Patient Body Temperature Research Articles

Repeated Transfusion of Granulocytes to Control Multidrug-Resistant Pseudomonas Aeruginosa Sepsis in Haploidentical Hematopoietic Stem Cell Transplant Patients during Pre-Engraftment Stage

Background and Objectives: Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is a potentially curative therapy for treating pediatric hematological malignancies that are refractory to other therapies. However, severe infections in neutropenic patients remain the major cause of morbidity and mortality, as well as influence the engraftment during HSCT. Multidrug-resistance (MDR) pseudomonas aeruginosa sepsis during the pre-engraftment stage has a highly prevalence of mortality, especially in patients with the primary infection site at the facial dangerous triangle. Without the efficient and time treatment, the bacterium may readily spread into the brain, causing severe intracranial infection and even death. There is an urgent need to effectively control MDR-pseudomonas aeruginosa infection and reduce the mortality of patients undergoing allo-HSCT.Method: We report herein a 5-year-old boy with acquired severe aplastic anemia (SAA) who experienced a secondary engraftment failure eight months after receiving haploidentical HSCT from his father. Owing to recurrent fever and severe pneumonia during persistent neutropenia, the patient received second transplant using bone marrow cells from his farther. Two days after the secondary transplant bloodstream identified an infection of MDR-pseudomonas aeruginosa accompanied with symptoms of chills and high fever, and deteriorating pneumonia. On day +4 he had a cellulitis at facial dangerous triangle with lacrimal gland and nasolacrimal duct involved, and secretion culture also confirmed the same bacteria. He was given antibiotics of Tetracycline, Levofloxacin, and Cefoperazone schubatam. However, the involved skin became worse and high fever peak became more frequent, suggesting the progression of sepsis. To facilitate the reconstitution of granulocytes in the patient, we performed six doses of granulocyte transfusion (GTX) from father once every over a period of six days. Granulocyte counts were performed every 12 hours after transfusion in order to maintain a level of granulocyte more than 0.5×109/L. Blood typing showed that the patient was type A and the farther was type AB. To avoid a possible hemolysis due to ABO-mismatched, we treated granulocytes with hydroxyethyl starch before transfusion.Results: During GTXs (from day +6 to +11 after transfusion), the patient's body temperature fluctuated between 37.0℃-38.2℃. There were no signs and symptoms of exacerbated pneumonia, such as cough, hemoptysis and moist rale. We didn't observe transfusion related acute lung injury (TRALI) and respiratory failure. The urine was clear without hematuria. The area of skin involved became under control. Notably, the patient had granulocyte engrafted on day +15 after transfusion, decrease of body temperature on day +16 and normal temperature on day +20. Concurrently, the facial cellulitis was gradually narrowing and moist rale of the lung disappeared. A repeat chest CT scan confirmed disappearance of the infection site in the lung. The bloodstream culture was negative on day +9 and secretion culture was negative on day +15. We maintained the treatment with antibiotics until the negative blood culture was confirmed twice. Eleven months after the treatment, the patient is alive with full donor chimaerism. His blood type becomes AB type. Other tests, including peripheral blood cell counts, liver and renal functions as well as pulmonary function, are all normal.Conclusion: Multidrug-resistant bacteria infection is a common and yet fatal complication in SAA patients. These patients usually experience a prolonged period of neutropenia when undergoing HSCT. We demonstrate here that when being combined with the utilization of broad spectrum antibiotics, repeated GTXs from donor source prove to be an effective therapy for controlling these infections, thereby reducing early death and improving successful rate of allo-HSCT. Therefore, GTXs are recommended as, at best, a “bridge” procedure, that may protect the patient from fatal infections until myeloid recovery ensues DisclosuresNo relevant conflicts of interest to declare.

Clinical Characteristics of Febrile Outpatients : Possible Involvement of Thyroid Dysfunction in Febrile Tachycardia.

We retrospectively analyzed the cases of 148 febrile patients whose body temperature (BT) was ≥ 37.5°C at our hospital. We categorized them into seven groups; those with bacterial and viral infection, nonspecific inflammation, neoplasm, connective tissue disease (CTD), drug-induced disease, and unidentified causes. Our analysis revealed that the patient's BT at the 1st visit (BT-1st visit) and highest BT during the febrile period (BT-max) differed significantly among all categories except neoplasm. The greatest difference between BT-1st visit and BT-max was highest in the CTD group (1.5°C). Positive correlations of heart rate and C-reactive protein (CRP) level with BT-max and a negative correlation between serum sodium level with BT-max were uncovered. The serum thyroid-stimulating hormone (TSH) level and the ratio of TSH/free thyroxine were negatively correlated with BT-max, especially in the viral infection group, suggesting the existence of occult thyrotoxicosis in accord with a febrile condition, possibly leading to febrile tachycardia. A febrile gap between BT-1st visit and BT-max (except in the neoplasm group) was shown, in which BT-max was correlated with thyroid function. Clinicians should recognize the fluctuation of BT when diagnosing febrile patients, and tachycardia in such febrile patients may be, at least in part, associated with subclinical thyroid dysfunction.

Unclassifiable Infectious Complications after Lobectomy for Cancer: Etiology, Risks, and Outcomes

Although infectious complications occur occasionally after lung lobectomy, some of them are overlooked if the pathogen or origin is unidentifiable. We retrospectively reviewed 425 patients who underwent lobectomy for lung cancer. Infectious complications developed in 61 patients who consequently underwent empiric therapy: 44 had an identifiable focus and 17 did not irrespective of systemic surveillance. The 17 patients without an identifiable focus were predominantly patients with squamous cell carcinoma, a smoking history, large tumor size, and undergoing lower lobectomy. These 17 patients were able to be distinguished from those without infectious complications with a sensitivity of 88% and a specificity of 98% based on the patient's body temperature, C-reactive protein, and white blood cell count. The median onset of the 17 patients was 8 days (5-30 days) after operation. None of these 17 patients had air leak for more than 3 days, major cardiopulmonary complications, superficial surgical site infection, organ-specific symptoms (e.g., cough and diarrhea), or increased dead space size. Inflammatory markers were normalized by antibiotics alone in 14 of the 17 patients, while the condition of the remaining 3 worsened to empyema that required some intervention. One patient eventually died after thoracoscopic debridement. Postoperative acute onset of infectious complication without any specific symptoms or any identifiable focus should be included in a separate category of complications. We must clarify the pathology of this complication (e.g., occult bronchopleural fistula), but for now, careful management is mandatory, as therapeutic failure can lead to a fatal outcome.

Development of Perioperative Hypothermia Management Protocol for Surgical Patients

Unintended perioperative hypothermia is occurring in 50-90% of surgical patients, leading to problems such as increased infections, increased bleeding, cardiovascular complications, and delayed recovery. Therefore, it is important to manage the patient's body temperature integrally.

Hypothermia, bradycardia and hypotension in a Dachshund undergoing a hemilaminectomy

A 3-year-10-month-old female neutered Dachshund was presented for investigation of acute onset paraparesis. Magnetic resonance imaging showed an intervertebral disc extrusion, therefore a dorsal hemilaminectomy was performed. While under general anaesthesia, the patient became hypothermic (33.1 °C) and severely bradycardic, with a concurrent severe decrease in blood pressure. Initial management of the bradycardia included glycopyrrolate at a dose rate of 10 μg/kg, administered twice, however the patient was unresponsive to this. Active warming was initiated and the patient's body temperature slowly increased. A single dose of atropine was administered, following which the patient's bradycardia resolved. It is likely that once the patient's temperature increased, all the vasoactive substances were able to take effect. This suggests that the bradycardia was probably, in part, due to the hypothermia, although other factors may have contributed.

An ontology-driven clinical decision support system (IDDAP) for infectious disease diagnosis and antibiotic prescription.

The available antibiotic decision-making systems were developed from a physician's perspective. However, because infectious diseases are common, many patients desire access to knowledge via a search engine. Although the use of antibiotics should, in principle, be subject to a doctor's advice, many patients take them without authorization, and some people cannot easily or rapidly consult a doctor. In such cases, a reliable antibiotic prescription support system is needed. This study describes the construction and optimization of the sensitivity and specificity of a decision support system named IDDAP, which is based on ontologies for infectious disease diagnosis and antibiotic therapy. The ontology for this system was constructed by collecting existing ontologies associated with infectious diseases, syndromes, bacteria and drugs into the ontology's hierarchical conceptual schema. First, IDDAP identifies a potential infectious disease based on a patient's self-described disease state. Then, the system searches for and proposes an appropriate antibiotic therapy specifically adapted to the patient based on factors such as the patient's body temperature, infection sites, symptoms/signs, complications, antibacterial spectrum, contraindications, drug-drug interactions between the proposed therapy and previously prescribed medication, and the route of therapy administration. The constructed domain ontology contains 1,267,004 classes, 7,608,725 axioms, and 1,266,993 members of "SubClassOf" that pertain to infectious diseases, bacteria, syndromes, anti-bacterial drugs and other relevant components. The system includes 507 infectious diseases and their therapy methods in combination with 332 different infection sites, 936 relevant symptoms of the digestive, reproductive, neurological and other systems, 371 types of complications, 838,407 types of bacteria, 341 types of antibiotics, 1504 pairs of reaction rates (antibacterial spectrum) between antibiotics and bacteria, 431 pairs of drug interaction relationships and 86 pairs of antibiotic-specific population contraindicated relationships. Compared with the existing infectious disease-relevant ontologies in the field of knowledge comprehension, this ontology is more complete. Analysis of IDDAP's performance in terms of classifiers based on receiver operating characteristic (ROC) curve results (89.91%) revealed IDDAP's advantages when combined with our ontology. This study attempted to bridge the patient/caregiver gap by building a sophisticated application that uses artificial intelligence and machine learning computational techniques to perform data-driven decision-making at the point of primary care. The first level of decision-making is conducted by the IDDAP and provides the patient with a first-line therapy. Patients can then make a subjective judgment, and if any questions arise, should consult a physician for subsequent decisions, particularly in complicated cases or in cases in which the necessary information is not yet available in the knowledge base.

Predictability of successful trans-arterial embolization in pelvic fracture bleeding based on patient initial presentation

BackgroundPelvic fracture bleeding generally leads to hemorrhagic shock. Trans-arterial embolization (TAE) is regarded as the most useful treatment; however, the initial presentation of the patient can impact the effectiveness of TAE for pelvic fracture bleeding. The aim of this retrospective study is to explore whether the patient data at the initial presentation can predict the success of TAE for pelvic fracture bleeding. MethodsTwenty-seven charts were retrospectively reviewed. TAE failure was defined as any patient who eventually received an exigent laparotomy or who died due to uncontrolled bleeding after TAE. For patients who received TAE, we analyzed factors recorded at the initial presentation, including age, gender, systolic blood pressure, heart rate, respiratory rate, body temperature, Glasgow coma scale (GCS) score, injury severity score (ISS) and associated injuries, using Pearson's correlation and independent t-tests. The odds ratio was used to determine the cut-off values for the patient presentation findings related to successful TAE and thus was used to assess congruity. ResultsSuccessful TAE was not correlated with age or gender. The hierarchical order of statistically significant associations between successful TAE and initial presentation data was as follows: the patient's body temperature, associated injury, respiratory rate, systolic blood pressure, GCS score, and ISS. The odds ratios for all statistically significant initial presentation factors were within a 95% confidence interval. ConclusionThe findings upon initial presentation of a patient with pelvic fracture bleeding that were related to the predictability of successful TAE include the following: hypothermia prevention with maintenance of the body temperature above 36°C, associated injuries limited to two organ systems, maintenance of the respiratory rate at approximately twenty-two breaths per minute, a sustained systolic blood pressure of approximately 90mmHg, maintenance of a heart rate of approximately one hundred beats per minute, a minor head injury with a GCS score greater than thirteen and a moderate ISS of less than twenty.

Effectiveness of Early Warming With Self-Warming Blankets on Postoperative Hypothermia in Total Hip and Knee Arthroplasty.

Hypothermia is an important complication in joint arthroplasty. Commonly, forced air warming (FAW) devices are used intraoperatively to maintain body temperature in patients undergoing surgery. However, it is believed that these convective warming systems could increase the risk of deep surgical site infections due to disruption of unidirectional downward laminar airflow. Conductive warming devices have no noticeable effect on ventilation airflow. Nevertheless, the effectiveness of the self-warming (SW) blanket, a novel conductive warming device, on postoperative hypothermia in elective joint arthroplasty is unknown. The purpose of this study was to evaluate the effectiveness of early warming with SW blankets in the prevention of postoperative hypothermia in elective total hip (THA) and knee arthroplasty (TKA) compared with FAW devices. Patients who underwent elective THA or TKA between May and June 2014 were assigned in the FAW or SW group. A total of 105 patients were enrolled into the study. In the FAW group, the FAW devices were applied after disinfection of the surgical site. In the SW group, the SW blankets were already applied in the orthopaedic department. The duration of warming with SW blankets before anesthetic induction was documented. The body temperature was measured preoperatively upon arrival in the orthopaedic department and postoperatively upon arrival in the postanesthesia care unit. The patient's body temperature was measured at the tympanic membrane, and hypothermia was defined as a body temperature of less than 35.5°C. The SW blankets were applied for a median of 86.8 minutes (78.8-94.8) before anesthetic induction. Postoperative hypothermia was observed in 15 (31.3%) and eight (14.0%) patients in the FAW group and the SW group, respectively (p = .029). The median postoperative body temperature was 35.59°C (35.44-35.74) and 35.95°C (35.83-36.06) in the FAW group and the SW group, respectively (p < .001). Early warming with SW blankets was more effective than FAW devices in the prevention of postoperative hypothermia in elective THA and TKA.

The Case Files

The Case Files

Accuracy and precision of four common peripheral temperature measurement methods in intensive care patients.

IntroductionAn accurate determination of body temperature in critically ill patients is a fundamental requirement for initiating the proper process of diagnosis, and also therapeutic actions; therefore, the aim of the study was to assess the accuracy and precision of four noninvasive peripheral methods of temperature measurement compared to the central nasopharyngeal measurement.MethodsIn this observational prospective study, 237 patients were recruited from the intensive care unit of Imam Ali Hospital of Kermanshah. The patients’ body temperatures were measured by four peripheral methods; oral, axillary, tympanic, and forehead along with a standard central nasopharyngeal measurement. After data collection, the results were analyzed by paired t-test, kappa coefficient, receiver operating characteristic curve, and using Statistical Package for the Social Sciences, version 19, software.ResultsThere was a significant meaningful correlation between all the peripheral methods when compared with the central measurement (P<0.001). Kappa coefficients showed good agreement between the temperatures of right and left tympanic membranes and the standard central nasopharyngeal measurement (88%). Paired t-test demonstrated an acceptable precision with forehead (P=0.132), left (P=0.18) and right (P=0.318) tympanic membranes, oral (P=1.00), and axillary (P=1.00) methods. Sensitivity and specificity of both the left and right tympanic membranes were more than for other methods.ConclusionThe tympanic and forehead methods had the highest and lowest accuracy for measuring body temperature, respectively. It is recommended to use the tympanic method (right and left) for assessing a patient’s body temperature in the intensive care units because of high accuracy and acceptable precision.

Interventions for Treating Inadvertent Postoperative Hypothermia.

Postoperative hypothermia is the drop in body heat that occurs in patients within the postoperative setting, resulting from the surgery, surgical environment and/or anaesthetic drugs administered (Warttig et al 2014). Interventions for treating inadvertent postoperative hypothermia are useful for any general nurse responsible for postoperative care. When a patient's body temperature drops after surgery, the postoperative staff must act to re-establish the patient's body temperature to avoid associated physical complications. This review considered the interventions that are available to re-establish a patient's body temperature.

Influence of temperature on thromboelastometry and platelet aggregation in cardiac arrest patients undergoing targeted temperature management

BackgroundCoagulation can be visualised using whole blood coagulation analyses such as thromboelastometry and platelet aggregation tests; however, the role of temperature in the analyses is ambiguous. The aim was to examine whether temperature influences the whole blood coagulation tests.MethodsWe included 40 patients treated with targeted temperature management (33 ± 1 °C) after out-of-hospital cardiac arrest. The blood samples were obtained on hypothermia and normothermia. Each blood sample was analysed simultaneously at 33 °C and 37 °C by thromboelastography (ROTEM®) employing the assays EXTEM®, INTEM®, FIBTEM® and HEPTEM®, and by Multiplate®Analyzer, using COLtest®, ADPtest®, ASPItest® and TRAPtest® as agonists. Data on antithrombotic drugs were collected systematically from medical records, and data were analysed using repeated measurement analysis of variance (ANOVA).ResultsThe ROTEM® analyses showed increased clotting time, lower maximum velocity and increased time to maximum velocity (all p values <0.02) when performed at 33 °C compared with 37 °C, irrespective of the patients being hypothermic (median 33.1 °C) or normothermic (median 37.5 °C). However, EXTEM® time to maximum velocity showed no difference between the analyses performed at 33 °C and 37 °C when the patients were hypothermic (p = 0.83). No differences were found in maximum clot firmness (all p values >0.09) analysed at 33 °C and 37 °C, independent of the body temperature.In the hypothermic blood sample, no difference was found when using the COLtest®, ASPItest® or TRAPtest® to compare platelet aggregation analysed at 33 °C and 37 °C (all p values >0.19), but platelet aggregation was significantly higher using the ADPtest® (p < 0.001) when analysed at 33 °C. In the normothermic blood sample, the TRAPtest® showed no difference (p = 0.73) when performed at 33 °C; however, significantly lower aggregation was found using the COLtest® and ASPItest® (all p values <0.001), while a higher aggregation at 33 °C was found using the ADPtest® (p = 0.003).ConclusionROTEM® analyses seemed not to be dependent on body temperature but showed a slower initiation of coagulation when analysed at 33 °C compared with 37 °C. The Multiplate®Analyzer results were dependent on the temperature used in the analyses and the body temperature. In whole blood coagulation tests, the temperature used in the analyses should be kept at 37 °C irrespective of the patient’s body temperature being 33 °C or 37 °C.

SYSTEMIC LUPUS ERYTHEMATOSUS AND INFECTIVE ENDOCARDITIS: CLINICAL AND DIAGNOSTIC PARALLELS AND IMAGINARY MIMICRY

Aim of the study – draw attention to the differential diagnosis of systemic lupus erythematosus (SLE) and infective endocarditis. Materials and methods. Patient A., 44 years old, was admitted to the cardiologic department of Ryazan Regional Clinical Cardiology Clinic diagnosed with probable infective subacute endocarditis, glomerulonephritis, with complaints of weakness, fatigue, increase in body temperature up to 37.7 °C preferably in the evening, dry cough, shortness of breath on mild exertion, swelling of legs and feet. In early October 2015, the patient's body temperature increased up to 37.8 °C, there was a dry cough. Patient was treated on an outpatient basis for acute respiratory viral infections with antibiotics, decreased body temperature. Acute deterioration of the condition was observed in mid-October: severe shortness of breath even on mild physical exertion, heart rate increased, as well as lower limb edema, blood pressure (BP) increased up to 240/140 mmHg. The patient was hospitalized in the therapeutic department. Against the background of the treatment (antibiotics, antihypertensive agents, diuretics, digoxin) patient’s condition was improved: shortness of breath decreased, as well as the heart rate, limb edema, blood pressure down to 180/110–190/120 mmHg. However, there was persistent proteinuria (0.33–1.65–3.3 g/L), low grade fever persisting in the evening. On admission to the cardiological department of Ryazan Regional Clinical Cardiology Clinic patient underwent the following survey: assessment of lab parameters in dynamics, electrocardiography, heart echocardiography, computed tomography (CT) of lungs. Results. We revealed left ventricular hypertrophy on heart ultrasonography; an increase in the volume of left atrium, right ventricle, right atrium; mitral, aortic, tricuspid valve insufficiency (grade II regurgitation); pulmonary hypertension; on lung CT – the picture of hydrothorax on the right side, hydropericardium. General analysis of the urine revealed proteinuria equal to 3.3 g/L. These data, combined with the history of the disease (fever for several months) confirmed diagnosis of infective endocarditis, despite the absence of vegetations on heart valves. However, high degree of proteinuria required differential diagnosis with systemic connective tissue diseases, such as system lupus erythematosus. Additional examination revealed increased titers of antinuclear factor (1:5120) antibodies (AB) to the double-stranded deoxyribonucleic acid (DNA) (93 IU/mL). In this regard, and due to an increase in proteinuria up to 10 g/L we re-assessed diagnosis: systemic lupus erythematosus, acute course, grade III of activity with the affection of kidneys (lupus nephritis with nephrotic syndrome and impaired renal function, glomerular filtration rate equal to 35 mL/min), serous membranes (hydrothorax on the right side, hydropericardium), heart (moderate insufficiency of mitral, aortic, tricuspid valve (grade II regurgitation), respiratory system (grade I pulmonary hypertension), haematological disorders (anemia, thrombocytopenia), seropositive for antibodies to double-stranded DNA, anti-nuclear factor; secondary hypertension. