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Background The efficacy of vancomycin compared with ampicillin for enterococcal infections is unknown. This study aimed to compare their efficacy among patients with enterococcal bacteraemia. Methods Retrospective cohort study including adults aged >16 years with enterococcal bacteraemia, treated with β-lactam antibiotics active against Enterococcus spp. or vancomycin. Treatment classification was based on the first antibiotic used for >4 days in the 7 days after blood culture collection. Subgroup analyses for patients with penicillin-susceptible enterococcal bacteraemia and patients with monomicrobial penicillin-susceptible enterococcal bacteraemia were performed. The dependent variable was 30-day all-cause mortality. The propensity score (PS) for vancomycin treatment was calculated. Univariate and multi-variate analyses adjusted for PS were performed. Results In total, 516 patients with enterococcal bacteraemia were included. Mortality was similar for patients treated with β-lactams (123/315, 39%) and vancomycin (82/201, 40.8%). Independent factors significantly associated with mortality included healthcare-associated or hospital-acquired infection, age, female sex, Charlson Comorbidity Index, dialysis, SOFA score and low albumin. After adjustment for these factors and PS, the odds ratio (OR) for death in patients treated with vancomycin was 0.95 [95% confidence interval (CI) 0.56–1.59]. Results were similar among patients with penicillin-susceptible enterococcal bacteraemia and patients with monomicrobial penicillin-susceptible enterococcal bacteraemia (n=237, adjusted OR 0.59, 95% CI 0.25–1.43). Conclusion No difference in mortality was observed following treatment with a β-lactam or vancomycin among patients with enterococcal bacteraemia. Vancomycin is not recommended for the treatment of penicillin-susceptible enterococcal infections; however, when needed, it is not inferior to β-lactams and the addition of a β-lactam is not necessary.

Introduction. A clinical and/or research fellowship abroad has become a prevalent choice among Israeli physicians. However, the influence of fellowship programs on the career path is unclear. We evaluated the role of physicians returning from fellowship in the organizational hierarchy and their professional and academic status. Methods. This was a retrospective, descriptive, cross-sectional study of physicians who completed a survey after accomplishing a fellowship. The survey included questions about the physicians’ attitudes toward the program, programs’ details, and the physicians’ current academic, professional, and administrative status. Information about scientific publications was also collected. Results. Of the 106 physicians receiving the questionnaire, 101 responded. The majority completed a two-year fellowship in North America. Forty percent participated in an integrated program (research and clinical), and 40% participated in clinical programs. Subjectively, the physicians attributed a significant value to the fellowship and positively recommend it. Most of the physicians held managerial positions, academic appointments, and had generated significant research. Discussion. The subjective perspective of all physicians participating in the study was that attending a fellowship program had a positive impact on their careers. Objectively, the accomplishment of a fellowship program empowered the studied physicians to become scholars, senior executives, and opinion leaders in their professional field.

The purpose of this study was to determine the rate of decline in the diagnostic yield of influenza PCR assay after oseltamivir administration, and to identify risk factors for prolonged shedding. This was a prospective observational study. We included adult inpatients with clinical signs of influenza during the influenza seasons 2015 and 2016, who had positive influenza PCR tests and who were treated with oseltamivir. Clinical follow-up and repeat PCR testing were performed on days 2, 4 and 6 after the first positive test. We defined prolonged shedders as patients who still required hospitalization and had a positive PCR assay on day 4. Risk factors for prolonged shedding were assessed in univariate and multivariate analyses. A total of 215 patients were included in our study. The median age was 64 years and 49.3% were men. The main influenza type was H1N1 (50.1%). Rates of PCR positivity among evaluable patients on days 2, 4 and 6 were 142/215 (66%), 50/78 (64.1%) and 20/30 (66.6%), respectively. Independent risk factors for prolonged shedding (50 patients) included hypoxemia [odds ratio (OR) 2.55, 95% confidence interval (1.3-5.1)] and lower diastolic blood pressure [OR 0.94, 95% CI (0.92-0.97)] on admission. Negative PCR tests taken more than 48 h after initiation of treatment had low diagnostic yield. More severe disease, manifested by hypoxemia and lower blood pressure, is associated with prolonged shedding on oseltamivir treatment.

