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Background and objectives Candida species are one of the most common causes of healthcare-associated bloodstream infections. However, recurrent candidemia is rare, and the characteristics of late recurrent (LR) candidemia are partly unclear. Our aim was to evaluate the characteristics of LR candidemia in adult patients. Patients and methods A retrospective cohort study was performed in the hospital district of Helsinki and Uusimaa in Finland (2007-2016). All candidemia cases were searched in an electronic database during the study period. Patients with LR candidemia were compared with patients with a single candidemia episode to evaluate the characteristics of LR candidemia. LR candidemia was defined as having at least two episodes of candidemia more than 30 days apart. Results We identified 24 episodes of LR candidemia in 20 patients. Patients with LR candidemia represented 6% of all patients with candidemia during the study period, and most of the these cases were nosocomial. The median time between the first and the recurrent episode was 5.1 months. One-year mortality in LR candidemia was 45%. Underlying gastrointestinal disease (OR 7.21, 95% CI 2.52-20.61) and history of intra venous drug use (IVDU) (OR 3.62, 95% CI 1.03-12.69) were independent risk factors for LR candidemia in the multivariable analysis. Conclusion Our study indicates that the gastrointestinal tract may be a continuous source of infection in patients with chronic gastrointestinal diseases. Gastrointestinal diseases and IVDU should be regarded as risk factors for LR candidemia.

The aim of this study was comparison of the severity of the recurrent episode in the group of subjects suffering from Major Depressive Disorder with comorbid Posttraumatic Stress Disorder and the group of subjects suffering only from Major Depressive Disorder. A total of 120 subjects were assessed and divided into two groups. Group D/PTSD consisted of subjects who fulfilled diagnostic criteria for recurrent episode of Major Depressive Disorder and comorbid Posttraumatic Stress Disorder. Group D/only consisted of subjects who fulfilled diagnostic criteria for Recurrent episode of Major Depressive Disorder. Assessments were performed using the following instruments: Montgomery-Asberg Depression Rating Scale, Hamilton Depression Rating Scale and Quick Inventory for Depressive Symptomatology Self -Report Version. Statistical analyses were performed using chi square and independent-samples t-test. Results suggest that recurrent episode of Major Depressive Disorder occurring in comorbidity with Posttraumatic stress disorder is more severe than the recurrent episode in the category of patients suffering from recurrent episode of Major Depressive Disorder only and that recurrent episode occurring in comorbidity with Posttraumatic stress disorder might represent a significant clinical entity.

Background Primary spontaneous pneumothorax is a common disorder occurring in young adults without underlying lung disease. Although tobacco smoking is a well-documented risk factor for spontaneous pneumothorax, an association between electronic cigarette use (that is, vaping) and spontaneous pneumothorax has not been noted. We report a case of spontaneous pneumothoraces correlated with vaping. Case presentation An 18-year-old Caucasian man presented twice with recurrent right-sided spontaneous pneumothoraces within 2 weeks. He reported a history of vaping just prior to both episodes. Diagnostic testing was notable for a right-sided spontaneous pneumothorax on chest X-ray and computed tomography scan. His symptoms improved following insertion of a chest tube and drainage of air on each occasion. In the 2-week follow-up visit for the recurrent episode, he was asymptomatic and reported that he was no longer using electronic cigarettes. Conclusions Providers and patients should be aware of the potential risk of spontaneous pneumothorax associated with electronic cigarettes.

Takotsubo syndrome is a rare cause of reversible ventricular dysfunction that imitate an acute coronary syndrome. The entity is unusual among pediatric populations and a recurrent episode is extremely rare. We report a case of recurrent takotsubo syndrome in an eight-year-old boy with Duchenne muscular dystrophy (DMD). His chest pain episodes were aggravated by a strong emotional stimuli. During episodes of chest pain, electrocardiograms (ECG) showed ST elevation while echocardiograms showed left ventricle apical ballooning; however, a coronary angiography was normal. Serial ECG and echocardiogram revealed a spontaneous resolution of ST elevation and normalized apical contraction which were compatible with the diagnosis of takotsubo syndrome. Interestingly, serial cardiac magnetic resonance imaging demonstrated increasing subepicardial enhancement which was compatible with progression of cardiac involvement in DMD.

Trigeminal neuralgia is a recurrent episode of facial pain, that may be associated with other conditions such as multiple sclerosis, neoplasms, and nerve compromises or may occur due to an unknown cause. The available treatments are pharmacotherapy or surgery; however, both are susceptible to develop side effects. Photobiomodulation could be a promising alternative therapy for trigeminal neuralgia. A systematic review of literature was carried out using the PRISMA protocol, in the PubMed/MEDLINE, Embase, and Web of Science databases. Risk of bias by ROB 2.0 protocol was performed in included studies. Initially, 20 identified articles were collected varying between the years of 1983-2018, from which 6 were included. A total of 193 patients were evaluated; photobiomodulation was compared to conventional therapies, TENS, and therapy combinations with pharmacotherapy. The overall risk of bias was low, with some concerns in the randomization and double-blinding process; moreover, there are few reports in the literature. Photobiomodulation appears to be as effective as conventional therapies, being a coadjutant therapeutic opportunity for the treatment of trigeminal neuralgia.

