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PubMed2003

[Clinical and epidemiologic characteristics of hemorrhagic fever with renal syndrome in patients treated at the Dr. Fran Mihaljević Clinic for Infectious Diseases in Zagreb].

AIM: The aim of the study was to examine and analyze the main epidemiologic and clinical data of 94 patients with hemorrhagic fever with renal syndrome (HFRS) hospitalized at the University Hospital for Infectious Diseases in Zagreb during the HFRS outbreak in Croatia in 2002. PATIENTS AND METHODS: A total of 110 patients with clinical diagnosis HFRS were treated at the University Hospital for Infectious Diseases in Zagreb. In 110 of HFRS suspected patients, the clinical diagnosis was verified serologically in 94 patients and they were included in the retrospective study. In 93 patients the diagnosis was confirmed by enzyme-linked immunosorbent assay (ELISA), and in one patient by indirect immunofluorescence assay (IFA). Results were analyzed by the use of descriptive statistics. RESULTS: Puumala (PUU) virus infection was verified in 80 (85.1%), Dobrava (DOB) infection in 8 (8.5%) and cross-reactive antibodies to both PUU and DOB viruses in 5 (5.3%) HFRS patients. In one patient who was confirmed by IFA the hantavirus serotype causing HFRS could not be determined. The localities of the presumed HFRS patient exposure to hantaviruses were mostly in the Zagreb area. Most patients were aged 21-50 (83.0%) and male (76.6%). The majority of HFRS cases occurred between May and August (75.5%). A high proportion of HFRS cases were found in the general population from Zagreb and its surroundings (78.7%). The majority of patients were hospitalized in the febrile stage of the disease (70.2%). The main symptoms were: fever (100%), headache (88.3%) and backache (87.2%). Oliguria was recorded in 56.4% and, anuria in 7.5% of patients, however, only three (3.2%) patients required hemodialysis. Six patients developed hemorrhagic manifestations, especially petechiae on the skin and mucosa. One patient in the convalescent stage had subarachnoidal bleeding. Six patients had pathologic electroencephalogram (EEG) findings and two developed epileptic seizures. Lumbar puncture was performed in 12 patients without inflammatory changes in the cerebrospinal fluid. Pathologic ECG findings were recorded in 30/79 (38.0%) patients, primarily including mild and translent disturbances such as sinus tachycardia, sinus bradycardia, nonspecific alteration of the final complex and incomplete right bundle branch block. Conventional chest radiography revealed abnormal findings in 23/84 (27.4%) patients. The abnormalities consisted of interstitial infiltrates and/or pleural effusions and atelectasis. The patients were divided into 4 groups according to the disease severity: mild in 74 (78.7%), moderate in 15 (16.0%), severe in 4 (4.2%), and very severe in one (1.1%) patient. The latter developed multiorgan failure and died. CONCLUSION: The largest outbreak of HFRS to date was recorded in Croatia in 2002. Ninety-four patients with clinical and serologically verified HFRS were treated at the Dr. Fran Mihaljević University Hospital for Infectious Disease, Zagreb. The majority of patients were hospitalized between May and August. Most patients had mild form of the disease primarily caused by PUU virus.

Adolescent↗
PubMed2006

Development of a clinical pathway for near-term and convalescing premature infants in a Level II nursery.

A subcategory of premature infants, those born near term at 34 to 36 and 6/7 weeks gestation, may represent a previously unrecognized at-risk neonatal population. Evidence-based practice guidelines, crafted specifically for this population, are needed to effectively manage their care. In an effort to meet the needs of the near-term infant (NTI) population, and concurrently address the needs of the convalescing premature infants reverse transported to a Level II nursery setting, a multidisciplinary team of clinicians designed tools to provide a more consistent approach to care for and discharge these infants. This article describes the design, implementation, and evaluation of an evidence-based multidisciplinary clinical pathway specific to the needs of the NTI, including care plans, a standardized physician admission and discharge order set, evidence-based interventions, parent education, and recommendations for follow-up after hospital discharge that were developed for use in a Level II nursery. The use of the premature and near-term infant pathway has now been expanded to NTIs cared for in the newborn nursery, thereby ensuring safe, consistent, quality care for this population, regardless of their setting.

