Effects of human intravenous immune globulin on diarrhea caused by Shiga-like toxin I and Shiga-like toxin II in infant rabbits.

Shiga toxin and the related Shiga-like toxins (SLT), produced by Escherichia coli, can cause hemorrhagic colitis and hemolytic uremic syndrome (HUS). Human intravenous immune globulin (HIVIg) blocks the cytotoxicity of some SLTs in vitro. To examine the ability of HIVIg to modify disease caused by Shiga-like toxin I or Shiga-like toxin II (SLT-I or SLT-II), we injected 3-day-old rabbits intraperitoneally with SLT-containing cell-free supernatants from Escherichia coli O157: H7. A subset of rabbits was treated with subcutaneous HIVIg. All rabbits given 10(4) CD50 of SLT-I developed severe diarrhea, and 5 died. When HIVIg 500 mg/kg was given in addition to SLT-I, only 6 of 18 rabbits (33.3%) developed diarrhea (P < 0.0001), and 1 died. HIVIg 500 mg/kg or 1,000 mg/kg protected against diarrhea when given one hour prior to toxin. HIVIg 1,000 mg/kg was protective when administered one hour after toxin, but not at 6 or 24 hr. Seventeen of 18 rabbits given 10(6) CD50 of SLT-II developed severe diarrhea, and 4 died. In contrast to SLT-I-associated disease, HIVIg had no effect on diarrhea in rabbits given SLT-II. We conclude that HIVIg protects infant rabbits from diarrhea and death caused by intraperitoneally administered SLT-I, but does not affect the course of SLT-II-associated illness.     

Why do patients with lupus nephritis die?

Over 20 years 42 of 138 patients with systemic lupus erythematosus "died"--that is, suffered actual death or went into terminal renal failure, or both; data from 41 were available for analysis. In most patients the causes of death were multiple. Twenty seven patients went into terminal renal failure, of whom 25 were offered dialysis treatment. Three regained renal function later, 12 survived on dialysis or with functioning kidney allografts--almost all with inactive lupus--but 13 died after starting dialysis, most within a few weeks or months. The principal causes were active lupus or infection. In those patients with renal failure after rapid deterioration in renal function (n = 14) there were nine deaths, while of 10 patients with a slow evolution into renal failure, only four died. Four patients with impaired and 10 with normal renal function died, again most often from complications of lupus or from infection. Vascular disease was a major cause of death in seven patients, all but two of whom were young; of 15 postmortem examinations, eight showed severe coronary artery atheroma, and three surviving patients required coronary bypass operations. Analysis of the timing of death or entry into renal failure showed that in 12 out of 13 patients who died within two years of onset the lupus was judged to be active, while this was true in only eight out of 19 patients who died later. Six of the seven vascular deaths occurred later than two years from onset, while only nine of 26 renal "deaths" occurred before two years; deaths from infections (n = 13) were distributed equally. Despite this and aggressive treatment of active disease, the principal cause of actual death was uncontrolled lupus.     

The effect of preceding mild hypoxia on the alteration of acquisition and retention of the conditioned passive avoidance behavior caused by severe hypobaric hypoxia in rats

The purpose of this study was to determine whether mild hypobaric hypoxic preconditioning provides protection against learning deficit caused by subsequent more severe hypoxia insult. Learning was examined using a passive avoidance task. Three groups of Wistar male rats: the intact and exposed to either severe hypoxia (160 Torr, exposition 3 h) or mild hypobaric hypoxic preconditioning (360 Torr, exposition 2 h, repeated three or six times daily) followed by severe hypoxia, were included in this study. In experiment 1 a passive avoidance response was acquired in 15 min immediately after hypoxia. In experiment 2 rats were exposed to hypoxia in 60 min after the acquisition of passive avoidance response. The mild hypobaric hypoxic preconditioning significantly attenuated the hypoxia-induced learning deficit in rats in Experiments 1 and 2. In experiment 1 the mild hypobaric hypoxic preconditioning repeated six times was more effective in protection against learning deficit in hypoxia exposed rats than in the case of triple mild hypobaric hypoxic preconditioning. The amount of rats suffered irreversible respiratory arrest was also assessed in this study. It was found that 50% of rats exposed to severe hypoxia died in consequence of this pathology, whereas in rats preconditioned before the severe hypoxia only 15% died for this reason. The overall results indicate that the mild hypobaric hypoxic preconditioning significantly increases CNS resistance to severe hypoxia in rats.     

