Transfusion-related Plasmodium ovale malaria complicated by acute respiratory distress syndrome (ARDS) in a non-endemic country

46year old female presented with a one week history of high grade fever, chills, cough, and severe nausea. The patient had been admitted a month earlier with severe lower gastrointestinal bleeding from hemorrhoids necessitating transfusion of 7 units of packed red blood cells. Initial work-up was unremarkable. Because of persistent symptoms, the patient was admitted 2 days later. Malaria smear was positive. Due to the severity of her symptoms, she was managed as falciparum malaria and was started on intravenous quinine and oral doxycycline. On the second day of treatment the patient developed respiratory failure, requiring intubation and ventilatory support with new bilateral pulmonary infiltrates. Antimalarial treatment was continued for a total of 7 days followed by primaquine for 14 days once the blood smear results revealed Plasmodium ovale infection. The patient remained intubated in the intensive care unit (ICU) for 16 days, and was later extubated successfully with a clear chest x-ray after a total of one month hospitalization. To our knowledge, this is the first case of acute respiratory distress syndrome (ARDS) secondary to blood transfusion related P. ovale malaria infection in a non-endemic country.     

Obese patients in medical intensive care unit: influence of counseling on weight loss and cardiovascular parameters

A case series of 12 obese patients admitted to medical intensive care unit (ICU) due to life-threatening diseases and the influence of weight loss on cardiovascular parameters is presented. We assessed body weight, body mass index (BMI), blood pressure, pulse, and laboratory values on admission. At discharge from ICU patients were counseled on how to lose weight. They were examined one and six months later. Statistically significant (p < 0.05) decrease of body weight (median at the beginning of a treatment 134 kg, after six months 127.5 kg), BMI (median 41.5 kg/m2 at the beginning of a treatment; 38.9 kg/m2 after six months), systolic blood pressure (medians 145 mmHg and 130 mmHg), diastolic blood pressure (medians 95 mmHg and 85 mmHg) and pulse (medians 104 beats per minute, 78 beats per minute) was found. The reduction of the waist circumference was not significant. One patient died due to severe acute pancreatitis. Patients reported feeling much better after losing weight.     

Splenic abscess caused by Propionibacterium acnes.

A 59-year-old male diabetic was admitted with an acute myocardial infarction and had recurrent. Propionibacterium acnes bacteremia. Fifteen months after the initial admission a splenectomy was required for removal of a large splenic abscess caused by P. acnes. Although this organism represents part of the normal skin flora, its presence of blood cultures requires serious evaluation since it may signify clinical disease, not merely contamination of blood cultures by skin flora.     

连续性肾脏替代疗法治疗重症急性胰腺炎的临床观察

目的观察连续性肾脏替代疗法（CRRT）治疗重症急性胰腺炎（SAP）患者的疗效及预后。方法回顾性分析广西医科大学第一附属医院ICU 2006年5月～2012年2月收治的22例SAP患者的临床资料,比较CRRT治疗前,治疗后3、5、7天患者生命征,APACHEⅡ评分及白细胞、SCr、血AMS、血气等变化,记录腹部症状并统计并发症及死亡率。结果 22例患者死亡4例,死亡率18.20%。22例患者均有急性肾损伤;急性肺损伤/急性呼吸窘迫综合征/肺部感染发生率为81.82%,其中胸腔积液50%;MODS 45.45%;感染性休克13.64%;急性肝损伤、胰性脑病均为9.09%;DIC、ACS均为4.55%。与治疗前相比,CRRT治疗3天后,T、RR、WBC、血AMS、血乳酸、APACHⅡ评分均下降（P〈0.05）,pH升高（P〈0.05）;5天后,脉搏、SCr、CRP均下降（P〈0.05）,PaO2/FiO2升高（P〈0.05）。3～5天后临床症状及体征改善。MAP呈下降趋势,但差异无统计学意义（P〉0.05）。结论 CRRT能快速有效改善SAP患者病情,稳定生命征、改善血气分析指标、清除体内代谢毒素,入住ICU的SAP患者及早进行CRRT的效果较好。     