Bottle Feeding↗
PubMed1984

Epidemic non-A, non-B hepatitis in Nepal. Recovery of a possible etiologic agent and transmission studies in marmosets.

An epidemic of non-A, non-B hepatitis occurred in Kathmandu Valley, Nepal, during 1981-1982, with approximately 7.6% of households and 1.4% of individuals affected. Cases occurred preponderantly in the 15- to 34-year-old age group (70%), with most cases (75%) occurring in males. A high mortality rate (21%) occurred in pregnant women admitted to the hospital. No single water source was implicated, but epidemic peaks occurred during monsoon rains, and multiple opportunities for enteric transmission existed. One of eight patient stools examined by immune electron microscopy revealed aggregated, antibody-coated, 27-nm viruslike particles when convalescent serum samples were used as sources of antibody. Inoculation of two chimpanzees and four marmosets with a suspension of this stool resulted in elevated liver enzyme activity in three marmosets. Fecal excretion of 27-nm particles during the acute phase of disease (with temporally coincident antigen activity by radioimmunoassay) was observed in one marmoset, which also developed convalescent antibody against the particles in the original inoculum.

Adolescent↗
PubMed1992

Primary human herpesvirus 6 infection in young children.

BACKGROUND: Human herpesvirus 6 (HHV-6) is a recently discovered virus that, on the basis of serologic evidence, appears to infect most children by the age of three years. However, the clinical manifestations of primary HHV-6 infection have not been well defined. METHODS: We studied consecutive children two years old or younger who presented to an emergency ward with febrile illnesses. Our evaluation included the isolation of HHV-6 from peripheral-blood mononuclear cells, an immunofluorescent-antibody assay, the detection of HHV-6 by the polymerase chain reaction (PCR), and restriction-endonuclease-fragment profiles of HHV-6 isolates. RESULTS: HHV-6 was isolated from 34 of 243 acutely ill children (14 percent). The children with viremia had irritability, high temperatures (mean, 39.7 degrees C), and inflammation of tympanic membranes (in 21), but few other localizing signs. Two children were hospitalized, but all 34 recovered after an average of four days of fever. The rash characteristic of roseola, which has been associated with HHV-6 infection, was noted in only three children. In 29 children (85 percent), serum samples obtained during convalescence had at least a fourfold increase in IgG antibody titers; 4 infants less than three months old who presumably had maternal antibody did not have this increase. HHV-6 was isolated from blood obtained during convalescence in only one child, but in two thirds of the children the virus could be detected by PCR. The isolates had genomic heterogeneity, indicating the presence of multiple strains. CONCLUSIONS: Primary infection with HHV-6 is a major cause of acute febrile illness in young children. Such infection is associated with varied clinical manifestations, viremia, and the frequent persistence of the viral genome in mononuclear cells.

Antibodies, Viral↗
PubMed1984

The gastrocnemius myocutaneous flap in lower-extremity injuries.

Coverage of full-thickness lower extremity wounds has been the bane of surgeons who care for patients with skin and soft-tissue losses. A prolonged period of convalescence may be avoided by immediate coverage with a gastrocnemius myocutaneous flap. Case reports demonstrating the successful use of medial and lateral gastrocnemius myocutaneous flaps are presented. Advantages are that large amounts of tissue can be moved in one step, shortening hospitalization, and most are reliable because of their excellent blood supply. Care must be taken to preserve deep fascia and to dissect the fascia from the Achilles tendon. Fluorescein examination is recommended.

Adult↗
PubMed2007

Rapid diagnostic tests for dengue and leptospirosis: antibody detection is insensitive at presentation.

