Ml Of Fluid Research Articles

The effects of flavored rope additives on commercial pen-based oral fluid yield in pigs

Abstract Oral fluid (OF) can be easily collected from pens of pigs and used for the diagnosis of a number of key endemic swine diseases or biomarkers of stress or metabolic state. Large OF volumes may increase the capacity for diagnostic testing by enabling more components to be tested for in a single pen-based sample. It is known that acidic and pleasant-tasting compounds can stimulate salivary secretion in humans. The present study investigated the effect of using flavored rope additives (apple juice, pineapple juice, and sucrose solution) on pen-based OF yield, based on their citric acid content and palatable taste. Flavored and control ropes were presented to 4 commercial pens, each of weaner and finisher pigs, according to a Latin square design across 2 replicates. Ropes were presented for 30 minutes, allowing pigs to chew the ropes and deposit OF. The OF was extracted from each rope by handwringing and subsequent centrifugation for measurement of the total volume deposited during presentation. Analysis of variance confirmed that the use of flavor had no significant effect on OF yield for weaner ( F (3,22) = 0.01, P = 0.998) or finisher ( F (3,22) = 0.53, P = 0.668) pigs. A decrease in the OF volume deposited by weaners was observed after trial day 1 ( F (3,22) = 3.67, P = 0.028), but the opposite time pattern was seen for the finisher pigs, with a progressive increase in OF volume deposited across the 4 trial days ( F (3,22) = 6.19, P = 0.003). Approximately 20 mL of fluid was yielded from each rope presentation, and a 2-sample t test confirmed that pig age had no effect on OF deposition. The results suggest that citrus or sweet flavored rope additives are unlikely to affect pen-based pig OF yield via salivary stimulation. However, suitable OF volumes for multiple diagnostic tests can be obtained from both weaner and finisher pigs by the simple handwringing of ropes after presentation.

The role of inferior vena cava diameter in volume status monitoring; the best sonographic measurement method?

ObjectivesThis study aims to determine the site of and the best sonographic method for measurement of inferior vena cava (IVC) diameter in volume status monitoring. MethodsThis observational before-and-after study was performed at the intensive care unit of the emergency department. It included hypotensive adult patients with suspected sepsis who were recommended to receive at least 20 mg/kg fluid replacement by the emergency physician. The patients were fluid replaced at a rate of 1000 mL/h, and maximum and minimum IVC diameters were measured and the Caval index calculated sonographically via both B-mode and M-mode. Hence, IVC’s volume response was assessed by a total of 6 parameters, 3 each in M-mode and B-mode. Freidman test was used to assess the change in IVC diameter with fluid replacement. Wilcoxon test with Bonferroni correction was used to determine which measurement method more sensitively measured IVC diameter change. ResultsTwenty-eight patients with a mean age of 71.3 were included in the final analysis.The IVC diameter change was significant with all 6 methods (P < .001). The IVC minimum diameter change measured on M-mode during inspiration (M-mode i) was the only measurement method that significantly showed diameter change with each 500-mL fluid replacements. The initial and the subsequent M-mode i values after each 500 mL of fluid were 5.65 ± 3.34; 8.05 ± 3.66; 10.16 ± 3.61, and 11.21 ± 2.94, respectively (P < .001, P < .002, and P < .003, respectively). ConclusionInferior vena cava diameter was changed by fluid administration. The M-mode i method that most sensitively measures that change may be the most successful method in volume status monitoring.

Greater Trochanteric Pain Syndrome Due to Tumoral Calcinosis in a Patient with Chronic Kidney Disease

Tumoral calcinosis is a rare syndrome characterized by massive subcutaneous soft tissue deposits of calcium phosphate near the large joints. It is more prevalent in patients with chronic kidney disease undergoing dialysis. A 57-year-old woman was referred to our pain clinic with the complaint of severe pain in the left buttock and lateral hip. The patient had been suffering from chronic kidney disease for 10 years and had been undergoing peritoneal dialysis over the past 5 years. The patient’s symptom was initially suspected to be of lumbar origin at the L5 level and a left L5 transforaminal epidural block was performed, but without success. Reevaluation of the physical examination revealed severe tenderness over the left greater trochanter and piriformis muscle. On ultrasonographic evaluation, multiple mass-like lesions in the left buttock were observed. About 30 mL of fluid was aspirated from the cystic lesions, followed by 30 mL mixture of 0.08% levobupivacaine and triamcinolone 40 mg injected into the bursa under ultrasound guidance, which brought pain relief. Trochanteric bursitis was thought of as the cause of the symptoms. The patient was diagnosed with tumoral calcinosis based on the past medical history, simple plain radiographs, and hip magnetic resonance imaging (MRI). We diagnosed a case of greater trochanteric pain syndrome due to tumoral calcinosis related to chronic kidney disease in a patient whose symptoms had initially been considered to be radiating leg pain caused by lumbar spinal disease. We report our experience of symptomatic improvement following the repeated ultrasound-guided aspiration of calcific fluid and the injection of a mixture of local anesthetic and steroid. Key words: Trochanteric bursitis, greater trochanteric pain syndrome, tumoral calcinosis

Individualized early goal-directed therapy in systemic inflammation: is full utilization of preload reserve the optimal strategy?