BACKGROUND The neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) have emerged as markers of various outcomes of inflammatory and malignant diseases. The association of those markers with short-term outcomes of acute diverticulitis has been discussed in recent studies. This study aimed at evaluation of the association of NLR and PLR with long-term outcomes in patients presenting with acute diverticulitis. METHODS A retrospective single institute study included patients admitted with acute diverticulitis between 2012 and 2016. Associations were analysed of NLR and PLR values at admission with patient outcomes. RESULTS A total of 456 patients were included in the study. High NLR and PLR values were associated with complicated disease (P

Objective: to evaluate the effectiveness of postoperative peritoneal lavage (PPL) in prevention of recurrent Adhesive Small Bowel Obstruction (ASBO).Patients and methods: a total of 36 patients were included in this study. All of these patients suffered from ASBO. They were randomized into two groups. Group I (18 patients) were treated with adhesiolysis followed by PPL and group II (18 patients) were treated with adhesiolysis alone . Patients were followed up for an average period of 15 months to detect the incidence of recurrent ASBO. Results: :In group1 only one (5.6%) patient had an attack of ASBO which responded to conservative management and did not need redo operation while in group II seven (38.9%) patients developed a recurrent episode of ASBO four of them(22.2%)needed surgical re exploration. So the rate of surgical reoperation in group 1 was zero in comparison to group 2 which was( 16.6%). Conclusion: PPL is a new hope for prevention of recurrent ASBO that achieved statistically significant reduction in the recurrence rate and surgical redo

Ansa pancreatica is a rare anatomic variation of pancreatic ducts. It is a predisposing factor of recurrent pancreatitis. In this case report, we describe a case of a 24-year-old male suffering from an ansa pancreatica with a non-patent major papilla, diagnosed on magnetic resonance cholangiopancreatography (MRCP).The ansa pancreatica was revealed by an episode of acute pancreatitis attacks in chronic pancreatitis. Endoscopic retrograde cholangiopancreatography (ERCP) confirmed important abrupt dilation in the main pancreatic duct with an ansa loop in the pancreatic duct in the head of the pancreas, and a sphincterotomy of the minor papilla was performed. The procedure was difficult and the placement of a long-term pancreatic stent during the ERCP was impossible, thus a surgical pancreatico-jejunostomy was proposed as a treatment of an ansa pancreatica with a non-patent major papilla.

We present a 62-year-old gentleman with history of Crohn’s disease, G6PD deficiency, who presented with immune-mediated thrombotic thrombocytopenia purpura (iTTP) one week after the diagnosis of COVID-19 infection. He was admitted with worsening dyspnea, acute renal failure, and profound thrombocytopenia with marked schistocytosis on peripheral smear. ADAMTS13 level was severely deficient. He was treated with oral prednisone, plasma exchange and rituximab with complete clinical resolution. Given the temporal association of this recurrent episode of iTTP with COVID-19 infection and no other discernible cause, COVID-19 infection was the most likely trigger.

Kidney stones affect 11% of men and 6% of women and incidence is on the rise. When stones pass through urinary tract, the symptoms can be debilitating, resulting in significant morbidity and cost to the medical system. Almost half of first-time stone formers have a recurrent episode. Thus, prevention of recurrence is important. Evaluation of the patient for stone-forming risk factors includes history, imaging, stone analysis, and metabolic workup. The evaluation begins with patient history focused on medications, diseases, diet, and work habits that increase the risk. Imaging with computed tomography and ultrasound helps determine the burden, size, and location of the stone(s) in the urinary tract. Stone analysis when available is important in determining the type of stone. Metabolic workup consists of targeted blood work and urinalysis as well as a 24-hour urine collection. The cornerstone of the stone evaluation is the 24-hour urine collection especially in recurrent stone formers as its components determine the risk of stone formation. The 24-hour urine values guide medical management and dietary modifications for prevention of recurrence, and follow-up collections determine the effectiveness of the therapy.

To assess the efficacy of intravenous immunoglobulin (IVIG) as add-on treatment for intractable cholangitis (IC) after Kasai portoenterostomy (KPE) in biliary atresia (BA) patients. 113 BA patients who had one or more episodes of cholangitis after KPE were recruited in this study. According to whether response to routine conservative treatment, all patients were divided into IC group and simple cholangitis (SC) group. Meanwhile, patients with IC subdivided into IVIG group and control group according to whether application of IVIG. The IC group had higher serum procalcitonin (PCT) (P = 0.014), C-reactive protein (CRP) (P = 0.023), and γ-Gltamyltranspeptidase (γ-GGT) (P = 0.031) level than the SC group. The IVIG group had shorter duration of fever after treatment (P = 0.011) and length of hospital stay (P = 0.018) than the control group. The time until recurrent episode of cholangitis was significant longer in IVIG group than in control group (P = 0.019). IVIG as add-on treatment may be an effective treatment for the cholangitis acute episode, and we conclude by calling for more prospective studies to attest to the role of IVIG in the treatment of cholangitis.

Background: Increasing array of medical intervention available to modify the likelihood of developing recurrent episode of myocardial ischemia, it is important to identify patients of risk of provocable myocardial ischemia before discharge. Material Methods: It was a cross-sectional study carried out in a tertiary care hospital of central India, during July 2012 to October 2014. During the monitoring period, the patient was once subjected for 100-meter brisk walk. Result: Out of 64 cases, 6 (9.5%) cases developed ischemia during Holter, in male it was 5(10.2%) while in female it was 1(6.67%). 13.33% of cases with tobacco consumption developed ischemia on Holter monitoring and this was found to statistically significant ( x 2 = 5.36, p

SummaryVenous thromboembolism (VTE) poses a worldwide health burden affecting millions of people each year. The annual incidence of symptomatic VTE, the collective term used here for deep venous thrombosis, pulmonary embolism or both, is 2–3 per thousand inhabitants. The one-year mortality is 20% after a first VTE. Of the surviving patients 15–25% will experience a recurrent episode of VTE in the three years after the first event. Primary and secondary prevention is key to reducing death and disability from VTE. How to make use of our current knowledge of inherited risk of VTE for primary and secondary disease prevention is not straightforward. This despite the fact that in the past two or three decades we have made major strides in enlarging our understanding of inherited VTE risk, and that new inherited risk factors continue to be identified.For primary prevention of VTE genetic testing is not likely to play a role in the future. Genetic variations also determine recurrence risk, albeit that the effect sizes for individual genetic variations are invariably lower than those for first VTE events. Multilocus genetic risk scores improve risk classification, and it is now possible to stratify patients who have had a first venous thrombosis, into subgroups with a high and low risk of recurrence. Whether this approach can be used to tailor intensity and duration of treatment remains to be established.