OBJECTIVE: To determine the performance of rapid diagnostic tests for dengue and leptospirosis that rely on detecting antibodies that may not be produced when patients present for medical treatment. METHODS: We prospectively enrolled 723 patients with undifferentiated febrile illness presenting to rural hospitals in northern and northeastern Thailand over a 1-year period. We evaluated rapid antibody detection diagnostic tests for dengue and leptospirosis on these patients. RESULTS: Sensitivity of the tests was low at the acute visit (7.6-21.5%). Sensitivity at the convalescent visit ranged from 25.8% to 81.5% and was significantly higher than at the acute visit for all tests (chi(2), P < 0.001). CONCLUSIONS: Low sensitivity of the rapid tests at presentation suggests that their utility in the acute phase of dengue and leptospirosis is limited.

Adolescent↗
PubMed1991

Laser lithotripsy: a nursing perspective.

Laser lithotripsy represents the urologist's newest option in urinary stone management and is fast becoming the procedure of choice when treating calculi. Approximately 400,000 people yearly require treatment for urinary stone disease. 60% pass the calculi spontaneously while 40% require some type of intervention (Dretler, 1988). While the initial cost of the laser is expensive, maintenance cost is relativity low. Therefore, the laser lithotripter becomes a very cost effective tool when compared with other alternatives because of the decreased hospital stay and the absence of significant complications. Adverse effects to the patient are primarily due to the endoscopic procedure and not the laser itself. Additional benefits to the patient include reduced pain and edema, minimal bleeding, no incision and decreased convalescence time.

Humans↗
PubMed1978

Femoral neuropathy after renal transplantation.

Two cases of postoperative femoral neuropathy have been encountered in 135 renal transplant patients operated upon at Groote Schuur Hospital since 1967. It is thought that the lesions were due to anoxia secondary to compression of the nerve by a self-retaining retractor blade. Electromyographic studies were useful in assessing the severity and prognosis of the lesion. A prolonged convalescence may occur with a varying degree of residual neurological deficit.

Adult↗
PubMed1994

Laparoscopic resection of a giant mesenteric cyst.

Laparoscopic resection of a giant retroperitoneal, mesenteric cyst in a 38-year-old man who presented with abdominal distension and pedal edema is described. The diagnosis was made by abdominal computed tomography, which revealed a large cystic mass that was causing extrinsic compression of the inferior vena cava and the right ureter. The hospital course was uneventful, and the patient was discharged 2 days postoperatively. This new endoscopic approach offers a useful alternative to the traditional transabdominal excision of a mesenteric cyst and may have some theoretical advantages, including less postoperative pain and shorter convalescence.

Adult↗
PubMed2006

Bacterial coinfections in children with viral wheezing.

Bacterial coinfections occur in respiratory viral infections, but the attack rates and the clinical profile are not clear. The aim of this study was to determine bacterial coinfections in children hospitalized for acute expiratory wheezing with defined viral etiology. A total of 220 children aged 3 months to 16 years were investigated. The viral etiology of wheezing was confirmed by viral culture, antigen detection, serologic investigation, and/or PCR. Specific antibodies to common respiratory bacteria were measured from acute and convalescent serum samples. All children were examined clinically for acute otitis media, and subgroups of children were examined radiologically for sinusitis and pneumonia. Rhinovirus (32%), respiratory syncytial virus (31%), and enteroviruses (31%) were the most common causative viruses. Serologic evidence of bacterial coinfection was found in 18% of the children. Streptococcus pneumoniae (8%) and Mycoplasma pneumoniae (5%) were the most common causative bacteria. Acute otitis media was diagnosed in 44% of the children. Chest radiographs showed alveolar infiltrates in 10%, and paranasal radiographs and clinical signs showed sinusitis in 17% of the older children studied. Leukocyte counts and serum C-reactive protein levels were low in a great majority of patients. Viral lower respiratory tract infection in children is often associated with bacterial-type upper respiratory tract infections. However, coexisting bacterial lower respiratory tract infections that induce systemic inflammatory response are seldom detected.

Adolescent↗
PubMed1996

[Cost analysis of inguinal hernia surgery in ambulatory and inpatient management].