Effects of a multi-year drought on a drought-adapted shrub, <Emphasis Type="Italic">Artemisia tridentata</Emphasis>

Models of climate change predict more variable precipitation for much of western North America, including more severe multi-year droughts. Droughts are known to increase mortality to trees although less is known about effects on shrubs from arid environments and about effects on reproduction. In this study, we followed a cohort of young sagebrush plants from 2010 to 2016, a period that included a severe drought from 2012 to 2015. Plants experienced little mortality preceding and during the drought. However, in the year following the drought, 14% of individuals died and 33% of branches on living plants died. There was little flowering in the years preceding the drought and flowering increased in each successive year from 2014 to 2016. Plants that produced more flowers in 2015 had more dead branches in 2016. Larger plants had fewer branches that died. Contrary to expectations, afternoon shade was not associated with greater survival or flowering, perhaps because shaded plants were in proximity to large trees which likely competed for water. Plants of the two common chemotypes had similar rates of survival and flowering. Experimental watering during the summer of 2015 did not affect survival and may have increased flowering in 2016. If multi-year droughts become more common in the future, even drought-adapted shrubs may be expected to suffer high rates of mortality.     

Post-Discharge Mortality in Children with Severe Malnutrition and Pneumonia in Bangladesh

Background

Post-discharge mortality among children with severe illness in resource-limited settings is under-recognized and there are limited data. We evaluated post-discharge mortality in a recently reported cohort of children with severe malnutrition and pneumonia, and identified characteristics associated with an increased risk of death.

Methods

Young children (<5 years of age) with severe malnutrition (WHO criteria) and radiographic pneumonia on admission to Dhaka Hospital of icddr,b over a 15-month period were managed according to standard protocols. Those discharged were followed-up and survival status at 12 weeks post-discharge was determined. Verbal autopsy was requested from families of those that died.

Results

Of 405 children hospitalized with severe malnutrition and pneumonia, 369 (median age, 10 months) were discharged alive with a follow-up plan. Of these, 32 (8.7%) died in the community within 3 months of discharge: median 22 (IQR 9–35) days from discharge to death. Most deaths were reportedly associated with acute onset of new respiratory or gastrointestinal symptoms. Those that died following discharge were significantly younger (median 6 [IQR 3,12] months) and more severely malnourished, on admission and on discharge, than those that survived. Bivariate analysis found that severe wasting on admission (OR 3.64, 95% CI 1.66–7.97) and age <12 months (OR 2.54, 95% CI 1.1–8.8) were significantly associated with post-discharge death. Of those that died in the community, none had attended a scheduled follow-up and care-seeking from a traditional healer was more common (p<0.001) compared to those who survived.

Conclusion and Significance

Post-discharge mortality was common in Bangladeshi children following inpatient care for severe malnutrition and pneumonia. The underlying contributing factors require a better understanding to inform the potential of interventions that could improve survival.     

Athyreotic cretinism associated with thymic hypoplasia and amyloidosis of lymphoid tissue

A child presenting at 5 months of age with Hemophilus influenzae meningitis was also found to be severely hypothyroid. The child died two years later from the complications of measles pneumonia. At autopsy, no thyroid tissue was found and the thymus was hypoplastic. Most of the lymphoid tissues were infiltrated by amyloid.It is possible that there was a combined developmental defect involving thyroid and thymus. The alternatives are that the association occurred purely by chance or that the severe hypothyroid state led to thymic insufficiency.     