Background Perimesencephalic nonaneurysmal subarachnoid hemorrhage (PNSAH) is a benign form of subarachnoid hemorrhage (SAH) with a favorable prognosis. The risk of recurrent hemorrhage of this benign entity is extremely low. Case Description We describe a rare case of recurrent, spontaneous PNSAH in a 56-year-old man. This hypertensive patient suffered a recurrent episode of PNSAH 1 month after its first ictus, suggesting rebleeding can still occur in the setting of PNSAH; however, the risk is much less than that in aneurysmal SAH. No source of the hemorrhage was identified in the imaging examinations, even with the performance of a 6-vessel angiography. Conclusions Despite the PNSAH owning benign clinical manifestations and a favorable outcome, this distinct case of recurrent PNSAH demonstrated that the risk of recurrent hemorrhage of PNSAH does exist, although it is rather low. A conservative approach with close follow-up is still warranted for PNSAH patients.

Recurrent tuberculosis (TB) can result from reactivation of a previous TB episode or reinfection with a new Mycobacterium tuberculosis strain. A retrospective analysis of all recurrent TB cases reported in the United States during 1993-2010 was conducted. The proportion of recurrent cases remained stable during the study period (annual range 4.2-5.7%). Compared with persons without a previous diagnosis of TB, persons with recurrent TB experienced lower treatment completion within 12 months and higher mortality during the recurrent episode. Persons with recurrent TB have poorer outcomes, suggesting the need for targeted interventions to ensure treatment completion.

We describe a patient with anomalous left coronary artery with a short intramural course and a previously unrecognized myocardial bridge who presented with a recurrent episode of aborted sudden cardiac death. Intravascular ultrasound and fractional flow reserve showed significant compression at the left coronary artery ostium by the intercoronary pillar and at the myocardial bridge. Intravascular ultrasound and fractional flow reserve were normal after coronary translocation and unroofing of the myocardial bridge. All potential anatomic culprits should be addressed when operating on patients with anomalous coronaries.

index (BMI) of our population continues to rise, nurses in almost all areas of health care are increasingly faced with managing the heavy limbs and skin problems typical of chronic oedema. Any swelling persisting beyond 3 months is defined as chronic oedema (Moffatt et al, 2003; Lymphoedema Framework, 2006) and is indicative of a lymphatic system that is no longer able to deal with the fluid load, whatever the cause (Mortimer and Rockson, 2014). While insufficiency of the veins or lymphatics is the primary cause, obesity is a known contributor. Lymphoedema brings a 71-fold increased risk over normal (Dupuy et al, 1999), with 29% having a recurrent episode within 12 months (Moffatt et al, 2003). Cellulitis admissions already account for 2–3% of all hospital admissions (Halpern et al, 2008) and the resultant costs are estimated to be in the millions. Research has shown that early identification and management of lymphoedema reduces the morbidity, improves outcomes and reduces health and social costs Compression moves on: advances in care are changing practice

A 59-year-old man presents with a recurrent episode of symptomatic atrial fibrillation despite attempts to maintain sinus rhythm with antiarrhythmic drugs. Catheter ablation can be effective in such patients, but more than one procedure may be necessary.

Recurrent Guillain-Barre syndrome (RGBS) episodes appear in up to 6% of Guillain-Barre syndrome (GBS) patients. The purpose of this study was to identify patients with previous episodes of GBS and to assess their clinical features in a large cohort of adult GBS patients. GBS patients hospitalized at tertiary centers in three Balkan countries were included in the study (n = 404). We identified 13 (3.2%) patients with recurrent GBS (RGBS). The male to female ratio was 3: 1. All RGBS patients had two episodes of the disease. The most common GBS subtype in both episodes of the disease was acute inflammatory demyelinating polyradiculoneuropathy (AIDP) (77%, first episode; 85%, second episode). Around 23% of patients presented with a different variant during the second GBS attack. Disability seems to be equally severe at both episodes (P > 0.05). Recurrent GBS was registered in 3% of our GBS patients. The majority of them were younger males. Different GBS subtypes were found to recur.

We describe a case of obstruction of the cervical oesophagus in which ultrasonography and computed tomography revealed characteristic dislocation of the cervical oesophagus and food impaction in a segmental canal. Although the patient presented with complete obstruction initially, spontaneous recovery of passage was achieved with conservative therapy. One recurrent episode was noted during her remaining life span. To our knowledge, no similar case has been described previously.

Objective. It is uncommon for dermatomyositis to be associated with papillary thyroid cancer. We report an unusual case of papillary thyroid cancer presenting with dermatomyositis. Methods. The case history, imaging and laboratory data is reviewed. Results. We report the case of a 62-year-old female with a prior history of dermatomyositis and breast cancer who presented with a recurrent episode of dermatomyositis. Extensive evaluation of the cause of the dermatomyositis recurrence revealed no recurrence of the breast cancer but a thyroid nodule was identified. The nodule was biopsied and the patient was noted to have papillary thyroid cancer. The patient subsequently underwent total thyroidectomy and had gradual improvement in her dermatomyositis. Conclusion. It is very uncommon for dermatomyositis to be associated with papillary thyroid cancer.

