy.Secondary infection occurred in 27 cases.and ventilatorassociated pneumonia happened in 10 patients.In the early stage of onset,C-reactive protein(CRP) increased [ (131 ± 130)mg/L] and low counts of T lymphecytes were present [ CD4+ , CD8+T was (217 ±139)/μl and (162 ± 82)/μl]. With the progress of disease, the non-survival cases had persistently increased CRP and the counts of T lymphocytes did not recover, while the secondary fungal infection was significantly higher than in the survivor cases (P <0. 05). By using BMI, underlying diseases, ARDS, the day of Oseltamivir initiated, steroid therapy, following bacterial and fungal infection as variables through logistic regression analysis, it was shown that higher BMI and following fungal infection were associated with higher fatal risks ( OR was 6. 512, 19. 631 respective0ly, both of P value was low than 0. 05 ). There was no death case who received oseltamivir treatment within 48 hours of onset of disease. Conclusions Critical illness in pandemic 2009 influenza A (H1N1)was associated with patients under age 65, with obesity,underlying diseases, and pregnancy. Persistently increased CRP and lower counts of T lymphocytes were associated with unfavorable prognosis. The patients with higher BMI and secondary fungal infection had higher fatal risks. Oseltamivir treatments at early stage would probably reduce mortality.     

新型甲型H1N1流感危重症存活和死亡病例的临床特点分析

Objective To understand the clinical features of critically ill patients with pandemic 2009 influenza A(H1N1)and investigate the risk factors associated with death cases. Methods The clinical features of 55 critically ill patients with pandemic 2009 influenza A(H1N1)viral infection hospitalized at Beijing Ditan Hospital from October 3 to December 15,2009 were retrospectively analyzed,and a comparative analysis was performed on the manifestations of the survival and the death groups of patients. Results There were 31 males and 24 females.The age ranged from 10 months to 84 year old,and the mean(SD)was 38(20)year old.The critically ill cases were more in patients under age 65(48/55),with obesity(33/49),with underlying diseases(26/49),and pregnancy(6/24).Both the survivors and non-survivors of patients had high fever,cough,sputum(some sputum with blood),dyspnea,r(a)les of both lungs fields.and all further developed severe pneumonia.The patients also showed respiratory failure(54/55)and ARDS(26/55).All of them received oseltamivir therapy,and 38 patients received mechanical ventilation and 30 were giyen steroid therapy.Secondary infection occurred in 27 cases.and ventilatorassociated pneumonia happened in 10 patients.In the early stage of onset,C-reactive protein(CRP) increased [ (131 ± 130)mg/L] and low counts of T lymphecytes were present [ CD4+ , CD8+T was (217 ±139)/μl and (162 ± 82)/μl]. With the progress of disease, the non-survival cases had persistently increased CRP and the counts of T lymphocytes did not recover, while the secondary fungal infection was significantly higher than in the survivor cases (P <0. 05). By using BMI, underlying diseases, ARDS, the day of Oseltamivir initiated, steroid therapy, following bacterial and fungal infection as variables through logistic regression analysis, it was shown that higher BMI and following fungal infection were associated with higher fatal risks ( OR was 6. 512, 19. 631 respective0ly, both of P value was low than 0. 05 ). There was no death case who received oseltamivir treatment within 48 hours of onset of disease. Conclusions Critical illness in pandemic 2009 influenza A (H1N1)was associated with patients under age 65, with obesity,underlying diseases, and pregnancy. Persistently increased CRP and lower counts of T lymphocytes were associated with unfavorable prognosis. The patients with higher BMI and secondary fungal infection had higher fatal risks. Oseltamivir treatments at early stage would probably reduce mortality.     

