Association between fluid balance and survival in critically ill patients.

OBJECTIVE: Although the consequences of chronic fluid retention are well known, those of iatrogenic fluid retention that occurs during critical illness have not been fully determined. Therefore, we investigated the association between fluid balance and survival in a cohort of almost 16,000 individuals who survived an intensive care unit (ICU) stay in a large, urban, tertiary medical centre. DESIGN: Longitudinal analysis of fluid balance at ICU discharge and 90-day post-ICU survival. MEASUREMENTS: Associations between fluid balance during the ICU stay, determined from the electronic bedside record, and survival were tested using Cox proportional hazard models adjusted for severity of critical illness. RESULTS: There were 1827 deaths in the first 90 days after ICU discharge. Compared with the lowest quartile of discharge fluid balance [median (interquartile range) -1.5 (-3.1, -0.7) L], the highest quartile [7.6 (5.7, 10.8) L] was associated with a 35% [95% confidence interval (CI) 1.13-1.61)] higher adjusted risk of death. Fluid balance was not associated with outcome amongst individuals without congestive heart failure or renal dysfunction. Amongst patients with either comorbidity, however, fluid balance was strongly associated with outcome, with the highest quartile having a 55% (95% CI 1.24-1.95) higher adjusted risk of death than the lowest quartile. Isotonic fluid balance, defined as the difference between intravenous isotonic fluid administration and urine output, was similarly associated with 90-day outcomes. CONCLUSION: Positive fluid balance at the time of ICU discharge is associated with increased risk of death, after adjusting for markers of illness severity and chronic medical conditions, particularly in patients with underlying heart or kidney disease. Restoration of euvolaemia prior to discharge may improve survival after acute illness.

X-ray illumination of the ejecta of supernova 1987A.

When a massive star explodes as a supernova, substantial amounts of radioactive elements--primarily (56)Ni, (57)Ni and (44)Ti--are produced. After the initial flash of light from shock heating, the fading light emitted by the supernova is due to the decay of these elements. However, after decades, the energy powering a supernova remnant comes from the shock interaction between the ejecta and the surrounding medium. The transition to this phase has hitherto not been observed: supernovae occur too infrequently in the Milky Way to provide a young example, and extragalactic supernovae are generally too faint and too small. Here we report observations that show this transition in the supernova SN 1987A in the Large Magellanic Cloud. From 1994 to 2001, the ejecta faded owing to radioactive decay of (44)Ti as predicted. Then the flux started to increase, more than doubling by the end of 2009. We show that this increase is the result of heat deposited by X-rays produced as the ejecta interacts with the surrounding material. In time, the X-rays will penetrate farther into the ejecta, enabling us to analyse the structure and chemistry of the vanished star.

Bilateral plantar amyloidosis: a unique presentation of localized cutaneous amyloidosis.

Nodular amyloidosis is uncommon and is due to a local production of amyloid by aberrant plasma cells. Localized bosselated plantar amyloidosis has been reported before but we present the first case to our knowledge of bilateral plantar amyloidosis. The clinical presentation as well as therapeutic options for this uncommon entity are reviewed.

Growth inhibition of oral streptococci in saliva by anionic proteins from two caries-free individuals.

Mixed saliva from two caries-free individuals possessed antimicrobial activity toward Streptococcus mutans and S. sanguis. This inhibitory activity was attributed to the presence of a group of four anionic proteins each of which strongly inhibited the growth of the oral streptococci in a saliva protein-based medium but not in a medium containing amino acids as a nitrogen source. These proteins, with isoelectric points of 4.70, 4.90, 4.98, and 5.05, respectively, neither reacted with antisera to immunoglobulin A, G, or M nor appeared to be functionally related to a number of salivary peroxidases, lactoferrin, or lysozyme. On this basis, they may represent a previously unreported group of growth-inhibitory antimicrobial factors occurring in the saliva of some individuals.

Visual field defects produced by basilar artery ectasia.

The authors report two cases of visual field defects which are postulated to be due to the distal end of an elongated basilar artery compressing the visual pathways in the posterior suprasellar region. The mechanism of production of these defects is discussed, relating the abnormal position of the distal end of the basilar artery to a normally situated or only slightly post-fixed optic chiasm and optic tract and to a markedly post-fixed optic chiasm.