Background: Recurrent intussusceptions in child and infants are problematic and there are controversies about its management. The aim of this study is to determine the details of the clinical diagnosis of recurrent intussusception and to determine the aetiology of recurrent intussusceptions. Patients and Methods: It′s a retrospective study of 28 cases of recurrent intussusception treated in the paediatric surgery department of Monastir (Tunisia) between January 1998 and December 2011. Results: During the study period, 505 patients were treated for 544 episodes of intussusception; there were 39 episodes of recurrent intussusceptions in 28 patients; the rate of patients with recurrence was 5.5%. With comparison to the initial episode, clinical features were similar to the recurrent episode, except bloody stool that was absent in the recurrent group (P = 0,016). Only one patient had a pathologic local point. Conclusion: In recurrent intussusception, patients are less symptomatic and consult quickly. Systematic surgical exploration is not needed as recurrent intussusceptions are easily reduced by air or hydrostatic enema and are not associated with a high rate of pathologic leading points.

The accompanying case report by Patel and colleagues1 concerns recurrent takotsubo cardiomyopathy (TC) in the context of hyperthyroidism's onset. The authors deserve compliments on their interesting article and their correct phenotypic diagnosis of both TC and hyperthyroidism. Their report prompts me to comment about the importance of prospectively establishing the cause and nature of TC. The medical literature's focus on clinical conditions associated with TC seems intended to clarify causative or predisposing factors in the genesis of TC. Indeed, a simple association of hyperthyroidism with TC might suggest that the former causes the latter; however, to convince the medical community, a prospective approach should document a substantial association. Ideally, this involves duplicating the exposure to the possible cause (in this case, excessive thyroidal hormones) and carefully looking for signs of recurrent TC, usually by means of echocardiographic monitoring. The authors1 did this in one recurrent episode. Although thyroid hormones are not known to activate any recognized mechanism that might produce TC, the second episode of TC upon the reappearance of hyperthyroidism is a significant observation arising from an implied natural experiment. Recurrent TC is observed in fewer than 10% of cases. Its recurrence presents an opportunity to better understand the causative factors that are still at work. Two kinds of studies offer promise in this regard: 1) those that focus on reproducing TC through the administration of short-acting, suspected causative agents (typically, catecholamines in patients who develop TC after dobutamine stress testing); and 2) studies of acetylcholine (Ach) stimulation as a test of endothelial dysfunction. Endothelial dysfunction might be an underreported predisposing condition that underlies many clinical episodes of TC.2–4 In light of the benign, short-term, and local effects of Ach,2–4 we and our colleagues have launched an international, multicenter investigation of its use in studying TC.5 In pilot studies during the first few weeks after an episode of TC, Ach has frequently yielded amazingly effective results—reproducing symptoms, electrocardiographic changes, and left ventricular segmental dysfunction (at the time of severe and diffuse coronary spasm) similar to the changes that occur spontaneously during the presenting stage of TC. Then, within mere seconds, infused intracoronary nitroglycerin consistently reverses the coronary and left ventricular changes. The Ach test is correlated with the history of TC (potentially making Ach a specific diagnostic tool) and seems to predict TC recurrence (potentially making Ach an important prognostic marker). The endothelial dysfunction typically persists for only a few weeks after an episode of TC, and it responds to specific therapy involving nitrates, calcium antagonists, and possibly L-arginine.2,3 Like Patel and colleagues,1 we emphasize the importance of prospective and safe mechanistic investigations in the quest to clarify the nature of TC.

Major depressive disorder with alcohol dependence is an easily recurrent disorder, and its dysfunction has increased risk of recurrence. The main purpose of the family therapy model at issue is to prevent the recurrent major depression with alcoholism patient against recurrent episode.All three patients have had more than 10 relapses and hospitalizations during the past 5 years. Focuses of the therapy are on the apples drawn by the patient (DDAA), the patient, the couple, and the patient–child relationship. Keywords are gathered from every participant during the therapy session. Besides, the subjects to have verbalized meaningful ideas or successful experiences are immediately, intensely praised by applause. DAILY DRAW AN APPLE (DDAA) homework is that the patient has drawn an apple on a calendar everyday and shares with family members about the apple as well as the patient's feelings of the day. The participants of the therapy are the patient, wife/husband, children and the therapists (psychiatrist, social worker). The frequency of the model is from once weekly to twice monthly. Each session consists of the 10 minutes pre-session, the 40 minutes therapeutic session, the 10 minutes post-session. All patients have never been relapsed over the past 18 months after receiving our family therapy under medications.Finally, with the aid of the family therapy, they have been almost free from affective symptoms and the ambivalence, guilty feeling toward family, frustrations have been steadily gradually improved. To prevent the recurrent major depression with alcohol dependence patient against recurrent episode has been achieved in family therapy presented here.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Szrmmarv.-The mood modules from the Primary Care Evaluation of Mental Disorders (PRIME-MD) and the Patient Health Questionnaire (PHQ) were administered to 17 (52%) female and 16 (48%) male adolescent (13-17 years old) psychiatric inpatients. The internal consistencies of both were good (KR-20 for PRIME-MD=.80, Cronbach coefficient a for Patient Health Questionnaire= 35). The correlation between the PRIME-MD and Patient Health Questionnaire total scores was .87 (p< 001 and the point-biserial correlation of both questionnaires' total scores with being tl~.~~nosed with a Major Depressive Disorder was .54 (p

Lithium, prescribed for bipolar disorder, is known to induce thyroid dysfunction, most commonly hypothyroidism. Thyrotoxicosis due to lithium-induced painless thyroiditis is a rare complication. We have previously reported that the serum concentration of immunosuppressive acidic protein (IAP), an α1-acid glycoprotein, increased during the acute phase of subacute thyroiditis, but was within the normal range in patients with painless thyroiditis. In the present case, a 31-year-old woman, receiving long-term lithium therapy for bipolar disorder, had a recurrent episode of painless thyroiditis, and her serum IAP was increased. The pathogenic mechanism for lithium-associated painless thyroiditis may differ from that of autoimmune conditions.