厄贝沙坦联合氨氯地平治疗2 型糖尿病合并高血压的疗效及对糖代谢和 血压的影响

目的：探索厄贝沙坦联合氨氯地平治疗2型糖尿病合并高血压的疗效及对糖代谢和血压的影响。方法：选择2013年7 月至 2014 年8月期间我院收治的2 型糖尿病合并高血压患者50 例,根据随机数字表法,将患者分成联合用药组和美托洛尔组。联合 用药组口服厄贝沙坦和氨氯地平;美托洛尔组口服美托洛尔,疗程为3个月。分析比较治疗前后两组患者的空腹血糖（FBG）、空腹 胰岛素（FINS）、胰岛素敏感指数（HOMA-IR）、收缩压（SBP）和舒张压（DBP）水平之间的差异,观察临床疗效。结果：治疗后,两组 患者FBG、FINS、HOMA-IR、SBP和DBP 水平较治疗前均有所下降,其中联合用药组下降得更明显（P<0.05）,且治疗后联合用药 组上述指标均显著低于美托洛尔组,差异均有统计学意义（P<0.05）。治疗后,联合用药组的治疗有效率为88.00%,显著高于美托 洛尔组的48.00%,且差异具有统计学意义（P<0.05）。结论：厄贝沙坦联合氨氯地平治疗2 型糖尿病合并高血压患者具有良好的疗 效,可以改善血糖和血压情况,对于指导临床用药具有重要意义。     

Ethchlorvynol (Placidyl) Intoxication and Its Treatment by Hemodialysis

Twenty hours after ingesting 15-25 g. of ethchlorvynol, a 37-year-old woman was admitted comatose and in shock. The blood level of ethchlorvynol was 21.6 mg. % (method of Wallace). Supportive measures were instituted and hemodialysis, carried out for 10 hours, removed 5.49 g. of the drug. The post-dialysis blood level was 9.05 mg. % and the rate of dialysance was 50.5 ml./min. Only 0.6 g. of the substance was recovered from the urine over the same period.Although dialysis removed significant amounts of the drug and sustained life, the patient remained comatose for five days before withdrawal symptoms and seizures developed.     

Transfusion Patterns in All Patients Admitted to the Intensive Care Unit and in Those Who Die in Hospital: A Descriptive Analysis

While it is known that the use of health care resources increases at the end of life in patients admitted to the Intensive Care Unit (ICU), the allocation of blood products at the end of life has not been described. The objective of this study was to describe overall transfusion patterns in the ICU, and specifically in patients who die in hospital. We conducted a retrospective cohort study of adult patients admitted to the ICU of a university-affiliated hospital, who were discharged or died between November 1, 2006 and June 30, 2012. During the study period, 10,642 patients were admitted at least once to the ICU. Of these patients, 4079 (38.3%) received red blood cells (RBCs), plasma or platelets in the ICU. The ICU mortality rate was 28.1% and in-hospital mortality rate was 32.3%. Among 39,591 blood product units transfused over the course of the study in the ICU (18,144 RBC units, 16,920 plasma units and 4527 platelet units), 46.2% were administered to patients who later died within the same hospitalization (41.2% of RBCs, 50.4% of plasma and 50.8% of platelets). Of all blood product units (RBCs, plasma and platelets) administered in the ICU over the study period, 11% were given within the last 24 hours before death. A large proportion of blood products used in the ICU are administered to patients who ultimately succumb to their illness in hospital, and many of these blood units are given in close proximity to death.     

Pure red cell aplasia and thymoma associated with high levels of the suppressor/cytotoxic T lymphocyte subset.

A 64 year old man admitted to hospital with increasing effort dyspnoea and lethargy was found to have a thymoma and pure red cell aplasia. Lymphocytes accounted for 20-30% of marrow cells, and numbers of T8 suppressor/cytotoxic cells in peripheral blood were greatly increased. He remained anaemic after removal of the thymoma despite blood transfusions, and immunosuppression with prednisolone 60 mg and cyclophosphamide 50 mg daily was started. The dose of prednisolone was reduced to 15 mg owing to steroid myopathy and the risk of opportunistic infection. He went into remission, and the dose was further decreased to 10 mg daily.     

Blood ethanol levels in sober alcohol users seen in an emergency room

During the course of two years, 76 representative subjects seen in a community hospital emergency room who admitted to having recently used alcohol while still appearing sober had their blood alcohol levels measured to determine the levels of blood alcohol present in ambulatory sober alcohol users. As a group the mean blood alcohol level obtained in those who had measurable levels was 268 ± 10 mg/dl mean ± SEM). More men (47) than women (18) admitted to having used ethanol and had measurable blood ethanol levels and therefore were studied. Moreover, the mean blood alcohol level in the men studied was arithmetically greater (272 ± 13 mg/d1) than that present in the women (260 ± 13mg/d1). The range of alcohol levels seen in the two sexes, however, were quite similar. Using a blood alcohol level > 200 mg/dl in a clinically “non-intoxicated” individual as the cut-off level for defining one as a suspect chronic alcohol user, our data would suggest that such individuals not uncommonly have blood alcohol levels as high as 290 ± 9 mg/dl.     

