Microbiology of acute bacterial skin and skin-structure infections in Greece: A proposed clinical prediction score for the causative pathogen.

Although clinical definitions of acute bacterial skin and skin-structure infection (ABSSSI) are now well established, guidance of the prediction of likely pathogens based on evidence is missing. This was a large survey of the microbiology of ABSSSIs in Greece. During the period November 2014 to December 2016, all admissions for ABSSSI in 16 departments of internal medicine or surgery in Greece were screened to determine the likely bacterial aetiology. Samples were cultured on conventional media. Expression of the SA442, mecA/mecC and SCCmec-orfX junction genes was assessed. Following univariate and forward logistic regression analysis, clinical characteristics were used to develop scores to predict the likely pathogen with a target of 90% specificity. In total, 1027 patients were screened and 633 had positive microbiology. Monomicrobial infection by Gram-positive cocci occurred in 52.1% and by Gram-negative bacteria in 20.5%, and mixed infection by Gram-positive cocci and Gram-negative bacteria in 27.3%. The most common isolated pathogens were Staphylococcus aureus and coagulase-negative staphylococci. Resistance to methicillin was 57.3% (53.5-61.1%). Three predictive scores were developed: one for infection by methicillin-resistant S. aureus, incorporating recent hospitalisation, atrial fibrillation, residency in long-term care facility (LTCF) and stroke; one for mixed Gram-positive and Gram-negative infections, incorporating localisation of ABSSSI in lumbar area, fluoroquinolone intake in last 6 days, residency in LTCF and stroke; and another for Gram-negative infection, incorporating skin ulcer presentation, peptic ulcer and solid tumour malignancy. In conclusion, methicillin-resistant staphylococci are the main pathogens of ABSSSIs. The scores developed may help to predict the likely pathogen.

Adult Kawasaki disease in a European patient: a case report and review of the literature.

INTRODUCTION: Kawasaki disease is an acute necrotising vasculitis of the medium- and small-sized vessels, occurring mainly in Japanese and Korean babies and children, aged 6 months to 5 years. Its main complication is damage of coronary arteries, which has the potential to be fatal. Here we report a rare case of Kawasaki disease that occurred in a 20-year-old Greek adult. CASE PRESENTATION: A 20-year-old Greek man presented with high fever, appetite loss, nausea and vomiting, headache and significant malaise. He had an erythema of the palms and strikingly red lips and conjunctiva. As he did not respond to broad-spectrum antibiotics and after having excluded other possible diagnoses, the diagnosis of Kawasaki disease was set. He was treated with intravenous immunoglobulin and oral aspirin on the 10th day since the onset of the illness. His clinico-laboratory response was excellent and no coronary artery aneurysms were detected in coronary artery computed tomography performed 1 month later. CONCLUSIONS: This report of an adult case of European Kawasaki disease may be of benefit to physicians of various specialties, including primary care doctors, hospital internists, intensivists and cardiologists. It demonstrates that a case of prolonged fever, unresponsive to antibiotics, in the absence of other diagnoses may be an incident of Kawasaki disease. It is worth stressing that such a diagnosis should be considered, even if the patient is adult and not of Asian lineage.

Automated office versus home measurement of blood pressure in the assessment of morning hypertension.

OBJECTIVE: To compare the quality and accuracy of morning blood pressure (BP) readings as taken by automated office BP (AOBP) and morning home BP (mHBP) techniques using morning ambulatory BP (mABP) measurements as the gold standard. METHODS: A total of 139 individuals were included, 70 men and 69 women, mean age 53±13 years. The average AOBP readings as measured using a Microlife Watch BP office device taking triplicate automated simultaneous readings of both arms were compared with mHBP monitored on 6 routine days, using a validated automated electronic device. Both modalities were also compared with the ambulatory readings of the 3 h of waking (mABP3h). RESULTS: The AOBP values were slightly higher than the mABP3h (mean difference 8.2 mmHg, 95% limits of agreement, -18.8 to 35.2 mmHg for the systolic BP and mean difference 4.3 mmHg, 95% limits of agreement, -15.3 to 23.9 mmHg for the diastolic BP). Systolic and diastolic AOBP readings correlated with mABP3h (r=0.66, P=0.001 and r=0.64, P=0.001, respectively). Agreement was fair between AOBP and mHBP in the detection of morning hypertensive patients (agreement 70%, κ=0.32) as compared with AOBP and mABP3h (agreement 67%, κ=0.32) and mHBP and mABP3h (agreement 65%, κ=0.31). CONCLUSION: The AOBP technique could replace mHBP monitoring in the assessment of morning BP, as it provides comparable data in relation to the awake ambulatory BP. Given the simplicity of this method, it could be more readily applied in a larger number of individuals.

Automated office blood pressure is associated with urine albumin excretion in hypertensive subjects.