Microcirculatory changes in the cheek pouch mucosa of hamsters in the dynamics of experimental traumatic shock]

Acute experiments conducted on hamsters demonstrated significant disturbances of the microcirculation in the mucosa of the cheek pouch during a severe traumatic shock after a standardized mechanical injury of the hip. All the animals died in the course of the first 24 hours after this trauma. If the animals died not earlier than in one hour after the trauma the microcirculation changes were distinctly phasic in character; particularly there was seen a phase of temporary relative adaptation and stabilization of the peripheral circulation, invariably followed by the phase of decompensation, the terminal phase and death. In cases with a rapid lethal issue in the course of one hour no distinct phasic character of the microcirculation changes was observed, but there was a more or less rapid aggravation of all he indices. In difference from the majority of other investigators, no marked intravascular erythrocyte aggregation was seen by the authors in the experiments described.     

Five years' experience with aortocoronary bypass grafting.

During a 5-year period (Apr. 14, 1970 to Apr. 14, 1975) 930 patients underwent aortocoronary bypass grafting; the procedure was done as an emergency in 141. Of the entire group 3.3% died at operation, 1.6% died in hospital and 5.8% died later; of the patients undergoing emergency grafting 12.1% died at operation and 5.7% died later. From a detailed analysis of the first 600 patients it was found that both operative and late mortality were clearly related to two factors: severe left ventricular dysfunction at the time of operation and inadequate surgical treatment because of insertion of insufficient numbers of grafts or because of poor blood flow through the grafts.     

Staphylococcal Nuclease in Udder Secretions of Cows with Acute Mastitis

High concentrations of nuclease produced by Staphylococcus aureus were demonstrated within a few hours by direct examination of udder secretions from cows with a severe staphylococcal mastitis. A positive correlation between the nuclease concentration and the severity of the mastitis was found. The cows with high nuclease concentrations were generally young individuals and/or in the first 2 weeks of the lactation period. Most had a low titre of antibodies against staphylococcal nuclease. Two-thirds of the cows in which high nuclease concentrations were demonstrated were culled or died because of the mastitis attack. The role which nuclease plays for staphylococcal virulence is discussed, and it is concluded that nuclease contributes to the pathogenicity of S. aureus.     

Sudden Death in Hospital after Discharge from Coronary Care Unit

In a group of 339 patients with acute myocardial infarction treated in a coronary care unit, 273 left the unit while improving and were expected to leave hospital alive; 23 had a cardiac arrest or died suddenly while still in hospital—17 died immediately or after temporary resuscitation and six were resuscitated to leave hospital alive. Ventricular fibrillation was found in 13 of the 20 patients attended by the cardiac arrest team. The incidents were scattered from the 4th to the 24th day after the onset of infarction. Risk factors in these “late sudden death” patients were compared with the 250 patients who left the unit while improving and did not die or suffer cardiac arrest. The patients susceptible to late sudden death were characterized early in their hospital course by the findings of severe, predominantly anterior infarction, left ventricular failure, persistent sinus tachycardia, and frequent ventricular arrhythmias. It is suggested that such patients be chosen for prolonged observation in a second-stage coronary care unit.     

Cardiac arrhythmias during rewarming of patients with accidental hypothermia.

Accidental hypothermia has a high mortality and is associated with cardiac arrhythmias. To determine the incidence of arrhythmias and their importance 22 patients with accidental hypothermia (core temperature less than 35 degrees C) were studied by 12 lead electrocardiography and continuous recording of cardiac rhythm. Although 14 of the patients died (64%), only six died while hypothermic. Prolongation of the Q-T interval and the presence of J waves were related to the severity of the hypothermia. Supraventricular arrhythmias, including atrial fibrillation, were common (nine cases) and benign. Ventricular extrasystoles were also common (10 cases), but ventricular tachycardia or fibrillation did not occur during rewarming. In eight patients who died while being monitored the terminal rhythm was asystole. There was no correlation between the severity of hypothermia or the rate of rewarming and the clinical outcome. In the absence of malignant arrhythmias there is no indication for using prophylactic antiarrhythmic treatment in patients with accidental hypothermia. The presence or absence of severe underlying disease is the main determinant of prognosis.     

Congenital osteogenesis imperfecta in three sibs

Summary Three sibs of a Turkish family were affected with lethal congenital osteogenesis imperfecta (OI). The disease was characterized by extremely fragile bones and crumpled femora, but in contrast to reported cases of OI type II, relatively normal ribs with only few fractures. The children affected died shortly after birth. Although their parents both came from the same small village in Turkey, consanguinity could not be demonstrated. Our observations support that this disorder is inherited in an autosomal recessive mode. We consider the possibility that these patients represent either a new subgroup of OI type II (milder, although still lethal) or of type III (more severe).This investigation was supported in part by research grants from the Deutsche Forschungsgemeinschaft.     

