Association Between Volume of Fluid Resuscitation and Intubation in High-Risk Patients With Sepsis, Heart Failure, End-Stage Renal Disease, and Cirrhosis.

BACKGROUND: Initial fluid resuscitation volume for sepsis is controversial, particularly in patients at high baseline risk for complications. This study was designed to assess the association between 30 mL/kg crystalloids and intubation in patients with sepsis or septic shock and heart failure, end-stage renal disease, or cirrhosis. METHODS: This propensity score-matched retrospective cohort study included patients with sepsis or septic shock admitted to a large medical ICU. Primary exposure was IV fluid volume in the first 6 h following sepsis diagnosis, divided into two cohorts: ≥ 30 mL/kg (standard group) and < 30 mL/kg (restricted group). The primary outcome was need for mechanical ventilation within 72 h following initiation of fluid resuscitation. Secondary outcomes were length of stay, ventilator days, and time to intubation. RESULTS: A total of 208 patients were included, with 104 (50%) in the restricted group (< 30 mL/kg) and 104 in the standard group (≥ 30 mL/kg). No difference in intubation incidence was detected between the two groups, with 36 patients (35%) in the restricted group and 33 (32%) in the standard group (adjusted OR, 0.75; 95% CI, 0.41-1.36; P = .34) intubated. There was no difference between standard and restricted groups in alive ICU-free days (17 ± 11 days vs 17 ± 10 days; P = .64), duration of mechanical ventilation (10 ± 12 days vs 11 ± 16 days; P = .96), or hours to intubation (16 ± 19 h vs 14 ± 15; P = .55). CONCLUSIONS: No differences were detected in the incidence of intubation in patients with sepsis and cirrhosis, end-stage renal disease, or heart failure who received guideline-recommended fluid resuscitation with 30 mL/kg compared with patients initially resuscitated with a lower fluid volume.

Pulmonary Edema Following Initiation of Parenteral Prostacyclin Therapy for Pulmonary Arterial Hypertension: A Retrospective Study.

BACKGROUND: Pulmonary edema may complicate the use of pulmonary arterial hypertension (PAH)-targeted therapies. We aimed to determine the proportion of patients who develop pulmonary edema after initiation of parenteral prostacyclin therapy, to identify its risk factors, and to assess its implications for hospital length of stay and mortality. METHODS: A retrospective cohort study of patients with PAH at the initiation of parenteral prostacyclin between 1997 and 2015 enrolled in the Cleveland Clinic PAH registry. Pulmonary edema was defined as at least one symptom or clinical sign and radiographic evidence of pulmonary edema. We determined patient characteristics predictive of pulmonary edema as well as the association between pulmonary edema and hospital length of stay (LOS) and 6-month mortality. RESULTS: One hundred and fifty-five patients were included (median age, 51 years; female, 72%; white, 85%; idiopathic, 64%; and connective tissue disease [CTD], 23%). Pulmonary edema developed in 33 of 155 patients (21%). Independent predictors of pulmonary edema were high right atrial pressure (RAP), CTD etiology, and the presence of three or more risk factors for left heart disease (LHD). Pulmonary edema was associated with a 4.5-day increase in hospital LOS (95% CI, 1.4-7.5 days; P < .001) and a 4-fold increase in 6-month mortality (OR, 4.3; 95% CI, 1.28-14.36; P = .031). CONCLUSIONS: Pulmonary edema occurred in 21% of patients with PAH initiated on parenteral prostacyclin. Three or more risk factors for LHD, CTD-PAH, and a high baseline RAP were independent predictors of pulmonary edema. Pulmonary edema was associated with a prolonged hospital LOS and increased 6-month mortality.

Challenges in the diagnosis and management of spontaneous bile duct perforation: A case report and review of literature.

We report a case of 14-year-old male, who presented to us with complaints of severe pain in abdomen, vomiting, and inability to pass feces and flatus. He was diagnosed as a case of peritonitis after careful history, examination, and investigations. The exact cause of peritonitis was not known. Exploratory laparotomy was done, and it was found that there was perforation of the right hepatic duct about 1 cm proximal to its confluence with the left hepatic duct. Perforation was closed around the T-tube. Postoperative T-tube cholangiogram was done after 3 weeks which confirmed the free passage of dye into the duodenum, and there was no leakage of dye. T-Tube was removed 4 weeks after the operation, and the patient was discharged in satisfactory condition. Postoperative follow-up was done for 3 months, and it was uneventful.