BACKGROUND: We aimed to investigate the association between automated office blood pressure (AOBP) readings and urine albumin excretion (UAE), and to assess if this association is as close as that between 24-h ambulatory blood pressure (ABP) and UAE. A strong association would suggest that AOBP may serve as an indicator of early renal impairment. METHODS: In a sample of 162 hypertensives, we compared AOBP with ABP measurements and their associations with UAE in two consecutive 24-h urine collections measured by an immunoturbidimetric assay. Microalbuminuria was defined as UAE of 30-300 mg/24 h. RESULTS: The age of the subjects was 53 ± 13 (mean ± s.d.) years. Twenty-two were microalbuminuric. In those, AOBP and 24-h ABP were higher than in the normoalbuminuric subjects: 152 ± 19 and 147 ± 20 vs. 138 ± 15 and 130 ± 11 mm Hg for systolic blood pressure (SBP), and 97 ± 15 and 92 ± 14 vs. 86 ± 10 and 82 ± 8 mm Hg for diastolic blood pressure (DBP) (P < 0.001). Correlations between AOBP and 24-h ABP with log-transformed urine albumin were 0.30 (P < 0.001) and 0.43 (P < 0.001) for SBP and 0.27 (P < 0.001) and 0.33 (P < 0.001) for DBP. Adjusting for age, sex, body mass index, and estimated glomerular filtration rate, both AOBP and 24-h ABP were independently associated with urine albumin (P < 0.001 for both associations). Receiver operating characteristics curve analysis showed a similar predictive ability for microalbuminuria for AOBP and for 24-h ABP (area under the curve: 0.819 (P < 0.001) for SBP, 0.836 (P < 0.001) for DBP vs. 0.830 (P < 0.001) for SBP and 0.845 (P < 0.001) for DBP). CONCLUSIONS: In this study, microalbuminuria correlated similarly with high-quality AOBP and ABP readings, further supporting the use of AOBP in the clinical setting.

Automated office blood pressure and 24-h ambulatory measurements are equally associated with left ventricular mass index.

BACKGROUND: To determine whether automated office blood pressure (AOBP) readings are associated with left ventricular mass (LVM) index as closely as those of 24-h ambulatory blood pressure (ABP) and also to confirm that the values of the two methods are comparable in the appraisal of blood pressure in a European population referred for suspected hypertension. METHODS: In a sample of 90 individuals with office hypertension, we compared AOBP to awake systolic ABP measurements (ABPM) values and their associations with LVM indices, expressed as LVM divided by body surface area (LVMI(BSA)) and by height(2.7) (LVMI(H)). RESULTS: Mean awake systolic ABP was 136 ± 16 mm Hg and mean systolic AOBP was 140 ± 15 mm Hg (P < 0.002). Mean awake diastolic ABP was 87 ± 11 mm Hg and mean diastolic AOBP was 88 ± 12 mm Hg (P = 0.08). AOBP readings were as closely associated with LVMI(BSA) (r = 0.37) as were those of awake systolic blood pressure (SBP) (r = 0.37). The correlation between LVMI(H) and both mean awake systolic ABP and mean systolic AOBP was r = 0.37 (P < 0.001) and r = 0.34 (P = 0.001), respectively. CONCLUSIONS: High-quality AOBP readings and ABP measurements correlate equally well with LVM indices, further supporting the use of AOBP in the clinical setting. Moreover, readings from both techniques are comparable in the assessment of blood pressure.

Why use automated office blood pressure measurements in clinical practice?

Automated office blood pressure (AOBP) measurement with the patient resting alone in a quiet examining room can eliminate the white-coat effect associated with conventional readings taken by manual sphygmomanometer. The key to reducing the white-coat response appears to be multiple blood pressure (BP) readings taken in a non-observer office setting, thus eliminating any interaction that could provoke an office-induced increase in BP. Furthermore, AOBP readings have shown a higher correlation with the mean awake ambulatory BP compared with BP readings recorded in routine clinical practice. Although there is a paucity of studies connecting AOBP with organ damage, AOBP values were recently found to be equally associated with left ventricular mass index as those of ambulatory BP. This concludes that in contrast to routine manual office BP, AOBP readings compare favourably with 24-hour ambulatory BP measurements in the appraisal of cardiac remodelling and, as such, could be complementary to ambulatory readings in a way similar to home BP measurements.

Leptospirosis presenting in a woman with fulminant hepatic failure from Wilson's disease: a case report.

INTRODUCTION: We report an unusual case of Wilson's disease that was revealed by presentation of leptospirosis. The prompt detection of this potentially life-threatening disease highlights the importance of careful investigation. To the best of our knowledge, this is the first reported case of leptospirosis involving the development of fulminant liver failure due to Wilson's disease. CASE PRESENTATION: A 17-year-old Caucasian woman presented with fever, rigors, vomiting and scleral jaundice. Following clinical and laboratory evaluation she was diagnosed with leptospirosis. After remission of this disease her condition inexplicably deteriorated. Further investigations revealed that she had Wilson's disease. CONCLUSIONS: The unexplained deterioration of hepatic function in a young person in remission from leptospirosis should alert the clinician to the presence of an underlying disorder, such as Wilson's disease, the early detection of which is crucial to the prognosis. The mechanism that initiates the development of Wilson's disease is not fully understood, but it is thought that an intercurrent illness, such as viral infection or drug toxicity, could be implicated. In our case, leptospirosis appeared to precipitate the deterioration of liver function in a patient with Wilson's disease, advancing our knowledge of this association. This original case report could have a broader clinical impact across medicine.