Complication Of Pneumonia Research Articles

Case Report—Escherichia coli Pericarditis after Recent COVID-19 Pneumonia

Before the widespread use of antibiotics, purulent pericarditis was not uncommon and was predominantly a complication of bacterial pneumonia. We present a rare case of Escherichia coli (E. coli) purulent pericarditis without a clear source after a recent COVID-19 infection. Background: COVID-19 has been affecting millions of people worldwide since the outbreak in December 2019, and its involvement in multiple organ systems has been observed and studied. Multiple cardiac complications have been reported, most significantly the virus’ ability to induce acute coronary syndrome and myocarditis. Pericardial disease has also been reported but less frequently. COVID-19 infection is associated with a higher risk of secondary bacterial infection, but it is rare to see purulent pericarditis in the setting of a recent COVID-19 infection. Objective: Our case report depicts a patient who developed E. coli purulent pericarditis in the setting of a recent COVID-19 infection. It indicates a possible association between COVID-19 infection with dysregulation of the immune system.

Antiviral response and immunopathogenesis of interleukin 27 in COVID-19

The coronavirus disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is associated with a high mortality rate. The clinical course is attributed to the severity of pneumonia and systemic complications. In COVID-19 patients and murine models of SARS-CoV-2 infection, the disease may be accompanied by excessive production of cytokines, leading to an accumulation of immune cells in affected organs such as lungs. Previous reports have shown that SARS-CoV-2 infection antagonizes interferon (IFN)-dependent antiviral response, thereby preventing the expression of IFN-stimulated genes (ISGs). Lower IFN levels have been linked to more-severe COVID-19. Interleukin 27 (IL27) is a heterodimeric cytokine composed of IL27p28 and EBI3 subunits, which induce both pro- and anti-inflammatory responses. Recently, we and others have reported that IL27 also induces a strong antiviral response in an IFN-independent manner. Here, we investigated transcription levels of both IL27 subunits in COVID-19 patients. The results show that SARS-CoV-2 infection modulates TLR1/2-MyD88 signaling in PBMCs and monocytes and induces NF-κB activation and expression of NF-κB-target genes that are dependent on a robust pro-inflammatory response, including EBI3; and activates IRF1 signaling which induces IL27p28 mRNA expression. The results suggest that IL27 induces a robust STAT1-dependent pro-inflammatory and antiviral response in an IFN-independent manner in COVID-derived PBMCs and monocytes as a function of a severe clinical course of COVID-19. Similar results were observed in macrophages stimulated with the SARS-CoV-2 spike protein. Thus, IL27 can trigger an antiviral response in the host, suggesting the possibility of novel therapeutics against SARS-CoV-2 infection in humans.

Extracorporeal Membrane Oxygenation to Support COVID-19 Patients: A Propensity-Matched Cohort Study.

In patients with severe respiratory failure from COVID-19, extracorporeal membrane oxygenation (ECMO) treatment can facilitate lung-protective ventilation and may improve outcome and survival if conventional therapy fails to assure adequate oxygenation and ventilation. We aimed to perform a confirmatory propensity-matched cohort study comparing the impact of ECMO and maximum invasive mechanical ventilation alone (MVA) on mortality and complications in severe COVID-19 pneumonia. All 295 consecutive adult patients with confirmed COVID-19 pneumonia admitted to the intensive care unit (ICU) from March 13th, 2020, to July 31st, 2021 were included. At admission, all patients were classified into 3 categories: (1) full code including the initiation of ECMO therapy (AAA code), (2) full code excluding ECMO (AA code), and (3) do-not-intubate (A code). For the 271 non-ECMO patients, match eligibility was determined for all patients with the AAA code treated with MVA. Propensity score matching was performed using a logistic regression model including the following variables: gender, P/F ratio, SOFA score at admission, and date of ICU admission. The primary endpoint was ICU mortality. A total of 24 ECMO patients were propensity matched to an equal number of MVA patients. ICU mortality was significantly higher in the ECMO arm (45.8%) compared with the MVA cohort (16.67%) (OR 4.23 (1.11, 16.17); p=0.02). Three-month mortality was 50% with ECMO compared to 16.67% after MVA (OR 5.91 (1.55, 22.58); p < 0.01). Applied peak inspiratory pressures (33.42 ± 8.52 vs. 24.74 ± 4.86 mmHg; p < 0.01) and maximal PEEP levels (14.47 ± 3.22 vs. 13.52 ± 3.86 mmHg; p=0.01) were higher with MVA. ICU length of stay (LOS) and hospital LOS were comparable in both groups. ECMO therapy may be associated with an up to a three-fold increase in ICU mortality and 3-month mortality compared to MVA despite the facilitation of lung-protective ventilation settings in mechanically ventilated COVID-19 patients. We cannot confirm the positive results of the first propensity-matched cohort study on this topic. This trial is registered with NCT05158816.