自身免疫性胰腺炎误诊误治17例临床分析

Objective To summarize the reasons of mis-diagnosis and mis-treatment of autoimmune pancreatitis (AIP). Methods Clinical data of 17 patients with AIP,who were admitted to the hospital from May 2005 to July 2010 and experienced mis-diagnosis and mis-treatment, were retrospectively analyzed. Results The main clinical manifestations included epigastric pain (13 cases),progressive obstructive jaundice (12 cases), fever (6 cases) and weight loss (9 cases). Fifteen patients had extrapancreatic organ involvemnet, including allergic rhinitis, swelling of lymphoglandulae submaxillares, swelling of submaxillary gland, allergic asthma, rheumatoid arthritis, Sjogren syndrome, diabetes mellitus, primary sclerosing cholangitis and autoimmune hepatitis. Of these 17 cases, 11 cases presented with high serum globulin, 14 cases with high serum IgG, 13 cases with high serum γ-globulin, 13 cases with positive anti-nuclear antibody and 2 cases with positive anti-insulin IgG antibody. The abdominal imaging demonstrated that 15 patients had diffuse enlargement of the pancreas with diffuse or segmental narrowing of main pancreatic duct, narrowing of the intrapancreatic common bile duct, dilation of the proximal biliary duct and gallbladder enlargement. Focal enlargement of the pancreas was found in 2 cases. Thirteen cases were misdiagnosed as pancreatic carcinoma. Among them, 4 cases underwent pancreaticoduodenectomy and 7 cases underwent choledochojejunostomy. Two cases were misdiagnosed as end stage of cancer that lost therapeutic chance. Another 4 cases were misdiagnosed as chronic pancreatitis. Steroid therapy was administered in all patients with satisfactory response. All patients were followed-up for 15 months (ranged from 6 months to 45 months), and recurrence was found in 4 cases. Satisfactory response was found in patients treated with steroid for the second time. No pancreatic cancer was found in these patients in the follow up period. Conclusion The main causes of mis-diagnosis and mis-treatment of AIP may be contributed by difficulty in differentiating AIP from pancreatic carcinoma based on clinical manifestations and inadequate knowledge of AIP as well as insufficient attention to AIP in China.     

不明原因长期发热110例临床分析

目的探讨我国不明原因长期发热的病因。方法回顾性地总结分析１９９５年１月至１９９６年１２月间在我科住院且符合不明原因长期发热（ＦＵＯ）诊断标准的患者１１０例。结果１１０例患者经各种检查或特异性治疗最后明确诊断者有１０２例，确诊率为９２７％。病因：感染性疾病５８例，占５２７％，其中结核病２７例，占感染性疾病的４６６％（２７／５８）；自身免疫性疾病２１例，占１９１％，Ｓｔｉｌ病占自身免疫性疾病的４２９％（９／２１）；肿瘤性疾病７例，占６４％；其他疾病１６例，占１４５％；原因仍未明者８例，占７３％。结论感染性疾病仍然是ＦＵＯ的主要病因，结核病尤其是肺外结核的发病率有增高趋势，本组肺外结核占３１０％（１８／５８）；其次自身免疫性疾病和肿瘤性疾病在ＦＵＯ中也占有相当比例，Ｓｔｉｌ病和不典型淋巴瘤诊断比较困难，但大多数ＦＵＯ通过仔细检查和分析最终可明确诊断     

Fever of unknown origin in a Mediterranean survey from a division of internal medicine: report of 91 cases during a 12-year-period (1991–2002)

Despite the availability of all advanced diagnostic tools, fever of unknown origin (FUO) remains a diagnostic challenge for physicians. The objective was to define, through a retrospective study, the categories of the diseases of Sicilian patients admitted at the Department of Clinical Medicine and Emerging Diseases, University of Palermo, Italy, for classical FUO. Using the registration system for patients admitted from 1991 to 2002, 508 charts of patients admitted because of fever were reviewed. Of these, only 91 patients fulfilled the criteria for classical FUO. The origin of FUO was diagnosed in 62 (68.1%) patients. Infection was the most common cause of FUO with 29 cases (31.8% of total of FUO), neoplasms accounted for 13 cases (14.2%), collagen vascular disease for 11 cases (12.0%), and miscellaneous for 9 cases (9.8%). Undiagnosed FUO were 29 (31.8%) and, of them, 22 cases were followed-up for 2 years. A definite diagnosis could be established only in 8 cases, 13 subjects completely recovered and 4 of them died. In the 73.4% of cases, the FUO have been the result of misleading factors in the diagnostic approaches as made by the physician. The results of our study are similar to those already reported by other authors in other populations, with infections as first, neoplasm as second, and collagen vascular diseases as third most important causes of FUO. In our study the prognosis for undiagnosed FUO cases was good, but a definite diagnosis could be established only in few cases. Therefore, further multicentric, prospective studies of good design are required.     