BACKGROUND ESBL-producing Enterobacteriaceae and carbapenem-resistant Enterobacteriaceae (CRE) are rapidly spreading worldwide. Their natural reservoir is intestinal. METHODS We carried out a systematic review and meta-analysis to estimate CRE and ESBL carriage duration and to evaluate the effect of decolonization therapy. We included cohort and comparative studies examining the natural history of CRE/ESBL colonization, examining rates of carriage following decolonization or comparing decolonization and no decolonization conducted in the healthcare setting or in the community. A comprehensive search was conducted until November 2015. We compiled carriage rates at 1, 3, 6 and 12 months with and without decolonization therapy and assessed the effect of decolonization. RESULTS Thirty-seven studies fulfilled inclusion criteria. In healthcare settings, pooled ESBL/CRE colonization rates decreased without intervention from 76.7% (95% CI = 69.3%-82.8%) at 1 month to 35.2% (95% CI = 28.2%-42.9%) at 12 months of follow-up. Following decolonization, the rate was 37.1% (95% CI = 27.5%-47.7%) at end of therapy and 57.9% (95% CI = 43.1%-71.4%) at 1 month. In two randomized trials, carriage was significantly reduced at end of therapy (risk ratio = 0.42, 95% CI = 0.25-0.65), but the effect was not significant after 1 month (risk ratio = 0.72, 95% CI = 0.48-1.05), with no longer follow-up. Heterogeneity was explained by surveillance methodology, with no differences observed between ESBLs and CREs. Among community dwellers, ESBL colonization decreased from 52.3% (95% CI = 29.5%-74.2%) at 1 month to 19.2% (95% CI = 9.7%-34.4%) at 6 months. CONCLUSIONS A significant proportion of ESBL and CRE carriers remain colonized up to 1 year in the healthcare setting. While short-term decolonization therapy reduces carriage during therapy, its longer-term effects are unclear.

Background Community acquired pneumonia (CAP) is a common illness affecting hundreds of millions worldwide. Few studies have investigated the relationship between serum magnesium levels and outcomes of these patients. We aimed to study the association between serum magnesium levels and 30-day mortality among patients with CAP. Methods Retrospective overview of patients hospitalized with CAP between January 1, 2010 and December 31, 2016. Participants were analyzed retrospectively in order to identify the risk factors for a primary endpoint of 30-day mortality. Normal levels of magnesium levels in our laboratory varies between 1.35 and 2.4 mg/dl. Results 3851 patients were included in our cohort. Age > 75 years, blood urea nitrogen (BUN) > 20 mg/dl, hypoalbuminemia, and abnormal levels of magnesium were all associated with increased risk of 30-day mortality. Normal magnesium levels were associated with the lowest mortality rate (14.7%). Notably, within the normal levels, high normal magnesium levels (2–2.4 mg/dl) were correlated with higher mortality rates (30.3%) as compared to levels that ranged between 1.35–2 mg/dl (12.9%). Hypomagnesemia and hypermagnesemia were both associated with excess of 30-day mortality, 18.4 and 50%, respectively. Conclusion Hypomagnesemia and hypermagnesemia on admission were associated with an increased rate of 30-day mortality among adult patients hospitalized with CAP. Interestingly, magnesium levels within the upper normal limits were associated with higher mortality.

Staphylococcus aureus infective endocarditis (IE) is a characteristic community-acquired infection, however most cases are presently occurring in the health care setting. This study investigated the incidence and risk factors for S. aureus IE in patients with nosocomial and health care-associated S. aureus bacteraemia (SAB).Consecutive patients with health care-associated and hospital-acquired SAB were prospectively recruited over a 30-month period. Patients were followed up for at least 12 weeks after the initial positive blood culture result. The primary endpoint was the diagnosis of IE.IE occurred in 11 of 303 patients (3.6%). Patient characteristics at diagnosis and that were associated with IE included the number of positive blood cultures obtained during hospitalization (p = 0.003), the duration of bacteraemia (p 0.001), bacteraemia persisting for 3 days (odds ratio (OR) 14.5, 95% confidence interval (CI) 4.0-52.8; p 0.001), performance of echocardiography (OR 1.88, 95% CI 1.69-2.1; p = 0.001), presence of a well known predisposing risk for IE (OR 57.2, 95% CI 13.6-240.5; p 0.001), a non-fatal McCabe score (OR 2.10, 95% CI 1.4-3.1; p = 0.02), and the duration of fever related to the infection (p = 0.026). On multivariable analysis, the presence of a predisposing risk for IE, prolonged bacteraemia, and non-fatal McCabe score remained significantly associated with IE.In this study the incidence of IE was lower than previously reported. Three clinical characteristics were identified as risk factors for IE among patients with SAB acquired in a health care setting.