Impact of 1-week preoperative auto-CPAP treatment on postoperative outcomes in patients undergoing heart valve replacement surgery: a prospective randomized controlled trial.

Whether preoperative continuous positive airway pressure (CPAP) treatment improves postoperative outcomes in patients undergoing cardiac valve replacement (CVR) remains unknown. This study was to evaluate the effects of 1-week perioperative auto-continuous positive airway pressure (CPAP) treatment on postoperative heart and pulmonary outcomes in patients with obstructive sleep apnea (OSA) and valvular heart disease. Thirty-two patients with OSA and valvular heart disease were randomly assigned to 1-week CPAP (n = 15) group and non-CPAP treatments (n = 17) group. After the treatment, all patients underwent CVR surgery. The length of ICU and hospital stays, postoperative cardiac and respiratory complications were assessed and compared between the 2 groups. The results showed there was no significant difference in the baseline characteristics between the CPAP and non-CPAP treatment groups. The length of postoperative ICU and hospital stays, as well as the duration of mechanical ventilation were significantly reduced in the CPAP treatment group compared to the non-CPAP treatment group; however, there were no significant differences in cardiac complications (postoperative arrhythmias, pacemaker use, first dose of dopamine in the ICU, and first dose of dobutamine in the ICU), and respiratory complications (reintubation and pneumonia). We concluded that in patients underwent CVR, preoperative use of auto-CPAP for OSA significantly decreased the duration of mechanical ventilation, and postoperative stays in the ICU and hospital.Clinical Trial Registration: https://ClinicalTrials.gov, identifier NCT03398733.

Newly-onset Autoimmune Diabetes Mellitus Triggered by COVID 19 Infection: A Case-based Review.

The devastating global pandemic Coronavirus disease 2019 (COVID 19) isolated in China in January 2020 is responsible for an outbreak of pneumonia and other multisystemic complications. The clinical picture of the infection has extreme variability: it goes from asymptomatic patients or mild forms with fever, cough, fatigue and loss of smell and taste to severe cases ending up in the intensive care unit (ICU). This is due to a possible cytokine storm that may lead to multiorgan failure, septic shock, or thrombosis. Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV -2), which is the virus that causes COVID 19, binds to angiotensin-converting enzyme 2 (ACE2) receptors, which are expressed in key metabolic organs and tissues, including pancreatic beta cells, adipose tissue, the small intestine and the kidneys. Therefore it is possible to state that newly-onset diabetes is triggered by COVID 19 infection. Although many hypotheses have clarified the potential diabetogenic effect of COVID 19, a few observations were reported during this pandemic. Two male patients admitted to us with devastating hyperglycemia symptoms were diagnosed with type 1/autoimmune diabetes mellitus within 3 months following COVID 19 infection. Autoantibodies and decreased C peptide levels were detected in these patients. We speculated that several mechanisms might trigger autoimmune insulitis and pancreatic beta-cell destruction by COVID 19 infection. We aim to raise awareness of the possible link between SARS-CoV-2 and newly onset type 1 diabetes mellitus. Further studies are needed to determine a more definitive link between the two clinical entities.