不明原因发热449例临床分析

目的探讨不明原因发热(FUO)的原因。方法回顾性分析2000年1月∽2003年12月间在我院住院诊治的符合不明原因发热诊断标准的患者449例。结果449例患者中经各种检查或诊断性治疗最终明确诊断者387例,确诊率为86．2％。病因包括：感染性疾病220例(56．8％),其中结核病96例,占43．6％(96／220);结缔组织病76例(19．6％),其中Still病占34．2％(26／76),系统性红斑狼疮占18．4％(14／76),血管炎占13．2％(10／76);肿瘤性疾病64例(16．5％),其中淋巴瘤占39．1％(25／64);其他疾病27例(7．0％),其中坏死性淋巴结炎占33．3％(9／27),伪热占22．2％(6／27),药物热占26％(7／27);出院时仍未确诊的62例(13．8％)。结论感染性疾病是本组FUO患者的主要病因,结核病是其中的主要病种,结缔组织病和肿瘤性疾病在本组FUO病因中也占重要地位;大多数FUO经仔细的临床检查和分析是可以得到确诊的。     

Brucellosis as a cause of fever of unknown origin in children admitted to a tertiary hospital in the Aegean region of Turkey

The aim of the study was to determine the role of brucellosis in children with fever of unknown origin (FUO) in the Aegean region of Turkey. For this purpose, the records of all children referred or admitted with diagnosis of FUO to the Department of Pediatric Infectious Diseases, Ege University Medical School, between 2003 and 2008 were scanned and 92 cases were identified retrospectively. Fifty-eight of these 92 children (63%) were diagnosed with infectious diseases, brucellosis being the most frequent cause (15.2%). Although several other infectious diseases do appear as a cause of FUO, brucellosis should be particularly considered as a differential diagnosis.     

The clinical characteristics and outcomes of patients with fever of unknown origin caused by parasitic infection

There are over 200 causes of fever of unknown origin (FUO), and although parasitic infection is an increasingly uncommon cause, a definitive diagnosis remains important to ensure rapid treatment and to prevent adverse sequelae through delay. Here, we studied the clinical features and outcomes of patients admitted with FUO and diagnosed with parasitic infection to improve our understanding of the features of parasitic FUO.Medical records of patients admitted to Peking Union Medical College Hospital between 2013 and 2019 with FUO and diagnosed with parasitic infection were reviewed. The clinical features and outcomes of patients for whom follow-up data were available were summarized.Six patients were admitted with FUO and diagnosed with parasitic infections (6/1013; 0.59%). Patients were more commonly middle-aged men and had a relatively long disease course. Most suffered from hyperpyrexia and other non-specific symptoms. Routine examinations were non-specific, and some patients had positive tumor markers, antinuclear antibodies, or positron emission tomography/computed tomography results. Diagnoses were confirmed by bone marrow smears, serum antibody testing, or feces examination. All 6 cases received anthelmintic treatments and recovered well.Parasitic infections must be screened for and actively excluded in FUO patients so that targeted therapy can be rapidly administered to ensure optimal outcomes.     

Clinical outcomes in medical outliers admitted to hospital with heart failure

BackgroundDue to the lack of beds in medical wards, many patients are placed in other departments' wards (usually in surgical wards). These patients are called “medical outliers”. This is a common problem in countries with public national health services. We determined whether location influences progress and prognosis of patients.MethodsThis was a retrospective cohort study in a public university hospital in Madrid, Spain. 243 patients discharged from the Department of Internal Medicine during 2006 with the same diagnosis-related group (DRG) (congestive heart failure and cardiac arrhythmia with major complications or comorbidity) were studied. Patients admitted to departments other than the Internal Medicine department or Intensive Care Unit were excluded. “Medical outlier” was defined as a patient admitted to a ward different from the Internal Medicine ward. Medical outliers transferred to the Internal Medicine ward were not excluded.Results109 (45%) patients were medical outliers. They had a longer stay in hospital (mean difference 2.6 days, 95% confidence interval 0.6–4.7) but with no statistically significant differences in mortality, readmission, or intra-hospital morbidity. These patterns persisted after control for confounding in multivariate analysis.ConclusionPatients admitted to the Department of Internal Medicine with heart failure had a longer stay if they initially start in other departments' wards. Significant differences were not seen in this group of patients with respect to mortality, readmission, or intra-hospital morbidity.     