In severe acute pancreatitis, the administration of fluids in the presence of positive fluid responsiveness is associated with better outcome when compared to guiding therapy on central venous pressure. We compared the effects of such consequent maximization of stroke volume index with a regime using individual values of stroke volume index assessed prior to severe acute pancreatitis induction as therapeutic hemodynamic goals. Prospective, randomized animal study. University animal research laboratory. Thirty domestic pigs. After randomization, fluid resuscitation was started 2 hours after severe acute pancreatitis induction and continued for 6 hours according to the respective treatment algorithms. In the control group, fluid therapy was directed by maximizing stroke volume index, and in the study group, stroke volume index assessed prior to severe acute pancreatitis served as primary hemodynamic goal. Within the first 6 hours of severe acute pancreatitis, the study group received a total of 1,935.8 ± 540.7 mL of fluids compared with 3,462.8 ± 828.2 mL in the control group (p < 0.001). Pancreatic tissue oxygenation did not differ significantly between both groups. Vascular endothelial function, measured by flow-mediated vasodilation before and 6 hours after severe acute pancreatitis induction, revealed less impairment in the study group after treatment interval (-90.76% [study group] vs -130.89% [control group]; p = 0.046). Further, lower levels of heparan sulfate (3.41 ± 5.6 pg/mL [study group] vs 43.67 ± 46.61 pg/mL [control group]; p = 0.032) and interleukin 6 (32.18 ± 8.81 pg/mL [study group] vs 77.76 ± 56.86 pg/mL [control group]; p = 0.021) were found in the study group compared with control group. Histopathological examination of the pancreatic head and corpus at day 7 revealed less edema for the study group compared with the control group (1.82 ± 0.87 [study group] vs 2.89 ± 0.33 [control group, pancreatic head]; p = 0.03; 2.2 ± 0.92 [study group] vs 2.91 ± 0.3 [control group, pancreatic corpus]; p = 0.025). Individualized optimization of intravascular fluid status during the early course of severe acute pancreatitis, compared with a treatment strategy of maximizing stroke volume by fluid loading, leads to less vascular endothelial damage, pancreatic edema, and inflammatory response.

Thoracentesis outcomes: a 12-year experience

BackgroundDespite a lack of evidence in the literature, several assumptions exist about the safety of thoracentesis in clinical guidelines and practice patterns. We aimed to evaluate specific demographic and clinical...

The impact of suction drainage on orbital compartment syndrome after craniofacial surgery.

Postoperative orbital compartment syndrome is a potentially blinding complication of surgery in the orbital region. We describe the technique of orbital drain placement as a method of preventing vision loss resulting from orbital compartment syndrome. We present a retrospective case series of 29 patients who underwent orbital fracture, facial fracture, and orbital implant removal from 7/4/2008 to 5/3/2013 by the same craniofacial surgeon. An orbital drain was placed in each patient. The drainage was recorded daily until drain removal. Criteria for removal included less than or equal to 5 mL of drainage in 24 hours. Of the 29 patients included in this study, 21 were men and 8 were women. Ages ranged from 17 to 67 years. The postoperative drainage ranged from less than 1 mL to 71 mL of serosanguinous fluid. All drains were removed between the first and sixth postoperative days. No postoperative visual loss, infections, or additional antibiotics were recorded with follow-up reaching as far as 40 months. Postoperative orbital compartment syndrome is a dangerous complication of surgery in the orbital region. Its rapid onset necessitates immediate intervention to prevent permanent vision loss. Morphologic changes to the optic nerve as well as reductions in electroretinogram a- and b-wave amplitudes have been demonstrated with as little as 7 mL of fluid accumulation. Intraoperative orbital drain placement should be considered in all patients undergoing surgery in the orbital region as a preventative measure.

Role of sonography in assessing complications after laparoscopic cholecystectomy.

