Two cases of tick-borne transmitted tularemia on Southern Zealand, Denmark.

Francisella tularensis is a zoonotic bacterium which causes the infection tularemia. It colonizes invertebrates and vertebrates, counting wildlife animals and rodents. Humans can become infected through several pathways including contaminated food, water, and handling animals and due to bites from vectors. Ticks are known to cause tularemia in humans, though their role as a disease transferring vector is not well understood. We describe two case reports of tularemia transferred by ticks on Southern Zealand, Denmark. Case 1: A 49-year-old woman presented with lymphadenopathy and an unhealed sifting wound after a tick bite. Serology tests for F. tularensis were initially negative but turned positive five weeks after symptom onset, when abscess drainage was performed. Gentamicin and ciprofloxacin treatment improved the patient's clinical condition, and she completely recovered. Case 2: A 74-year-old man presented with malaise, fever, and an abdominal ulcer allegedly caused after a vector bite. CRP and leukocytes were increased, while serology tests for F. tularensis were negative. Doxycycline treatment improved the patient's clinical condition, and he completely recovered. Three weeks after symptom onset, renewed serology tests for F. tularensis were positive.

Historical Study (1986-2014): Improvements in Nutritional Status of Dialysis Patients.

OBJECTIVE: Malnutrition is common in dialysis patients and is associated with adverse clinical outcomes. Despite an increased focus on improved nutrition in dialysis patients, it is claimed that the prevalence of malnutrition in this group of patients has not changed during the last decades. Direct historical comparisons of the nutritional status of dialysis patients have never been published. To directly compare the nutritional status of past and current dialysis patients, we implemented the methodology of a study from 1986 on a population of dialysis patients in 2014. DESIGN: Historical study comparing results of two cross-sectional studies performed in 1986 and 2014. SETTING: We compared the nutritional status of hemodialysis (HD) and peritoneal dialysis (PD) patients attending the dialysis center at Roskilde Hospital, Denmark, in February to June 2014, with that of HD and PD patients treated at the dialysis center at Fredericia Hospital, Denmark, in April 1986. SUBJECTS: Maintenance PD and HD patients (n = 64 in 2014 and n = 48 in 1986). METHODS: We performed anthropometry (body weight, triceps skinfold, and midarm muscle circumferences [MAMCs]) and determined plasma transferrin. MAIN OUTCOME MEASURE: Relative body weight, triceps skinfold, MAMC, body mass index, and prevalence of protein-caloric malnutrition as defined in the original study from 1986. RESULTS: Average relative body weight, triceps skinfold, MAMC, and body mass index were significantly higher in 2014 compared with 1986. The prevalence of protein-caloric malnutrition was significantly lower in 2014 (18%) compared with 1986 (52%). CONCLUSIONS: The nutritional status of maintenance dialysis patients has improved during the last 3 decades. The reason for this improvement could not be identified in the present study, but the most likely contributors are the higher prevalence of obesity in the general population, less predialytic malnutrition, and an improved focus on nutrition in maintenance dialysis patients.

Nutritional Status of Maintenance Dialysis Patients: Low Lean Body Mass Index and Obesity Are Common, Protein-Energy Wasting Is Uncommon.

BACKGROUND AND AIMS: Maintenance dialysis patients are at increased risk of abnormal nutritional status due to numerous causative factors, both nutritional and non-nutritional. The present study assessed the current prevalence of protein-energy wasting, low lean body mass index and obesity in maintenance dialysis patients, and compared different methods of nutritional assessment. METHODS: In a cross-sectional study conducted in 2014 at Roskilde Hospital, Denmark, we performed anthropometry (body weight, skinfolds, mid-arm, waist, and hip circumferences), and determined plasma albumin and normalized protein catabolic rate in order to assess the prevalence of protein-energy wasting, low lean body mass index and obesity in these patients. RESULTS: Seventy-nine eligible maintenance dialysis patients participated. The prevalence of protein-energy wasted patients was 4% (95% CI: 2-12) as assessed by the coexistence of low lean body mass index and low fat mass index. Low lean body mass index was seen in 32% (95% CI: 22-44). Obesity prevalence as assessed from fat mass index was 43% (95% CI: 32-55). Coexistence of low lean body mass index and obesity was seen in 10% (95% CI: 5-19). The prevalence of protein-energy wasting and obesity varied considerably, depending on nutritional assessment methodology. CONCLUSIONS: Our data indicate that protein-energy wasting is uncommon, whereas low lean body mass index and obesity are frequent conditions among patients in maintenance dialysis. A focus on how to increase and preserve lean body mass in dialysis patients is suggested in the future. In order to clearly distinguish between shortage, sufficiency and abundance of protein and/or fat deposits in maintenance dialysis patients, we suggest the simple measurements of lean body mass index and fat mass index.

[Renal angiomyolipoma with spontaneous retroperitoneal bleeding]. / Renalt angiomyolipom medspontan retroperitoneal blødning

Angiomyolipoma (AML) is a benign tumour composed predominantly of blood vessels, smooth muscle tissue and adipose tissue. It is a rare disorder found in 0.1% of men and 0.22% of women. AML is most often manifested as a solitary tumour, but can also be found with multiple lesions in various organs. AML is predominantly asymptomatic, but may present with different symptoms depending on the size and position. Patients often have flank pain and microscopic or macroscopic haematuria. AML can also debut with spontaneous atraumatic bleeding in the retroperitoneum, Wunderlich's syndrome.

A case of cola dependency in a woman with recurrent depression.

BACKGROUND: Cola is an extremely popular caffeinated soft drink. The media have recently cited a poll in which 16% of the respondents considered themselves to be addicted to cola soft drinks. We find the contrast between the apparent prevalence of cola addiction and the lack of scientific literature on the subject remarkable. To our knowledge, this is the first case of cola dependency described in the scientific literature. CASE PRESENTATION: The patient is a 40-year-old woman, who when feeling down used cola to give her an energy boost and feel better about herself. During the past seven years her symptoms increased, and she was prescribed antidepressant medication by her family doctor. Due to worsening of symptoms she was hospitalised and later referred to a specialised outpatient clinic for affective disorders. At entry to the clinic she suffered from constant tiredness, lack of energy, failing concentration, problems falling asleep as well as interrupted sleep. She drank about three litres of cola daily, and she had developed a metabolic syndrome.The patient fulfilled the ICD-10 criteria for dependency, and on the Yale Food Addiction Scale (YFAS) she scored 40 points. Her clinical mental status was at baseline assessed by the Major Depression Inventory (MDI) = 41, Hamilton Depression - 17 item Scale (HAMD-17) = 14, Young Mania Rating Scale (YMRS) = 2 and the Global Assessment of Functioning (GAF) Scale = 45.During cognitive therapy sessions she was guided to stop drinking cola and was able to moderate her use to an average daily consumption of 200 ml of cola. Her concentration improved and she felt mentally and physically better. At discharge one year after entry her YFAS was zero. She was mentally stable (MDI =1, HAMD-17 = 0, YMRS = 0 and GAF = 85) and without antidepressant medication. She had lost 7.2 kg, her waistline was reduced by 13 cm and the metabolic syndrome disappeared. CONCLUSION: This case serves as an example of how the overconsumption of a caffeinated soft drink likely was causing or accentuating the patient's symptoms of mental disorder. When diagnosing and treating depression, health professionals should pay attention to potential overuse of cola or other caffeinated beverages.

[Subphrenic Meckel's diverticulum as a differential diagnosis to Chilaiditi's syndrome]. / Subfrenisk Meckels divertikel som differentialdiagnose til Chilaiditis syndrom.

Meckel's diverticulum (MD) occurs in 2-4% of the population and is the most common congenital abnormality of the gastrointestinal tract. A 67 year-old woman was admitted with acute abdomen. Abdominal X-ray showed pneumoperitoneum. During explorative laparoscopy a large perforated MD was found over the right hepatic lobe. CT-scans from an earlier admission revealed the MD but it was misinterpreted on that occasion. An MD in this place and in a person of this age is extremely rare. This case can primarily serve as differential diagnosis when CT-scans reveal mysterious subphrenic configurations.