Improvement Of Failure Research Articles

A Case Report of Oral Ulcer in Rheumatoid Arthritis: A Diagnostic and Management Dilemma

Chronic oral ulcer in patients with rheumatoid arthritis is a diagnostic challenge in primary health care. The possible causes include the disease itself, side effect of treatment, malignancy and infections. This is a case of a 63-year-old woman with underlying rheumatoid arthritis presented with chronic solitary oral ulcer. She was on oral methotrexate (MTX) and high dose folic acid for five years with good compliance. Tissue biopsy showed marked inflammatory cells infiltration and nuclear hyperchromatism with no evidence of malignancy nor infection. The ulcer was resolved after completing antifungal treatment for six weeks following failure of improvement after empirical antibiotic, elimination of possible trauma and discontinuation of MTX. The fungal staining was negative. There are possibilities of false negative results, thus broadened diagnosis with repeated and further investigations are recommended in cases who did not respond to conventional treatment.

A Single-Institution Experience of Acute Neuropathic Lumbosacral Pain in Patients Treated with Short Course Hypofractionated Radiotherapy in Locally Advanced Rectal Cancer

There has been increased interest in the use of short course hypofractionated radiotherapy as part of a total neoadjuvant treatment (TNT) approach in the management of rectal cancer since publication of the RAPIDO trial. However, the literature on short course radiation for rectal cancer has not reported significant acute toxicities in the weeks immediately following the completion of treatment. Anecdotally, a subset of patients has experienced acute neuropathic pain characterized in a lumbosacral distribution. This study investigates acute lumbosacral toxicity for patients receiving hypofractionated short course radiation as part of their definitive treatment for rectal cancer. We retrospectively analyzed 75 patients with locally advanced rectal adenocarcinoma treated with hypofractionated short course radiation (25 Gy in 5 fractions) at our institution between 2016 and 2022. Acute toxicity caused by radiation was defined as that occurring from the start of radiation treatment to either 30 days post radiation completion, the start of chemotherapy, or date of surgery, whichever occurred first. Among 75 patients treated with hypofractionated short course preoperative radiation with definitive intent, we identified 10 patients (13.3%) who experienced significant lumbosacral neuropathic pain and initiated a report to their medical providers during the acute toxicity time frame. Commonly, this was described as an achy pain in the bilateral buttocks radiating down to the knees or posterior claves. Patients rated this pain between moderate to extreme and management included steroids after failure of improvement with conservative measures, gabapentin, and conservative treatment with NSAIDs and Tylenol. Average time to onset of acute lumbosacral neuropathic pain was 3.7 days (SD 2.05) from start of RT. We have identified a previously underappreciated acute toxicity of neuropathic lumbosacral pain in short course hypofractionated radiation therapy, which may be due to a lumbosacral plexus toxicity. Further analysis will seek to identify predictive factors such as comorbidities and dose to the lumbosacral plexus, and to determine whether there is a correlation between these observed acute toxicities and long-term outcomes.

Predictors of failure of early neurological improvement in early time window following endovascular thrombectomy: a multi-center study.

Endovascular thrombectomy (EVT) has become the gold standard in the treatment of acute stroke patients. However, not all patients respond well to this treatment despite successful attempts. In this study, we aimed to identify variables associated with the failure of improvements following EVT. We retrospectively analyzed prospectively collected data of 292 ischemic stroke patients with large vessel occlusion who underwent EVT at three academic stroke centers in China from January 2019 to February 2022. All patients were above 18 years old and had symptoms onset ≤6 h. A decrease of more than 4 points on the National Institute of Health Stroke Scale (NIHSS) after 24 h compared with admission or an NIHSS of 0 or 1 after 24 h was defined as early neurological improvement (ENI), whereas a lack of such improvement in the NIHSS was defined as a failure of early neurological improvement (FENI). A favorable outcome was defined as a modified Rankin scale (mRS) score of 0-2 after 90 days. A total of 183 patients were included in the final analyses, 126 of whom had FENI, while 57 had ENI. Favorable outcomes occurred in 80.7% of patients in the ENI group, in contrast to only 22.2% in the FENI group (p < 0.001). Mortality was 7.0% in the ENI group in comparison to 42.1% in the FENI group (p < 0.001). The multiple logistic regression model showed that diabetes mellitus [OR (95% CI), 2.985 (1.070-8.324), p = 0.037], pre-stroke mRS [OR (95% CI), 6.221 (1.421-27.248), p = 0.015], last known well to puncture time [OR (95% CI), 1.010 (1.003-1.016), p = 0.002], modified thrombolysis in cerebral infarction = 3 [OR (95% CI), 0.291 (0.122-0.692), p = 0.005], and number of mechanical thrombectomy passes [OR (95% CI), 1.582 (1.087-2.302), p = 0.017] were the predictors of FENI. Diabetes mellitus history, pre-stroke mRS, longer last known well-to-puncture time, lack of modified thrombolysis in cerebral infarction = 3, and the number of mechanical thrombectomy passes are the predictors of FENI. Future large-scale studies are required to validate these findings.

