Nontoxic Patients Research Articles

S3155 Recurrent Liver Abscess in a Non-Toxic Patient

Introduction: Liver abscesses are caused by direct spread from peritonitis, biliary tract infection or via hematogenous seeding from a distant source. Most are polymicrobial, however Escherichia coli and Klebsiella pneumoniae are the most common offending pathogens. Patients usually present with pain, fever, and clinical signs of infection. We describe a case of spontaneous liver abscess in a non-toxic patient that recurred 10 years after a previous abscess. Case Description/Methods: A 73-year-old-man with a history of type 2 diabetes mellitus, hypertension, CAD status post CABG and PCI 3 years ago, and abdominal aortic aneurysm status post endovascular aneurysm repair presented with 2 weeks of dark urine. After receiving his COVID-19 booster and influenza vaccinations, he developed flu-like symptoms with a self-resolving fever of 101.8°F. He had dark amber urine without dysuria or hematuria. Later, he experienced generalized weakness and decreased oral intake. Outpatient labs showed elevated liver function tests, and he was told to present to the ED. On arrival, he was afebrile with stable vitals. Physical exam was unremarkable. Laboratory evaluation showed a hemoglobin of 11.7 g/dL, sodium of 133 mEq/L, creatinine of 1.4 mg/dL, aspartate aminotransferase of 117 U/L, alanine aminotransferase of 212 U/L, alkaline phosphatase of 825 U/L, total bilirubin of 4.1 mg/dL, and direct bilirubin of 2.1 mg/dL. Triple-phase CT showed a 2.8 cm mass in the right liver lobe with linear enhancement. Ultrasound showed mixed echogenicity measuring 3.6 × 2.9 × 3.3 cm in segment 8 of the liver. On further evaluation, patient had an E. coli abscess diagnosed 10 years prior, managed with antibiotics and drainage. At that time, the abscess was within the right inferior liver lobe, similar to his current abscess. LFTs downtrended. Abscess was aspirated, with culture growing oxidase negative, gram-negative rods, likely E. coli. Patient started on ceftriaxone and metronidazole, to undergo colonoscopy as an outpatient and rule out colonic bacterial translocation. Discussion: Pyogenic liver abscess can result in significant morbidity and mortality because of worsening infection and sepsis. Abscesses occur because of spread from adjacent infection or after recent surgeries. Recurrence is very rare. Here, we describe a very unusual case of a pyogenic liver abscess growing E. coli in a non-toxic patient, with the same location and causative organism as an abscess managed 10 years prior.Figure 1.: Triple phase CT scan of the abdomen and pelvis in the transverse plane (a) demonstrating a 2.8 cm mass (arrow) in the right lobe of the liver with a small area of linear enhancement. Abdominal ultrasound demonstrating an area of mixed echogenicity (arrows) with areas of increased and decreased sonographic texture measuring 3.6 × 2.9 × 3.3 cm in segment 8 of the liver (b). CT, computed tomography.

65-Year-Old Man With Weight Loss and Dyspnea on Exertion

65-Year-Old Man With Weight Loss and Dyspnea on Exertion

478. Contemporaneous Evaluation of Kawasaki Disease and Multi-system Inflammatory Syndrome in Children in Northern Virginia