We evaluated changes in the epidemiology of catheter-related bloodstream infections (CRBSIs) between 1996 and 2012 in a tertiary care centre in Israel. The cohort included 1754 episodes of CRBSI. The incidence of CRBSIs decreased throughout the study period, whereas 30-day mortality following bacteraemia increased. There was a linear shift toward predominance of Gram-negative bacilli throughout the study period (p for trend

Many patients encounter problems in the first weeks after discharge from hospital. Telephone follow-up (TFU) is reputed to be a good tool for providing medical advice, managing symptoms, identifying complications and giving reassurance after discharge. Therefore, we aimed to study whether tight TFU would increase patient satisfaction, improve compliance and reduce re-hospitalization rate.The study population included 400 patients, hospitalized in an Internal Medicine Department, randomly divided into two groups; TFU and control. TFU took place one week and one month after discharge. Three months later, members of both groups were contacted by telephone.Satisfaction was increased in the TFU group compared with control group by 6-12% in most fields. Notably, 87% of patients in the TFU group indicated that earlier telephone contact increased their satisfaction. In addition, 78.2% of the patients in the control group reported that they performed the tests that were recommended at discharge and 86.5% reported that they received explanations regarding their medications. In the TFU group, this percentage was increased significantly to 86.9% (P=0.02) and 96.7% (P0.0001), respectively. As to treatment results, 93% of the patients in the TFU group as compared to 84% in the control group reported improvement in their symptoms. A non-significant trend towards fewer readmission was observed in the TFU group (26% vs. 35% P=0.062).TFU can improve medical treatment by increasing satisfaction and compliance. A trend towards decreased readmission rates was observed, which may lead to a reduction in the burden on the medical system.

Background Community acquired pneumonia is a major cause of morbidity and mortality. The association between serum phosphorus levels on admission and the outcome of patients with community acquired pneumonia has not been widely examined. We aimed to investigate the prognostic value of serum phosphorus levels on admission on the 30- day mortality. Methods The cohort included patients of 18 years old or older who were diagnosed with community acquired pneumonia between 2006 and 2012. Patients were retrospectively analyzed to identify risk factors for a primary endpoint of 30-day mortality. Binary logistic regression analysis was used for the calculation of the odds ratios (OR) and p values in bivariate and multivariate analysis to identify association between patients’ characteristic and 30-day mortality. Results The cohort included 3894 patients. In multivariate regression analysis, variables associated with increased risk of 30-day mortality included: age >80 years, increased CURB-65 score, RDW >15, hypernatremia >150 mmol/l, hypoalbuminemia 4.5 mg/dl were significantly associated with excess 30-day mortality, 38 % (OR 2.9, CI 1.8-4.9, P = 0.001) and 39 % (OR 3.4, CI 2.7-4.2, P = 0.001), respectively. Phosphorus levels within the upper normal limits (4-4.5 mg/dl) were associated with higher mortality rates compared to levels between 1.5-3.5 mg/dl, the reference group, 24 % (OR 1.9, CI 1.5-2.4, P = 0.001). Conclusions Abnormal phosphorus levels on admission are associated with increased mortality rates among patients hospitalized with Community acquired pneumonia.

Purpose The aim of this study was to analyze prospectively antibiotic utilization, comparing two in-patient Internal Medicine units. Methods Data on individual antibiotic utilization pattern and antibiotic costs were collected prospectively from hospitalized patient charts over a 12-month period, using the prescription-point prevalence method twice a month, for a total of 24 encounters for each admission unit. Results The antibiotic volume/patient (number of prescriptions), using the prescription-point prevalence methodology, was 330 and 557 in Internal Medicine B and D, respectively, resulting in 1.29 and 1.25 antibiotic courses/patient for each of the two units, respectively (p = 0.91). Thirty-five percent and 39% of the patients received at least one anti-microbial prescription. The total defined daily dose (DDD) and drug utilization 90% (DU90%) index for the units were 432.7 DDD, DU90% 389.7 and 727.8 DDD, DU90% 660.4, respectively (p = 0.01). The drug cost 90% index (DC90%) placed piperacillin–tazobactam in the first place in both units, while amoxycillin–clavulanic acid was in first place when the DU90% index was applied. Conclusions A significant statistical difference was found in the anti-microbial cost analyzes of DDD, DU90% and DC90% indexes of the two units, using the prescription-point prevalence methodology. The intervention of a clinical pharmacology specialist in one of the units was effective in reducing the costs registered in that unit. Copyright © 2004 John Wiley & Sons, Ltd.

Purpose To characterize the local population that turns to complementary medicine. Methods Participants were selected randomly: Medicine [A] (201 patients); Surgery [B] (100 patients); Control [C] (128 patients). The answers to the first two questions determined whether the questionnaire was to be completed. Results More females sought complementary medicine treatment, with no significant demographic differences among the groups. Nearly 20% of the subjects had academic education while 43% had completed high school. The results of the 16 significant questions were statistically different when comparing groups C and A (p = 0.025) and B (p = 0.011) respectively. A total of 16%, 12.4% and 9% of the subjects respectively preferred a physician MD as their complementary medicine practitioner and 49% [C], 34% [A] and 29% [B] respectively, favored teaching complementary medicine in medical and nursing schools. Conclusions A total of 37% [C], 21% [B] and 27% [A] of the subjects experienced complementary medicine intervention at least once. The percentage of individuals holding academic degrees was higher in the group utilizing complementary medicine than those who did not. Only 21% of C and A groups and 12% of B group knew about adverse reactions to complementary therapies. More than 30% favored ‘legalizing’ complementary medicine. Copyright © 2003 John Wiley & Sons, Ltd.

Type-2 Diabetes mellitus may present in several ways, one of which, is Diabetic Ketoacidosis. Diabetes itself may be caused by acute pancreatitis. We discuss a case of 46 years old male, with no history of diabetes mellitus, who was admitted for abdominal pain and vomiting, and finally diagnosed with diabetic ketoacidosis. Serum amylase and lipase could not be measured at admission owing to the heavily lipemic serum. Subsequent measures demonstrated very high levels of lipase. Serum triglycerides were significantly elevated; 3200 mg/dl. Initial computed tomography scan of the abdomen did not reveal findings typical for acute pancreatitis. Hypertriglyceridemia-induced pancreatitis leading to overt diabetic ketoacidosis in a previously non-diabetic patient was our leading diagnosis. Lipo-pharesis was instituted shortly after the initiation of intra-venous insulin and fluid resus-citation. Subcutaneous heparin and fibrates were added later on, leading to clinical improvement, and reduction in serum triglycerides and pancreatic enzymes. Normal 0 false false false EN-US ZH-CN HE

We describe the case of a 53-year-old man who presented with abdominal pain, diarrhoea and hypomagnesaemia. The hypomagnesaemia proved to be due to gastrointestinal loss as urinary fractional excretion was very low, suggesting non-renal loss. Common causes were discarded and the hypomagnesaemia was attributed to chronic use of the proton pump inhibitor, omeprazole. As such, omeprazole was discontinued and an H2 blocker was given. Several days later the patient presented with upper gastrointestinal bleeding. CT scan demonstrated marked enlargement of the duodenum and proximal jejunum, and abnormal thickening and enhancement of the bowel wall. Urgent oesophagogastroduodenoscopy revealed coffee-ground and bloody contents in the distal oesophagus and stomach, and numerous ulcers along the duodenum and jejunum. A positron emission tomography-CT scan using GA 68-DOTANOC demonstrated increased uptake in the gastroduodenum junction, suggesting a neuroendocrine tumour. Pancreaticoduodenectomy was performed and tumour cells stained positive for gastrin, confirming the tentative diagnosis of Zollinger-Ellison syndrome.

