1448. Prostate Abscess: Clinical Features, Management, and Outcomes of a “Stealth” Infection: A Case Series

Abstract Background Prostate abscess (PA) is uncommon and the diagnosis is often delayed or missed. Traditionally, PA has resulted from acute prostatitis or ascending genitourinary (GU) infection due to gram-negative bacilli but S. aureus is an emerging cause. Methods A retrospective review of all adult patients admitted with an ICD-9 or -10 diagnosis of PA between January 2013 and July 2018 was conducted. Inclusion criteria included age ≥18 years, a compatible GU infection syndrome, and imaging consistent with PA. Results Twenty-two patients with PA were identified. The median age was 57 years. Five patients (22.7%) were immunosuppressed and 11 (50%) had diabetes. The median Charlson Comorbidity Index was 2. No patient had a prior history of PA but 3 patients had a past diagnosis of prostatitis. Only 1 patient had GU instrumentation in the preceding 6 weeks and no patient had an indwelling urethral catheter. Fever (59%), dysuria (49%), and urinary retention (32%) were the most common presenting symptoms. Only 7/18 (39%) patients had a tender prostate on examination; fluctuance was not described. Pelvic CT revealed PAs in all patients; 14 (64%) were solitary and 16 (73%) were >2 cm in greatest diameter. The median abscess size was 3.2 cm. Urine cultures were positive in 11/18 (61%) patients with 6/11 (55%) growing S. aureus (MRSA 3); 9/16 (56%) patients had positive blood cultures (S. aureus 7 with MRSA 3) and 5/5 had positive PA cultures (S. aureus 1). Nine patients (41%) were managed with antibiotics alone whereas 13 (59%) underwent abscess drainage. The median duration of antibiotic therapy was 34.5 days. All-cause mortality at 4 weeks was 9.1%. No relapses were documented at 6 months. When comparing patients with S. aureus PA to those with other causes, S. aureus patients more often had diabetes (86% vs. 33%, P = 0.06) and a longer median duration of antibiotic therapy (35 days vs. 31 days, P = 0.04) but age, abscess size, and mortality did not differ between groups. Conclusion PA is relatively uncommon and may be difficult to distinguish clinically from acute prostatitis. CT is critical to an accurate diagnosis. Optimal management usually requires both antibiotics and drainage. Given the frequent occurrence of S. aureus as a cause, coverage for MRSA should be a component of empiric treatment for PA. Disclosures All authors: No reported disclosures.

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WP1-5 Surgical management of spinal meningiomas and appraisal of possible association with oestrogen receptor positive breast carcinoma

Journal of Neurology Neurosurgery & Psychiatry ◽

10.1136/jnnp-2019-abn.8 ◽

2019 ◽

Vol 90 (3) ◽

pp. e3.1-e3

Author(s):

D Wang ◽

AR Sadek ◽

A Nader-Sepahi

Keyword(s):

Breast Carcinoma ◽

Surgical Management ◽

Oestrogen Receptor ◽

Case Series ◽

Cancer Registries ◽

Presenting Symptoms ◽

History Of ◽

Comorbidity Index ◽

Spinal Meningiomas ◽

Grade 3

ObjectivesEvaluation of the presentation, demographics, pathology and outcomes associated with surgical management of spinal meningiomas and review of an association with a history of preceding breast carcinoma.DesignA retrospective single-centre case series of surgically managed meningiomas over a 4 year period.Subjects184 cases of surgically managed intradural lesions from 2014 to 2018.Results48 patients were identified as having a spinal meningioma [26% of all spinal tumours]. 42 [88%] were female with a cumulative mean age of 69 years [SD ±10]. Most lesions were located in the thoracic spine [n=41]. The cohort had a Charlson comorbidity index of 3. Weakness [median MRC grade 3], neuropathic pain [mean NPS of 26/100] and problems with gait [median mJOA score of 2] were the commonest presenting symptoms. Post-operatively improvements in MRC, NPS, mJOA and SF36 scores were observed. 16% [n=7] of cases had a preceding history of oestrogen-receptor positive breast carcinoma, with a mean interval time between diagnoses of 8.1 years [SD ±5.1]. Risk analysis using baseline data from national cancer registries demonstrates that the likelihood of both diagnoses to be 4.9%, this is considerably lower than the observed 16% (p=0.01).ConclusionsAnalysis of our cohort has demonstrated an association between a preceding diagnosis of oestrogen-receptor positive breast carcinoma and spinal meningiomas that cannot be explained by chance alone.