BackgroundMulti-system inflammatory syndrome in children (MIS-C) can present like Kawasaki disease (KD). After Centers for Disease Control and Prevention guidance was issued in May 2020, we implemented local management strategies emphasizing limited laboratory work up of non-toxic children with suspected MIS-C or KD. We then re-evaluated our management recommendations to ensure appropriate resource utilization for children with MIS-C and KD. MethodsWe identified MIS-C and KD cases via convenience sampling of Pediatric Infectious Diseases records at Inova Fairfax Medical Center from May 1, 2020 to February 28, 2021. Manual chart review extracted clinical points of interest and descriptive statistics compared cohorts. Oral changes included edema, erythema, cracking, or strawberry tongue. Abdominal symptoms included pain, emesis, and diarrhea. Respiratory symptoms included shortness of breath, tachypnea, cough, and need for mechanical ventilation. Musculoskeletal symptoms included pain and edema. Neurological symptoms included headache, dizziness, altered mental status, and irritability. ResultsWe identified 8 KD cases and 29 concurrent MIS-C cases. MIS-C cases tended to be older and have presenting abdominal symptoms (median age 8 years old versus 2 years old, p < 0.01) and hypotension (20 versus 0, p < 0.01), otherwise there was no difference in the frequency of oral changes, rash, conjunctivitis, musculoskeletal symptoms, or neurological symptoms. 7 KD cases and 8 MIS-C cases did not require intensive care. Patients with MIS-C who did not need intensive care still had a lower initial absolute lymphocyte count (ALC) (median 1275/µL, p < 0.01), lower initial platelet count (median 217/µL, p = 0.05), and higher initial C-reactive protein (CRP) (median 18.3 mg/dL, p = 0.06) compared to KD cases; other results were not different between the two cohorts. ConclusionWe observed differences in the initial ALC, platelet count, and CRP between KD and MIS-C cases not requiring intensive care, whereas other labs such as ferritin, troponin, B-natriuretic peptide, and initial echocardiograms did not significantly differ between the two cohorts. Thus, our diagnostic management recommending limited laboratory evaluation for non-toxic patients with suspected KD or MIS-C is reasonable. Disclosures All Authors: No reported disclosures

#25: Contemporaneous Evaluation of Kawasaki Disease and Multisystem Inflammatory Syndrome in Children Cases in Northern Virginia

BackgroundMultisystem inflammatory syndrome in children (MIS-C) has a temporal association with SARS-coronavirus 2 (SARS-CoV-2) infection and can present similarly to Kawasaki disease (KD). After the Centers for Disease Control and Prevention issued a MIS-C case definition in May 2020, we implemented local diagnostic and management strategies to standardize the care for patients with MIS-C encouraging limited laboratory evaluation of non-toxic patients presenting with a febrile illness. We then sought to re-evaluate our diagnostic and management recommendations to ensure appropriate resource utilization for children with MIS-C and KD.MethodsPatients with MIS-C and KD were identified via convenience sampling of Pediatric Infectious Diseases clinical records at Inova Children’s Hospital from May 1, 2020 to August 28, 2020. Manual chart review was done to extract clinical points of interest and the two cohorts were compared with descriptive statistics. Abdominal symptoms included pain, emesis, and diarrhea. Respiratory symptoms included shortness of breath, tachypnea, cough, and need for mechanical ventilation. Musculoskeletal symptoms included pain and edema. Neurologic symptoms included headache, dizziness, altered mental status, and irritability.Results7 patients with KD and 14 patients with MIS-C were identified. No patients with KD had presenting hypotension and 9 patients with MIS-C had presenting hypotension (p < 0.01). Oral changes were seen in 5 patients with KD and 3 patients with MIS-C (p = 0.05). Conjunctival injection, rash, abdominal symptoms, musculoskeletal symptoms, and neurologic symptoms were seen in some patients with KD and MIS-C with no statistically significant occurrence of these symptoms between the two cohorts. The median initial absolute lymphocyte count was 2,860/µL in KD cases whereas it was 1,325/µL in MIS-C cases (p < 0.01). The median platelet count was 367,000/ µL in KD cases versus 193,000 in MIS-C cases (p = 0.03). The median initial C-reactive protein was 11.2 mg/dL in KD cases versus 23.2 mg/dL in MIS-C cases (p < 0.01). There was no statistically significant difference in the white blood cell count, erythrocyte sedimentation rate, alanine transaminase, B-natriuretic peptide, troponin I, or ferritin values between KD and MIS-C patients. Coronary artery dilation or prominence was seen in 4 patients with KD and in 8 patients with MIS-C (p > 0.99). There were no deaths.ConclusionsFollowing national recognition of MIS-C we saw approximately 1 MIS-C case per week. Presenting hypotension, an absolute lymphocyte count less than 1400/µL, a platelet count less than 200,000/µL, and a CRP greater than 20 mg/dL best predicted MIS-C versus KD. The initial white blood cell count, alanine transaminase, erythrocyte sedimentation rate, B-natriuretic peptide, troponin I, ferritin, and initial coronary artery dilation did not readily distinguish KD from MIS-C. Thus, our diagnostic management recommending limited laboratory evaluation for non-toxic patients presenting with a febrile rash illness, fever and abdominal symptoms, or fever with conjunctival injection is reasonable.

