Absence Of Life-threatening Complications Research Articles

Medical and conservative surgical management of bacterial sternoclavicular joint septic arthritis: a case series.

Sternoclavicular joint septic arthritis (SCJ SA) is a rare infectious disease process with reported life-threatening complications such as mediastinal abscess and mediastinitis. The available literature reports variable success of medical management and a predominance of surgical management, with a 58% rate of surgical washout/debridement and high rates (47%) of resection of the SCJ and medial third of the clavicle. A retrospective case series of radiologically or microbiologically confirmed cases of bacterial SCJ SA at Fiona Stanley Hospital was analysed. Demographic data, investigations, management and outcomes were assessed. Eleven cases of bacterial SCJ SA were identified. Eight cases were of primary SCJ SA, whilst three cases were secondary to haematogenous seeding. Recognized risk factors such as intravenous drug use, diabetes mellitus, trauma, smoking and immunosuppression were present. The most common complication was clavicular osteomyelitis (64%). Life-threatening complications included mediastinal abscess and rapidly progressive necrotizing myositis. Nine patients (82%) were managed with primary medical therapy, with two patients failing antibiotic therapy and requiring joint washout. Two patients were taken for urgent washout on presentation. Four cases (36%) resulted in operative SCJ washout. There were no cases requiring resection of the SCJ or clavicle. This series suggests that SCJ SA can be primarily treated medically in the absence of life-threatening complications. In addition, medical management may be sufficient for cases complicated by clavicular osteomyelitis. Need for surgical resection of the SCJ and medial third of the clavicle may be less than previously reported.

Renal replacement therapy in critically ill patients: who, when, why, and how.

The increasing incidence of acute kidney injury has the immediate effect of a growing need for renal replacement therapy (RRT). Shedding light on the questions of who, when, why, and how RRT should be performed is difficult to accomplish because of ambiguous study results, poor quality evidence, and low standardization. Critically ill patients are exposed to multiple factors known to deteriorate kidney function. Especially severe fluid overload is strongly associated with worse outcome and may be considered as a trigger for initiating RRT. In the absence of life-threatening complications, a strategy of early initiation of RRT might be most advantageous keeping in mind the potential adverse effects of RRT. By providing better hemodynamic stability and superior control of fluid balance continuous RRT is the first choice therapeutic tool as compared with intermittent techniques. The femoral and jugular veins are the preferred insertion sites for temporary catheters. Although data are still weak, there is some preliminary evidence that regional citrate anticoagulation is superior to systemic heparinization. The best management of RRT is still a subject of controversy. Continuous RRT with regional citrate anticoagulation via a temporary catheter in a jugular vein is the recommended first choice treatment option in critically ill patients with acute kidney injury.

Exertional heat illness in a Marine training on the endurance course

Exercise-induced heat stroke is defined as core temperature greater than 104 degrees F (400 degrees C) accompanied by signs or symptoms of organ system failure, most commonly CNS dysfunction. Exertional heatstroke is a life-threatening emergency that requires immediate whole-body cooling for a satisfactory outcome. Cooling should be initiated and, in the absence of life-threatening complications, completed on site prior to evacuation to an emergency department or other facility. Cool-water immersion provides the fastest whole body cooling rate and the lowest morbidity and mortality for exertional heat stroke. When water immersion is unavailable, ice water towels combined with ice packs on the head, trunk, and extremities provide effective but slower whole-body cooling. Medications, including antipyretics and dantrolene, are not effective in treating heatstroke and should not be used. Clinical observations indicate that prognosis is closely linked to the amount of time a patient's temperature remains elevated. Prevention strategies are essential to reducing the incidence of exertional heatstroke, heat exhaustion, and exercise-associated muscle cramping.

Acacia gum supplementation of a low-protein diet in children with end-stage renal disease

Patients with end-stage renal disease (ESRD) die in the absence of renal replacement therapy (RRT). In developing countries RRT is not uniformly available and treatment often relies on conservative management and intermittent peritoneal dialysis (IPD). This study investigates the possibility of using acacia gum supplementation to improve the quality of life and provide children with ESRD with a dialysis-free period. Three patients referred to our hospital with ESRD during a 3-month period were enrolled in a therapeutic trial to investigate the efficacy of acacia gum (1 g/kg per day in divided doses) as a complementary conservative measure aimed at improving the quality of life. Inclusion criteria included a pre-dialysis creatinine clearance of <5 ml/min, current dietary restrictions and supplementation, at least one dialysis session to control uremic symptoms, absence of life-threatening complications, and sufficient motivation to ensure compliance with the study protocol. One patient complied with the protocol for only 10 days and died after 6 months, despite IPD. Two patients completed the study. Both reported improved well-being. Neither became acidotic or uremic, and neither required dialysis during the study period. Both patients maintained urinary creatinine and urea levels not previously achieved without dialysis. In conclusion, dietary supplementation with acacia gum may be an alternative to renal replacement therapy to improve the quality of life and reduce or eliminate the need for dialysis in children with ESRD in some developing countries.