An 83-year-old female patient recovered from her primary Clostridium difficile-associated colitis upon antibiotic treatment and the suspension of her regular proton pump inhibitor (PPI) therapy, and had a recurrence of the infection once PPI was restarted. After the treatment of the recurrent episode, the PPI was replaced with a histamine H2 receptor blocker, and she developed no more relapses. The switch from PPI to a H2 blocker may have been a recovery factor. More research is encouraged to clarify the extent of the suggested effect.

Acromegaly is always complicated with comorbidities and increased mortality. The disease activity and mortality outcomes are highly correlated to the level of growth hormone and insulin-like growth factor 1. A variety of clinical manifestations of acromegaly have been reported. We present a unique case where a 49-year-old male was diagnosed with acromegaly with a first manifestation as an episode of diabetic ketoacidosis. Because he refused any suggestion of treatment, a recurrent episode of diabetic ketoacidosis with pituitary apoplexy occurred. A huge B-cell lymphoma displaying as a huge facial mass followed within 1 year of the diagnosis of acromegaly. Death from advanced cancer ensued 3 years later. This clinical experience strongly reinforces the urgency of controlling growth hormone and insulin-like growth factor 1 as soon as possible once acromegaly is diagnosed.

Background: A recurrent episode of diverticulitis is a new distinct episode of acute inflammation after a period of complete remission of symptoms. Outdated literature suggested a high recurrence rate (>40%) and a worse clinical presentation with less chance of conservative treatment. More recent studies showed a more benign course with no need toward an aggressive policy of treatment. Methods: We report data from revised literature and from our study: a 4-year multicenter retrospective and prospective database analysis of 743 patients hospitalized for acute diverticulitis (AD) treated medically or surgically and then followed for a minimum of 9 years. Results: The literature showed a recurrence rate of 25–35% at 5 years of follow-up, with a reduced risk of severe complications (i.e. perforations), a risk of subsequent emergency surgery of 2–14% and a risk of stoma and related death of 0–2.7%. Several risk factors of recurrence have been advocated: family history, abscess, severe CT stage, comorbidities (renal failure, collagen vascular disease) and nonsteroidal anti-inflammatory drugs. Young age is still a matter of debate. These studies have different limitations: retrospective, lack of definition of AD, small number of patients, long recruiting time, short follow-up, study population or hospital-system based. In our study of 320 followed-up, medically treated patients, 61% were asymptomatic and 22% complained of chronic symptoms: the 12-year actuarial risk of recurrence, emergency surgery, stoma and death was 21.2, 8.3, 1 and 0%, respectively. Recurrence was related to very young age (Conclusion: This study confirms the benign course of diverticulitis treated conservatively, with a low long-term risk of serious complications and death, and does not support an aggressive surgical policy to prevent them.

Recent-onset atrial fibrillation, defined as a first detected or recurrent episode of atrial fibrillation lasting less than 48 hours, is a commonly encountered dysrhythmia in the emergency department (ED). Cardioversion of stable patients in the ED with recent-onset atrial fibrillation without antecedent anticoagulation would allow for these patients to be discharged directly to home. We searched the literature to determine whether any studies have investigated the safety of this management strategy and identified five that addressed this question. These studies are reviewed herein; importantly, not one ED patient who was cardioverted in any of the five studies suffered a thromboembolic event - the feared complication responsible for most of the controversy surrounding the ED management of atrial fibrillation. According to the available evidence, we conclude that it would be within the standard of care to discharge home stable patients with recent-onset atrial fibrillation after cardioversion in the ED with adequate follow-up. It should be noted that although this strategy is safe and effective, the return visit rate for relapsed atrial fibrillation is 3% to 17%, and patients should be made aware of this possibility.

Background and purpose The aim of the study was to search for differences between clinical characteristics of recurrent ischaemic stroke which occurred within the fifth year after the first event or later, and early recurrence, i.e. within the first year after first-ever ischaemic stroke. We also tried to determine prognostic factors of late recurrent ischaemic episodes. Material and methods The patients were divided into two groups: group I comprised 124 individuals with recurrence within the first year, and group II − 98 individuals in whom the recurrent episode appeared within the fifth year or later. Results A significantly higher percentage of patients in group I demonstrated evident stenosis (70% or more) of internal carotid artery ipsilateral to stroke ( p = 0.023). In this group more cardioembolic strokes were found compared to group II, while in the latter, predominantly lacunar strokes appeared ( p = 0.046 and 0.0002, respectively). Group II patients significantly more frequently reported acetylsalicylic acid application, including systematic drug use ( p = 0.001). No evident differences were found between groups considering other important non-modifiable and modifiable risk factors of stroke. Conclusions Small differences between risk factors of ischaemic stroke profiles in patients with early and late recurrent episodes do not allow us to distinguish unequivocally a group of patients with better prognosis regarding the time of recurrent stroke. Use of antiplatelet drugs, either systematic or non-systematic, and lacunar stroke are independent, positive prognostic factors of delay of potential recurrent stroke.

PURPOSE The authors describe the case of a 58-year-old female patient that came to their observation for recurrent episode of transient blurred vision due to an idiopathic monolateral vitreal cyst localised in the posterior vitreous in the left eye. METHODS Patient evaluation included: best corrected visual acuity, slit-lamp examination, vitreo-retinal biomicroscopy, ultrasound examination, ultrabiomicroscopy, fluorescein angiography. CONCLUSIONS The authors review the literature including the most recent reports regarding this rare condition.

Recurrent deep venous thrombosis despite well conducted anticoagulant treatment is an uncommon, but possible, event. It has been hypothesized that overt hyperthyroidism may increase thromboembolic risk. We present the case of an elderly man with a recurrent episode of deep venous thrombosis during optimal oral vitamin K antagonist treatment, associated with a new diagnosis of overt hyperthyroidism, with no evidence of occult cancer and normal levels of antiphosholipid antibodies.

The Beck Depression Inventory-II, published in 1996, was administered to 100 adult outpatients (Age M = 43.1 yr., SD = 15.6) who were diagnosed with a recurrent-episode Major Depressive Disorder and 100 outpatients (Age M = 42.8 yr., SD = 15.7) who were diagnosed with a Dysthymic Disorder. Each diagnostic group was composed of 50 men and 50 women who did not have a comorbid depressive disorder. The mean Beck Depression Inventory-II total score and the mean number of symptoms endorsed by the outpatients with a Major Depressive Disorder were significantly (ps < .001) higher than those for outpatients with a Dysthymic Disorder. The usefulness of the Beck Depression Inventory–II was discussed in helping clinicians discriminate between these two unipolar disorders.

A case of recurrent unilateral varicella-zoster virus (VZV) retinitis is reported. The retinitis was characterized by arteriolitis and retinal necrosis with secondary chorioretinal atrophy localized in the periphery of the supratemporal quadrant of the retina. Polymerase chain reaction analysis of aqueous humor demonstrated VZV DNA in both the initial and recurrent episode. The Goldmann-Witmer coefficient for VZV IgG was elevated. The initial VZV retinitis was successfully treated with acyclovir and corticosteroids. Three years later, high-dose corti-costeroids alone were used to treat idiopathic facial nerve palsy. One month after concluding corticosteroids therapy, the VZV retinitis recurred in the same eye, suggesting that administration of the high-dose corticosteroids caused VZV reactivation and induced recurrence of VZV retinitis.

Introduction - Objecives According to the cognitive theory, negative automatic thoughts (NAT) and dysfunctional attitudes (DA) are important causal factors for the onset and maintanence of depression. There is limited data on the effects of NATs and DAs on the recurrence of depressive episodes. This study aims to compare the NATs and DAs of first versus recurrent episode depressive patients. The hypothesis of the study is that the intensity of negative cognitions will parallel the number of recurrences. Methods For the study, 100 first episode and 100 recurrent episode major depressive disorder diagnosed outpatients and 100 healthy volunteers presenting to the psychiatry clinics of three hospitals in Turkey were recruited. The participants were diagnosed by MINI, asked to complete the BDI, ATQ and DAS. Statistical analyses were undertaken to predict the variables affecting recurrence. Results The groups were not statistically different on sociodemographic variables. The mean NAT and DA scores were highest in the recurrent depression group. Regression analyses for the prediction of recurrence revealed that perfectionistic attitude, severity of depression and number of hospitalizations were the most correlated variables. The number of recurrences was correlated with the perfectionistic attitude scores. Conclusion These results show that the NATs and DAs of first episode depression patients differ from those of the recurrent episode depression patients, and the number of recurrences are predicted by perfectionistic attitudes. This has clinical implications in the treatment of depression, particularly points out to the need to manage perfectionistic attitudes to prevent recurrences.

Aortic dissection (AD) is a cardiovascular emergency whose most frequent symptom is chest pain. However, clinical presentation can also be varied and atypical. In the present study we report a case of painless AD, which resulted in a sudden memory loss at presentation. Physical examination and laboratory tests regarding the patient did not show any abnormal findings and a benign transient global amnesia was diagnosed. The day after being discharged, the patient came back to the emergency department because a recurrent episode of severe memory impairment occurred. This time, additional clinical and laboratory signs suggested clinical suspicion of AD. A chest computed tomography angiogram was performed and an extensive AD type A involving carotid and iliac arteries was found. Our case report shows that acute aortic dissection diagnosis can be difficult if clinical presentation is atypical and must be assessed in the light of various clinical signs and laboratory data.

Major depressive disorder comorbid with borderline personality is a highly recurrent disorder, and its dysfunction has increased risk of relapse. The main purpose of the family therapy model is to prevent the recurrent major depression with borderline personality patient against recurrent episode. These three patients have had more than 10 relapses and hospitalizations during the past 5 years.Focuses of the therapy are on the apples drawn by the patient(DDAA), the patient, and the patient-parent relationship. Keywords are gathered from every participant during the therapy session and the after-meeting. Besides, the subjects to have verbalized meaningful ideas or successful experiences are immediately, intensely praised by applause. DAILY DRAW AN APPLE(DDAA) homework is that the patient has drawn an apple on a calendar everyday and shares with parents about the apple as well as the patient's feelings of the day. The participants of the therapy are the patient, parents, and the therapists(psychiatrist and social worker). The frequency of the model is twice monthly. Each session consists of the 10 minutes pre-session, the 40 minutes therapeutic session, and the 10 minutes post-session. All three patients have never been relapsed over the past 20 months after receiving family therapy under medications. Finally, with the aid of family therapy, they have been almost free from affective symptoms and their abandonment fear, hostile dependent tie with parents have been steadily gradually improved. To prevent the recurrent major depression with borderline personality patient against recurrent episode has been achieved in family therapy presented here.

