A man with culture sterile cavitating lung lesions: molecular techniques can provide the key to diagnosis.

A 20-year-old male presented to the Emergency Department with pyrexia, dyspnoea, chest pain and haemoptysis. Cavitating lung lesions were noted on chest X-ray and the patient was admitted to the intensive care unit where he was intubated and ventilated. Routine investigations including serial cultures did not provide an aetiological diagnosis. As such, a CT-guided lung biopsy was carried out and 16S rDNA PCR was undertaken on the sample. This identified Fusobacterium necrophorum as the causative organism. The patient was treated for Lemierre's syndrome and successfully discharged from hospital. This case highlights how DNA tissue typing on a lung biopsy sample can be the key to successful diagnosis in an atypical pneumonia and raises the question as to whether this infrequently used approach should be added to forthcoming community acquired pneumonia guidelines.

Frailty is associated with adverse outcome from in-hospital cardiopulmonary resuscitation.

AIM: To assess whether frailty was associated with cardio-pulmonary resuscitation (CPR) outcome in a UK setting. METHOD: Retrospective review of prospectively collected data on in-hospital cardio-respiratory arrests between 1/1/17 and 31/12/17. Clinical Frailty Scale (CFS) scores were assigned from notes review, patients with CFS scores ≥6 signified moderate or greater frailty. RESULTS: There were 179 in-hospital cardiac arrest cases where the CFS could be calculated. The median age on admission was 74 (mean 71, range 27-102), 110 patients were male and 69 female. The initial rhythm was non-shockable in 64% of cases. In 49% of cases return of spontaneous circulation (ROSC) was achieved, 22% of the study population survived to hospital discharge. Moderate or greater frailty was present in 31.3% of patients. Return of spontaneous circulation (ROSC) was achieved in 56.1% of patients with a CFS score of 1-5 and 32.1% with scores 6-9 (p < 0.001). Survival to hospital discharge was also associated with frailty, being seen in 31.7% of CFS 1-5 patients but only in 1.8% of CFS 6-9 patients (p < 0.001). In multivariable analysis adjusting for age, presenting rhythm and admitting specialty the effect of frailty on survival to discharge remained significant (p = 0.044). CONCLUSION: Patients with moderate or greater frailty as determined by CFS score are unlikely to survive to hospital discharge even if ROSC occurs following CPR. This should be considered when making resuscitation status and ceiling of care decisions in this patient group.

Functional Segregation within the Muscles of Aquatic Propulsion in the Asiatic Water Monitor (Varanus salvator).

Water monitor lizards (Varanus salvator) swim using sinusoidal oscillations generated at the base of their long (50% of total body length) tail. In an effort to determine which level of the structural/organizational hierarchy of muscle is associated with functional segregation between the muscles of the tail base, an array of muscle features-myosin heavy chain profiles, enzymatic fiber types, twitch and tetanic force production, rates of fatigue, muscle compliance, and electrical activity patterns-were quantitated. The two examined axial muscles, longissimus, and iliocaudalis, were generally similar at the molecular, biochemical, and physiological levels, but differed at the biomechanics level and in their activation pattern. The appendicular muscle examined, caudofemoralis, differed from the axial muscles particularly at the molecular and physiological levels, and it exhibited a unique compliance profile and pattern of electrical activation. There were some apparent contradictions between the different structural/organizational levels examined. These contradictions, coupled with a unique myosin heavy chain profile, lead to the hypothesis that there are previously un-described molecular/biochemical specializations within varanid skeletal muscles.

Always consider the possibility of opioid induced respiratory depression in patients presenting with hypercapnic respiratory failure who fail to improve as expected with appropriate therapy.

Hypercapnic respiratory failure is a frequently encountered medical emergency. Two common causes are acute exacerbations of chronic obstructive pulmonary disease (COPD) and as a side effect of opioids. The two causes may coexist leading to diagnostic confusion and consequent delay in optimal management. We report a case of what was initially thought to be an exacerbation of COPD. The patient failed to improve with treatment as expected which led to the empirical administration of naloxone resulting in a dramatic reversal of her respiratory failure. The patient was subsequently discovered to be taking regular dihydrocodeine for chronic back pain.

Under-diagnosis of diabetes mellitus in patients with coronary artery disease.

BACKGROUND: The uptake of medical treatment in patients with coronary artery disease may be suboptimal. Our intention was to review the medical treatment of these patients in the light of current evidence. METHODS: One hundred ninety six consecutive patients with known or suspected coronary artery disease attending a tertiary centre for day case cardiac catheterisation were assessed. Fasting blood samples were sent for glucose and cholesterol. The results of coronary angiography and left ventriculography and any changes in medications were noted. RESULT: One hundred eighty two patients (93%) had fasting blood samples taken. The management of cholesterol in patients with coronary artery disease has improved since 1994. We have demonstrated the benefit of taking fasting blood samples in patients attending for day case angiography: 10% of non-diabetics actually had fasting blood glucose levels of greater than 7.0 mmol/l. All of these newly diagnosed diabetics had coronary artery disease. A further 9% of non-diabetics had impaired fasting glycaemia; 69% had coronary artery disease and 8% had left ventricular dysfunction. Among patients with coronary artery disease, there was a statistically significant increase on most categories of medications on discharge compared to admission. For those with left ventricular dysfunction, there was a statistically significant increase in the use of Angiotensin-Converting-Enzyme (ACE)-inhibitors. CONCLUSION: Diabetes mellitus is under-diagnosed in patients with coronary heart disease. They are at higher risk of coronary artery disease and therefore need intensive management. Testing all patients attending for day case cardiac catheterisation for fasting glucose would enable diagnosis and initiation of treatment of a high-risk group.

Critical care management of neuromuscular disease, including long-term ventilation.

PURPOSE OF REVIEW: This review highlights recent advances in the critical care management of neuromuscular disease, particularly in the long-term management of chronic respiratory failure occurring as a consequence of neuromuscular disease. RECENT FINDINGS: Although randomized clinical trial evidence of benefit is sparse, a large volume of nonrandomized clinical trial evidence has accumulated demonstrating that noninvasive positive pressure ventilation prolongs and improves quality of life in conditions such as Duchenne muscular dystrophy and motor neuron disease. SUMMARY: Immunomodulatory treatments favorably modify the course of neuromuscular diseases such as Guillain-Barré syndrome, whereas long-term noninvasive positive pressure ventilation has transformed the outlook in previously untreatable conditions such as motor neuron disease and muscular dystrophies. The availability of long-term noninvasive positive pressure ventilation raises major medical, social, economic, and ethical issues that are increasingly being investigated and discussed.

Endocrine measurements in survivors and non-survivors from critical illness.

OBJECTIVE: To compare measurements of thyroid and adrenal function between survivors and non-survivors in critical illness. DESIGN AND SETTING: Prospective, observational study at the medical/surgical intensive care unit (ICU) at Royal Infirmary of Edinburgh, Scotland. PATIENTS: 163 patients admitted to the intensive care unit over a 4-month period. INTERVENTIONS: We took blood samples within 1 h of ICU admission, and at 08:00 hours on the subsequent 2 days of ICU admission. We measured serum total (TT(4)) and free (fT(4)) thyroxine, total (TT(3)) and free (fT(3)) tri-iodothyronine, thyrotropin (TSH) and plasma cortisol concentrations. MEASUREMENTS AND RESULTS: TT(3) and TT(4) concentrations were significantly less in non-survivors than in survivors on admission and on day 1 but not on day 2. Cortisol concentrations were higher in non-survivors on admission and on day 1 but not on day 2. TSH, fT(3) and fT(4) concentrations did not differ significantly between survivors and non-survivors at any time. Only TT(4) and cortisol were independent predictors of outcome. Prediction of outcome from the admission sample values was not better than using APACHE II scoring. CONCLUSIONS: Thyroid hormone and cortisol concentrations differ between survivors and non-survivors on admission to intensive care, but the values overlap. These differences do not allow accurate prediction of outcome from critical illness.