Spontaneous intestinal perforation.

Neonatal necrotizing enterocolitis, the most common gastrointestinal emergency in neonates, typically affects the preterm infants and carries high mortality. Classic clinical trad consists of abdominal distension, bloody stools, and pneumatosis intestinalis. Occasionally, signs and symptoms may not be classic and a number of papers have highlighted the difficulty of relying on radiological features to make a definitive diagnosis of necrotising enterocolitis. We report herein a case of neonate referred to us as a case of obstructed inguinal hernia and was diagnosed as a necrotizing enterocolitis perforation revealed by a rare manifestation of pneumoscrotum.

Routine histopathological examination of appendectomy specimens in children: is there any rationale?

OBJECTIVE: Primary carcinoma of the bowel is a rare malignancy in pediatric age group. The aim of the study was to assess the incidence of appendicular malignancies in children and the possibility of reducing the need for routine histopathological examination of appendix. MATERIALS AND METHODS: In last 15 years, all the cases of appendectomies in children were analyzed. Retrospective analysis of the data was done to document the clinical presentation, diagnosis, outcome and histopathology reports of the specimen. The case files and operation notes were studied thoroughly in cases where HPR was positive for malignancy. RESULTS: From July 1995 to June 2010, 595 appendectomies were done in children. Three cases of carcinoid tumor were detected. All were less than 1 cm and were on the tip of the appendix. There was no preoperative or intraoperative suspicion. CONCLUSION: Routine histopathological analysis did not help in the management of any of the cases. Therefore, selective utilization of the already burdened histopathology section of the hospital would be more cost effective without affecting the patient outcome.

Beware of neonatal appendicitis.

We report a neonate with acute appendicitis who was mistakenly diagnosed and treated initially as neonatal necrotizing enterocolitis. The diagnostic dilemma of this rare and life-threatening condition in premature babies and newborns is underlined. Awareness of this rare condition and possible differential diagnosis in this age group is also discussed.

Macrodystrophia lipomatosa: four case reports.

AIM: Macrodystrophia lipomatosa is a rare cause of gigantism of limb which can be confused with other common causes like congenital lymphedema. It presents usually with loss of function and cosmetic problems. Four cases are described with emphasis on clinical presentation, differential diagnoses, imaging and treatment options. METHODS & RESULTS: Four patients of macrodystrophia lipomatosa were thoroughly examined and subjected to investigations. CONCLUSION: Besides diligent clinical examination, imaging and histopathology are crucial in clinching the diagnosis.

Role of shunts with antisiphon device in treatment of pediatric hydrocephalus.

OBJECTIVE: The use of ventriculo-peritoneal shunts having antisiphon device has been reported in adult patients, but there is a dearth of experience with such shunts in pediatric age group. This study is being undertaken to compare the effectiveness of these types of shunt for the treatment of congenital hydrocephalus. PATIENTS AND METHODS: Forty patients with congenital hydrocephalus with or without neural tube were divided randomly into two groups (A and B). Patients in antisiphon group were treated with shunts with differential valve including antisiphon device (Vygon shunt) while patients in non-antisiphon group were treated with differential valve shunts (Chhabra shunt and Ceredrain). Mann-Whitney test, asymmetric t-test and Chi-square test were used to assess the correlation and the significance. RESULTS: The mean age was 3.5 months and 3.4 months in antisiphon group and non-antisiphon group, respectively. The M:F ratio was 2.3:1 in antisiphon group while it was 3:1 in non-antisiphon group. The mean decrease in OFC was more in non-antisiphon group than antisiphon group during the follow up from 3 months to 6 months while mean decrease in MEI was more in non-antisiphon group from 0 month to 3 months than antisiphon group. There were two cases of shunt overdrainage in non-antisiphon group. The shunt blockage rate was 20% in antisiphon group and 15% in non-antisiphon group, respectively. There was 20% and 15% shunt infection rate in antisiphon group and non-antisiphon group, respectively. This study demonstrated overdrainage syndrome in two of the patients of differential valve shunts. CONCLUSION: Though rare, complication associated with overdrainage is certainly a problem in children. In our study, the patients who received shunts with antisiphon device do not show any overdrainage.

Children with significant cervical lymphadenopathy: clinicopathological analysis and role of fine-needle aspiration in Indian setup.