The study evaluates the management of peritonsillar abscess (PTA) by comparing needle aspiration versus incision and drainage of the abscess. Twenty-four of 86 patients treated by needle aspiration underwent a single aspiration, and 38 had 2, 19 had 3, and 5 had 4 aspirations before the abscess resolved. A significant amount of pus, up to 8, 5, and 3 mL, respectively, was detected in the subsequent aspirations. Recurrent PTA was noted in 20 patients (23.26%). In 9 of these patients (10.47%) the recurrent episode occurred immediately (in less than 1 month) and was considered residual disease. Seventy-four patients were treated by incision and drainage, and none had an immediate recurrence. Only 3 (4.05%) patients developed a late recurrent episode. The difference in the recurrence rate between the two groups is statistically significant. A history of recurrent tonsillitis prior to abscess formation did not show a significant influence on the recurrence rate. A high incidence of streptococcal infections was noted in both groups, with anaerobes detected in only 15% of samples. There was a good response to penicillin-resistant organisms. Although needle aspiration is a tempting modality for treating PTA in community clinics, one should be aware of the risks of a higher incidence of residual and recurrent disease in comparison to incision and drainage, as well as the need for repeated aspirations.

Bipolar disorder is a chronic, recurrent disorder, and its dysfunction has been correlated with poor outcomes and increased risk of recurrence. The main purpose of the family therapy model at issue is to prevent the bipolar patient against recurrent episode.The focuses of the therapy sessions are on the apples drawn by the patient(DDAA), the patient, and the patient-parent relationship. Keywords are gathered from every participant during the therapy session. Besides, the subjects to have verbalized meaningful ideas or successful experiences are immediately, intensely praised by applause during the session. DAILY DRAW AN APPLE(DDAA) homework is that the patient has drawn an apple on a calendar everyday and shares with parents about the apple as well as the patient's feelings of the day. The participants of the family therapy are the patient, parents, and the therapists. The frequency of the model is once monthly. Each session consists of the 10 minutes pre-session, the 60 minutes family therapeutic session, and the 30 minutes post-session. It needs to be emphasized that the frequency of re-hospitalization definitely decreased after receiving therapy.Finally, positive transference was demonstrated in the high attendance rate, in their excitement in receiving the applause, and in their collaboration in presenting the keywords. With the aid of the family therapy, they have been almost free from affective symptoms, and the hostile dependent tie with their parents having been steadily improved. To prevent the bipolar patient against recurrent episode has been achieved in the five cases family therapy presented here.

Sweet's syndrome (acute febrile neutrophilic dermatosis) is a steroid-responsive dermatosis characterized by pyrexia, neutrophilia, and painful erythematous plaques that histologically show a dense dermal infiltrate of neutrophils. Pregnancy-associated Sweet's syndrome is defined as the initial appearance or recurrent episode of Sweet's syndrome in a pregnant woman. Sweet's syndrome occurring during pregnancy has only been described in four women. The clinical characteristics of the women with pregnancy-associated Sweet's syndrome are reviewed and the differential diagnosis of pregnancy-associated dermatoses that clinically mimic Sweet's syndrome are discussed.

To define risk factors associated with recurrent genital herpes-simplex-virus infection caused by either Type 1 or 2 herpesvirus (HSV-1 or HSV-2), we prospectively studied 137 patients with a first symptomatic episode of the disease and 87 with a recurrent episode. First episodes were divided into 78 primary infections (no antibodies to HSV in acute-phase serum) and 59 nonprimary infections (antibodies present). HSV-1 infections were less frequent and less likely to recur than HSV-2 infections. Fifteen per cent of primary first episodes were caused by HSV-1, as compared with 3 per cent of nonprimary first episodes and 2 per cent of recurrent episodes. Moreover, during follow-up of first-episode patients, only 14 per cent of HSV-1 infections recurred, as compared with 60 per cent of HSV-2 infections. Recurrences were more likely to follow an index recurrent episode than an index first episode, whether primary or nonprimary, and were more likely to occur in men than in women. Among patients with primary HSV-2 infections, the probability of recurrence was directly related to the presence and titer of neutralizing antibody to HSV-2 in convalescent-phase serum.

昭和36年11月1日現在, 満40歳以上の久山町住民1,621名を18年間追跡し, この間に発症した脳梗塞例171名を対象に長期予後と再発作について検討した.脳梗塞例の長期生命予後は一般住民に比べ明らかに不良で, 5年・10年生存率は51%, 36%と一般住民の約2/3, 1/2であった.また70歳以下の発症者の長期生命予後は70歳以上の一般住民のそれに相当した.発症者間で長期生命予後に性差はなく, 高齢者 (70歳以上) とADL不良群で明らかに不良であった.また高血圧群 (収縮期≧160mmHg and/or拡張期≧95mmHg) で生命予後不良の傾向がみられた.発症後1ヵ月以上生存した154例中31例 (20%) に再発作があり, 初回発作後2年以内に48%, 5年以内に84%が起っていた.年間再発率は5年間で平均5.4%であった.再発作は男女とも高血圧群, 心房細動群, 男で糖尿病群に多い傾向がみられた.