Epiploik Apendiks Enflamasyonu: Primer Epiploik Apandajit

Epiploic appendices are extensions of omentum which covers most of the colon. Most of the pathologic changes are related with spontaneous torsion or venous thrombosis culminating with inflammation and is referred as primary epiploic appendagitis (PEA). There is no pathognomonic symptom, finding or laboratory test for this relatively rare intra-abdominal inflammation. A non-toxic patient with acute onset localized abdominal pain in the right or left lower quadrant is the typical presentation. Imaging studies such as ultrasound and tomography with the awareness of PEA in differential diagnoses of intra-abdominal pathologies are the key to correct diagnosis. Since the conservative treatment is sufficient in most of cases, accurate and timely diagnosis can ensure the appropriate patient management and can prevent unnecessary hospitalizations and interventions.

The significance of hypoxia as a molecular and cellular event in patients with toxic and non-toxic goitre: A statistical inference based on cross-sectional analytic of Iraqi patients

Background: Disorders of the thyroid gland, including toxic and non-toxic goitre, are more common in adult female patients. Hypoxia-inducible factors, including HIF-1 and HIF-2, represent transcriptional activators that function as regulators of oxygen homeostasis. Rapid progress is being made in clarifying the homeostatic functions of HIFs in several physiological systems. However, there are much to be learned in connection with the thyroid gland and its pathologies.Aims and Objectives: To assess the biochemical and clinical significance of hypoxia-inducible factors in patients with multinodular goitre.Materials and Methods: The study is observational and cross-sectional analytic conducted among a population of individuals with diffuse and nodular thyroid goitre including clinically toxic and non-toxic patients. It will attempt to answer the research question concerning the significance of HIFs, via applying techniques of immunohistochemistry to histological samples of resected thyroid tissue, and in pertinence with the demographic and clinical parameters of patients.Results: The total number of patients was forty-three,and most was in their fifth decades of life. The percentile contribution of males and females was 11.63% and 88.37% respectively. Individuals with toxic goitres accounted for 13.95%, and those had significantly higher levels of both HIF-1 and HIF-2 than non-toxic patients (p=0.019, p=0.072). Clinically-toxic patients also had notably more elevated levels of HIF-1 as they grew older when compared to non-toxic patients.Conclusion: There is an evident inadequacy of published literature on hypoxia-inducible factors in patients with goitre. There are no studies whatsoever in correspondence to the research questions explored in this study. Future attempts should explore experimental designs while using human as well as animal models and from an interdisciplinary perspective.Asian Journal of Medical Sciences Vol.9(5) 2018 44-49

Puzzling situation of acetaminophen toxicity in a referral hospital, Tehran, Iran

Puzzling situation of acetaminophen toxicity in a referral hospital, Tehran, Iran Acetaminophen carries a higher risk of overdose. A puzzling situation of acetaminophen toxicity was encouraging enough to explore the epidemiologic situation of acetaminophen toxicity and its outcomes among patients acquired poisoning. This cross-sectional study retrospectively reviewed the medical records of 185 patients with acetaminophen poisoning referred to Loghman Hakim Hospital. Toxicity determined by acetaminophen serum concentration and time elapsed after drug ingestion. Demographics, laboratory markers, toxic hepatitis, renal failures and liver enzyme elevations were compared between toxic and non-toxic patients. Twelve cases belonged to the former group and 173 patients fitted with the latter one. Having a mean age of 24.27±7.19 and 21.58±3.47 years, respectively; females were predominant. The average serum acetaminophen level was 70.37±61.92 and 24.90±26.36 within toxic and nontoxic patients respectively. Median of consumed tablets were estimated as 40 for non-toxic and 18 for toxic patients (p=0.017). Mean hospital stay was 1.75±1.05 days for toxic patients and 1.35±3.25 days for the non-toxic group (p-value<0.001), and of whom 92.4 % discharged within the first day. The laboratory assessments revealed no significant difference between groups. No death was recorded. Whereas hepatotoxicity was present in three toxic patients, renal failure was predominant in non-toxic patients. Rarely, a rise in liver enzyme noticed, however, 33.33 % of toxic and 2.31 % of the non-toxic group had elevated AST; and 33.33 % of toxic versus 1.73 % percent of non-toxic patients had increased ALT. Acetaminophen toxicity is a worldwide noteworthy cause of poisoning which has distinct mortality and morbidity rates and showed an amazing and undebatable poisoning effect in the present study. A comprehensive study is required to examine the possible reasons for the difference between Iranian acetaminophen products with other non-Iranian company products. Keywords: Acetaminophen; Hepatotoxicity; Poisoning; Renal failure; Toxicity; Iranian

Determining risk of severe gastrointestinal toxicity based on pretreatment gut microbial community in patients receiving cancer treatment: a new predictive strategy in the quest for personalized cancer medicine.

Currently, our ability to accurately predict a patient's risk of developing severe gastrointestinal toxicity from their cancer treatment is limited. Risk stratification continues to rely on traditional patient-related and treatment-related factors including age, ethnicity, sex, comorbidities, genetics, agent, dose and schedule. Although informative, these crude measures continue to underestimate toxicity risk, and hence alternative methods of risk prediction must be investigated. Given the increasing focus on the gut microbiome in driving disease, this review will provide an overview of the current literature proposing the gut microbiome as a novel predictive tool for treatment-induced gastrointestinal toxicity. Predictive gut microbial phenotypes have been identified for gastrointestinal toxicity induced by radiation and the checkpoint blocker, Ipilimumab. Each study employed slightly different methods of gut microbiome assessment; however, in all cases, separation of toxic versus nontoxic patients was achieved. No studies have investigated chemotherapy-induced gastrointestinal toxicity. The gut microbiome offers an exciting new method of risk stratification for gastrointestinal toxicity. This would enable identification of high-risk patients prior to treatment, enabling tailored treatment regimens based on personalized risk assessment and the proactive provision of supportive care measures. Based on the plasticity of the gut microbiome, methods of risk mitigation may be investigated.

NASPGHAN Clinical Report on the Evaluation and Treatment of Pediatric Patients With Internal Penetrating Crohn Disease

Natural History of Pediatric Crohn Disease T he natural history of pediatric Crohn disease (CD) remains unpredictable, although some trends are observed that differentiate children from adults. Pediatric CD often presents with more severe disease and more frequent need for immunosuppressive therapy (1). Growth failure, present in 15% to 20% of patients, is a unique characteristic of pediatric CD not seen in adult-onset CD (2). Colonic disease distribution is common in patients younger than 10 years (1). The need for surgical intervention also varies, with 1 study reporting the actuarial risk of having undergone an extensive intestinal resection being 48.6% 5% in a childhood-onset group versus 14.6% 2% in the adult-onset group (P< 0.001) (1). More recently, long-term follow-up of patients enrolled in pediatric registries shows a cumulative surgical rate of 14% to 17% at 5 years and 28% at 10 years (3,4).

Costimulatory molecule CD40 expression in thyroid tissue of Graves' disease patients and its immune pathogenetic significance

To explore the expression of costimulatory molecule CD40 in thyroid tissue of Graves' disease patients and understand its immune pathogenetic significance. From January 2008 to December 2011, 8 patients undergoing partial thyroidectomy for Graves' disease (n = 3) or non-toxic goiter (n = 5) at Affiliated Suzhou Hospital of Nanjing Medical University and Third Affiliated Hospital of Soochow University were enrolled. Using the method of immunohistochemistry, the expression of CD40 was detected in their thyroid tissues. Variation in CD40 expression on thyroid follicular (TFC) in primary cultures was analyzed in the absence (no stimulation group) or presence of inflammatory cytokines including interleukin interferon-γ (IFN-γ) (IFN-γ stimulation group), interferon-6 (IL-6) (IL-6 stimulation group)and tumor necrosis factor (TNF)-α (TNF-α stimulation group) with flow cytometry. IFN-γ-stimulated TFC were cultured with agonist CD40 monoclonal antibody (5C11) (IFN-γ + CD40 group) or isotypic mouse IgG (mIgG) antibody (IFN-γ + mIgG group). And the proliferation of TFC was assessed by 3-(4,5)-dimethyl-thiazolyl-3,5-di-phenytetrazoliumromide (MTT) assays for each donor. The production of free triiodothyronine (FT3) and free thyroxine (FT4) and the release of thyroglobulin (Tg) were measured with radioimmunoassays. The expression of CD40 on infiltrated lymphocytes and TFC were detected in Graves' disease but not in non-toxic goiter patient tissues. Compared with no stimulation group (23.7% ± 7.3%), the expression of CD40 on TFC increased in IFN-γ stimulation group (86.4% ± 4.6%), IL-6 stimulation group (90.0% ± 4.2%) and TNF-α stimulation group (87.3% ± 4.2%). Compared with the IFN-γ + mIgG group (0.75 ± 0.06), the TFC proliferation of IFN-γ + CD40 group (1.14 ± 0.14) significantly increased (P < 0.01). The levels of FT3, FT4 and Tg secretion of IFN-γ + CD40 group were (1.10 ± 0.15) pmol/L, (0.80 ± 0.14) pmol/L and (30.23 ± 1.60) µg/L respectively. They were all significantly increased compared with the IFN-γ + mIgG group, of which the FT3, FT4 and Tg production were (0.76 ± 0.07) pmol/L, (0.63 ± 0.09) pmol/L and (21.37 ± 3.22) µg/L respectively (all P < 0.05). CD40 is abnormally expressed in thyroid tissue of Graves' disease patients. And its costimulatory signal may take part in the immunopathologic mechanism of Graves' disease.

99mTc-MDP uptake in thyroid nodule: Contribution of SPECT-CT and ultrasonography

Iodine kinetic studies were performed in seven patients with hot thyroid nodules, three diffuse toxic goiters and one normal control, using a double label technique (131I and 125I-thyroxine). The investigation was complemented by partial kinetic studies in 29 further subjects, including normal control subjects and euthyroid or hyperthyroid patients with diffuse or nodular goiter. Thyroid iodide uptake and hormonal secretion parameters were significantly increased, up to twice control values, in hot nodules without clinical signs of thyrotoxicosis. Values similar to those of Graves' disease were found in toxic nodular goiter. The exchangeable iodine pool was markedly reduced in those glands where the nodule was adenomatous and radioiodide uptake of normal parenchyma was completely suppressed. In two cases of nontoxic hot nodule with histologic diagnosis of multinodular goiter, and incomplete suppression of the “extranodular” thyroid, the exchangeable iodine pool was comparable to that of normals. The T4 disposal rate was increased, mainly due to a significantly higher metabolic deiodination which seemed to keep pace with the increased T4 production rate in nontoxic nodules. This could be the reason why the mean peripheral T4 pool of clinically nontoxic patients with hot nodules is comparable to that of normal persons, and there are no evident signs of hypermetabolism in spite of the greater thyroid hormone production. A significant “non-T4-iodine” release, probably mainly iodide, was found in every subject. The amount of iodine lost by the thyroid through this “iodide leak” did not relate to the T4 secretion rate but seems to be directly related to the thyroid exchangeable iodine pool size.