In Belgium 27,426 hernia repairs were performed in 1994 but only 1,451 (5.29%) were done on ambulatory basis, whereas in the U.S. over 50% of the yearly 600,000 hernia repairs are one day surgery procedures with interstate variation ranging from 6% to 89%. The mean treatment cost of inguinal hernia repair (doctors fees + hotel cost) was 53,704 BEF for inpatients vs. 30,510 BEF (general anesthesia) and 27,501 BEF (local anesthesia) for outpatients. Rates of complication and recurrence were not significantly different. This difference in total costs for hospital admission are determined by the mean length of stay and by the individual forfeitairy day price according to size of the hospital. Also the use of routine diagnostic procedures (clinical chemistry and medical imaging) - not necessarily essential for treatment - is higher at hospitalization. Even with 50% of all hernia repairs carried out in the one day clinic, total cost savings for treatment will hardly exceed 20% if the mean length of stay of the remaining inpatients will not decrease simultaneously. Supplementary and dramatic cost reductions however are possible by an earlier resumption of professional activities. The mean advised sick leave period of 4 weeks (+/- 2) still depends on irrelevant parameters as tradition, patients' preferences, job characteristics and type of insurance. Total costs for work incapacity add up to 2.5 billion BEF (vs. 1.4 billion BEF for total treatment costs) and can be cut by 50.18% via a mean 2 weeks earlier return to work. Since open primary hernia repair under local anesthesia can be easily carried out on outpatients resuming unrestricted daily activities in less than 1 week, the laparoscopic procedure with general anesthesia, higher treatment cost (endoscopic material) and still debated advantages in convalescence time and long-term outcome is not the gold standard for uncomplicated inguinal hernia.

Ambulatory Surgical Procedures↗
PubMed1999

Peripheral blood cytokine responses and disease severity in respiratory syncytial virus bronchiolitis.

The role of cellular immunity in disease severity in respiratory syncytial virus (RSV) bronchiolitis is largely unknown. This study investigated the association between disease severity and systemic cytokine responses in hospitalized ventilated and nonventilated RSV bronchiolitis patients. In whole blood cultures stimulated with phytohaemagglutinin (PHA), lymphoproliferative responses and interferon (IFN)-gamma and interleukin (IL)-4 production during acute illness were measured. In addition, plasma cytokines were measured. Measurements were repeated in the convalescent phase, 3-4 weeks after admission. Fifty patients were included. The median age in ventilaled patients was significantly lower than in nonventilated patients (1 versus 4 months, p<0.05). In comparison with nonventilated patients, the ventilated patients had significantly lower lymphoproliferative responses and a lower production of IFN-gamma and IL-4. In fact, IFN-gamma and IL-4 production in ventilated patients was almost completely undetectable. Plasma IL-8 levels in ventilated patients were significantly higher than in nonventilated patients. In the convalescent phase, lymphoproliferative and cytokine responses as well as plasma IL-8 levels were normal in both patient groups. Since RSV bronchiolitis is associated with the subsequent development of asthma, the possible skewing of the T-helper (Th1/Th2) cytokine balance was investigated. This was found neither in the acute nor in the convalescent phase. In conclusion, the data indicate that depressed lymphocyte function and elevated plasma interleukin-8 levels are markers of severe disease. It is suggested that age and maturation related immune mechanisms could explain the occurrence of severe respiratory syncytial virus bronchiolitis requiring mechanical ventilation in young infants.

Antibodies, Viral↗
PubMed2002

La Crosse encephalitis in Eastern Tennessee: clinical, environmental, and entomological characteristics from a blinded cohort study.