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Abstract P011: Heart Failure and the Obesity Paradox Among Participants in the in the REasons for Geographic and Racial Differences in Stroke (REGARDS) Study

Circulation ◽

10.1161/circ.127.suppl_12.ap011 ◽

2013 ◽

Vol 127 (suppl_12) ◽

Author(s):

Raegan W Durant ◽

Todd M Brown ◽

Emily B Levitan ◽

Joshua S Richman ◽

Nicole Redmond ◽

...

Keyword(s):

Heart Failure ◽

Health Behaviors ◽

Normal Weight ◽

Community Dwelling ◽

Prior History ◽

Central Adiposity ◽

All Cause Mortality ◽

History Of ◽

Regards Study

Background: Overweight and obese adults living with heart failure (HF) have lower mortality compared to those of normal weight. However, the specific relationships of overall weight status and central adiposity with mortality among those with HF are less well-defined. We examined the relationships among body mass index (BMI), waist circumference (WC) and mortality among patients hospitalized for HF in the REGARDS Study. Methods: REGARDS is a national cohort of US community-dwelling adults aged >45 recruited from 2003 to 2007. We measured all-cause mortality rates among 565 participants hospitalized with HF who were normal weight (BMI 18.5-24.9 kg/m 2 ), overweight (BMI 25.0-29.9 kg/m 2 ), or obese (BMI > 30.0 kg/m 2 ) at baseline. Underweight participants (BMI < 18.5 kg/m 2 ) were excluded. Baseline WC, weight, and height were measured during an in-home exam. Index HF hospitalizations during follow-up were adjudicated by a panel of experts. Vital status was determined using the Social Security Death Index or the National Death Index. Cox proportional models estimated hazard ratios for all-cause mortality following the index HF hospitalization. Models were sequentially adjusted for WC, sociodemographics, HF severity (EF and BNP during HF hospitalization, prior history of HF, prior history of diastolic dysfunction), comorbidities, and health behaviors. Results: Among 565 participants hospitalized for HF, 116 (21%) were normal weight, 209 (37%) overweight, and 240 (42%) obese at baseline. Over a mean follow-up of 2.5 years, 253 deaths occurred. In multivariable analyses, overweight was associated with lower all-cause mortality in all models (Table). Each 1-cm increase in WC was associated with higher risk of all-cause mortality, but the relationship was not statistically significant after health behaviors were added in the final model. . Conclusions: Among adults hospitalized for HF, overweight as assessed by BMI may be associated with lower risk for mortality. However, central adiposity may confer higher risk of mortality.

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Modafinil for Wakefulness in the Critical Care Units: A Literature Review and Case Series including COVID-19 Patients at a Tertiary Care Saudi Hospital

10.1101/2021.02.11.21250832 ◽

2021 ◽

Author(s):

Marwa Amer ◽

Mohammed Bawazeer ◽

Abid Shahzad Butt ◽

Talal I. Dahhan ◽

Eiad Kseibi ◽

...

Keyword(s):

Median Duration ◽

Hemorrhagic Stroke ◽

Tertiary Care ◽

Case Series ◽

Hemorrhagic Transformation ◽

Critical Care Units ◽

Cognitive Improvement ◽

Obstructive Sleep ◽

All Cause Mortality ◽

Speed Up

AbstractCognitive improvement after critical illness is complex. Neuro-stimulants are used to speed up physical and mental processes through the increase in arousal, and wakefulness. In this case series, we reviewed the literature and described the effect of modafinil for wakefulness in a cohort of adult patients admitted to our COVID and non-COVID intensive care unit (ICU) between January 2017 and June 2020. A total of 8 patients included; 3 admitted to COVID-19, 4 surgical, and 1 transplant ICU. Obstructive sleep apnea was noted in 2 (25%), 2 patients (25 %) had an initial neuroimaging that showed hemorrhagic stroke, and 1 (12.5%) showed ischemic stroke with hemorrhagic transformation. Modafinil 100-200 mg daily was started for a median duration of 4 days and the median initiation time in relation to ICU admission was 11 (IQR 9-17) days. Glasgow coma Scale improvement was noted on 5 patients (62.5%). The median duration of mechanical ventilation was 17.5 (IQR 15-31.75) days, and the median ICU stay was 28.5 (IQR 20.25-48) days. All-cause mortality rate was 25 % at 28 days and 62.5 % at 90 days. Modafinil prevented tracheostomy in 1 COVID-19 patient. No significant adverse drug reactions were documented. In our case series, we described our experience for modafinil use for wakefulness in ICU ventilated patients including COVID-19 patients. Based on our observations, the known effects of modafinil, and its safety profile, it holds the potential to facilitate recovery from cognitive impairment. Larger studies are warranted to fully evaluate its role for this indication.

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General medical disorders with psychiatric implications

10.1093/med/9780199360574.003.0038 ◽

2015 ◽

Author(s):

Erik J. Garcia ◽

Warren J. Ferguson

Keyword(s):

Mental Illness ◽

Psychiatric Symptoms ◽

The United States ◽

Prior History ◽

Medical Illness ◽

Medical Conditions ◽

Presenting Symptoms ◽

Medical Disorders ◽

Increased Risk ◽

History Of

Traditionally the domain of consultation/ liaison psychiatry, the challenge of recognizing and then appropriately treating the psychiatric complications of general medical disorders requires thoughtful planning and attention in corrections. Medical conditions that have psychiatric symptoms represent a significant diagnostic dilemma, particularly in the correctional health setting. Over half of the inmates in the United States have symptoms of a major mental illness, but the pervasiveness of substance use disorders, the increasing prevalence of elderly inmates, and limited access to a patient’s past medical and psychiatric records all contribute to the challenge of discerning when a psychiatric presentation results from an underlying medical condition. One early study underscored this challenge, noting that 46% of the patients admitted to community psychiatric wards had an unrecognized medical illness that either caused or exacerbated their psychiatric illness. A more recent study observed that 2.8% of admissions to inpatient psychiatry were due to unrecognized medical conditions. Emergency room medical clearance of patients presenting for psychiatric admission has revealed an increased risk for such underlying medical conditions among patients with any of five characteristics: elderly, a history of substance abuse, no prior history of mental illness, lower socioeconomic status, or significant preexisting medical illnesses. This chapter examines several of these risk groups and focuses on the presenting symptoms of delirium, mood disorders, and psychosis and the underlying medical conditions that can mimic or exacerbate them.

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Acute Uncomplicated Bronchitis

10.1093/med/9780199976805.003.0029 ◽

2016 ◽

Author(s):

Sarina Sahetya

Keyword(s):

Antibiotic Therapy ◽

Bacterial Pathogens ◽

Acute Bronchitis ◽

Respiratory Illness ◽

Low Grade ◽

Presenting Symptoms ◽

Sputum Production ◽

History Of ◽

Normal Chest ◽

Interstitial Disease

Acute bronchitis is a respiratory illness characterized predominantly by cough with or without sputum production that lasts for up to 3 weeks in the presence of normal chest radiography. Additional presenting symptoms include rhinorrhea, congestion, sneeze, sore throat, wheezing, low-grade fever, myalgia, and fatigue. Causative organisms include viral and bacterial pathogens. The disease course is characterized by self-limited inflammation of the airways. Chest radiographs should be utilized to distinguish acute bronchitis from pneumonia or interstitial disease. Therapeutic recommendations are typically supportive; however, studies reveal that between 60% and 80% of patients receive unwarranted antibiotic therapy. Only those patients at high risk for serious complications (including patients over 65 with a history of hospitalization, diabetes mellitus, congestive heart failure, or current use of oral glucocorticoids) usually require routine antibiotic therapy directed toward both typical and atypical bacterial pathogens.

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Primarily treated patients versus referred patients in the treatment of native septic arthritis of digits: a retrospective comparative study

BMC Musculoskeletal Disorders ◽

10.1186/s12891-020-03770-9 ◽

2020 ◽

Vol 21 (1) ◽

Author(s):

Sang Ho Kwak ◽

Jung Yun Bae ◽

Youngkwang Oh ◽

Hyo Seok Jang ◽

Tae Young Ahn ◽

...

Keyword(s):

Antibiotic Therapy ◽

Septic Arthritis ◽

Hospital Stay ◽

Surgical Intervention ◽

Treatment Plan ◽

Case Series ◽

Flap Surgery ◽

Surgical History ◽

History Of ◽

Retrospective Comparative Study

Abstract Background Septic arthritis of digits needs urgent treatment. When treatments delayed or insufficient, patients may be referred to the upper-level hospital due to uncontrolled infection. We reviewed the treatment history of referred patients and compared the microorganisms and the clinical course of both primary and referred patients as relevant studies are rare. Methods In this retrospective review of consecutive case series, 45 patients (primary, n = 11; referred, n = 34) were treated with multiple irrigation and debridement. Cefazolin was used as empiric antibiotics, then changed according to microbiologic study. Previously used antibiotics, treatment delay, surgical history of the referred patients were reviewed. Identified microorganisms, required surgical intervention, hospital stay, radiologic outcome, functional outcomes were compared between both groups. Results In the referred patients, methicillin-resistant Staphylococcus aureus (MRSA) was commonly found and cefazolin was susceptible in only 15% of the cases. Longer hospital stay, prolonged antibiotic therapy, more surgical intervention including flap surgery was required to treat the referred patients. Postoperative pain was not severe in daily activities, but the final range of motion was significantly less in the referred patients compared to the primary patients. Conclusions This study suggests that in the treatment of uncontrolled septic arthritis of the digits, antibiotic agents covering MRSA may shorten the duration of antibiotic therapy in areas of high MRSA incidence. Besides, more number of I & D including flap surgery may be required for the referred patients compared with the primary patients. These findings can help the surgeon in setting up a treatment plan or in counseling of referred patients with uncontrolled septic arthritis of the digits.

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Labyrinthitis ossificans: How accurate is MRI in predicting cochlear obstruction?

Otolaryngology ◽

10.1016/j.otohns.2008.12.029 ◽

2009 ◽

Vol 140 (5) ◽

pp. 692-696 ◽

Cited By ~ 59

Author(s):

Brandon Isaacson ◽

Timothy Booth ◽

Joe W. Kutz ◽

Kenneth H. Lee ◽

Peter S. Roland

Keyword(s):

High Resolution ◽

Bacterial Meningitis ◽

Cochlear Implant ◽

Tertiary Care ◽

Fibrous Tissue ◽

Case Series ◽

Prior History ◽

Basal Turn ◽

Labyrinthitis Ossificans ◽

History Of

Objective: To determine the accuracy of preoperative MRI in predicting cochlear obstruction in pediatric patients with a history of bacterial meningitis. Methods: A case series with chart review was performed at a tertiary care multidisciplinary cochlear implant program. Forty-five children with hearing loss that resulted from bacterial meningitis were implanted from 1991 to 2006. Twenty-five children had preoperative MRI with high-resolution axial T2-weighted images to assess for cochlear patency. Results: Seventeen of 25 patients (68%) had surgical evidence of cochlear obstruction. Six patients (37.5%) required circummodiolar drill-outs, and one patient (6.25%) underwent placement of a double array cochlear implant. The nine remaining patients (56%) with cochlear obstruction required removal of fibrous tissue or drilling of the inferior basal turn, but did not require manipulation of the ascending basal turn to achieve full electrode insertion. The sensitivity, specificity, and positive and negative predictive value of MRI predicting intraoperative cochlear obstruction with 95 percent confidence intervals was 94.1 percent (71–99), 87.5 percent (47–99), 94.1 percent (71–99) and 87.5 percent (47–99), respectively. Conclusion: Preoperative high-resolution T2 MRI may be useful in predicting cochlear obstruction in patients with a prior history of bacterial meningitis.

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Case Study: Pneumococcal Prosthetic Valve Endocarditis with Mitral Annular Abscess Fistulised in the Left Atrium: An Uncommon Germ with Dramatic End

RA Journal Of Applied Research ◽

10.47191/rajar/v7i6.02 ◽

2021 ◽

Vol 07 (06) ◽

Author(s):

S. Hilal ◽

Keyword(s):

Antibiotic Therapy ◽

Left Atrium ◽

High Mortality ◽

Prosthetic Valve ◽

Case Series ◽

Prosthetic Valve Endocarditis ◽

History Of ◽

Efficient Care ◽

Annular Abscess

Background: Streptococcus pneumoniae is an infrequent cause of infectious endocarditis. Several case series have underscored the aggressive course of Streptocoque Pneumiae with acute clinical presentation, rapid valvular destruction, and high mortality despite appropriate antibiotic therapy. Case summary: We present a 74-year-old woman with previous aortic and mitral valve replacement 12 years ago, presented with a 5 days history of persistent fever and a red, hot, and swollen right knee. Atrial fibrillation was demonstrated on a 12-lead electrocardiogram. The initial echocardiography did not show any sign of endocarditis but in front of the clinical symptomatology the patient was put under probabilistic antibiotic therapy. in the meantime blood culture grew Streptocoque Pneumiae and then the antibiotic treatment was adapted. The sudden deterioration of the patient brought us back to control the heart by a transthoracic echocardiography, which revealed a mitral annular abscess fistulizing to the left atrium. the patient expired 30 days after admission from presumed severe sepsis and cardiogenic choc. Conclusion: Pneumococcal endocarditis in prosthetic valve is associated with very high mortality, especially when complicated by paravalvular abscess and other comorbidities. This case highlights the need for a carefull considered approach for fast and efficient care.

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Primarily Treated Patients versus Referred Patients in the Treatment of Native Septic Arthritis of Digits: A Retrospective Comparative Study

10.21203/rs.3.rs-26632/v4 ◽

2020 ◽

Author(s):

Sang Ho Kwak ◽

Jung Yun Bae ◽

Youngkwang Oh ◽

Hyo Seok Jang ◽

Tae Young Ahn ◽

...

Keyword(s):

Antibiotic Therapy ◽

Septic Arthritis ◽

Hospital Stay ◽

Surgical Intervention ◽

Treatment Plan ◽

Case Series ◽

Flap Surgery ◽

Surgical History ◽

History Of ◽

Retrospective Comparative Study

Abstract BackgroundSeptic arthritis of digits needs urgent treatment. When treatments delayed or insufficient, patients may be referred to the upper-level hospital due to uncontrolled infection. We reviewed the treatment history of referred patients and compared the microorganisms and the clinical course of both primary and referred patients as relevant studies are rare.MethodsIn this retrospective review of consecutive case series, 45 patients (primary, n=11; referred, n=34) were treated with multiple irrigation and debridement. Cefazolin was used as empiric antibiotics, then changed according to microbiologic study. Previously used antibiotics, treatment delay, surgical history of the referred patients were reviewed. Identified microorganisms, required surgical intervention, hospital stay, radiologic outcome, functional outcomes were compared between both groups. ResultsIn the referred patients, methicillin-resistant Staphylococcus aureus (MRSA) was commonly found and cefazolin was susceptible in only 15% of the cases. Longer hospital stay, prolonged antibiotic therapy, more surgical intervention including flap surgery was required to treat the referred patients. Postoperative pain was not severe in daily activities, but the final range of motion was significantly less in the referred patients compared to the primary patients.ConclusionsThis study suggests that in the treatment of uncontrolled septic arthritis of the digits, antibiotic agents covering MRSA may shorten the duration of antibiotic therapy in areas of high MRSA incidence. Besides, more number of I & D including flap surgery may be required for the referred patients compared with the primary patients. These findings can help the surgeon in setting up a treatment plan or in counseling of referred patients with uncontrolled septic arthritis of the digits.

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Spontaneous Gallbladdre Perforation: A case series

Journal of Society of Surgeons of Nepal ◽

10.3126/jssn.v18i3.15294 ◽

2016 ◽

Vol 18 (3) ◽

pp. 31

Author(s):

Sujit Kumar ◽

Sanjay Negi ◽

BN Patowary ◽

Aditya Jalan ◽

Sulabh Rajbhandari

Keyword(s):

Rare Complication ◽

Case Series ◽

Biliary Colic ◽

Gallbladder Perforation ◽

Prior History ◽

Aged Patients ◽

Abdominal Radiographs ◽

History Of ◽

Abdominal Paracentesis ◽

Fluid Levels

Background: Gallbladder is rarely injured as it is embedded in the liver and well protected by ribcage. Gallbladder perforation is a rare complication of acute calculus cholecystitis. Spontaneous gallbladder perforation is even rarer.Case Series: We present our experience of 4 cases of spontaneous gallbladder perforation. The patients were mostly males (3:1) with age ranging from 42-64 years. All the patients presented with abdominal pain, distension, ileus and fever ranging from 2-5 days duration. There was no prior history of biliary colic. Examination revealed abdominal tenderness and ileus. Abdominal radiographs showed multiple air-fluid levels and no pneumoperitoneum. Sonography and CT scan of abdomen revealed pericholecystic fluid, intra-abdominal collection with no evidence of gallstones. Provisional diagnosis was peritonitis in 3 and acute pancreatitis in one case. Image guided abdominal paracentesis yielded bilious fluid. In view of lack of clinical improvement and aspiration of bilious content all the patients were subjected to laparotomy. Gallbladder perforation in fundus region without stones and intra-abdominal bile collection was noted in all the patients. Cholecystectomy with peritoneal lavage and abdominal drainage was performed in all cases. Postoperative course was uneventful except wound infection in 2 cases. Histopathology report revealed features of acute cholecystitis in 2 and acute on chronic cholecystitis in the remaining 2 patients.Conclusion: Diagnosis of spontaneous gallbladder perforation should be suspected in middle aged patients who present with acute abdomen but does not have classical signs of peritonitis and in whom paracentesis has yielded bilious fluid.

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