A guideline for the inpatient care of children with pyelonephritis

BACKGROUND AND OBJECTIVES:Febrile urinary tract infections and pyelonephritis are common in children and frequently lead to hospitalization for management, especially in the child who appears toxic. The American Academy of Pediatrics (AAP) practice parameter on the diagnosis, treatment and evaluation of the initial urinary tract infection in febrile infants and young children provides experience and evidence-based guidelines for the practitioner caring for children between the ages of 2 months to 2 years. No established guideline exists for older children and the AAP guideline does not specifically focus on inpatient care.METHODS:We conducted a comprehensive review of recently published literature and practice guidelines to develop a consensus on the inpatient diagnosis and management of children with pyelonephritis.RESULTS:Eight recommendations are proposed for the diagnosis and management, including revised guidelines for the imaging studies postpyelonephritis on the basis of current best evidence.CONCLUSION:Proper diagnosis of pyelonephritis, timely initiation of appropriate therapy and identification of children at risk for renal injury will help to reduce immediate as well as long-term complications due to chronic kidney disease.

Optimization of Postoperative Analgesia in Patients with Nontoxic Goiter

Objective: to comparatively evaluate the analgesic activity and hemostatic effects of two nonsteroidal anti-inflammatory drugs (NSAID) that are most commonly used for postoperative analgesia — ketorolac and ketoprofen in patients operated on for diffuse nodular nontoxic goiter. Subjects and methods. At surgical treatment stages, the authors examined the degree of the pain syndrome by the visual analog scale and hemostatic parameters in 90 patients divided into three groups according to the postoperative analgesia mode (ketorol, ketonal, and promedol). Results. Postoperative analgesia in nontoxic goiter patients with ketorol and ketonal has been ascertained to be highly competitive with that with promedol and to give no rise to clinically significant complications inherent in NSAID. Ketorol provides a rapider, prolonged and effective postoperative analgesia than does ketonal. Ketorol affects the hemostatic system to a lesser extent than does ketonal. Conclusion. Ketorol analgesia may be considered to be the method of choice of postoperative analgesia in patients with nontoxic goiter. Key words: ketorol, ketonal, hemostasis, analgesia.

Methotrexate‐associated alterations of the folate and methyl‐transfer pathway in the CSF of ALL patients with and without symptoms of neurotoxicity

Severe neurotoxicity has been observed after systemic high-dose and intrathecal methotrexate (MTX) treatment. The role of biochemical MTX-induced alterations of the folate and methyl-transfer pathway in the development of neurotoxic symptoms is not yet fully elucidated. MTX, 5-methyltetrahydrofolate, calcium folinate, S-adenosylmethionine, and S-adenosylhomocysteine were measured in the cerebrospinal fluid (CSF) of 29 patients with acute lymphoblastic leukemia (ALL) who were treated with high-dose MTX (5 g/m(2)) followed by calcium folinate rescue (3 x 15 mg/m(2)) and/or intrathecal (8-12 mg) MTX. Two patients developed subacute MTX-associated neurotoxicity. CSF was obtained by lumbal puncture 1-3 weeks after administration of MTX and shortly after the occurrence of neurotoxicity. The analytes were measured using HPLC assays with UV and/or fluorescence detection. In non-toxic patients, CSF concentrations of 5-methyltetrahydrofolate and S-adenosylmethionine were in the normal range 2 weeks after administration of high-dose and intrathecal MTX followed by rescue. In contrast, when these patients received intrathecal MTX without rescue, 5-methyltetrahydrofolate concentrations were significantly decreased 12 days after the first MTX administration. S-adenosylmethionine concentrations were significantly decreased up to 45 days. The two patients suffering from neurotoxicity had decreased levels of 5-methyltetrahydrofolate and S-adenosylmethionine during or following toxicity. S-adenosylhomocysteine was determined in all samples of neurotoxic patients but was below the limit of quantification in most samples of non-toxic patients. Calcium folinate was not detected; MTX was present only in samples obtained during its infusion. Intrathecal MTX without folinate rescue as well as MTX-associated neurotoxicity are likely to be associated with specific alterations of the folate and methyl-transfer pathway.