A blinded cohort study was conducted in 2000 to better understand the emergence of La Crosse virus infection in eastern Tennessee, with special emphasis on the potential mosquito vector(s). Children with suspected central nervous system infection were enrolled at the time of clinical presentation at a large pediatric referral hospital. Clinical, environmental, and entomological data were collected prior to case confirmation. Sixteen of the 40 children included in the final analysis were confirmed to have La Crosse infection by a fourfold increase in antibody titers between collection of acute- and convalescent-phase sera. Factors significantly associated with La Crosse infection included average number of hours per day spent outdoors (5.9 for La Crosse virus cases vs. 4.0 for noncases, p = 0.049); living in a residence with one or more tree holes within 100 m (relative risk = 3.96 vs. no tree holes within 100 m, p = 0.028); and total burden of Aedes albopictus (number of female and male larvae and adults collected at a site), which was more than three times greater around the residences of La Crosse virus cases versus noncases (p = 0.013). Evidence is accumulating that the newly introduced mosquito species Ae. albopictus may be involved in the emergence of La Crosse virus infection in eastern Tennessee.

Aedes↗
PubMed1996

[Double infection of Chlamydia pneumoniae and Mycoplasma pneumoniae in children].

There have been fewer reports on Chlamydia pneumoniae infection during childhood than those in adults, although many of the C. pneumoniae infections occurred during childhood based on prevalence of the antibody. And there have been no reports concerning the double infection of C. pneumoniae and M. pneumoniae. We reported three cases of children with the double infection. We diagnosed this from significant alteration of these antibodies from the acute to convalescent phases. We omitted the cases without significant alteration of the antibodies, even diagnosed from isolation or detection of the antigens in the samples by direct fluorescent antibody. Case 1 was an 8-year-old-boy who was admitted to our hospital because of fever, cough with vomiting and erythema multiforme. The symptoms did not subside after administration of clindamycin but subsided after minocycline. Case 2 was an 1-year-old-boy who was admitted because of fever, cough, rhinorrhea and vomiting. C. pneumoniae organisms were isolated from the pharyngeal swab specimen, the symptoms subsided after administration of clindamycin. Case 3 was a 9-year-old boy who was admitted because of fever and a cough followed by erythema multiforme. The symptoms did not decrease after administration of clindamycin but after minocycline. The characteristic of these cases are a strong cough with vomiting, weak response of acute reactants on the laboratory data, and skin eruption similar with that due to M. mycoplasmae in two of the three cases. We suspect that these double infections may induce the eruption, about which there have been no previous reports.

Child↗
PubMed1998

Longitudinal fractures of the condyles of the third metacarpal and metatarsal bones in racehorses: 224 cases (1986-1995).

OBJECTIVE: To determine type, distribution, and radiographic appearance of condylar fractures of the third metacarpal bone (MC-3) or third metatarsal bone (MT-3) in Thoroughbreds (TB), Standardbreds (SB), and Arabians, to assess long-term outcome of horses in which fractures were repaired surgically, and to identify variables associated with prognosis for return to racing. DESIGN: Retrospective study. ANIMALS: 224 horses with 233 fractures. PROCEDURE: Medical records and radiographs obtained before and after treatment were reviewed. Racing performance before and after treatment was determined by reviewing race records. RESULTS: TB were overrepresented and SB were underrepresented, compared with the hospital population. Thoroughbreds had significantly more lateral condylar fractures and significantly more forelimb fractures than did SB. Thoroughbreds were less likely to race after treatment if they had complete, rather than incomplete, lateral condylar fracture or had concurrent proximal sesamoid bone fracture. Convalescent time for TB with medial condylar fractures of MT-3 was significantly longer than that for TB with lateral condylar fractures of MT-3. CLINICAL IMPLICATIONS: Horses with condylar fractures of MC-3 and MT-3 that had minimal pathologic changes in the involved joint had a favorable prognosis for returning to racing after surgical treatment. Prognosis for horses with complete condylar fractures, particularly those with substantial pathologic changes in the involved joint, was worse.

Animals↗
PubMed1979

Contribution from geriatric medicine within acute medical wards.