Report of the xenotransplantation advisory committee of the international society for heart and lung transplantation:: The present status of xenotransplantation and its potential role in the treatment of end-stage cardiac and pulmonary diseases

An urgent and steadily increasing need exists world-wide for a greater supply of donor thoracic organs. Xenotransplantation offers the possibility of an unlimited supply of hearts and lungs that could be available electively when required. However, anti-body- mediated mechanisms cause the rejection of pig organs transplanted into non-human primates, and these mechanisms provide major immunologic barriers that have not yet been overcome. Having reviewed the literature on xenotransplantation, we present a number of conclusions on its present status with regard to thoracic organs, and we make a number of recommendations relating to eventual clinical trials. Although pig hearts have functioned in heterotopic sites in non-human primates for periods of several weeks, median survival of orthotopically transplanted hearts is currently ,1 month. No transplanted pig lung has functioned for even 24 hours. Current experimental results indicate that a clinical trial would be premature. A potential risk exists, hitherto undetermined, of transferring infectious organisms along with the donor pig organ to the recipient, and possibly to other members of the community. A clinical trial of xeno-transplantation should not be undertaken until experts in microbiology and the relevant regulatory authorities consider this risk to be minimal. A clinical trial should be considered when approximately 60% survival of life-supporting pig organs in non-human primates has been achieved for a minimum of 3 months, with at least 10 animals surviving for this minimum period. Furthermore, evidence should suggest that longer survival (.6 months) can be achieved. These results should be achieved in the absence of life-threatening complications caused by the immunosuppressive regimen used. The relationship between the presence of anti-HLA antibody and anti-pig antibody and their cross-reactivity, and the outcome of pig-organ xenotransplantation in recipients previously sensitized to HLA antigens require further investigation. We recommend that the patients who initially enter into a clinical trial of cardiac xenotransplantation be unacceptable for allotransplantation, or acceptable for allotransplantation but unlikely to survive until a human cadaveric organ becomes available, and in whom mechanical assist-device bridging is not possible. National bodies that have wide-reaching government-backed control over all aspects of the trials should regulate the initial clinical trial and all subsequent clinical xenotransplantation procedures for the foreseeable future. We recommend coordination and monitoring of these trials through an international body, such as the International Society for Heart and Lung Transplantation, and setting up a registry to record and widely disperse the results of these trials. Xenotransplantation has the potential to solve the problem of donor-organ supply, and therefore research in this field should be actively encouraged and supported.

Diagnostic aids in inflammatory pseudotumor of the liver

Inflammatory pseudotumor (IPT) of the liver is a rare entity often mistaken for malignancy. All children reported to date have been diagnosed and treated surgically, whereas successful medical diagnosis and treatment has been reported in adults. In this report, we describe the 13th child presenting with IPT of the liver and review the literature to determine diagnostic means to avoid unnecessary surgery. There are no specific presumptive clinical and laboratory findings, including tumor markers and imaging techniques, that distinguish IPT from other space-occupying liver lesions. The negativity of malignant liver tumor markers and hepatitis antigens and normal liver, renal, and other systems are supportive of IPT. The most important diagnostic aid is to bear this entity in mind when a child presents with an unexplained liver mass. Fine-needle aspiration is the most helpful measure to confirm the diagnosis. Surgery should be avoided in the absence of life-threatening complications.

Gastroesophageal reflux

It is now widely recognized that gastroesophageal reflux causes a number of symptoms in children. Numerous tests have been developed and document the presence of GER, but none is infallible, partially because some reflux is a normal phenomenon. A carefully obtained history and esophagram are the two most useful and available clinical tools. Other tests are useful if there is no agreement between history and esophagram, if specific problems need to be documented (esophagitis), or if more certain documentation is desired because of atypical disease or in anticipation of surgery. If two tests of esophageal function agree, presence or absence of GER is diagnosed with a high degree of accuracy. At present, there is no test that will consistently demonstrate that reflux is causing respiratory symptoms. Most cases of GER in infants will respond to therapy or benign neglect by the time the babies are 18 months of age. This is in contrast to the adult situation, where reflux exists for decades and therapy is directed at the chief symptom, heartburn. Unless there are life-threatening complications or strictures, an intensive course of medical therapy is indicated. Positional therapy is presently the keystone of medical therapy, but is less effective and harder to institute in older patients. Use of thickened feedings may have some benefit. If heartburn or esophagitis is present, attempts to neutralize gastric contents are indicated. Some experience is developing in the use of drugs to control reflux, and a trial of bethanechol is warranted in difficult cases. Since most cases will improve by 18 months of age, therapy is required for only a limited time. At present, surgery is quite safe and is very effective in controlling reflux, although there is no clear consensus on how prolonged and severe symptoms must be to justify surgery in the absence of life-threatening complications.