Maxillomandibular Advancement for OSA: Serious Complications and Failures

The focus of this report was to analyze patients who presented for second opinion due to complications and failure following maxillomandibular advancement (MMA) performed elsewhere. During a five-year period, 16 patients presented with complications and/ or failure of MMA. The indication for treatment was obstructive sleep apnea (OSA). Analysis of treatment records including plane radiography and/or cone beam computed tomography (CBCT), progress photographs and clinical examination were performed. Complete clinical and imaging records were available in all patients for analysis. Thirteen patients were surgical failures with advancement ranging from -4 to 5 mm. Five of the 13 patients had limited advancement at the initial surgery, and eight patients had hardware failure that required removal with resultant retrodisplacement of the mandible. Due to complications occurring in 11 patients, additional surgery ranging from two to six additional procedures after the initial operation was required. The complications included hardware failure (ten patients) that led to bone segment displacement (eight patients), non-union of the maxilla (two patients), non-union of the mandible (eight patients), chronic facial and/or joint pain (five patients), facial nerve injury (two patients), complete anesthesia of the lip/chin (five patients) and severe malocclusion (four patients). Although MMA is typically a predictable operation with excellent outcomes, failure of improvement and severe long-term sequelae from surgical complications are possible. Surgical precision with sufficient skeletal advancement for airway improvement and stable skeletal fixation is necessary to achieve a successful outcome.

Hierarchical improvement of regional tissue oxygenation after packed red blood cell transfusion.

BackgroundIt is well established that counter-regulation to hypoxia follows a hierarchical pattern, with brain-sparing in preference to peripheral tissues. In contrast, it is unknown if the same hierarchical sequence applies to recovery from hypoxia after correction of anemia with packed red blood cell transfusion (PRBCT).ObjectiveTo understand the chronology of cerebral and splanchnic tissue oxygenation resulting after correction of anemia by PRBCT in preterm infants using near-infrared spectroscopy (NIRS).DesignProspective cohort study.SettingNeonatal intensive care.Patients includedHaemodynamically stable infants: <32 weeks gestation, <37weeks postmenstrual age, <1500 grams birth weight; and ≥120 mL/kg/day feeds tolerated.InterventionPRBCT at 15 mL/Kg over 4 hours.Main outcome measuresTransfusion-associated changes were determined by comparing the 4-hour mean pre-transfusion cerebral and splanchnic fractional tissue oxygen extraction (FTOEc0; FTOEs0) with hourly means during (FTOEc1-4; FTOEs1-4) and for 24 hours after PRBCT completion (FTOEc5-28; FTOEs5-28).ResultsOf 30 enrolled infants, 14[46.7%] male; median[IQR] birth weight, 923[655–1064]g; gestation, 26.4[25.5–28.1]weeks; enrolment weight, 1549[1113–1882]g; and postmenstrual age, 33.6[32.4–35]weeks, 1 infant was excluded because of corrupted NIRS data. FTOEc significantly decreased during and for 24 hours after PRBCT (p < 0.001), indicating prompt improvement in cerebral oxygenation. In contrast, FTOEs showed no significant changes during and after PRBCT (p>0.05), indicating failure of improvement in splanchnic oxygenation.ConclusionImprovement in regional oxygenation after PRBCT follows the same hierarchical pattern with a prompt improvement of cerebral but not splanchnic tissue oxygenation. We hypothesise that this hierarchical recovery may indicate continued splanchnic hypoxia in the immediate post-transfusion period and vulnerability to transfusion-associated necrotizing enterocolitis (TANEC). Our study provides a possible mechanistic underpinning for TANEC and warrants future randomised controlled studies to stratify its prevention.