Background Listeria monocytogenes is a foodborne pathogen that causes life-threatening infections in elderly, immunocompromised, and pregnant women. In pregnancy it may cause fetal loss or a preterm delivery, and the neonate is prone to neonatal sepsis and death. Methods We created a cohort of all L. monocytogenes cases during 10 years (1998-2007) in Israel, by a comprehensive review of cases in hospitals throughout the country and cases reported to the Ministry of Health. Results One hundred sixty-six pregnancy-related listeriosis cases were identified, resulting in a yearly incidence of 5-25 cases per 100 000 births. Presentation associated with fetal demise was more common in the second trimester (55.3%), and preterm labor (52.3%) and abnormal fetal heart rate monitoring (22.2%) were more common in the third trimester (P = .001). Fetal viability was low in the second trimester (29.2%) and much higher (95.3%) in the third trimester. Each additional week of pregnancy increased the survival chance by 33% (odds ratio, 1.331 [95% confidence interval, 1.189-1.489]). A single case of maternal mortality was identified. Listeria monocytogenes serotype 4b was more common in pregnancy-related than in non-pregnancy-related cases (79.5% vs 61.3%, P = .011). Pulsed-field gel electrophoresis analysis suggested that 1 pulsotype is responsible for 35.7% of the pregnancy cases between 2001 and 2007. This clone is closely related to the Italian gastroenteritis-associated HPB2262 and the invasive US Scott A L. monocytogenes strains. Conclusions Our survey emphasizes the high rate of pregnancy-related listeriosis in Israel and shows that specific clones might account for this.

An apparently healthy 46-year-old woman was admitted because of progressive shortness of breath that had begun 2 months before her admission. Physical examination revealed a patient with respiratory distress, tachycardia, and mild jugular venous distention; otherwise, results were unremarkable. Our investigation revealed hypoxia and severe pulmonary hypertension with signs of right heart dysfunction, but no primary cause was found. The patient died 5 days after admission. Autopsy revealed pulmonary lymphangitis carcinomatosis caused by papillary carcinoma. No primary tumor was found.

Objective: To report a case of seizures that probably developed because of the disinfectant and antiseptic agent povidone iodine (PVI). Case Summary: A 67-year-old healthy white man developed pleural empyema that was treated with drainage and intrapleural PVI irrigation. Within 10 minutes, complex partial seizures with secondary generalization lasting several minutes were documented. Several hours later, the patient developed a similar episode. Both events resolved spontaneously and, in 10 months of follow-up, there was no recurrence. Discussion: The adverse effects of iodine are known; however, little has been reported about seizures following the administration of PVI. This complication is thought to be due to either the osmotic and hydrophilic qualities or the presence of ionic changes and lipid solubility of PVI. Conclusions: Intracavitary PVI should be considered in the differential diagnosis of localized and generalized seizures.

Widespread vascular endothelial injury is the major mechanism for multiorgan dysfunction in sepsis. Following this process, the permeability of the alveolar capillaries is augmented with subsequent increase in water content and acute respiratory distress syndrome (ARDS). Nevertheless, the role of alveolar epithelium is less known. Therefore, we examined alveolar fluid clearance (AFC) using isolated perfused rat lung model in septic rats without ARDS. Sepsis was induced by ligating and puncturing the cecum with a 21-gauge needle. AFC was examined 24 and 48 h later. The expression of Na-K-ATPase proteins was examined in type II alveolar epithelial cells (ATII) and basolateral membrane (BLM). The rate of AFC in control rats was 0.51 ± 0.02 ml/h (means ± SE) and decreased to 0.3 ± 0.02 and 0.33 ± 0.03 ml/h in 24 and 48 h after sepsis induction, respectively ( P < 0.0001). Amiloride, significantly decreased AFC in sepsis; conversely, isoproterenol reversed the inhibitory effect of sepsis. The alveolar-capillary barrier in septic rats was intact; therefore the finding of increased extravascular lung water in early sepsis could be attributed to accumulation of protein-poor fluid. The expression of epithelial sodium channel and Na-K-ATPase proteins in whole ATII cells was not different in both cecal ligation and puncture and control groups; however, the abundance of Na-K-ATPase proteins was significantly decreased in BLMs of ATII cells in sepsis. Early decrease in AFC in remote sepsis is probably related to endocytosis of the Na-K-ATPase proteins from the cell plasma membrane into intracellular pools, with resultant inhibition of active sodium transport in ATII cells.

Pseudomonas aeruginosa is an uncommon cause of bacteremia upon hospital admission (UHA) and the chosen empirical antimicrobial therapy may not cover it appropriately. In a multicenter prospective study conducted in Israel, we evaluated risk factors for in-hospital mortality in patients with P. aeruginosa bacteremia UHA and determined the influence of delay in adequate empirical antimicrobial therapy on patients' outcome. Seventy-six adult patients with P. aeruginosa bacteremia within 72 h of hospital admission were included. Demographic, clinical, and treatment data were collected. Microbiological adequacy of empirical therapy was determined. Severe sepsis or septic shock at admission (OR, 21.9; P < 0.001), respiratory or unknown sources of bacteremia (OR, 11.5; P = 0.003), recent hospitalization (OR, 6.2; P = 0.032), and poor functional status (OR, 5.8; P = 0.029) were identified as independent predictors of mortality. Inadequate empirical antimicrobial therapy was marginally associated with increased mortality only among patients who presented with severe sepsis or septic shock (P = 0.051).

Extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae are pathogens that may lead to a spectrum of clinical syndromes. We aimed to identify predictors and outcomes of ESBL bacteremia upon hospital admission (UHA) in a nationwide prospective study. Thus, a multicenter prospective study was conducted in 10 Israeli hospitals. Adult patients with bacteremia due to Enterobacteriaceae diagnosed within 72 h of hospitalization were included. Patients with ESBL producers (cases) were compared to those with non-ESBL producers (controls), and a 1:1 ratio was attempted in each center. A case-control study to identify predictors and a cohort study to identify outcomes were conducted. Bivariate and multivariate logistic regressions were used for analyses. Overall, 447 patients with bacteremia due to Enterobacteriaceae were recruited: 205 cases and 242 controls. Independent predictors of ESBL were increased age, multiple comorbid conditions, poor functional status, recent contact with health care settings, invasive procedures, and prior receipt of antimicrobial therapy. In addition, patients presenting with septic shock and/or multiorgan failure were more likely to have ESBL infections. Patients with ESBL producers suffered more frequently from a delay in appropriate antimicrobial therapy (odds ratio [OR], 4.7; P , P , P , 9.1) and a delay in adequate therapy (OR, 0.05; P , 0.001) were significant predictors for mortality and other adverse outcomes. We conclude that among patients with bacteremia due to Enterobacteriaceae UHA, those with ESBL producers tend to be older and chronically ill and to have a delay in effective therapy and severe adverse outcomes. Efforts should be directed to improving the detection of patients with ESBL bacteremia UHA and to providing immediate appropriate therapy.

The lack of pain alarm in painless myocardial infarction (MI) leads to increased morbidity and mortality, since patients do not seek medical treatment in a timely manner. We aimed to explore whether reduced systemic pain perception in response to experimental stimuli and pain related personality variables characterizes painless MI patients.Level of chest pain intensity was assessed by numerical scale, range from 0 (no pain) to 100 (maximal pain). Heat pain threshold, magnitude estimation of supra-threshold phasic and tonic painful stimuli as well as anxiety and pain catastrophizing scores were assessed in 92 acute MI patients; 67 with and 25 without chest pain, respectively. All experimental stimuli were performed by Thermal Sensory Analysis (TSA) and applied to the right forearm.Greater intensity of chest pain scores was inversely correlated with lower pain threshold (r=-0.417, p0.001), and directly associated with higher pain scores in response to the heat pain (r=0.354, p=0.002). Patients with painful MI demonstrated lower pain threshold (41.9+/-3.6 degrees C vs. 44.9+/-3.8 degrees C, p=0.001) and higher catastrophizing level (10.6+/-12.0 vs. 5.4+/-8.8, p=0.032). Logistic regression analysis revealed that older age and lower pain scores in response to supra-threshold painful stimuli were associated with greater risk for painless MI. The demographic variables, history of ischemic heart, risk factors for coronary artery disease, ST-T segment changes on ECG and troponin levels were similar in both groups.This study suggests that reduced systemic pain perception as well as cognitive personality variables play an important role in the etiology of painless MI.