Effects on Right Ventricular Function One Year after COVID-19-Related Pulmonary Embolism.

The aim of this study was to investigate the presence of subclinical cardiac dysfunction in recovered coronavirus disease 2019 (COVID-19) patients, who were stratified according to a previous diagnosis of pulmonary embolism (PE) as a complication of COVID-19 pneumonia. Out of 68 patients with SARS-CoV-2 pneumonia followed up for one year, 44 patients (mean age 58.4 ± 13.3, 70% males) without known cardiopulmonary disease were divided in two groups (PE+ and PE-, each comprising 22 patients) and underwent clinical and transthoracic echocardiographic examination, including right-ventricle global longitudinal strain (RV-GLS), and RV free wall longitudinal strain (RV-FWLS). While no significant differences were found in the left- or right-heart chambers' dimensions between the two study groups, the PE+ patients showed a significant reduction in RV-GLS (-16.4 ± 2.9 vs. -21.6 ± 4.3%, p < 0.001) and RV-FWLS (-18.9 ± 4 vs. -24.6 ± 5.12%, p < 0.001) values compared to the PE- patients. According to the ROC-curve analysis, RV-FWLS < 21% was the best cut-off with which to predict PE diagnosis in patients after SARS-CoV-2 pneumonia (sensitivity 74%, specificity 89%, area under the curve = 0.819, p < 0.001). According to the multivariate logistic regression model, RV-FWLS < 21% was independently associated with PE (HR 34.96, 95% CI:3.24-377.09, p = 0.003) and obesity (HR 10.34, 95% CI:1.05-101.68, p = 0.045). In conclusion, in recovered COVID-19 patients with a history of PE+, there is a persistence of subclinical RV dysfunction one year after the acute phase of the disease, detectable by a significant impairment in RV-GLS and RV-FWLS. A reduction in RV-FWLS of lower than 21% is independently associated with COVID-related PE.

General Factors and Dental-Related Risk Factors for Postoperative Pneumonia or Infectious Complications: A Retrospective Study.

Numerous studies report that perioperative oral care decreases the frequency of postoperative pneumonia or infection. However, no studies have analyzed the specific impact of oral infection sources on the postoperative course, and the criteria for preoperative dental care differ among institutions. This study aimed to analyze the factors and dental conditions present in patients with postoperative pneumonia and infection. Our results suggest that general factors related to postoperative pneumonia, including thoracic surgery, sex (male > female), the presence or absence of perioperative oral management, smoking history, and operation time, were identified, but there were no dental-related risk factors associated with it. However, the only general factor related to postoperative infectious complications was operation time, and the only dental-related risk factor was periodontal pocket (4 mm or higher). These results suggest that oral management immediately before surgery is sufficient to prevent postoperative pneumonia, but that moderate periodontal disease must be eliminated to prevent postoperative infectious complication, which requires periodontal treatment not only immediately before surgery, but also on a daily basis.

A modern look at the development of intrauterine pneumonia in premature newborns: Literature review

Infectious diseases such as malaria, pneumonia, diarrhea and preventable neonatal diseases are common causes of death in children. Globally, neonatal mortality is 44% (2.9 million) annually, with up to 50% of babies dying within the first day of life. Pneumonia kills between 750000 and 1.2 million infants in the neonatal period each year in developing countries. Premature birth, pneumonia, and labor complications are common causes of neonatal mortality. The objective of the study is to present the general characteristics of congenital pneumonia, vitamin D deficiency and micronutrient deficiencies in premature infants. To date, numerous studies confirm the relationship between the inadequate supply of the body with macro- and microelements and the development of diseases of varying severity, including metabolic disorders. Based on this, primary screening, aimed at identifying metabolic disorders of macro- and microelements and further drug correction, should become the main concept for the management of patients in modern times.