Hematology and serum chemistry comparisons between free-ranging and rehabilitated harbor seal (Phoca vitulina richardsi) pups

The objectives of this study were to compare the hematology and serum chemistry values between free-ranging and stranded harbor seal (Phoca vitulina richardsi) pups and to ascertain how blood values of stranded pups changed during the rehabilitation process. Coincident with these comparisons, reference values were obtained for free-ranging pups. Stranded harbor seal pups (n = 28) recovered from areas between Pebble Beach and Moss Landing, California (USA) were admitted to The Marine Mammal Center, Sausalito, from March to May 1995, 1996, and 1998. Blood samples were collected from harbor seal pups before and after rehabilitation. As a control group, wild harbor seal pups were captured at Pebble Beach and Elkhorn Slough (n = 42) during the 1995, 1996, and 1998 pupping seasons. Mean eosinophil and calcium values of wild pups were significantly greater than those of newly admitted pups, whereas mean bands, aspartate aminotransferase, alanine aminotransferase, total bilirubin, and chloride values were significantly lower (P < or = 0.05). Mean neutrophil, band, lymphocyte, eosinophil, basophil, calcium, phosphorus, blood urea nitrogen, potassium, total protein, and globulin values of rehabilitated pups increased significantly after 2-3 mo in captivity, whereas, mean red blood cell, hemoglobin, hematocrit, cholesterol, and total bilirubin values decreased significantly (P < or = 0.05).     

不同比例新鲜冰冻血浆对大量输血患者凝血功能的影响

目的:探讨不同比例输注新鲜冰冻血浆对大量输血患者凝血功能的影响。方法:回顾性分析本院2018年1月至2018年12月收治的123例大量输血患者的临床资料,依据所输注新鲜冰冻血浆与红细胞比例不同,将其分为低比例组(1:3)、中比例组(1:2)、高比例组(1:1),比较三组患者输血前后凝血功能、血小板计数及电解质变化。结果:输血后,三组患者FIB较输血前明显降低,而PT、APTT较输血前显著升高(P0.05),高比例组PT和APTT明显低于中比例组和低比例组,FIB、血小板均高于中比例组和低比例组(P0.05),电解质水平优于低比例组和中比例组(P0.05)。结论:在大量输血时,提高血浆与红细胞比例有利于改善大量输血患者凝血功能障碍,减少电解质紊乱。     

Isolation of Dialister pneumosintes isolated from a bacteremia of vaginal origin

In this report, we review one case of bacteremia infection due to Dialister pneumosintes. The patient was admitted in post-partum with vaginosis and suppurative thrombosis of the ovarian veina. D. pneumosintes was isolated in pure culture from the three blood culture flasks. Identification of this bacterium was difficult and requires the amplification and partial sequencing of the 16S rRNA gene. The patients had favorable outcome after antibiotic treatment.     

Repeated blood glucose and plasma insulin levels in normal volunteer subjects receiving isocaloric meals, before and after chlorpropamide and glibenclamide.

The blood glucose and plasma insulin response to the two hypoglycaemic agents, chlorpropamide (Diabenese) and glibenclamide (Daonil) was determined in normal subjects under strict metabolic control in a double blind study. The subjects were admitted to hospital for the period of the study, during which time they received four isocaloric meals per day and their physical exercise was standardised. Chlorpropamide had a prolonged hypoglycaemic effect compared with the short lived response after glibenclamide. Thy hypoglycaemic characteristics of the two preparations could not be explained simply on the insulin responses. Chlorpropamide was capable of lowering blood glucose without raising plasma insulin levels, whereas glibenclamide produced a prolonged and marked increase in plasma insulin levels only to be associated with a short-lived hypoglycaemic response. The latter suggested that a degree of insulin resistance had been produced secondary to the early profound lowering of the blood glucose following glibenclamide. The data indicate therefore the need for caution in extrapolating to diabetic subjects the hypoglycaemic characteristics of an agent such as glibenclamide derived from studies in normal subjects.     

Recurrent Haemorrhage after Acute Gastrointestinal Bleeding

A retrospective survey of 472 consecutive hospital admissions for acute upper gastrointestinal bleeding showed that patients with a large initial bleed are more likely to bleed again than those with a small initial bleed. The incidence of recurrent haemorrhage is also related to the interval since the last bleeding episode, so that patients showing no clinical evidence of haemorrhage for 48 hours are unlikely to bleed again in the near future. Patients admitted after a haematemesis have a higher incidence of recurrent haemorrhage than those admitted after melaena only. Aetiology has been confirmed as an additional important factor, the incidence being highest in those with oesophageal varices or a chronic gastric ulcer. Contrary to widespread belief, age does not appear to affect the incidence of recurrent haemorrhage, nor do other constitutional factors such as sex or the ABO blood group.     

Interval between insulin injection and eating in relation to blood glucose control in adult diabetics.

In a survey of 225 diabetics treated with insulin 24 (10.6%) claimed never to have received advice concerning the interval between insulin injection and eating. Of the remainder, 67 (33%) admitted disregarding advice and using shorter intervals. There was a significant (p less than 0.01) difference between the reported frequencies of clinical hypoglycaemia in patients using different intervals. The effects on glucose control of intervals between insulin injection and breakfast of zero, 15, 30, and 45 minutes were studied for periods of one week in 11 patients with type I diabetes who were receiving twice daily injections of monocomponent porcine insulins and high fibre, high carbohydrate diets, using standard home blood glucose monitoring techniques to measure blood glucose concentrations each morning. The delay of 45 minutes resulted in the lowest frequency of hypoglycaemia and the most acceptable pattern of glucose concentrations measured one and two hours after breakfast and before lunch. Combining results obtained at these three times, the mean increment in blood glucose concentration was smaller after allowing a delay of 45 minutes than after delays of zero (p less than 0.001), 15 (p less than 0.03), and 30 (NS) minutes. A delay of 30 minutes resulted in smaller mean increments in blood glucose concentration than did delays of zero (p less than 0.001) and 15 (NS) minutes. These results suggest that this aspect of diabetic management may be neglected, with important consequences for blood glucose control. An increase in delay between insulin injection and eating to 45 minutes would be a simple and safe way of improving blood glucose control in at least the 37% of the diabetic population surveyed in this study who currently allow less than 15 minutes.     

Successful treatment of methemoglobinemia in an elderly couple with severe cyanosis: two case reports

ABSTRACT: INTRODUCTION: Methemoglobinemia should be considered in all cyanotic patients who remain unresponsive to oxygen therapy. Rapid diagnosis is very important in emergency cases. Here, we present the cases of two patients, a married couple, admitted to our hospital with methemoglobinemia after exposure to sodium nitrite. CASE PRESENTATION: Two patients, a married couple, presented with methemoglobinemia. The 72-year-old Taiwanese man and 68-year-old Taiwanese woman were referred to our hospital with dizziness and tachypnea. On examination, their mucous membranes were cyanotic, and their blood samples showed the classic 'chocolate brown' appearance. The man also reported having experienced twitching of his right arm for a few minutes before arrival at the hospital. The symptoms of both patients failed to improve in response to supplemental oxygen delivered via oxygen masks, although the arterial blood gas data of these patients were normal and their pulse oximetry showed oxyhemoglobin levels of approximately 85%. A carbon monoxide-oximeter showed that the man's methemoglobin concentration was 48.3%, and the woman's was 36.4%. Methylene blue (100mg) was administered intravenously to both patients, and their symptoms improved dramatically. They were admitted to the intensive care unit and discharged three days later, without neurological sequelae. CONCLUSION: Severe methemoglobinemia is a life-threatening condition and, if untreated, may result in death. Early diagnosis and appropriate antidotal treatment are crucial in treating this emergency situation.     

Hypoglycemia due to ectopic release of insulin from a paraganglioma

Insulin-secreting pancreatic tumors and insulin-like growth hormone-secreting non-islet cell tumors can cause hypoglycemia. However, insulin-releasing paraganglioma or pheochromocytoma has almost never been reported. A 67-year-old female patient was admitted to our hospital because of headache, palpitation, perspiration, faintness, frequent sense of hunger and absent-mindedness. These intermittent symptoms had begun approximately a year before admission. On physical examination, she had high blood pressure of 150/90 mm Hg. Hormonal studies demonstrated increased urinary norepinephrine levels, and hyperinsulinemic hypoglycemia was confirmed while the patient was symptomatic. Abdominal MRI revealed a retroperitoneal mass measuring 4.5 cm in the pancreatic region. She was treated with an alpha-blocking agent to control blood pressure preceding the removal of the mass. Histopathological diagnosis was paraganglioma, and immunohistochemically insulin staining in the neoplastic cells was demonstrated. Her blood pressure normalized and hypoglycemia relieved after the operation. The patient did not have recurrence of hypoglycemia after a year of follow-up. Paraganglioma is a rare tumor of the neural crest, and co-secretion of insulin and catecholamines has been reported only by a single case report in the literature. The present patient is another case with this co-secretion.     

SARS-CoV-2 and Aspergillus section Fumigati coinfection in an immunocompetent patient treated with corticosteroids

BackgroundPatients with severe viral pneumonia are likely to receive high-dose immunomodulatory drugs to prevent clinical worsening. Aspergillus species have been described as frequent secondary pneumonia agents in severely ill influenza patients receiving steroids. COVID-19 patients admitted to Intensive Care Unit (ICU) are receiving steroids as part of their treatment and they share clinical characteristics with other patients with severe viral pneumonias. COVID-19 patients receiving steroids should be considered a putative risk group of invasive aspergillosis.Case reportWe are reporting a SARS-CoV-2/Aspergillus section Fumigati coinfection in an elderly intubated patient with a history of pulmonary embolism treated with corticosteroids. The diagnosis was made following the ad hoc definitions described for patients admitted to ICU with severe influenza, including clinical criteria (fever for 3 days refractory to the appropriate antibiotic therapy, dyspnea, pleural friction rub, worsening of respiratory status despite antibiotic therapy and need of ventilator support), a radiological criterion (pulmonary infiltrate) and a mycological criterion (several positive galactomannan tests on serum with ratio ≥0.5). In addition, Aspergillus section Fumigati DNA was found in serum and blood samples. These tests were positive 4 weeks after the patient was admitted to the ICU. The patient received voriconazole and after two month in ICU his respiratory status improved; he was discharged after 6 weeks of antifungal treatment.ConclusionsSeverely ill COVID-19 patients would be considered a new aspergillosis risk group. Galactomannan and Aspergillus DNA detection would be useful methods for Aspergillus infection diagnosis as they allow avoiding the biosafety issues related to these patients.     

Hematological profiles of COVID-19 patients at the Ratlam district,Madhya Pradesh State,India

It is of interest to compare the hematological profile (using Complete blood count) of COVID patients admitted in ICU, private ward, and isolation ward with varying severity. This data will help predict the severity of infection at peripheries and rural areas.  Detailed history and CBC was performed for all the cases. Different ratios and indexes such as systemic inflammatory index (SII), Neutrophil lymphocyte ratio (NLR), platelet lymphocyte ratio (PLR) were assessed. A total of 862 cases with a mean age of 49.9 ±17.4 years were enrolled. Hemoglobin level, lymphocyte (count per liter and percentage) were significantly lower in patients admitted in ICU as compared to patients admitted in the isolation ward and private ward (p <0.05). However, TLC, neutrophils, platelet count were higher in patients admitted to ICU (p <0.05). The Various ratios such as SII, NLR, and PLR showed significantly higher value in cases admitted in ICU (p <0.05). The TLC, neutrophil count, neutrophil percentage, SII, NLR, and PLR were significant predictors of severe disease (admission in ICU) with high diagnostic accuracy. We show that complete blood count method is a simple, readily available, rapid, and inexpensive tool that can be utilized for diagnosis and can predicting the severity of COVID 19 where RTPCR or trained staff is not available. Thus, NLR (%), SII, PLR, and TLC can predict severe illness with high accuracy.     

Evolución clínica y funcional de los pacientes que ingresan en residencias tras una fractura de cadera. Implementación de un programa de intervención multinivel

Background and objectiveThe aim of this study was to determine the clinical and functional outcomes of patients discharged to nursing homes after a hip fracture.MethodsThe study included all patients admitted to a group of nursing homes after a hip fracture in 2016. A geriatric assessment protocol was applied, and patients were treated with a specific protocol for 90 days. They were assessed for nutritional status (Mini-Nutritional Assessment and Body Mass Index), pain (Visual Analogue Scale, and the PAINAD Scale), the presence of pressure ulcers, blood test (D vitamin, haemoglobin, proteins), and functional status (Barthel index and Functional Assessment Categories).ResultsOut of a total of 175 patients, 116 (75%) met the inclusion criteria. The mean age was 84.9 years old (±6.7 SD), and 91 (78.4%) were women. At admission, 73.8% of 65 residents had anaemia, 76.7% hypovitaminosis D, 88% malnutrition or «at risk of malnutrition», and 15.3% had pressure ulcers. After 90 days, the moderate-severe functional status (Barthel index < 60) was reduced from 90.4 to 39.6%, dependence due to gait from 97.3 to 36.1%, and moderate-severe pain from 88.9 to 14.4%. Most of the pressure ulcers healed (94.4%).ConclusionsPatients admitted to nursing homes after a hip fracture had poor clinical and functional status. This study shows that after 90 days from admission these patients had positive outcomes in terms of functionality, gait, pain control, and pressure ulcers healing.