Late Onset Diaphragmatic Hernia: A Forgotten Etiology of Recurrent Vomiting in the Adolescent Population.

Diaphragmatic hernia is a rare disorder in adolescents with oftentimes delayed diagnosis due to late-onset and non-specific clinical manifestations. In this report, we present a case of diaphragmatic hernia in an 18-year-old male, where initial diagnosis was complicated by confounding factors of type 1 diabetes mellitus and cannabinoid hyperemesis syndrome. This case highlights the importance of having a high index of suspicion for diaphragmatic hernia in patients with nonspecific gastrointestinal symptoms to ensure timely recognition and surgical intervention.

Use of Organ Dysfunction as a Primary Outcome Variable Following Cecal Ligation and Puncture: Recommendations for Future Studies.

Outcomes variables for research on sepsis have centered on mortality and changes in the host immune response. However, a recent task force (Sepsis-3) revised the definition of sepsis to "life-threatening organ dysfunction caused by a dysregulated host response to infection." This new definition suggests that human studies should focus on organ dysfunction. The appropriate criteria for organ dysfunction in either human sepsis or animal models are, however, poorly delineated, limiting the potential for translation. Further, in many systems, the difference between "dysfunction" and "injury" may not be clear. In this review, we identify criteria for organ dysfunction and/or injury in human sepsis and in rodents subjected to cecal ligation and puncture (CLP), the most commonly used animal model of sepsis. We further examine instances where overlap between human sepsis and CLP is sufficient to identify translational endpoints. Additional verification may demonstrate that these endpoints are applicable to other animals and to other sepsis models, for example, pneumonia. We believe that the use of these proposed measures of organ dysfunction will facilitate mechanistic studies on the pathobiology of sepsis and enhance our ability to develop animal model platforms to evaluate therapeutic approaches to human sepsis.

Pleth Variability Index to Assess Course of Illness in Children with Asthma.

BACKGROUND: Status asthmaticus (SA) is a common reason for admission to the pediatric emergency department (ED). Assessing asthma severity efficiently in the ED can be challenging for clinicians. Adjunctive tools for the clinician have demonstrated inconsistent results. Studies have shown that pulsus paradoxus (PP) correlates with asthma severity. Pleth Variability Index (PVI) is a surrogate measure of PP. OBJECTIVE: We investigated whether PVI at triage correlates with disposition from the ED. METHODS: We recruited children aged 2-18 years old who presented to the pediatric ED of a tertiary care children's hospital with SA. PVI, Respiratory Severity Score, and vital signs were documented at triage and 2 hours into each patient's ED stay. PVI was measured using the Masimo Radical-7® monitor (Masimo Corp., Irvine, CA). RESULTS: Thirty-eight patients were recruited. Twenty-seven patients were discharged home, 10 patients were admitted to the general pediatrics floor and 1 patient was admitted to the intensive care unit. PVI values at triage did not correlate with disposition from the ED (p = 0.63). Additionally, when trending the change in PVI after 2 hours of therapy in the ED, no statistically significant patterns were demonstrated. CONCLUSIONS: Our study did not demonstrate a correlation between PVI and clinical course for asthmatics. PVI may be more clinically relevant in sicker children. Furthermore, it is possible that continuous monitoring of PVI may demonstrate more unique trends in relation to asthma severity versus single values of PVI. Additional studies are necessary to help clarify the relationship between PVI and the clinical course of children with SA.

Using Pleth Variability as a Triage Tool for Children With Obstructive Airway Disease in a Pediatric Emergency Department.

OBJECTIVES: Patients with obstructive airway disease have varying degrees of pulsus paradoxus that correlate with illness severity. Pulsus paradoxus can be measured using plethysmography. We investigated whether plethysmograph (pleth) variability on admission to the pediatric emergency department (ED) could predict patient disposition. We hypothesized that patients with a larger pleth variability would have a higher likelihood of being admitted to a general pediatrics unit or the intensive care unit (ICU). METHODS: We conducted a prospective single-center study of children aged 1 to 18 years who presented to a pediatric ED with a diagnosis of asthma or reactive airway disease. The pleth variability index (PVI) was calculated from their initial plethysmography tracing. Disposition from the ED was recorded as discharge, admission to the floor, or admission to the ICU. RESULTS: A total of 117 patients were included in our study. Forty-eight patients were discharged home, 61 were admitted to the floor, and 8 were admitted to the ICU. The median PVI for each of these groups was 0.27 (interquartile range [IQR], 0.19-0.39) for discharges, 0.29 (IQR, 0.20-0.44) for patients admitted to the floor, and 0.56 (IQR, 0.35-0.70) for patients admitted to the ICU. A Kruskal-Wallis test demonstrated a significant difference in the PVI between each of the groups (P = 0.0087). CONCLUSIONS: Our results suggest that PVI may be a useful tool in the triage of children who present to the ED with obstructive airway disease. Further studies should aim to assess the validity of PVI in predicting the response to bronchodilator therapy during the course of a patient's hospitalization.