May 2023 Medical Image of the Month: Methamphetamine Inhalation Leading to Cavitary Pneumonia and Pleural Complications

No abstract available. Article truncated after 150 words. A 31-year-old man with a self-reported history significant for active methamphetamine and OxyContin use (last use of methamphetamine the same day with confirmation on urine drug screen) presented to the hospital with several hours of dyspnea. Having gone into cardiac arrest shortly after, he received several rounds of epinephrine and CPR and was intubated before spontaneous circulation returned. Bedside ultrasound revealed global hypokinesis with left ventricular ejection fraction of 10 to 15%, trivial pericardial effusion, and a moderate left pleural effusion. Chest CT (Figure 1) revealed segmental to subsegmental pulmonary emboli in the left lower lobe and ground-glass opacities in the left upper and bilateral lower lobes. He was treated as septic shock with Vancomycin and Cefepime, eventually speciating methicillin-sensitive Staphylococcus aureus in respiratory culture. Due to difficulty liberating the patient from the ventilator, he underwent tracheostomy tube placement. Chest x-ray on hospital day 18 showed a large left partially …

Epstein Barr Virus Positive Hodgkin's Lymphoma in a Patient with NEMO Deficiency

IntroductionHypomorphic mutations in the NF-kappaB essential modulator (NEMO) can manifest in diverse ways, but are best characterized by early susceptibility to viral, pyogenic and mycobacterial infections, ectodermal dysplasia and absent pneumococcal responses. We describe a case of EBV+ Hodgkin's lymphoma in a 9-year-old patient with NEMO on antimicrobial prophylaxis and immunoglobulin replacement therapy (IgRT). Case reportOur patient was diagnosed with NEMO deficiency at 2 years with initial presentation of recurrent pneumonia, recurrent skin abscesses and severe eczema herpeticum. His disease was moderately controlled with IgRT, and prophylaxis with trimethoprim/sulfamethoxazole, azithromycin and acylovir prophylaxis, with primary complications of continued recurrent pneumonia and finger clubbing. At 9 years of age however, he developed acute back pain and weakness, along with night sweats. MRI revealed thoracic spinal cord compression at T5 secondary to a possible neoplastic soft tissue mass. A laminectomy revealed Epstein Barr virus (EBV) positive Hodgkin lymphoma, stage 4 high risk due to PET positivity with uptake at large cervical chain nodal conglomerates bilaterally, mediastinal mass, thoracic paraspinal mass, periportal lymph nodes, splenic, and right medial femoral neck. He also had low level EBV viremia (EBV viral load 7,515 IU/mL). He was treated according to AHOD1331 with ABVE-PC (doxorubicin/bleomycin/vincristine/etoposide/prednisone), and also received rituximab and valganciclovir for treatment of EBV. He is now in remission after 4 months of treatment, and continues on IgRT, pneumocystis jiroveci pneumonia, mycobacterium avium complex, and herpes simplex virus prophylaxis. ConclusionPatients with certain inborn errors of immunity have a higher incidence of malignancy due to impaired immune function. Despite their viral susceptibility, EBV-induced lymphomas are not common in NEMO deficiency. NEMO patients may need further enhanced screening for development of malignancy, including regular surveillance for chronic, cancer-causing infections such as EBV and HPV.

Abstract #1406508: A Rare Case of Calcitriol-mediated Hypercalcemia in a Patient with Pneumocystis Jiroveci Pneumonia and the Role of Steroids in its Management

Calcitriol-mediated hypercalcemia is an uncommon complication of Pneumocystis jiroveci pneumonia (PJP). Some cases of PJP have been reported in patients with solid organ transplants and AIDS. Here we present a case of calcitriol-mediated hypercalcemia due to granulomatous Pneumocystis jiroveci pneumonia in a patient with a history of multiple sclerosis. A 45-year-old man with a medical history of multiple sclerosis, spondyloarthritis, smoking, and bipolar disorder was admitted for the evaluation of fever, fatigue, constipation, confusion, and weight loss of 10 Lbs over three months. His medications include rituximab, methotrexate, vitamin D-4000 IU, lithium, and calcium carbonate-600 mg. Laboratory evaluation showed elevated serum calcium (15 mg/dl) with a suppressed parathyroid hormone (9 pg/mL). Other pertinent findings include mildly elevated 25-hydroxyvitamin D (87 ng/ml), significantly elevated 1,25-dihydroxyvitamin D (381 pg/ml), and normal PTHrP (<2 pmol/L), vitamin A (0.82 mg/L) and TSH (1.31 mU/L). Extensive workup including AFB smear for tuberculosis, ACE level for sarcoidosis, SPEP for multiple myeloma, leukemia-lymphoma flow cytometry, and CT chest and PET-CT for malignancy were unremarkable. Treatment with large-volume intravenous fluids, calcitonin, and zoledronic acid followed by denosumab showed a transient reduction in serum calcium level to 10.5 mg/dl in 2 days and a rebound to a peak of 15.4 mg/dl in a week. Bronchoscopy with bronchoalveolar lavage which was done for persistent fever and new onset hypoxia revealed PJP confirmed by PCR. With this new finding, the diagnosis of PJP-induced calcitriol-mediated hypercalcemia was considered. He was then treated with Bactrim and prednisone 60 mg daily. Due to the severity of hypercalcemia, he required a hemodialysis session while waiting for the medications to take effect. His calcium normalized a week after the initiation of steroids and antibiotics and he was discharged on a slow prednisone taper. Clinic follow-up 4 weeks after discharge showed normal calcium, 1,25-dihydroxyvitamin D, and 25-hydroxyvitamin D levels. Discontinuation of prednisone was attempted but resulted in rebound elevation of 1,25-dihydroxyvitamin D requiring continuation of low-dose prednisone 5 mg. Our immunocompromised patient developed hypercalcemia induced by PJP infection due to granulomatous production of 1α-hydroxylase resulting in increased calcitriol formation. Steroids unsurprisingly appear to have the best impact on PJP-induced hypercalcemia because of their anti-inflammatory property. In this clinical entity, it inhibits inflammation and granuloma formation leading to a reduction in the release of 1α-hydroxylase and 1,25-dihydroxyvitamin D levels. It is essential to consider PJP as an etiology of hypercalcemia, especially in immunosuppressed patients. Steroid appears to be effective medical therapy in this setting. The timing and duration of treatment, and the efficacy of bisphosphonates and denosumab, require further studies.

TO THE TREATMENT OF ACUTE BACTERIAL DESTRUCTIVE PNEUMONIA IN CHILDREN

The basis of this study was the results of treatment of 176 sick children with acute bacterial destructive pneumonia. In the treatment of this pathology, a new approach to the treatment of inflammatory infiltrates of the lung was used, based on the optimal choice of an antibiotic administered percutaneously-intrapulmonary to the lesion, which prevented the transition of the disease to a purulent-destructive stage. And also tested a differentiated method of drainage treatment of severe pleural complications of acute bacterial destructive pneumonia (ABDP) in children.

Pneumatocele after lung transplantation

Pneumatoceles are a known complication of pneumonia or trauma, especially in young children. A 44-year-old male with pulmonary veno-occlusive disease and pulmonary hypertension underwent double lung transplantation with cardiopulmonary support. The patient had experienced severe primary graft dysfunction and bilateral lower lobe pneumonia. Posttransplant bronchoalveolar lavage fluid identified Staphylococcus aureus and Burkholderia cepacia. We started trimethoprim-sulfamethoxazole, meropenem, and minocycline. We also switched him to a prone position every 12 h for 3 days. The respiratory condition gradually improved with systemic therapy, prone position, oxygenation with ventilator, and venous-venous extracorporeal membrane oxygenation. Pneumatocele developed at the site of pneumonia. Although the pneumatocele was gradually increasing the size, we decided to continue conservative treatment. The pneumatocele spontaneously ruptured, and asymptomatic pneumothorax developed. We performed percutaneous drainage for pneumothorax, and the pneumatocele resolved. After he was discharged from the hospital, that pneumatocele shrank and disappeared. Pneumatocele can occur at the site of pneumonia after lung transplantation. It may be curable with conservative treatment, but the possibility of sudden rupture and pneumothorax should be considered.