In 1977 a scheme of attachment to acute medical wards of consultants in geriatric medicine and associated junior medical staff was instituted in a large Edinburgh teaching hospital. The effect on admissions of patients aged 65 and over was examined for comparable periods before and during this arrangement. Mean and median stays were reduced for both sexes but more noticeably for women. The mean stay for all women aged over 65 was reduced from 25 to 16 days and for women aged over 85 from 50 to 19 days. The proportion staying under two weeks was significantly increased in both sexes, and the proportion discharged home also increased, correspondingly fewer patients being transferred to convalescent wards. These changes were not accompanied by increased transfers to the geriatric department, and probably the skills and extra resources available to the geriatric service were the factors mainly responsible for the changes in performance.

Acute Disease↗
PubMed1987

Acute paranasal sinusitis related to nasotracheal intubation of head-injured patients.

One hundred eleven head-injured patients were examined for paranasal sinusitis during early convalescence. Glascow coma scale (GCS) was less than 8 in 79 patients. Ninety-three patients had sustained blunt injuries, and 18 had penetrating ones. Sixty-five orotracheal intubations (OTI) and 31 nasotracheal intubations (NTI) were performed at the scene or on hospital arrival. Fifteen patients were not tracheally intubated. Paranasal sinus air fluid levels (AFL) were present in 30 patients on their admitting computerized tomography scans. Paranasal sinusitis developed in 19 patients with a mean GCS of 5.4 +/- 3.3 (SD). Sixteen of the 19 had NTI, and three had OTI (p less than .05). Of 30 patients with AFL, sinusitis occurred in 13. Ten of these 13 had NTI, and three had OTI (p less than .05). Penetrating injury did not increase the risk of sinusitis (p greater than .1). Seventeen of the 19 infections were polymicrobial. Sinusitis after head trauma is related to NTI, AFL, and severity of head injury.

Acute Disease↗
PubMed1999

A prospective seroepidemiologic study on dengue in children four to nine years of age in Yogyakarta, Indonesia I. studies in 1995-1996.

A prospective study on dengue (DEN) viruses was initiated in October 1995 in Gondokusuman kecamatan, Yogyakarta, Indonesia. This report presents data from the first year of the study. The studied cohort included all children 4-9 years of age living in the kecamatan. Blood samples for serology were collected from 1,837 children in October 1995 and again in October 1996. Blood samples for virus isolation and serology were collected from cohort children who were seen in municipal health clinics with febrile syndromes or admitted to hospitals with a provisional diagnosis of dengue hemorrhagic fever. Dengue serotype antibody prevalence and 1995-1996 infection rates were calculated using a single dilution (1:60) 70% plaque reduction endpoint neutralization test. Prevalence of dengue antibody at the beginning of the study was DEN 1 = 12%, DEN 2 = 16%, DEN 3 = 2%, DEN 4 = 4%, and two or more dengue infections = 22%. Total dengue antibody prevalence increased from 38% in 4-year-old children to 69% in 9-year-old children. During the observation period, primary dengue infection rates were DEN 1 = 4.8%, DEN 2 = 7.7%, DEN 3 = 4.2%, and DEN 4 = 3.4%, while two or more dengue infections occurred in 6.7% of the study population. The secondary dengue infection rate was 19.0%. From febrile cases, all four dengue viruses were isolated with DEN 3 predominating. Seven children were hospitalized, including one fatal case with a hospital diagnosis of dengue shock syndrome. Based upon presence of antibody in the initial cohort bleeding and the serologic response both weeks and several months following illness, all had secondary dengue infections. Neutralizing antibody patterns in the initial cohort bleeding and in late convalescent serum samples permitted recognition of dengue infection sequence in five patients: DEN 2-DEN 1 (3), DEN 2-DEN 4 (1), DEN 1-DEN 3 (1), and none in the sequence DEN 1-DEN 2. In the total cohort 6.5% of the observed secondary infections were of the sequence DEN 2-DEN 1, while 4.9% were DEN 1-DEN 2, a highly pathogenic sequence in previous studies. Reduced pathogenic expression of secondary DEN 2 with enhanced pathogenic expression of secondary DEN 1 infections was an unexpected finding. Further studies will be required to understand the respective contributions to pathogenicity of antibody from initial dengue infections versus the biological attributes of the second infecting dengue viruses.

Age Distribution↗