Anticipating gemcitabine-related severe/lethal toxicities: A feasibility study

14652 Background: Gemcitabine is an antimetabolite drug extensively used for treating solid tumors in adults. Gemcitabine pharmacokinetics is altered by Cytidine Deaminase (CDA) gene polymorphism, resulting in impaired detoxification, systemic overexposure and potentially severe toxicities in deficient patients. To ensure a better safety in the handling of gemcitabine, we have developed a simple and rapid phenotypic test to determine the CDA status in patients with cancer. The aim of this work was to evaluate the feasibility and relevance of screening CDA status in patients undergoing gemcitabine-based therapy. Methods: CDA status was evaluated by measuring spectrophotometrically the residual CDA activity in serum. This retrospective study was performed in 100 adult patients (56M/44F, 64± 16 years) with either lung, pancreatic or vesical cancers. Early toxicities were monitored following standard NCI grading. Results: Four patients (2M/2F, mean age 68± 9 years, mean gemcitabine dose: 1200± 240 mg/m2) displayed early severe toxicities (e.g., > grade 3), including one toxic-death. Mean recorded CDA activities in non-toxic patients were 3.5± 2 U/mg protein. Conversely, mean CDA activities in patients with severe/lethal toxicities upon gemcitabine intake were as low as 0.8± 0.14 U/mg (i.e., -77% vs non-toxic patients), thus suggesting that CDA deficiency could be at the origin of the side-effects reported. Conclusions: In this study, 4% of the patients administred with gemcitabine displayed severe or lethal (1%) toxicities. All of them showed marked impairment in CDA function, as measured with the phenotypic test we used. These preliminary data strongly suggests, therefore, that our simple test could be of interest in a routine setting to detect CDA-deficient patients at risk with gemcitabine, a major drug extensively used in clinical oncology. No significant financial relationships to disclose.

Comparing different patterns for managing febrile children in the ED between emergency and pediatric physicians: impact on patient outcome

Objective The management of children with fever of indefinite source still remains controversial. This study aimed to compare different practice patterns between pediatric physicians (PPs) and emergency physicians (EPs) in the management of pediatric fever in the emergency department (ED) and correlate them to existing practice guidelines. Their impact on patient outcomes was also discussed. Methods Medical records of patients 3 to 36 months of age who presented to the ED with fever of indefinite source from June 1 to December 31, 2006, were retrospectively reviewed on day 5 after the patient's first visit. At the same time, telephone follow-up was carried out to determine whether the patient had been visiting or being admitted to another clinic or hospital after discharge. Variation in practice patterns were compared for the number of laboratory tests, ED length of stay (LOS), and the rate of immediate admission. Patient outcomes were measured as the rate of unscheduled revisit within 72 hours and the rate of subsequent admission. Compliance with existing practice guidelines between PPs and EPs were evaluated by dividing all eligible patients into 3 groups: (1) toxic appearing patients (group A), (2) nontoxic patients with body temperature (BT) ≧39°C (group B), and (3) nontoxic patients with BT below 39°C (group C). Results A total of 345 patients who met the inclusion and exclusion criteria were enrolled into this study. Pediatric physicians and EPs treated 163 and 182 febrile children, respectively. In group A, PPs admitted more patients than EPs (41% vs 12 %), whereas more unscheduled revisits were seen in EP-treated patients (44% vs 10%). In group B, PPs ordered more laboratory tests than EPs (2.3 vs 0.7 tests per patient), and their patients also had a longer ED LOS (3.4 ± 3.2 vs 1.5 ± 1.1 hours). However, no difference was found in their rates of immediate admission and unscheduled revisit. In group C, PPs admitted more patients (15% vs 0%) and ordered more laboratory tests (2.0 vs 0.5 tests/patient) than EPs. Longer ED LOS (3.3 ± 3.9 vs 1.0 ± 1.4 hours) was also noted among PP-treated patients. However, no difference was noted in their rates of unscheduled revisit. In all groups, the rates of subsequent admission were similar. Conclusion Compliance with existing practice guidelines (admit the toxic cases and work up those with BT ≧39°C) was higher among PPs, which resulted in a lower rate of unscheduled revisit, but no significant difference was found in the rate of subsequent admission.

General anaesthesia for the cocaine abusing patient. Is it safe?