A LL PATIENTS with clinically recognized pulmonary embolism have the constant threat of a recurrent episode which may prove fatal, making it imperative that treatment be give, n to prevent this development. In fact, autopsy studies indicate that in more than two-thirds of cases with fatal pulmonary embolism, evidence is found of prior emboli having occurred in the days or weeks preceding the fatal episode, and it has been suggested that untreated, more than one-third of patients will have recurrence. 1-3 Contrariwise, if recurrence is prevented, significant resolution of the pulmonary obstruction occurs over a period of weeks or months which returns the pulmonary circulation to preembolic condition in most cases. 4 Thus, in the majority of patients with pulmonary embolism, the primary objective of therapy is to prevent recurrence, and therefore, a course of anticoagulants is the only therapy indicated, and outlook for recovery is excellent. In a few cases, either because of the size or number of emboli, or presence of preexisting abnormality of the pulmonary circulation, there is severe compromises of cardiopulmonary dynamics which threaten survival. In such patients, it is desirable to accelerate removal of the obstruction of the pulmonary circulation as well as to prevent recurrence, and in those cases thrombolytic therapy may be of value.

To determine whether concurrent gonorrhea reactivates latent chlamydial infection, we studied 74 recurrent chlamydial infections and the effect of concurrent gonorrhea at the recurrent episode on the chlamydial serovar identified. Serotyping of 74 recurrent pairs of chlamydial isolates from patients attending a sexually transmitted diseases clinic indicated that 47.1% (16 of 34) with gonorrhea at the time of recurrence harbored chlamydiae of the same serovar as at the initial infection, while only 22.5% (9 of 40) without gonorrhea had the same serovar (P = .03). The proportion of recurrences by the same serovar in the group without gonorrhea did not differ from the proportion predicted by a random exposure model (22.2% vs. 18.4%, P = .46), while the proportion in the gonorrhea group did (47.1% vs. 19.8%, P less than .0001). The possibility of reinfection did not appear more likely in the group with gonorrhea than in the group without. These observations support the hypothesis that concurrent gonorrhea can reactivate latent chlamydial infection.

The method of treatment of the patient with spontaneous idiopathic pneumothorax seems controversial. Several authors have advocated an attitude of nonintervention whereas others have advised early thoracotomy. Intercostal drainage also has been recommended as the primary mode of treatment, with thoracotomy being performed when the condition persisted, recurred, or was complicated. Eighteen patients with spontaneous pneumothorax were treated during a thirty month observation period. Our therapeutic indications were adapted to the individual circumstances and were aimed at the correction of the disorder with the least possible delay. Treatment consisted therefore of immediate intercostal drainage, except in one patient. This brought about complete re-expansion of the lung in the majority of patients. Early thoracotomy and pleurectomy were performed in one patient because this was his third recurrent episode. Pneumothorax recurred in two of our patients. Thoracotomy and apical segmentectomy were performed in one of these patients because of persistent air leak and malexpansion of the lung despite intercostal drainage. Immediate thoracotomy and apical segmentectomy were also performed in another patient because of massive hemothorax accompanying the lung collapse. From experience gained in our small series, it seems preferable that patients with spontaneous idiopathic pneumothorax should be placed from the start under surgical observation, with the decision as to the best therapy to be applied then being readily taken. With the Usp of this method of management of our patients, the well known complications of this condition were practically avoided.

Surveillance for toxic-shock syndrome (TSS) in Wisconsin detected 38 cases with onsets from September 1975 through June 1980. Thirty-seven of the cases occurred after January 1, 1979; 37 of the patients were women; 35 cases occurred during menses; 38 patients were white; and one patient died. Cervical or vaginal cultures were obtained before antibiotic therapy in 23 patients, and 17 cultures were positive for Staphylococcus aureus. Ten patients had at least one recurrent episode during subsequent menstrual periods. The recurrence rate was lower in patients who had been treated with beta-lactamase-resistant antibiotics. Thirty-five patients were matched for age and menstruation to 105 controls: 34 of 35 cases (versus 80 of 105 controls) used tampons during every menstrual period (P

Epiglottitis should be suspected in the adolescent with throat pain and dysphagia out of proportion to pharyngeal inflammation. Endolateral neck radiographs or indirect laryngoscopy will confirm the diagnosis. Blood and throat or epiglottic cultures always should be obtained. Therapy consists of airway stabilization and antibiotic administration. Although epiglottitis in adolescents is often less acute and less severe than in younger children, it may be life-threatening.

Dr. M.A. Kibel, thundering like the Victoria Falls when the Zambezi River is in full flood, wrote in the Year Book of Pediatrics (1966–1967) that “there are still a few skeptics who would doubt the existence of a malady…affecting young children…(which is) characterized by hemolytic anemia and nephropathy of varying degrees.” “There is no doubt,”quoth he, “that this fascinating syndrome has not engendered the interest it deserves, presumably because the Great Seats of Learning, other than Johannesburg and Buenos Aires, have not experienced outbreaks. So, put an end to this torpor, Mr. Editor, sir. Step out and proclaim an International Conference of Gasser’s Syndrome!” Dr. Gellis gave one of his clasical replies: “(That Kibel is a gasser. — Ed.)” (1).

• A child, aged 24 months, incurred an episode of ataxic gait. Two months later, she had a recurrent episode of ataxic gait and bilateral blindness. Her symptoms were resolved with steroid therapy. A permanent visual deficit of 20/200 remained in the right eye. When she reached 16 years 10 months of age, she incurred the second episode of bilateral blindness. One month later, she had grand mal seizures. Her myelin basic protein level was elevated. Visual evoked responses were abnormal bilaterally. The combination of cerebellar, cortical, and eye symptoms, with a history of welldefined remissions, allowed the diagnosis of multiple sclerosis (MS) to be made. This is the youngest known patient with MS yet described, with the first attack occurring at 24 months of age.