Computerized tomography in rhabdomyosarcoma of the head and neck.

Rhabdomyosarcoma of the head and neck may be treated with surgery, radiotherapy and chemotherapy or a combination thereof. Precise delineation of the full extent of the tumor in the head and neck is essential. Routine radiographs with hypocycloidal tomography and CT are complementary in defining the full extent of the lesion. Tomography is superior to CT scanning in demonstrating fine bone detail. Demonstration of the soft tissue tumor and its extensions is better seen on CT. The ability to discriminate differences more accurately in densities allows computerized tomography to appreciate better the integrity of the bone margins such as the thin walls of the sinuses.

Radiographic features of olfactory neuroblastoma.

Olfactory neuroblastomas are malignant, slowly growing neurogenic tumors originating from the olfactory mucosa of the nasal cavity. Fourteen patients with this tumor were evaluated and showed variable extension into adjacent structures such as the ethmoid and sphenoid sinuses, orbit, and anterior cranial cavity.

Detection of foreign bodies with computerized tomography.

Computerized tomography scanning has been proven useful in defining complex anatomical areas of the head and neck and in delineating soft-density foreign bodies. This was helpful in a child in whom all other modalities, including surgical exploration, had failed to localize a foreign body.

The sella turcica in primary end organ failure.

Pituitary hyperplasia, or adenoma, may result from end or target organ failure as seen in primary hypothyroidism and hypogonadism. Associated enlargement of the sella turcica and contour alterations without significant increase in volume may be seen. A review was made of 12 patients with end organ failure demonstrating the spectrum of radiologic changes within the sella turcica. Recognition of pituitary enlargement resulting from end organ failure may eliminate unnecessary surgery.

Metastatic osteogenic sarcoma to the brain.

The radiographic appearances of intracranial metastases from primary osteogenic sarcomas in three patients are presented. In two patients, the diagnosis of metastatic disease could be made on conventional roentgenograms of the skull since mineralization of tumor osteoid could be seen within the brain parenchyma. This had a similar appearance to the primary bone tumor. Angiography in two of the three patients revealed the cerebral metastases to be hypervascular with tumor vessels, tumor stain and early draining veins.

Reactive pituitary abnormalities in patients with Klinefelter's and Turner's syndromes.

Ten unselected patients with gonadal dysgenesis, three with Klinefelter's and seven with Turner's syndromes, were studied. Two of the patients with Klinefelter's and two with Turner's syndromes had enlarged pituitary fossae. The other six patients had normal sized sella, but showed localized change in the sellar contour on polytomography, suggesting hyperplasia or microadenoma formation of the pituitary gland. All ten patients had abnormally high serum follicle-stimulating hormone levels both at basal and after luteinizing hormone-releasing hormone stimulation. These results suggest that hyperplasia or microadenoma of the pituitary gland may occur secondary to gonadal failure, producing enlarged volume or attenuation in the normal contour of the sella turcica. Lack of awareness of reactive pituitary changes secondary to gonadal failure may result in inappropriate surgical management of what may appear to be primary pituitary tumor.

Computed tomography in ocular neoplastic disease.

The computed tomographic findings of four patients with neoplastic disease of the global rim are discussed. All four patients demonstrated eccentric thickening of the scleraluveal rim with extension into the globe. Possible ways of differentiating these lesions from other orbital conditions are discussed. Window widths below 100 EMI units are best to visualize neoplasms of the global rim. For evaluation of the orbits, multiple window widths with varying window levels should be used.

The transport of dimer-X to the subarachnoid cisterns and convexity of the brain in normal people: case reports.

Computerized axial tomographic scans were performed on 7 patients, 3, 8 and 20 hours after lumbar myelography with Dimer-X. This contrast agent was seen in the subarachnoid cisterns 3 and 8 hours after injection, and 24 hours after injection it had completely disappeared.

Computerised axial tomography of the head.

The technique and applicaton of computerised axial tomography of the head is briefly reviewed with regard to both normal and some pathological tomographic features.

Cranial and intracranial tuberculosis.

The radiographic appearances of cranial and intracranial tuberculous lesions are reviewed. The manifestations of cranial and intracranial tuberculosis vary according to the location, severity of involvement and the chronicity of the disease.