Fever of Unknown Origin in Turkey

Abstract. Background: The etiology of fever of unknown origin (FUO) includes primarily infectious, collagen-vascular and neoplastic diseases. The distribution of the disorders causing FUO may differ according to the geographic area and the socioeconomical status of the country. Moreover, the developments in radiographic and microbiologic methods have changed the spectrum of diseases causing FUO. Materials and Methods: We reviewed 117 cases that fulfilled the criteria of FUO followed in our department during the period 1984 to 2001. Results: The etiology of FUO was infectious diseases in 34% of the patients, collagen-vascular diseases in 23%, neoplasms in 19% and miscellaneous diseases in 10%. In 14% of the cases the etiology could not be found. The three leading diseases were tuberculosis (24%), lymphomas (19%) and adult-onset Stills disease (11%). Tuberculosis was found to be a more common cause of FUO than reported in studies in developed countries. Invasive procedures helped to establish the diagnosis in 50 out of 92 patients (43%). As a final diagnostic procedure, laparotomy aided the establishment of a diagnosis in 15 out of 20 patients (75%). Conclusion: Although the relative rate of infectious disease as etiologic category is less commonly encountered, infectious disease, especially tuberculosis, remains a common cause of FUO. Although several diseases may lead to FUO, lymphomas, adult-onset Stills disease and particularly tuberculosis should be considered in the differential diagnosis of a patient admitted with FUO.     

Evolution of the incidence and aetiology of fever of unknown origin (FUO), and survival in HIV-infected patients after HAART (Highly Active Antiretroviral Therapy)

BackgroundFever of unknown origin (FUO) is common among HIV-infected patients with a CD4+ T-lymphocyte cell count below 200 cells/ml. The use of HAART has transformed the evolution of AIDS and related diseases.Design and methodCase-control study, nested on a historical cohort of 3777 HIV-infected patients who were attended at “12 de Octubre” University Hospital in Madrid, Spain, between 1994 and 2000.Results276 FUO episodes were recorded, 58 of which occurred in patients receiving HAART. The significant decrease on the accumulated FUO incidence along the study period of 7.3 episodes per 100 HIV-infected patients after 1997 corresponded with the introduction of HAART. FUO was more frequent in patients who did not receive HAART. The aetiological spectrum of FUO was transformed by the introduction of HAART: the incidence of tuberculosis decreased while that of leishmaniasis increased. The four year survival in the non-FUO group increased when compared to that of patients who had had FUO. Similarly, this four year survival increased in patients who received HAART at the time of FUO versus those not receiving it.ConclusionsOur results confirm that the incidence of FUO has significantly decreased with the introduction of HAART. HAART has also transformed the aetiological spectrum related to FUO considerably. The most frequent cause of FUO in non-HAART patients on this study was the disseminated infection by Mycobacterium avium intracellulare (MAI), followed by tuberculosis, while leishmaniasis was its most common cause in patients receiving HAART. Survival decreased in patients who developed FUO; however, patients who received HAART at the time of FUO had longer survival than patients who did not.     

Fever of unknown origin: analysis of 71 consecutive cases

BACKGROUND: Fever of unknown origin (FUO) is still an important problem in clinical practice. Evaluation of patient characteristics may clarify the utility of diagnostic tests and etiologies of FUO. METHODS: Fever of unknown origin in 71 patients was investigated at Ankara Numune Education and Research Hospital in Turkey between February 2001 and December 2004. RESULTS: Mean hospital stay and fever duration was 20.5 days and 44 days, respectively. Etiologies of FUO were as follows: infections 32 (45.1%), collagen vascular disease 19 (26.8%), neoplasm 10 (14.1%), and miscellaneous diseases 4 (5.6%). Diagnosis remained obscure in 6 patients (8.5 %). Tuberculosis was found to be 40% of the infectious causes of FUO. Mean hospital stay and fever duration were prolonged in infectious cases. Female predominance was observed in collagen vascular diseases (P = 0.047). Splenomegaly and lymphadenopathy were common in the neoplasm group (P = 0.017, P = 0.017, respectively). Erythrocyte sedimentation rate, aspartate aminotransferase, alanine aminotransferase and lactate hydrogenase levels were elevated in patients with collagen vascular diseases. Nine (12.7%) patients died during the follow-up period. CONCLUSIONS: Hospital stay and fever duration were prolonged in the infectious group of FUO patients. Infectious diseases, particularly tuberculosis, were the most important cause of FUO in our series. Tuberculosis should be kept in mind as an important etiology of FUO countries where tuberculosis is endemic.