Dengue deaths in Puerto Rico: lessons learned from the 2007 epidemic

Background

The incidence and severity of dengue in Latin America has increased substantially in recent decades and data from Puerto Rico suggests an increase in severe cases. Successful clinical management of severe dengue requires early recognition and supportive care.

Methods

Fatal cases were identified among suspected dengue cases reported to two disease surveillance systems and from death certificates. To be included, fatal cases had to have specimen submitted for dengue diagnostic testing including nucleic acid amplification for dengue virus (DENV) in serum or tissue, immunohistochemical testing of tissue, and immunoassay detection of anti-DENV IgM from serum. Medical records from laboratory-positive dengue fatal case-patients were reviewed to identify possible determinants for death.

Results

Among 10,576 reported dengue cases, 40 suspect fatal cases were identified, of which 11 were laboratory-positive, 14 were laboratory-negative, and 15 laboratory-indeterminate. The median age of laboratory-positive case-patients was 26 years (range 5 months to 78 years), including five children aged <15 years; 7 sought medical care at least once prior to hospital admission, 9 were admitted to hospital and 2 died upon arrival. The nine hospitalized case-patients stayed a mean of 15 hours (range: 3–48 hours) in the emergency department (ED) before inpatient admission. Five of the nine case-patients received intravenous methylprednisolone and four received non-isotonic saline while in shock. Eight case-patients died in the hospital; five had their terminal event on the inpatient ward and six died during a weekend. Dengue was listed on the death certificate in only 5 instances.

Conclusions

During a dengue epidemic in an endemic area, none of the 11 laboratory-positive case-patients who died were managed according to current WHO Guidelines. Management issues identified in this case-series included failure to recognize warning signs for severe dengue and shock, prolonged ED stays, and infrequent patient monitoring.     

Pathology and angiographical studies on urogenital organ system induced by idiopathic hemorrhage in male E1 mice.

Urogenital organ system induced by idiopathic hemorrhage in sudden died male E1 mice were investigated macro- and histopathologically and angiographically. The mortality of the male E1 mice with brief life span was 85% during observation period for 33 weeks, and about half of the male E1 mice died between 10-week-old and 20-week-old. In all dead mice, urine retention was prominent, and the seminal vesicle or the coagulating gland, especially the bulbocavernosus muscle had severe hemorrhage. There was coagulated blood mass in the urethral lumen and the lumen of the seminal vesicle and the coagulating gland. Further, in pars spongiosa, coagulated blood mass occupied the most area of the corpus spongiosum penis and corpus cavernosum penis with severe hemorrhage. Angiographically, the penile artery in not affected male E1 mice was thinner than that in control mice.     

Fatal falciparum malaria in Canadian travellers

The authors report 2 cases of severe falciparum malaria in Canadians that had fatal outcomes. In the first case a man presented to a local hospital shortly after returning from Africa, but a diagnosis of malaria was not considered. He was transferred to a secondary and then to a tertiary care facility, where he subsequently died. Intravenous quinidine therapy, the treatment of choice, was unavailable at all 3 hospitals. In the second case, a woman taking chloroquine prophylaxis while visiting Nigeria developed cerebral malaria and died. These cases illustrate critical management issues: appropriate advice on malaria prevention before departure; consideration of malaria in all febrile people returning from an endemic area; ready access to parenteral therapy for severe malaria in Canadian hospitals; and an increase in awareness of travel medicine among family physicians.     