Laparoscopic cholecystectomy, which was introduced to the arsenal of surgical procedures in the middle of the 1980s, is a common alternative for conventional cholecystectomy. Its primary advantage is less invasive character which entails shorter hospitalization and faster recovery. Nevertheless, the complications of both procedures are comparable and encompass multiple organs and tissues. The paper presents ultrasound presentation of the surgical bed after laparoscopic cholecystectomy and of complications associated with this procedure. In the first week following the surgery, the presence of up to 60 ml of fluid in the removed gallbladder bed should be considered normal in certain patients. The fluid will gradually absorb. In single cases, slight amounts of fluid are detected in the peritoneal cavity, which also should not be alarming. Carbon dioxide absorbs from the peritoneal cavity within two days. Ultrasound assessment of the surgical bed after cholecystectomy is inhibited by hemostatic material left during the surgery. Its presentation may mimic an abscess. In such cases, the decisive examination is magnetic resonance imaging but not computed tomography. On the other hand, rapidly accumulating fluid around the liver is an alarming symptom, particularly when there is inadequate blood supply or when peritoneum irritation symptoms develop. Depending on the suspected cause of the patient's deteriorating condition, it is essential to perform urgent computed tomography angiography, celiac angiography or endoscopic retrograde cholangiopancreatography or magnetic resonance cholangiopancreatography. The character of the fluid collection may be determined by its ultrasound-guided puncture. This procedure allows for aspiration of fluid and placement of a drain. Moreover, transabdominal ultrasound examination after laparoscopic cholecystectomy may contribute to the identification of: dropped stones in the right hypochondriac region, residual fragment of the gallbladder with possible concretions, undiagnosed choledocholithiasis, existing cholestasis, pseudoaneurysm of the hepatic artery, portal vein thrombosis and hematoma as well as hernias of the abdominal walls. Moreover, ultrasound examination helps to identify optimal sites in the abdominal integuments, which enables collision-free access to the peritoneal cavity.

Improving Visualization of the Central Compartment of the Hip with Direct MR Arthrography under Axial Leg Traction: A Feasibility Study

To evaluate the feasibility of a modified approach for direct magnetic resonance (MR) arthrography of the hip under leg traction in achieving a sufficient femoroacetabular interface and improving the visualization of the ligamentum teres. Forty-six MR arthrograms of 44 patients who underwent MR arthrography with and without leg traction were included into the study. Traction approach included injection of 18-27 mL of fluid (local anesthetic, contrast agent), application of weight-adapted traction load (15-23 kg), and the use of a supporting plate. Patients were instructed to report on pain and complications with an integer pain scale. Joint distraction was measured on coronal images obtained with and without traction, and two radiologists independently evaluated whether femoroacetabular cartilage layers and the ligamentum teres could be seen as distinct entities. McNemar test was used and interobserver agreement was assessed. No patient asked for termination of the examination. There were no cases of neuropraxia. Mean difference in distraction was 3.7 mm/3.6 mm (reader 1/reader 2). Cartilage layers could be seen as distinct entities in 43/43 (93.5%/93.5%) and 6/8 (13%/17.4%) of the joints with/without traction (P < .001/P < .001), respectively. The ligamentum teres could be differentiated in 33/30 (71.7%/65.2%) cases with traction, in 33/30 (71.7%/65.2%) cases without traction (P < .999/P < .999), and in 40/37 (87%/80.4%) cases with both the techniques combined. Traction MR arthrography is safe and technically feasible. It enabled the differentiation between femoroacetabular cartilage layers in most cases. Visualization of the ligamentum teres was optimal by combining imaging with both modalities.

Su1755 Use of ERCP in Pediatric Patients With Acute Recurrent and Chronic Pancreatitis: a Report From the Insppire (International Study Group of Pediatric Pancreatitis: in Search for a Cure) Consortium

Su1752 Comparison of Colonoscopy Preparations in a Pediatric Population Caroline T. Meyer*, Christina a. Hickey, June Y. Hu, Charles M. Samson, Elizabeth C. Utterson Pediatric Gastroenterology, Washington University in St. Louis, Saint Louis, MO; Pediatrics, Washington University in St. Louis, Saint Louis, MO Background: Poor quality colonoscopy preparation in pediatric patients can lead to inadequate visualization of colonic mucosa resulting in missed diagnoses, increased time under anesthesia and the need for repeat procedures. There have been few studies in the literature comparing colonoscopy preparation regimens in pediatric patients. Aims: To compare the efficacy of 2 different colonoscopy preparation regimens in pediatric patients at our institution. Methods: For our institutional quality improvement project, three endoscopists scored the visualization of colonic mucosa based on the Boston Bowel Prep Score (scores 0-9) and time to completion of colonoscopy (measured in!30 minutes, 30 minutes-1 hour, and O1 hour) in patients 8 years and older throughout a six month time period. An adequate cleanout was determined by a score R 5. Patients were prescribed either a regimen of 240 ml of magnesium citrate with two 10mg bisacodyl suppositories (phase 1) or polyethylene glycol (PEG) 3350 (8-12 years old: 119 grams in 960 ml of fluid and O12 years old: 238 grams of PEG 3350 in 1.92 liters of fluid) with oral bisacodyl (8-12 years old: 10mg and O12 years old: 20mg) (phase 2). Both groups were instructed to drink clear liquids the day prior to the procedure. The patients and their families were asked if they had completed all portions of the regimen prior to colonoscopy. Appropriate statistical tests were performed using IBM SPSS. Results: Forty-four patients were scored on the magnesium citrate/bisacodyl suppository prep and fifty patients were scored on the PEG 3350/oral bisacodyl prep. Two patients (one in each group) completed!75% of the regimen. Patients ranged in age from 8-25 years old. There was no significant difference in the mean age (pZ0.29) or the male to female ratio between groups (pZ0.85). The mean bowel prep score of the PEG 3350 group was 6.4 compared to 5.14 in the magnesium citrate group; the distributions of the two groups differed significantly (p!0.001) with statistically different medians (pZ0.03). The proportion of patients in the PEG 3350 group with a bowel prep score R 5 was 76% compared to 59% in patients receiving magensium citrate (pZ0.08) The percent of patients where the colonscopy was completed in less than 30 minutes was significantly higher in the PEG 3350 group (46% vs. 24%, pZ0.03). Conclusions: In our quality improvement project, there was a significant improvement in the efficacy as measured by visualization of colonic mucosa in the PEG 3350/oral bisacodyl treated group and improvement in the percent of colonoscopies completed in less than 30 minutes compared to the magnesium citrate/bisacodyl suppository group. Future studies utilizing patient questionnaire data and larger prospective blinded trials would provide additional information on tolerance and efficacy of bowel preparatory regimens in pediatric patients.

The Wrist Insufflation Test: A Confirmatory Test for Detecting Intercarpal Ligament and Triangular Fibrocartilage Complex Tears

The purpose of this study was to determine the accuracy of the wrist insufflation test based on mean radiocarpal and midcarpal joint space volumes. Twenty-nine patients underwent 3-4 portal radiocarpal and radial midcarpal portal insufflation before wrist arthroscopy. The volume remaining in the radiocarpal space at equilibrium was recorded, and the contour of the dorsal wrist and distal radioulnar joint was palpated for a fluid wave. After insufflation, wrist arthroscopy was performed and diagnoses were recorded. The mean volumes of the intact radiocarpal and midcarpal spaces were then compared with those of the compromised radiocarpal and midcarpal spaces to determine the overall sensitivity and specificity of the test. A total of 29 patients (18 male and 11 female) underwent wrist insufflation before wrist arthroscopy. The mean age of the patients was 42 years (range, 17 to 69 years). Intact radiocarpal spaces accepted a mean of 3.5 ± 0.16 mL of fluid, whereas compromised radiocarpal spaces accepted a mean of 5.5 ± 0.48 mL of fluid (P < .01; 95% confidence interval, 2.87 to 3.30). Intact midcarpal spaces accepted a mean of 2.5 ± 0.18 mL, whereas compromised midcarpal spaces accepted a mean of 5.6 ± 0.38 mL (P < .01; 95% confidence interval, 1.70 to 2.30). The overall sensitivity of the test was 83.3%, and the overall specificity was 100%. Complete scapholunate interosseous ligament and triangular fibrocartilage complex tears can be detected when there is an increased radiocarpal joint space volume with insufflation through the 3-4 portal combined with a fluid wave over the radial midcarpal space or the distal radioulnar joint. Complete scapholunate interosseous ligament and lunotriquetral interosseous ligament tears can also be detected when there is an increased midcarpal space volume with insufflation through the radial midcarpal portal combined with a fluid wave over the radial radiocarpal space or the ulnar radiocarpal space. Level IV, therapeutic case series.

Field Warming of IV Fluids

Several studies have been performed examining the use of heat packs from Meals Ready to Eat (MRE) to warm IV fluids. All have attempted to heat the fluid while it was still in the bag. In one study, that resulted in a delay of between 13 and 19 minutes in reaching the desired temperature. In a second study, there was a delay of 10 minutes, but only 500 mL of fluid was heated. The purpose of this study was to determine the feasibility of using MRE heat packs to adequately warm a bolus infusion of cold IV normal saline. The heat packs from 2 MREs were placed inside 1 plastic bag. The heat packs were activated with the recommended volume of water (time 0). Two sets of coils were made in 254-cm long IV tubing. Each set consisted of four 5-cm diameter coils held with duct tape. Both coils were placed between the activated heat packs in the plastic bag. A bolus infusion was simulated by running 5°C NS through the line with an 18G IV catheter. Fluid supply and infusion temperatures were recorded every second with thermocouples inside the fluid bag and inside the end of the IV tubing. Ambient temperature was 3°C. The IV fluid supply temperature was 5°C during the entire infusion. Simulated infusion temperature reached 35°C an average of 4.2 minutes after beginning setup. Average peak infusion temperature was 46.3°C. This method of heating IV fluids with MRE heat packs can effectively raise infusion temperature to the recommended levels within 5 minutes. This method is independent of supply bag volume and reduces heat loss in transit as heating occurs in the tubing.