We report a rare case of a patient with long-standing familial Mediterranean fever who presented with sudden onset of dyspnea, abdominal pain, and cutaneous manifestations. Chest CT and histologic preparations disclosed pulmonary hemorrhage and signs of systemic vasculitis. Cyclophosphamide and steroid therapy were initiated, with marked improvement. Based on this and 1 other case, we propose that systemic vasculitis should be included as a clinical manifestation of FMF.

We report a case of a 54-year-old woman presented with bilateral pitting leg oedema. Initial workup for common aetiologies was unrevealing and diuretic therapy was ineffective. A CT scan of the abdomen demonstrated left adrenal mass with direct invasion of the adrenal vein and inferior vena cava with direct extension to the right atrium. Adrenocortical carcinoma was confirmed in biopsy and the patient was operated within several days. Fifteen months postoperation, the patient is doing well with good performance status and still in oncological treatment and follow-up. When the common causes of bilateral oedema have been ruled out, no delay should be experienced seeking abdominal mass with vascular invasion potential, as early diagnosis and treatment may be lifesaving.

SummaryWe report the case of a 28-year-old previously healthy male who presented with a 1-week history of fever, headache, vomiting, and jaundice. Blood cultures were positive for group G streptococci and transesophageal echocardiography demonstrated vegetations on the aortic valve, leading to a definitive diagnosis of infective endocarditis. The combination of fever, splenomegaly, anemia, thrombocytopenia, hypertriglyceridemia, elevated ferritin level, low natural killer (NK) cell activity, and hemophagocytosis in bone marrow aspirate confirmed the diagnosis of hemophagocytic syndrome (hemophagocytic lymphohistiocytosis). Antibiotic treatment and intravenous immunoglobulins were administered and the patient made a full recovery.

Background Community acquired pneumonia (CAP) is a major cause of morbidity and mortality. We recently demonstrated that among young patients ( 70 years, high Charlson comorbidity index (>2), Hb 30 mg/dl, systolic blood pressure 15%. Variables associated with complicated hospitalization included high Charlson comorbidity index, BUN > 30 mg/dl, hemoglobin 124 bpm, systolic blood pressure

Introduction Community acquired pneumonia (CAP) is a major cause of morbidity and mortality. While there is much data about risk factors for severe outcome in the general population, there is less focus on younger group of patients. Therefore, we aimed to detect simple prognostic factors for severe morbidity and mortality in young patients with CAP. Methods Patients of 60 years old or younger, who were diagnosed with CAP (defined as pneumonia identified 48 hours or less from hospitalization) between March 1, 2005 and December 31, 2008 were retrospectively analyzed for risk factors for complicated hospitalization and 90-day mortality. Results The cohort included 637 patients. 90-day mortality rate was 6.6% and the median length of stay was 5 days. In univariate analysis, male patients and those with co-morbid conditions tended to have complicated disease. In multivariate analysis, variables associated with complicated hospitalization included post chest radiation state, prior neurologic damage, blood urea nitrogen (BUN) > 10.7 mmol/L and red cell distribution width (RDW) > 14.5%; whereas, variables associated with an increased risk of 90-day mortality included age ≥ 51 years, prior neurologic damage, immunosuppression, and the combination of abnormal white blood cells (WBC) and elevated RDW. Complicated hospitalization and mortality rate were significantly higher among patients with increased RDW regardless of the white blood cell count. Elevated RDW was associated with a significant increase in complicated hospitalization and 90-day mortality rates irrespective to hemoglobin levels. Conclusions In young patients with CAP, elevated RDW levels are associated with significantly higher rates of mortality and severe morbidity. RDW as a prognostic marker was unrelated with hemoglobin levels. Trial registration ClinicalTrials.Gov NCT00845312