Canine distemper and related diseases: report of a severe outbreak in a kennel

An outbreak of canine distemper in a kennel of German shepherds in the province of Bari is reported. Six 42-day-old pups developed typical signs of canine distemper (fever, conjunctivitis, respiratory distress and enteritis) and died within 7-10 days. Neurological symptoms were observed only in one pup. Four additional pups, which had shown no sign of illness, were separated and vaccinated, but two of these developed a severe, fatal nervous form 15 days later. Post-mortem examination, carried out on two pups which died without neurological signs, showed pneumonia and enteritis, more severe in one of the two examined pups. Smears from the brain and the conjunctiva of both dogs tested positive for canine distemper virus (CDV) by an immunofluorescent assay, confirmed by the identification of viral RNA using RT-PCR. Bordetella bronchiseptica and a canine adenovirus strain, characterized as canine adenovirus type 2 by a differential PCR assay, were isolated from the lungs of the pup showing the most pronounced lesions. Furthermore, canine coronavirus was detected by PCR in the intestinal content of this pup, suggesting a multifactorial aetiology of the outbreak.     

Sudden Death in a Young Asthmatic

A 14-year-old boy with severe asthma was treated with prednisone and disodium cromoglycate with considerable subjective improvement, though there was persistent airways obstruction. After several weeks'' freedom from symptoms he died in a severe attack of nocturnal asthma. Necropsy findings suggested that hypersecretion had been occurring in die medium-sized airways for several days before death.     

Hybrid approach for complex coronary artery and valve disease: a clinical follow-up study

For patients suffering from complex coronary artery disease (CAD) with or without concomitant valve disease, no evidence is available in the current guidelines to propose a predefined treatment regimen. We sought to assess the clinical impact of an unconventional or extended definition of the hybrid approach that combines percutaneous coronary intervention (PCI) and cardiac surgery in subjects suffering from severe solitary CAD or combined with valve disease. Between July 2002 and August 2004, 18 consecutive patients with complex CAD with or without significant valve disease who qualified for a hybrid approach were enrolled in a clinical follow-up study. Four patients eventually did not complete the proposed interventions. One patient refused treatment after inclusion, one patient died before treatment could be undertaken and two patients died after surgery but before PCI. In the other 14 cases combined treatment was technically successful. After a mean follow-up period of 15±5 months two patients had died, one due to sudden cardiac death and one of a noncardiac cause. No other major adverse clinical events were reported. A marked increase in quality of life was reported in those alive. Hybrid approach had a favourable long-term outcome in patients with complex cardiovascular disease undergoing successful treatment; however, this was observed at the expense of significant periprocedural mortality in these high-risk subjects. Therefore we believe that hybrid approaches may provide an alternative for selected cases. (Neth Heart J 2007;15:329-34.)     

Lafora disease and founder effect in a small neotropical locality

The Lafora disease is an uncommon genetic condition. Four cases (two families) were detected in Zarcero, a small town in Costa Rica (population under 2000). They belonged to two separate consanguineous marriages but both families had common ancestors. The diagnosis of Lafora disease was confirmed by liver biopsy in one of the patients. The ages of onset were 13, 14, 16 and 17 years. Patients died after four, nine, six and five years of severe progressive physical and mental deterioration, respectively. The gene for Lafora disease arrive to Zarcero from one of its founders. There are no other cases reported from Costa Rica: this is an example of genetic drift, or more specifically, founder effect.     

Selective mortality of waders during severe weather

Capsule The birds that died were generally smaller.

Aims To look for selective mortality of waders in severe weather.

Methods Biometric measurements of birds found dead in a local severe weather event in February 1991 on The Wash Estuary, UK, were compared with measurements of the same species caught alive in February in previous and following years.

Results Eight of 13 intraspecific biometric comparisons between birds found dead and those captured in February in previous years were significantly different. Of these comparisons seven showed that the birds that died were smaller. Three of nine intraspecific biometric comparisons between birds dying during the severe weather and those caught in subsequent years were significant; of these comparisons the dead birds were smaller in two cases. Of eight comparisons between the biometrics of live birds before and after the severe weather event, only one was significant: the bill lengths of Eurasian Oystercatchers Haematopus ostralegus were longer after the event.

Conclusions The birds that died due to the severe weather incident do not appear to be a random sample of the populations present. Smaller birds died disproportionately. However, in comparisons of birds captured before and after the severe weather event only Oystercatcher's bill lengths increased significantly and it is unlikely that this was related to the severe weather. Thus, the size‐biased mortality did not result in long‐term changes in the size distributions of the species affected.