The Mayo Clinic experience with Morel-Lavallée lesions

Although uncommon, Morel-Lavallée lesions (also called closed degloving injuries) are associated with considerable morbidity in trauma patients. There is lack of consensus regarding proper management of these lesions. Management options include nonoperative therapies, along with percutaneous and operative techniques. We sought to define the factors associated with failure of percutaneous aspiration to better identify patients requiring immediate operative management. We retrospectively searched our prospectively collected database for patient records containing the terms Morel-Lavallée, closed degloving injury, or posttraumatic seroma from February 2, 2004, through December 23, 2011. Treatment methods included compression wraps or observation (nonoperative management), percutaneous aspiration, or operative management with incision/drainage or formal debridement of skin and soft tissues that resulted in wound vacuum-assisted closure placement and/or split-thickness skin graft (operative management). The treatment groups were compared using univariate analysis and χ testing. We identified 79 patients with 87 Morel-Lavallée lesions in the setting of trauma. Most were caused by motor vehicle collisions (25%). No difference was observed between the treatment groups in sex, body mass index, anticoagulation treatment, diabetes mellitus, smoking history, or alcohol use. The percutaneous aspiration group had higher rates of recurrence (56% vs. 19% and 15% in nonoperative and operative groups, respectively). The percentage of patients who had aspiration of more than 50 mL of fluid was higher for lesions that recurred than for lesions that resolved (83% vs. 33%, p = 0.02). Aspiration of more than 50 mL of fluid from Morel-Lavallée lesions was much more common among lesions that recurred (83%) than among those that resolved (33%). We therefore recommend that aspiration of more than 50 mL of fluid from a Morel-Lavallée lesion prompts operative intervention. We have now adopted this as a practice management guideline. Therapeutic/care management study, level III.

Successful Uterovaginal Anastomosis in an Unusual Presentation of Congenital Absence of Cervix

ABSTRACT Cervical agenesis or dysgenesis (fragmentation, fibrous cord and obstruction) is an extremely rare congenital anomaly. Conservative surgical approach to these patients involves uterovaginal anastomosis, cervical canalization and cervical reconstruction. In failed conservative surgery, total hysterectomy is the treatment of choice. We report what we believe to be the first successful end-to-end uterovaginal anastomosis of an unusual case of congenital cervical agenesis. A 25-yearold female presented complaining of primary amenorrhea and primary subfertility for the same duration. At laparoscopy, complete separation between the cervix and the body of the uterus was found and hanging from surrounding supports. Both ovaries and fallopian tubes were anatomically positioned. There was another muscular tissue of 2 cm in diameter at the pouch of Douglas which was attached with lateral pelvic wall by transverse cervical ligament. Upon readmission, laparotomy was performed under general anesthesia in a semilithotomy position allowing both abdominal and vaginal approaches. Uterovaginal anastomosis was done by the restoration of the genital tract by direct suturing of the isthmus uteri to the vagina. Insertion of a 16F Foley catheter transvaginally through the vaginal opening into the endometrial cavity and was inflated with 5 ml of fluid into the catheter balloon. There were no postoperative complications. Foley catheter was kept in situ for 21 days. Patient had her first menstruation on 11th day of surgery and that was continued for 5 days with regular flow. Consecutive 3-cycles follow-up has been done and the patient is having her normal menstruation. In the presence of cervical anomaly with functional uterus and intact vagina, uterovaginal anastomosis is feasible and effective and should be applied as a first-line treatment option. How to cite this article Mahmud N, Mahtab NT, Chowdhury TA, Deb AK. Successful Uterovaginal Anastomosis in an Unusual Presentation of Congenital Absence of Cervix. J South Asian Feder Menopause Soc 2014;2(2):105-110.

Video-assisted Thoracoscopic Decortication of Trapped Lung in a Patient With Yellow Nail Syndrome

To the Editor: A 26-year-old Yemenite male presented with complaints of chronic shortness of breath, dyspnea, pleural effusions, and recurrent respiratory infections. At age 5, he developed lymphedema and was diagnosed with yellow nail syndrome (YNS). He underwent pericardial window at age 10 for pericardial effusion and myringotomy at age 19 to drain an effusion from the middle ear. He has several cousins with chronic lymphedema. In the 2 years before the current admission, he had undergone right-sided thoracentesis twice for recurrent pleural effusions. Pleural fluid analysis on both occasions revealed a serosanguinous, lymphocyte-predominant exudate. Cultures for bacteria, mycobacteria, and fungi were negative. Cytologic examination was negative for malignant cells. On the current admission, CT scan (Fig. 1) showed a large, loculated right and a moderate left pleural effusion. The patient underwent VATS and the right parietal and visceral pleura were found to be fibrotic with areas of calcification. A large amount of debris and approximately 100 mL of fluid were removed. The parietal pleura, which was 3 to 4 mm thick in some areas, was removed entirely down to the chest wall. The lung remained trapped by a dense visceral pleural peel. This was excised permitting almost complete reexpansion. Pathologic examination of the intrapleural debris showed organizing blood clots, granulation tissue, and fibrohyaline/collagenous tissue. The pleural showed fibrosis and chronic inflammatory changes. Pleural fluid cultures were negative for bacteria, fungi, and acid-fast bacilli. His postoperative course was complicated by an episode of hospital-acquired pneumonia. Exertional dyspnea improved progressively after discharge.FIGURE 1: Preoperative computed tomography scan showing loculated right pleural effusion and marked pleural thickening. Intrapleural air from recent thoracentesis.YNS is a rare lymphatic disorder of unknown etiology. It is characterized by the triad of deformed yellow nails, lymphedema, and respiratory manifestations. These most commonly include pleural effusions, bronchiectasis, sinusitis, and recurrent pneumonia.1 Women are affected twice as often as men.2 The characteristic nail findings are present in 89% of patients2 but are not necessary for diagnosis. The complete triad is seen in only about 30% of cases3 and the manifestations may become apparent over a considerable span of years.2 The pleural effusions are bilateral in 50% of cases. The fluid is most often a yellow exudate with lymphocytic predominance, and normal glucose level.2 The pathophysiology seems to result from hypoplasia or functional blockage of the lymphatic system.4 Previous literature on YNS demonstrates resolution of pleural effusions through thoracentesis,4 pleuroperitoneal shunting,5 pleurovenous shunting,6 and mechanical or talc slurry pleurodesis as a last resort.1 In our patient, extensive parietal and visceral pleural thickening resulted in a trapped lung. To the best of our knowledge, this has been previously reported only once before in YNS. In that case, the patient was managed with open thoracotomy and decortication of the parietal pleura.7 In our patient, parietal and visceral pleural decortication was accomplished exclusively through VATS. The patient’s clinical presentation was also atypical. It is rare for YNS to present in childhood.4 In one of the largest series of patients with YNS reported, the median age at diagnosis was 61 years.1 Our patient presented at the age of 5 with peripheral edema, pericardial effusion, and otitis media. In addition, although familial predisposition has not been reported,3 our patient had an extensive family history of lymphedema suggesting a possible hereditary component in YNS. Videoscopic surgical decortication seems to have benefit in this systemic disease. 13th INTERNATIONAL CONGRESS ON PEDIATRIC PULMONOLOGY The 13th International Congress on Pediatric Pulmonology (CIPP XIII) will take place in Bruges, Belgium, from June 26 through 29, 2014. As the only global congress devoted entirely to pediatric pulmonology, CIPP XIII offers a unique opportunity for state-of-the-art reviews of advances in this field, debates on controversial issues, unique clinical sessions and cutting-edge clinical science. For more information about the congress, please visit the Web site: www.cipp-meeting.org. Jessie Rosenberg, MD* Steven D. Herman, MD† Peter R. Smith, MD† Verena Liu, MD† Joshua Rosenberg, MD‡ *University of Maryland Medical Center, College Park, MD †Divisions of Thoracic Surgery and Pulmonary Medicine, SUNY-Downstate University Hospital of Brooklyn at Long Island College Hospital, and SUNY-Downstate Medical Center, Brooklyn ‡The Brooklyn Hospital Center, New York, NY

Anthropometry and Dietary Intake before and during a Competition in Mountain Runners.

Mountain running is a non-Olympic sport consisting of uphill or up- and downhill races at moderate-to-high altitude. Special nutritional requirements are anticipated, but no nutritional data of mountain runners are available. In three studies, physique of elite and recreational athletes (N = 62), maximum oxygen uptake (N = 3), and prerace and race day dietary intake (N = 6) were measured (mean ± SD). Mean oxygen uptake was 68.7 ± 5.2 mL/kg/min. Energy and carbohydrate intake before a race (29 ± 15 km, 1596 ± 556 m HD) was 3199 ± 701 kcal/d (13.4 ± 2.9 MJ/d) and 497 ± 128 g/d (8.3 ± 1.8 g/kg/d) in German national team members. Fluid intake was calculated as 2783 ± 1543 mL/d. During the race, athletes consumed 336 ± 364 kcal and 927 ± 705 mL of fluids. Substrate intake per hour was calculated as 23 ± 22 g of carbohydrates and 4.0 ± 3.2 g of proteins. In conclusion, anthropometric and oxygen uptake characteristics of mountain runners were similar to those reported for elite distance runners. Carbohydrate intake before and during the race was below recommendations for endurance athletes. This is of concern when considering the increased reliance on carbohydrates at altitude.

A 10-second fluid challenge guided by transthoracic echocardiography can predict fluid responsiveness.

IntroductionThe accurate assessment of intravascular volume status for the therapy of severe hypovolemia and shock is difficult and critical to critically ill patients. Non-invasive evaluation of fluid responsiveness by the rapid infusion of a very limited amount of volume is an important clinical goal. This study aimed to test whether echocardiographic parameters could predict fluid responsiveness in critically ill patients following a low-volume (50-ml crystalloid solution) infusion over 10 seconds.MethodsWe prospectively studied 55 mechanically ventilated patients. Echocardiography was performed during a 50-ml infusion of crystalloid solution over 10 seconds and a further 450 ml over 15 minutes. Cardiac output (CO), stroke volume (SV), aortic velocity time index (VTI), and left ventricular ejection fraction (LVEF) were recorded. Patients were classified as responders (Rs) if CO increased by at least 15% following the 500-ml volume expansion or were classified as non-responders (NRs) if CO increased by less than 15%. Area under the receiver operating characteristic curves (AUC) compared CO variations after 50 ml over 10 seconds (∆CO50) and 500 ml over 15 minutes (∆CO500) and the variation of VTI after infusion of 50 ml of fluid over 10 seconds (∆VTI50).ResultsIn total, 50 patients were enrolled, and 27 (54%) of them were Rs. General characteristics, LVEF, heart rate, and central venous pressure were similar between Rs and NRs. In the Rs group, the AUC for ∆CO50 was 0.95 ± 0.03 (P <0.01; best cutoff value, 6%; sensitivity, 93%; specificity, 91%). Moreover, ∆CO50 and ∆CO500 were strongly correlated (r = 0.87; P <0.01). The AUC for ∆VTI50 was 0.91 ± 0.04 (P <0.01; best cutoff value, 9%; sensitivity, 74%; specificity, 95%). ∆VTI50 and ∆CO500 were positively correlated (r = 0.72; P <0.01).ConclusionIn critically ill patients, the variation of CO and VTI after the administration of 50-ml crystalloid solution over 10 seconds (∆CO50 and ∆VTI50) can accurately predict fluid responsiveness.Trial registrationCurrent Controlled Trials ISRCTN10524328. Registered 12 December 2013.

Effect of a carbohydrate drink on soccer skill performance following a sport-specific training program

Monitoring personal hydration status as well as examining the contents of sports beverages is crucial to improve physical performance in soccer players. This study examined the effects of 60 minutes of soccer-specific training on skill performance, hydration status, and core temperature (Tc) of soccer players after ingesting either a carbohydrate-containing (CHO) or a carbohydrate-free (CHO-F) drink. This study recruited seven healthy male soccer players (age: 23 ± 2.9 years, height: 1.7 ± 0.04 m, mass: 62.7 ± 6.7 kg), each of whom completed a CHO and a CHO-F trial in a randomized crossover design. The participants underwent skill tests [Loughborough Soccer Passing Test (LSPT)] prior to and after 60 minutes of training in a hot and humid environment (30 °C, 85% relative humidity). They consumed 2 mL of fluid per/kg body mass every 15 minutes during exercise. Blood glucose, blood lactate, and Tc were monitored throughout the exercise session. Improvement was observed in movement time (p = 0.034) and overall LSPT performance (p = 0.031) postexercise in those consuming CHO drinks compared with those consuming CHO-F drinks. No differences were observed in Tc or absolute and relative body mass loss between the trial groups (p > 0.05). Urine output was greater in the CHO trial group (CHO: 0.086 ± 0.051 L; CHO-F: 0.030 ± 0.028 L; p = 0.043). Compared with the consumption of a CHO-F drink, that of a CHO drink during a 60-minute soccer-specific exercise session in a hot and humid climate can improve postexercise skill performance. Additionally, Tc can be regulated efficiently by commencing training in a state of euhydration and by regular ingestion of fluids throughout the exercise period.