OBJECTIVE: To study the clinicopathological profile of children from India with cervical lymphadenopathy and the role of fine-needle aspiration cytology with special emphasis on tuberculosis as a cause. METHODS: A total of 89 children in the age group of 10 months to 12 years, presenting to our hospital from April 2004 to March 2005, were included. All the patients underwent thorough clinical and investigational assessment vis-à-vis cervical lymphadenopathy. Outcome measurements included clinical status and ability of conventional tests to categorize different types of lymphadenopathy and their utility in diagnosing tubercular lymphadenitis. Interobserver variability was analyzed measuring kappa test and was found to be in agreement. RESULTS: Reactive hyperplasia was the most common type of lymphadenitis, followed by granulomatous involvement. Unilateral posterior triangle lymph nodes were the most commonly affected in the tubercular cervical lymphadenopathy group. Fine-needle aspiration followed by Ziehl-Neelsen staining, histopathology and culture in combination were able to perform the diagnosis in 85.7% of cases affected with tubercular etiology. CONCLUSIONS: Fine-needle aspiration is a valuable diagnostic tool in the management of children with the clinical presentation of enlarged cervical lymph nodes. The technique reduces the need for more invasive and costly procedures, especially in a Third World country. Culture and histopathology, however, should be considered in cases where repeated fine-needle aspiration cytology is non-diagnostic.

Crianças com linfadenopatia cervical significativa: análise clínico-patológica e papel da aspiração por agulha fina no contexto indiano / Children with significant cervical lymphadenopathy: clinicopathological analysis and role of fine-needle aspiration in Indian setup

OBJETIVO: Estudar o perfil clínico-patológico de crianças indianas com linfadenopatia cervical e o papel da citologia aspirativa por agulha fina com ênfase especial na tuberculose como causa. MÉTODOS: Foram incluídas 89 crianças com faixa etária de 10 meses a 12 anos, admitidas em nosso hospital de abril de 2004 a março de 2005. Todos os pacientes foram submetidos a completa avaliação clínica e investigativa em relação à linfadenopatia cervical. Medidas de desfecho incluíram estado clínico e a capacidade de testes convencionais em categorizar tipos diferentes de linfadenopatia e sua utilidade no diagnóstico de linfadenite tuberculosa. A variabilidade interobservador foi analisada através do teste de kappa, tendo boa concordância. RESULTADOS: A hiperplasia reativa foi o tipo mais comum de linfadenite, seguida da granulomatosa. Os linfonodos do triângulo posterior unilateral foram o grupo afetado com maior freqüência no grupo de linfadenopatia cervical tuberculosa. A aspiração por agulha fina, seguida da coloração de Ziehl-Neelsen, histopatologia e cultura em associação, obteve sucesso em realizar o diagnóstico em 85,7 por cento dos casos de etiologia tuberculosa. CONCLUSÕES: A aspiração por agulha fina é uma ferramenta diagnóstica valiosa no tratamento de crianças com apresentação clínica de linfonodos cervicais aumentados. A técnica reduz a necessidade de procedimentos mais invasivos e dispendiosos, principalmente em países em desenvolvimento.Cultura e histopatologia, entretanto, devem ser consideradas em casos nos quais a citologia aspirativa por agulha fina não é diagnóstica.

OBJECTIVE: To study the clinicopathological profile of children from India with cervical lymphadenopathy and the role of fine-needle aspiration cytology with special emphasis on tuberculosis as a cause. METHODS: A total of 89 children in the age group of 10 months to 12 years, presenting to our hospital from April 2004 to March 2005, were included. All the patients underwent thorough clinical and investigational assessment vis-à-vis cervical lymphadenopathy. Outcome measurements included clinical status and ability of conventional tests to categorize different types of lymphadenopathy and their utility in diagnosing tubercular lymphadenitis. Interobserver variability was analyzed measuring kappa test and was found to be in agreement. RESULTS: Reactive hyperplasia was the most common type of lymphadenitis, followed by granulomatous involvement. Unilateral posterior triangle lymph nodes were the most commonly affected in the tubercular cervical lymphadenopathy group. Fine-needle aspiration followed by Ziehl-Neelsen staining, histopathology and culture in combination were able to perform the diagnosis in 85.7 percent of cases affected with tubercular etiology. CONCLUSIONS: Fine-needle aspiration is a valuable diagnostic tool in the management of children with the clinical presentation of enlarged cervical lymph nodes. The technique reduces the need for more invasive and costly procedures, especially in a Third World country. Culture and histopathology, however, should be considered in cases where repeated fine-needle aspiration cytology is non-diagnostic.