Treatment of OSA by maxillomandibular advancement: Serious Complications and Failures

The focus of this report was to analyze patients who presented for second opinion due to complications and failure following maxillomandibular advancement (MMA)performed elsewhere. During a five-year period, 16 patients presented with complications and/or failure of MMA. The indication for treatment was obstructive sleep apnea (OSA). Analysis of treatment records including plane radiography and/or cone beam computed tomography (CBCT), progress photographs and clinical examination were performed. Complete clinical and imaging records were available in all patients for analysis. Thirteen patients were surgical failures with advancement ranging from -4 to 5 mm. Five of the 13 patients had limited advancement at the initial surgery, and eight patients had hardware failure that required removal with resultant retrodisplacement of the mandible. Due to complications occurring in 11 patients, additional surgery ranging from two to six additional procedures after the initial operation was required. The complications included hardware failure (ten patients) that led to bone segment displacement (eight patients), non-union of the maxilla (two patients), non-union of the mandible (eight patients), chronic facial and/or joint pain (five patients), facial nerve injury (two patient), complete anesthesia of the lip/chin (five patients) and severe malocclusion (four patients). Although MMA is typically a predictable operation with excellent outcomes, failure of improvement and severe long-term sequelae from surgical complications are possible. Surgical precision with sufficient skeletal advancement for airway improvement and stable skeletal fixation is necessary to achieve a successful outcome.

New insights into intestinal failure-associated liver disease in adults: A comprehensive review of the literature.

Intestinal failure–associated liver disease (IFALD) remains one of the most common and serious complications of parenteral nutrition (PN), causing a wide spectrum of hepatic manifestations from steatosis and mild cholestasis to portal hypertension and end-stage liver failure. The prevalence of IFALD depends on the diagnostic criteria and ranges from 4.3% to 65%. Moreover, many factors are shown to contribute to its development, including nutrient deficiencies, toxicity of PN, infections, and alterations of bile acid metabolism and gut microbiota. Prevention and management of IFALD aim at ameliorating or eliminating the risk factors associated with IFALD. The use of PN formulations with a lower ratio omega-6-to-omega-3 polyunsaturated fatty acids, cycle PN, optimization of enteral stimulation and prevention and early treatment of infections constitute the main therapeutic targets. However, failure of improvement and severe IFALD with end-stage liver failure should be considered as the indications of intestinal transplantation. The aim of this review is to provide an update of the epidemiology, pathophysiology, and diagnosis of IFALD in the adult population as well as to present a clinical approach of the therapeutic strategies of IFALD and present novel therapeutic targets.

P757Methamphetamine-associated cardiomyopathy: a case-controlled study of clinical characteristics, management and outcomes

Abstract Background Methamphetamine-associated cardiomyopathy (MAC) is an increasingly diagnosed condition with poor prognosis, and there remains paucity of literature including how MAC differs from other cardiomyopathies. We compared the characteristics and outcomes MAC patients with non-ischaemic cardiomyopathy controls at our centre. Methods Clinical profile, management and outcomes were prospectively assessed in consecutive patients with MAC at our hospital from 2006–2018. They were compared with randomly chosen controls with non-ischaemic dilated cardiomyopathy of similar age-group (20–65 year). Results Both groups had 62 patients followed for 3.0±2.9 years. MAC patients were younger, with higher proportion of Maori ethnicity, unemployment and cardiogenic shock during index admission and lower proportion of Pacific ethnicity, cardiovascular risk factors and atrial fibrillation. MAC patients also had higher peak NT-proBNP, lower ejection fraction, and lower attendance rate to outpatient appointments. There was no index admission mortality in both groups. MAC had higher mortality and trend to higher heart failure re-admissions rates during follow-up (Figure 1). Amongst MAC patients, baseline left ventricular end diastolic diameter and failure of improvement in right ventricular systolic function by one category during follow-up were independent predictors of mortality, while failure of improvement of left ventricular ejection fraction by one category predicted heart failure readmission. Figure 1 Conclusions MAC patients were younger but sicker on presentation, with higher mortality and trend towards higher heart failure readmission rates during medium-term follow-up than controls. Adherence to therapy and attendance to appointments may improve cardiac systolic function over time to reduce adverse clinical endpoints.

Unusual neurosurgical emergency in Paget\u2019s disease of the skull: a case report and review of the literature

IntroductionPaget’s disease of bone is usually asymptomatic in most cases. The neurosurgeon should be familiar with the common presentation and complications. The rare presentation of this case of Paget’s disease of the skull raised our attention to report it.Case descriptionA Paget’s disease patient presented in the emergency department with a disturbed conscious level (GCS 8) without any history of trauma or seizures. CT showed severe hypertrophied left frontal, temporal, and parietal bones with midline shift. The patient underwent an emergency left decompressive craniectomy. Postoperative CT scan was done and showed frontoparietal epidural hematoma on the opposite side which was evacuated immediately. The patient started to improve and became fully conscious in few days with marked improvement of the motor power of her right side.Discussion and evaluationSevere skull involvement and impending brain herniation may occur in Paget’s disease of the skull which needs urgent decompressive surgery. Contralateral epidural hematoma after decompressive surgery may rarely occur and should be suspected in case of intraoperative brain swelling and postoperative failure of improvement. Neurosurgeons and radiologists should recognize the rare phenomenon of periosteal bone formation in the pagetic bone and its extension into surrounding tissues.ConclusionsIn our case, we faced an unusual life-threatening condition in a patient of Paget’s disease with severe skull involvement leading to rapid deterioration of consciousness and impending brain herniation. The neurosurgeon should be aware of this rare emergency condition.

Therapeutic Role of Oral Water Soluble Contrast in Treatment of Early Adhesive Intestinal Obstruction in Pediatric Population

Introduction and objectives: Adhesive bowel obstruction is considered one of the commonest causes of intestinal obstruction managed in daily practice, medical schools differ in management plans from conservative to interventional measures with increased morbidity and mortality with recurrent surgical interventions, the aim of our study is to evaluate the therapeutic role of oral water soluble contrast (urographin) in treatment of early adhesive intestinal obstruction. Patients and methods: All pediatric patients presented at our units in the period from December 2016 to December 2017 by early adhesive intestinal obstruction were included in this study. All patients were given conservative treatment for 24 hours (nothing per mouth, insertion of nasogastric tube, and intravenous fluids). Patients with failure of improvement after 24 hours were divided to 2 groups in the first group we continued the same conservative measures for 48 hours, in the second group we used single oral dose of urographin. Follow up of the patients was done clinically and radiologically for another 48 hours. Demographic data, type of first surgery, results, complications, and outcome all were collected and statistically analyzed. Results: The study included 35 patients, oral urographin was used in 14 patients, and we continued traditional measures in 21 patients. The mean duration of hospital stay in the urographin group was 3.36 ± 0.49 while in the conservative group was 6.24 ± 0.89 with P value <0.001. Recurrence occurred in (14.3%) of cases in urographin group and in (33.3%) of cases in conservative group Conclusion: The period of hospital admission is significantly shorter with the use of oral water soluble contrast (urographin) with fewer incidences of recurrent attacks but it doesn’t decrease the incidence of shifting to surgery. The use of urographin is safe with no significant harmful side effects observed.

Abstract 280: Cerebral Blood Flow and Oxygenation During CPR in Swine

Introduction: Near-infrared spectroscopy (NIRS) has been used during cardiac arrest (CA) to non-invasively measure cerebral oxygenation. Studies have suggested that survival and neurological outcomes can be predicted using cerebral oxygenation, however, the physiology underlying cerebral oxygenation during CA is poorly understood. This exploratory study examined the behavior of cerebral blood flow and oxygenation in response to standard CPR (SCPR) and CPR with Active decompression and lift (ACD) and an impedance threshold device (ITD). Methods: Ventricular fibrillation was electrically induced in eight domestic swine. Following six minutes of untreated VF, SCPR (100 cpm at 20% anterior-posterior distance) was performed for six minutes. ACD+ITD was performed for an additional six minutes at the same rate and depth as SCPR, but with an additional 20% anterior-posterior distance of active lift. Cerebral blood flow was measured via microspheres and cerebral oxygenation was measured using NIRS. Animals were classified as responders if cerebral oxygenation increased within two minutes of initiating SCPR. Cerebral oxygenation did not change or declined during SCPR in non-responders. Results: Six out of eight animals were classified as responders. Cerebral blood flow and oxygenation increased with ACD+ITD compared to SCPR in responders but failed to increase for non-responders. Cerebral blood flow and oxygenation were lower during baseline (BL) in non-responders (Figure). Conclusions: ACD+ITD appears to improve cerebral blood flow and oxygenation. Changes in cerebral oxygenation during CA appear to be associated with measured changes in cerebral blood flow. NIRS may be clinically useful in estimating oxygenation and blood flow during low blood flow states and monitoring physiological responses to different interventions. Failure of improvement in NIRS during CPR may predict poor outcomes and/or the need for additional interventions guided by NIRS.

Posttraumatic hydrocephalus: Lessons learned from management and evaluation at a tertiary institute with review of literature

Abstract Background: Post traumatic hydrocephalus (PTH) is a commonest treatable complication of severe traumatic brain injury that’s leads to failure of improvement and worsening of the outcome. Incidence of posttraumatic hydrocephalus is 0.7%-29% reported in different literature. We have observed the development of PTH frequently seen in patients with severe head injury and after decompressive craniectomy (DC). Pathophysiology includes inflammatory changes and adhesion of arachnoid granulation, cerebral ischemia and alteration in cerebrospinal fluid (CSF) dynamics. We studied 35 cases of PTH diagnosed and treated at our institute from May 2008 to May 2017. Material and methods: This is hospital based retrospective and prospective study conducted in tertiary center on the basis of neuro-radiological examination of the patient. Clinical biodata and radiological profile of the patients was studied at initial presentation with trauma, and when the patient worsened with symptoms of raised intracranial pressure (ICP) in state of established PTH. These cases were treated by medium pressure ventriculoperitoneal shunt (V.P shunt) and outcome was evaluated. Results: Incidence of PTH in our study is (2.3%). Out of 35 cases 24 (68.57%) were male and 11(31.4%) were female. Road traffic accident (RTA) was the most common mode of injury (82.85%), acute subdural hematoma (SDH) was the most common finding on C.T scan in 15 cases (42.8 %). Decompressive craniectomy was performed in 77% at time of initial trauma. PTH had favourable outcome with V.P. shunting in 91.42%. Conclusion: Patients with traumatic brain injury present with many complications but PTH is most frequent sequeale that can present in form of various neurological symptoms after trauma and decompressive craniectomy. C.T. scan brain is the investigation of choice for diagnosis of PTH. Outcome was favourable after V.P. shunt in PTH.

An unusual cause of neonatal hip dislocation: infantile myofibromatosis presenting as developmental dysplasia of the hip.

Infantile myofibromatosis (IM) is a rare paediatric fibrous tumour also known as a desmoid tumour that occurs in around 1:150000 live births. It manifests as solitary or multicentric fibrous masses in the musculoaponeurotic soft tissues and can affect the visceral organs and bones. We report a case of infantile myofibromatosis of the gluteus maximus muscle in an 18-day old neonate presenting atypically as a case of developmental dysplasia of the hip due to local involvement of the sciatic nerve. However, failure of improvement with conventional management and clinical wasting of the lower leg muscles was indicative of a secondary cause of the patient's hip dislocation, which was confirmed on imaging and surgical biopsy. This case report aims to emphasise the importance of considering secondary causes of neonatal hip dislocation, especially in cases where imaging findings are atypical of conventional DDH. Although imaging appearances on ultrasound and CT may vary, the signal characteristics and enhancement pattern of soft tissue myofibromata on MRI with and without gadolinium contrast appear to be the most consistent finding in these cases.

Early warning score: a dynamic marker of severity and prognosis in patients with Gram-negative bacteraemia and sepsis.

BackgroundEarly Warning Score (EWS) is a physiological composite score of six bedside vital parameters, routinely used in UK hospitals. We evaluated the prognostic ability of EWS in Gram-negative bacteraemia causing sepsis.MethodsWe prospectively evaluated EWS as a marker of severity and prognosis in adult patients with Gram-negative bacteraemia. All adult patients with Gram-negative bacteraemia admitted to our tertiary Teaching hospital of the National Health Service in England were enrolled over 1 year period. The highest daily EWS score was recorded from 7 days before to 14 days after the date of onset of bacteraemia. The primary outcome was 28-day mortality.Main resultsA total of 245 consecutive adult patients with Gram-negative bacteraemia with sepsis were enrolled. On multivariate analysis, following variables were associated with death for every single unit change (odds ratio in the brackets): higher age (1.05), lower mean arterial pressure (1.03), lower serum bicarbonate (1.08), higher EWS (1.27), higher SOFA score (1.36), hospital-onset of infection (5.43) and need for vasopressor agents (16.4). EWS on day 0, 1, 2, and average 14-day score were significantly higher in patients who died by 28 days from the onset of bacteraemia [95 % CI 0.4–0.6] p < 0.001. A stepwise rise in EWS and failure of improvement in EWS by 2 points 48 h after the onset of bacteraemia were associated with poor outcome.ConclusionEWS is a simple and cost-effective bedside tool for the assessment of severity and prognosis of sepsis caused by Gram-negative bacteraemia.Electronic supplementary materialThe online version of this article (doi:10.1186/s12941-016-0139-z) contains supplementary material, which is available to authorized users.

Transluminal or Percutaneous Endoscopic Drainage and Debridement of Abscesses After Bariatric Surgery: a Case Series.

Since redo surgery is associated with a high risk of morbidity and mortality after bariatric surgery in case of leakage, we sought to evaluate whether endoscopic drainage and debridement of collections following bariatric surgery is an efficient step-up approach to the management of these complications. From 2007 to 2011, we retrospectively studied our cohort of nine cases treated by endoscopic drainage and debridement of abdominal abscesses secondary to postbariatric surgery leaks performed via the transluminal or percutaneous route. Three patients were treated by percutaneous endoscopic debridement of abscesses knowing that their leak was already closed by other endoscopic means and that their collection did not improve despite external drain in place. Six patients were treated by transluminal endoscopic drainage to perform necrosectomy as a first-line option or after failure of improvement after endoscopic treatment. The number of sessions required ranged from 1 to 3. Most severe patients had rapid improvement of their hemodynamic and respiratory conditions. In eight of the nine patients, we were able to close the fistula by stent, fistula plugs, or a macroclip. Resolution of collections was seen in seven out of nine patients, but two required further surgery. Endoscopic necrosectomy via the transluminal or percutaneous route is a feasible option in postbariatric surgery patients with necrotic abscesses not adequately managed by the classical combination of percutaneous drainage and stenting. Further wide-scale studies are needed to compare this non-surgical method with surgical necrosectomy in postbariatric surgery patients.

Clinical profile and Outcome of Enteric Fever in hospitalized children aged 6 months to 2 years

Background : Enteric fever is a common endemic disease in Bangladesh.1 Enteric fever caused by Salmonella typhi (typhoid fever) is a major therapeutic consideration of all prolonged illnesses with pyrexia in pediatric practices particularly in developing countries like Bangladesh.Objectives :To evaluate the clinical profile and outcome of enteric fever in hospitalized children aged 6 months to 2 years.Methods: This was a prospective study conducted in the paediatric medicine unit of Dhaka Shishu Hospital during the period of November 2003 to August 2004. Forty children (age 6 months to 2 years) with specific criteria for diagnosing enteric fever enrolled in this study. Statistical analysis were done using the SPSS. All the data were expressed in percentage, mean or standard deviation.Anova test was used as the test for significance.Results : The clinical features, laboratory data, response to treatment were studied in 40 cases of enteric fever(daignosed by prefixed criteria). Majority of the patients belonged to the age group between 9 months to 2 years. Fever was the main presenting feature in all the cases (100%).Other associated features were anorexia (95%), vomiting(85%), diarrhea (80%), abdominal distension(75%), cough (70%), pallor (70%) and lethargy (50%). Of the signs, high temperature 101OF (95%), coated tongue (92.5%), tachycardia (90%), toxic appearance (87.5%) and anemia (70%) were the commonest features while hepatomegaly was present in 37.5% of cases. Typhoid fever was the most frequent (82.5%) enteric fever and the Widal test was significantly positive in 100% of cases. Blood culture was positive in 4 cases only with S. typhi in 3 cases (75%) and S. paratyphi A in 1 case (25%) and all isolated organisms were sensitive to Ceftriaxone and Ciprofloxacin. The outcome of the study population was assessed in terms of improved, cured, failure of treatment, complications and relapse. Cure rate was high (82.5%) in the study group. In the remaining 17.5%, the patients were considered improved. No case of relapse was recorded during the follow-up period of these patients. Failure of improvement or deterioration of clinical condition after treatment was not noted in this study. Complications were minimal in the study population and none of the patients died in this study.Conclusion: Contrary to the popular belief and west-oriented teaching, typhoid is certainly common in infants and young children in countries of the Third World and younger children are more likely to present with a non-specific febrile illness which makes the diagnosis difficult and as such adequate knowledge of the clinical presentations of this age group is essential for effective diagnosis and treatment.Northern International Medical College Journal Vol.5(1) 2013: 301-305

1088 What is the pre-treatment factor contributing to failure in improvement of over-active bladder symptoms following alpha-1 blocker administration in patients with benign prostatic hyperplasia accompanied by overactive bladder?

1088 What is the pre-treatment factor contributing to failure in improvement of over-active bladder symptoms following alpha-1 blocker administration in patients with benign prostatic hyperplasia accompanied by overactive bladder?

Iatrogenic saline toxicity complicated by malnutrition

Introduciton: Hypotension is a common presenting symptom in elderly patients with malnutrition and dehydration, often being treated with a continuous volume of 0.9% normal saline. Since normal saline is slightly hypertonic, prolong continuous treatment with normal saline can result in hyperchloremic nonanion gap metabolic acidosis. Patients with a low albumin state are also at risk for third spacing that can lead to generalized edema. Case Report: We present a 63-year-old Caucasian female with history of schizophrenia, traumatic brain encephalopathy, and chronic kidney disease stage III who presented to the emergency room from a nursing home due to altered mental status and low blood pressure. The patient received continuous infusion of normal saline despite failure of improvement in blood pressures due to the wrong diagnosis of the cause of hypotension. The patient ended up with iatrogenic normal saline toxicity. Conclusion: It is important for healthcare professionals to recognize signs and symptoms of normal saline toxicities especially in elderly patients with many chronic illnesses. Hypotension treated with continuous normal saline will eventually led to hyperchloremic metabolic acidosis with edema from third spacing in patients with low albumin secondary to malnutrition.

A complicated case of orbital cellulitis: When the fog doesn't clear.

Orbital cellulitis is a potential sight-threatening infection of the ocular adnexal structures posterior to the orbital septum. Acute bacterial sinusitis remains the most common cause of orbital cellulitis in the paediatric age group. Simultaneous intracranial and orbital complications from orbital cellulitis are rare. We describe a case of orbital cellulitis, which proceeded to sub-periosteal abscess formation and intracranial abscess within days of the initial presentation. The specific features of this case including the rapid progression of the orbital inflammation, failure of improvement over 48 h despite maximal medical treatment and incorrect initial reporting of computed tomography imaging all contributed to the complications seen in this case.

Palliative dialysis: a change of perspective.

The aging phenomenon of dialysis patients is a worldwide reality, observed in developed and developing countries. Those patients have high incidence of chronic conditions along with high mortality rates and for some of them a decline in functional status within the first 12 months of dialysis therapy. Nevertheless, the elderly dialysis patients represent a very heterogeneous group where prognostic tools may help the decision-making process together with family members, medical staff and the patients. Despite the fact that there are many validated prognostic tools in elderly population, no score has the aim to guide the decision to withhold or withdrawn the dialysis procedure; therefore, in many cases, a time-limited trial is supported. After the failure of improvement in life quality and certitude of the poor prognosis, the withdrawing from renal replacement therapy can be done. Medical literature, from developed countries, brings robust evidence that the process of withdrawing the dialysis procedure, after a fail in the so-called “time-limited trial”, along with good quality palliative care in this scenario is related to a good quality of death. We, on the other hand, believe that the withdrawing process in countries where hospice and good palliative care is not a reality may be associated with bad outcomes. Therefore, this review discusses a way to improve end-of-life symptoms in countries where palliative care facilities are not a reality, the so-called “palliative dialysis”.