Right Upper Quadrant Abdominal Pain Ten Years Post-laparoscopic Cholecystectomy

Purpose: A 72-year-old woman with past history of laparoscopic cholecystectomy 10 years ago presented with a 6-month history of intermittent right upper quadrant abdominal and flank pain without association with food intake. She denied fever and weight loss. Physical examination revealed erythema and tenderness in the right lateral aspect of the upper abdomen. Labs were unremarkable. Computed tomography (CT) of the abdomen showed a complex 21 x 5.8 x 8.8 cm perihepatic fluid collection with internal septations, which fistulized through the abdominal wall and formed a 5.6 x 2 cm subcutaneous fluid collection in the right flank. HIDA scan and MRCP ruled out bile leak. Ultrasound guided drainage of the abscess drained thick, greenish fluid. The patient was empirically started on ceftriaxone and metronidazole. Bacterial and fungal cultures as well as PPD, Echinococcus, and Entamoeba serology were all negative. Cytology revealed proteinaceous material with few inflammatory cells and many degenerated structures, suspicious for, yet not definitive of, Echinococcus cyst. Patient received a 6-week course of albendazole, and PAIR procedure (puncture, aspiration, injection, and re-aspiration) was performed with no improvement in symptoms. Repeat CT scan showed persistence of the abscess. An exploratory laparotomy was performed with 500 ml of fluid drained and evacuated 28 gallstones, confirmed by pathology, from the cavity. The fluid cultures were again negative. Repeat CT scan performed a month after the surgery showed near complete resolution of the abscess. Gallbladder perforation during laparoscopy cholecystectomy can result in spillage of gallstones into the peritoneal cavity, which may lead to the development of intra-abdominal abscesses that are easily misidentified as tumors or parasitic infections on radiography due to their similar appearance. The rarity and chronicity of this problem makes the diagnosis very challenging. Treatment requires exploratory laparotomy to remove all dropped gallstones. Less invasive procedures such as percutaneous drainage are effective for resolving acute symptoms, but allow recurrence of abscess. Most patients get a short course of antibiotics based on fluid cultures that typically reveal E. coli, Klebsiella pneumoniae, and Enterococcus. Interestingly, in our patient, the cultures were negative, suggesting that the development of the abscess was secondary to foreign body reaction to the dropped gallstones. Our case illustrates the importance of considering dropped gallstones in the differential diagnosis of intra- or extraperitoneal abscesses in any patient with a history of laparoscopic cholecystectomy, regardless of the time elapsed since surgery.

Severely Symptomatic Esophagitis from an Overly Restrictive Laparoscopic Adjustable Gastric Band: Endoscopic Characterization

Purpose: A 33-year-old female with prior laparoscopic adjustable gastric band (LAGB) in 2010 for morbid obesity (BMI before surgery=34.5 kg/m2) presented with vomiting, epigastric pain, odynophagia, and heartburn without melena during the past 3 weeks. She had a similar episode 1 year earlier that resolved by removing fluid from her adjustable band. Physical examination revealed only mild epigastric tenderness. Routine blood tests showed no abnormalities. Abdominal roentgenography revealed the adjustable band mostly inflated in the proper position (Figure 1). Esophagogastroduodenoscopy showed multiple acute linear ulcers with surrounding erythema arising from the GE junction and extending proximally 8 cm, highly consistent with reflux/emetic esophagitis (Figure 2). Pathologic analysis of distal esophageal biopsies showed acute and chronic inflammation without Barrett's esophagus. Her bariatric surgeon removed 8 mL of fluid from the LABG to loosen the gastric band. The patient subsequently did well without further nausea, vomiting, or abdominal pain. LAGB, is a popular, minimally invasive bariatric procedure that involves placement of a band around the gastric cardia. This band is adjusted by inflating or deflating with saline, to constrict or restore patency of the stomach outlet. If the band is too tight, chronic reflux and regurgitation can occur. This case characterized the endoscopic appearance of the esophagitis from an overly restrictive adjustable band.FigureFigure

Short Hydration in Chemotherapy Containing Cisplatin (&gt;=75 mg/m2) for Patients with Lung Cancer: A Prospective Study

We previously reported that 22% of lung cancer patients experienced a Grade 2 or 3 elevation in creatinine after chemotherapy containing cisplatin. We conducted a Phase II trial to evaluate the safety and efficacy of short hydration. The major eligibility criteria included patients with lung cancer for whom a ≥75 mg/m(2) cisplatin-based regimen was indicated and adequate organ function. Cisplatin was administered with pre- and post-hydration containing 10 mEq of potassium chloride in 500 ml of fluid over a 60-min period. Immediately before the administration of cisplatin, mannitol (20%, 200 ml) was administered as forced diuresis over 30 min. And magnesium sulfate (8 mEq) was added to pre-hydration. Forty-four patients were enrolled between April and December 2011. The patients included 29 men and 15 women with a median (range) age of 64 (42-74) years. Twenty patients received cisplatin and pemetrexed as their most frequent regimen and 38 patients received three to four cycles of chemotherapy. The median (range) duration and volume of the chemotherapies were 4.0 (3.3-6.8) h and 1600 (1550-2050) ml, respectively. Of the 44 patients, 43 (97.8%) completed the cisplatin-based chemotherapy without Grade 2 or higher renal dysfunction. The only patient who had Grade 2 elevation in creatinine (maximum value 1.7 mg/dl) had prompt improvement in creatinine levels and completed four cycles of chemotherapy. The short hydration is safe without severe renal toxicities in regimens containing cisplatin (≥75 mg/m(2)) for patients with lung cancer.