Tension pyopneumothorax caused by Parvimonas micra: a case report

Tension pyopneumothorax is a rare and life-threatening complication of pneumonia, lung abscess, and empyema, and immediate thoracic drainage or surgery is required. A 70-year-old man presented to another hospital 2 weeks after exacerbation of dyspnea and anorexia. Chest X-ray imaging revealed leftward deviation of the mediastinum, pleural effusion, and collapse of the right lung. The patient was referred to our hospital for surgical treatment. He underwent chest drainage immediately after the transfer. The patient’s blood pressure was elevated after drainage. Chest X-ray imaging showed improvement in the mediastinal deviation, but expansion failure of the lung occurred. Debridement and parietal and visceral decortications were performed under thoracotomy. The thoracic cavity was irrigated using a pulse lavage irrigation system with 12,000 mL of saline. The patient underwent fibrinolytic therapy with intrathoracic urokinase postoperatively because of persistent high inflammatory marker levels and multilocular pleural effusion. Parvimonas micra was detected in the preoperative pleural fluid culture. He was discharged on postoperative day 22 and followed up as an outpatient afterwards. Two years have passed since the surgery, and there has been no recurrence of empyema. Decortication of the parietal and visceral pleura and irrigation using a pulse lavage irrigation system were effective.

Effect of probiotics as an immune modulator for the management of COVID-19.

COVID-19, an acute respiratory viral infection conveyed by pneumonia caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has affected millions of individuals globally, and is a public health emergency of international concern. Till now, there are no highly effective therapies for this infection without vaccination. As they can evolve quickly and cross the strain level easily, these viruses are causing epidemics or pandemics that are allied with more severe clinical diseases. A new approach is needed to improve immunity to confirm the protection against emerging viral infections. Probiotics can modify gut microbial dysbiosis, improve the host immune system, and stimulate immune signaling, increasing systemic immunity. Several probiotic bacterial therapies have been proven to decrease the period of bacterial or viral infections. Superinduction of inflammation, termed cytokine storm, has been directly linked with pneumonia and severe complications of viral respiratory infections. In this case, probiotics as potential immunomodulatory agents can be an appropriate candidate to improve the host's response to respiratory viral infections. During this COVID-19 pandemic, any approach that can induce mucosal and systemic immunity could be helpful. Here, we summarize contexts regarding the effectiveness of various probiotics for preventing virus-induced respiratory infectious diseases, especially those that could be employed for COVID-19 patients. In addition, the effects of probiotics, their mechanisms on different aspects of immune responses against respiratory viral infection, and their antiviral properties in clinical findings have been described in detail.

Determinants of poor clinical outcome in patients with influenza pneumonia: A systematic review and meta-analysis

BackgroundThe clinical burden of influenza is increasing worldwide. Aging, immunosuppression, and underlying respiratory illness are determinants of poor clinical outcomes, including greater mortality. Bacterial infections seem to be the main reason. Updated information on the role of bacterial infection as the cause of complications would be of value in improving the prognosis of patients with influenza. MethodsA systematic review and meta-analysis were performed by using the PubMed repository using keywords like: Influenza, H1N1, Streptococcus pneumoniae, bacterial coinfection, secondary coinfection, bacterial complications in pneumonia, and seasonal influenza. Only articles written in English were included in publications from 2010 to 2020. The analyses were conducted following the preferred reporting items for systematic review and meta-analyses guidelines. The results were independently validated using a TrinetX database cohort of roughly 4 million patients. ResultsWe included 135 studies that contained data from 48,259 patients hospitalized with influenza of any age. Bacterial infections were diagnosed in 5391 (11.2%). Streptococcus pneumoniae (30.7%) and Staphylococcus aureus (30.4%) were the most frequent microorganisms, followed by Haemophilus influenzae (7.1%) and Pseudomonas aeruginosa (5.9%). The random-effects model of the meta-analysis indicated that bacterial infections posed a 3.4-fold increased risk of death compared with influenza infection alone. Unexpectedly, asthma was protective (odds ratio 0.8). ConclusionBacterial infections diagnosed in 11.2% of patients with influenza increase 3.4-fold the mortality risk. S. pneumoniae, S. aureus, H. influenzae, and P. aeruginosa account for nearly 75% of the cases. Earlier diagnosis and use of antibiotics should improve outcomes in this population.

Comparative Analysis of Unicompartmental Total Knee Arthroplasty and High Tibial Osteotomy: Time to Total Knee Arthroplasty and Other Outcome Measures

There is no consensus on whether unicompartmental arthroplasty (UKA) or high tibial osteotomy (HTO) is superior for unicompartmental arthritis. While there are studies comparing revision and complication rates, none matched a large number of patients undergoing HTO and UKA in the United States and compared these outcomes. We investigated TKA conversion rate and the complications following HTO or UKA. This retrospective study queried the PearlDiver database of all patients undergoing UKA and HTO using CPT codes between January 2011 and January 2020. We compared propensity-matched populations based on age, gender, Charlson comorbidity index, and Elixhauser comorbidity index to compare odds of complications, TKA conversion, and drug use between UKA and HTO groups. Two-independent sample t-test for unequal variances and test of significance were performed. We found 32,583 UKA patients and 816 HTO patients. Each matched group had 535 patients. One-year complication showed higher risk of pneumonia, hematoma, infection, and mechanical complications among HTO patients. UKA patients used narcotics on average of 10.3 days compared to 9.1 days among HTO patients (P < .01). UKA conversion rates were 4.1%, 5.4%, 7.7%, and 9.2% at 1-, 2-, 5-, and 10-year intervals, respectively. HTO conversion rates were less than 2% at 1- and 2-year intervals, 3.4% at 5-year, and 4.5% at 10-year intervals. This difference was statistically significant at 5- and 10-year intervals (P < .01). Using large matched cohorts, HTO may be converted to TKA later than UKA in short- to mid-term follow-up, and HTO patients used opioids for shorter duration.

Parapneumonic effusion in children: Rapid pathogen detection in pleural fluid using multiplex bacterial PCR.

Parapneumonic effusion in children: Rapid pathogen detection in pleural fluid using multiplex bacterial PCR.

Comparing restrictive versus liberal oxygen strategies for trauma patients: The TRAUMOX2 trial-Statistical analysis plan.

The international advanced trauma life support guidelines recommend that all severely injured trauma patients receive supplemental oxygen based on very limited evidence. The TRAUMOX2 trial randomises adult trauma patients to a restrictive or liberal oxygen strategy for 8 h. The primary composite outcome consists of 30-day mortality and/or development of major respiratory complications (pneumonia and/or acute respiratory distress syndrome). This manuscript presents the statistical analysis plan for TRAUMOX2. Patients are randomised 1:1 in variable block sizes of four, six and eight, stratified by including centre (pre-hospital base or trauma centre) and tracheal intubation at inclusion. The trial will include 1420 patients to be able to detect a 33% relative risk reduction with the restrictive oxygen strategy of the composite primary outcome with 80% power at the 5% significance level. We will conduct modified intention-to-treat analyses on all randomised patients and per-protocol analyses for the primary composite outcome and key secondary outcomes. The primary composite outcome and two key secondary outcomes will be compared between the two allocated groups using logistic regression reported as odds ratios with 95% confidence intervals adjusted for the stratification variables as in the primary analysis. A p-value below 5% will be considered statistically significant. A Data Monitoring and Safety Committee has been established to conduct interim analyses after inclusion of 25% and 50% of the patients. This statistical analysis plan of the TRAUMOX2 trial will minimise bias and add transparency to the statistics applied in the analysis of the trial. The results will add evidence on restrictive and liberal supplemental oxygen strategies for trauma patients. EudraCT number: 2021-000556-19; ClinicalTrials.gov identifier: NCT05146700 (date of registration: 7 December 2021).

Contemporary outcomes for branch renal artery repair

BackgroundThe purpose of this study was to provide an updated description of demographics, technical details, and clinical outcomes of 101 consecutive branch renal artery repairs in 98 patients using cold perfusion. MethodsA single-institution, retrospective analysis branch renal artery reconstructions was performed between 1987 and 2019. ResultsPatients were predominantly Caucasian (80.6%) women (74.5%) with a mean age of 46.8 ± 15.3 years. The mean preoperative systolic and diastolic blood pressures were 170.4 ± 33.0 mm Hg and 99.2 ± 19.9 mm Hg, respectively, requiring a mean of 1.6 ± 1.1 antihypertensive medications. The estimated glomerular filtration rate was 84.0 ± 25.3 mL/min. Most patients (90.2%) were not diabetic and never smokers (68%). Treated pathology included aneurysm (87.4%) and stenosis (23.3%) with histology demonstrating fibromuscular dysplasia (44.4%), dissection (5.1%), and degenerative not otherwise specified (50.5%). The right renal arteries were most frequently treated (44.2%), with a mean of 3.1 ± 1.5 branches involved. Reconstruction was accomplished using bypass in 90.3% of cases using aortic inflow in 92.7% and a saphenous vein conduit in 92%. Branch vessels served as outflow in 96.9% and syndactylization of branches was used to decrease the number of distal anastomoses in 45.3% of repairs. The mean number of distal anastomoses was 1.5 ± 0.9. Postoperatively, the mean systolic blood pressure improved to 137.9 ± 20.8 mm Hg (mean decrease of 30.5 ± 32.8 mm Hg; P < .0001) and the mean diastolic blood pressure improved to 78.4 ± 12.7 mm Hg (mean decrease of 20.1 ± 20.7 mm Hg; P < .0001) with patients requiring a mean of 1.4 ± 1.0 antihypertensive medications (mean decrease of 0.2 ±1.0 medications; P = .048). The postoperative estimated glomerular filtration rate was 89.1 mL/min (mean increase of 4.1 mL/min; P = .08). The mean length of stay was 9.0 ± 5.8 days and 96.1% of patients were discharged home. The mortality rate was 1% (one patient with liver failure) and the major morbidity rate was 15%. There were five infectious complications (pneumonia, Clostridium difficile, and wound infection) and five patients required return to the operating room (one for nephrectomy, one for bleeding, two for thrombosis, and one for second trimester pregnancy loss requiring dilation and curettage and splenectomy). One patient required temporary dialysis owing to graft thrombosis. Two patients developed arrhythmias. No patients suffered a myocardial infarction, stroke, or limb loss. After 30 days, follow-up data were available for 82 bypasses. At this time, three reconstructions were no longer patent. Intervention was required to retain patency for five bypasses. After 1 year, patency data were available for 61 bypasses and five were no longer patent. Of the five grafts with loss of patency, two underwent intervention in attempt to maintain patency, which subsequently failed. ConclusionsRepair of renal artery pathology involving the branches can be performed with short- and long-term technical success and significant prospect of decreasing an elevated blood pressure. The operations required to fully address the presenting pathology are often quite complex involving multiple distal anastomoses and consolidation of small secondary branches. The procedure carries a small but significant risk of major morbidity and mortality.