Commonly, cocaine abusing patient are scheduled for elective surgery with a positive urine test for cocaine metabolites. As many of these patients were clinically non-toxic [normal arterial pressure and heart rate, normothermic, and a normal (or unchanged from previous) ECG, including a QTc interval <500 ms], we have recently proceeded with elective surgery requiring general anaesthesia in this patient group. Forty urine cocaine positive patients were compared with an equal number of drug-free controls in a prospective, non-randomized, blinded analysis. Intraoperative mean arterial blood pressure, ST segment analysis, heart rate and body temperature were recorded and compared. Cardiovascular stability during and after general anaesthesia in cocaine positive, non-toxic patients was not significantly different when compared with an age and ASA matched drug-free control group. These results demonstrate that the non-toxic cocaine abusing patient can be administered general anaesthesia with no greater risk than comparable age and ASA matched drug-free patients.

Thyroid function following partial thyroidectomy

Abstract The main objective of this investigation was to establish the incidence of hypothyroidism and recurrent goitre following partial thyroidectomy. Accurate measurements of the thyroid remnants and resected specimens have been made in all cases. The postoperative thyroid status has been assessed clinically and also biochemically by serum thyroxine as iodine, T3 resin uptake, free thyroxine index and thyroid-stimulating hormone estimations. Serum calcium and phosphorus have also been measured and the necessary histological material reviewed. Postoperative hypothyroidism occurred in approximately 11 per cent of previously toxic and 6.5 per cent of non-toxic patients, becoming evident in most cases within a year of operation. The T3 resin uptake measurement following operation in this and previous series suggests that in many patients there is a compensation process which is maintained by increased secretion of thyroid-stimulating hormone. No evidence has been adduced that patients who show this compensation mechanism are, as some have suggested, in a state of ‘subclinical hypothyroidism’ or that they become overtly hypothyroid later. In this series hypothyroidism was more closely related to small remnant size than the presence of lymphadenoid change. A significantly higher proportion of patients with small thyroid remnants became hypothyroid in both toxic and non-toxic groups. Remnants of about 8–16 ml ‘cuboid’ volume (roughly 8–16 g by weight) have seemed reasonable for our patients.

Peritonsillar and parapharyngeal space abscess in the older adult

Objective: To review the presentation and management of peritonsillar (PTA) and parapharyngeal space (PPSA) abscesses in older adults and compare this with the usual presentation and management in the younger patient. Study Design: An 18-year retrospective review at a tertiary care hospital. Methods: The patient database was searched by using the diagnosis codes for PTA and PPSA. The search included inpatient and outpatient visits of patients 50 years of age and older from 1983 to 2001. The charts were reviewed, and data regarding presentation, management, and outcome were recorded. Comparisons to the current literature were made. Results: Fourteen patients were identified, 8 with PTA and 6 with PPSA. The most common symptoms in both groups were sore throat and dysphagia. Only 1 patient in either group was febrile. All vitals signs were within normal limits in all other patients. Only 1 patient in each group experienced trismus, and no patients showed drooling. Five of the PTA patients required inpatient care, and 2 were taken to the operating room. Conclusions: PTA and PPSA are uncommon infections in the older adult, with only 14 patients identified at a tertiary care hospital over an 18-year period. Complaints of new onset sore throat and dysphagia of several days duration in patients over 50 years old should alert the evaluating physician to these 2 clinical entities, even in afebrile, nontoxic patients. PTA in this group may be more likely to require inpatient care along with surgical treatment in the operating room.

Community-acquired pneumonia in the emergency department: A practical approach to diagnosis and management

Pneumonia is one of the most common conditions for which patients seek emergency care. It is a challenging infection in that the spectrum of illness ranges from the nontoxic patient appropriate for outpatient antibiotics to the critically ill patient requiring intensive care hospitalization. Current data and diagnostic technology provide the emergency physician with the tools for an appropriately rapid evaluation and consideration of the differential diagnosis. Key critical thinking and application of published findings allow for intelligent empirical antibiotic treatment and risk stratification for the best disposition. Although antibiotic-resistant organisms increasingly are being identified, patients continue to benefit from early institution of standard ED treatment. Coverage for atypical organisms improves patient response and outcome. Finally, identification and treatment of the complications of pneumonia and accompanying sepsis must be considered by the ED physician when evaluating critically ill patients.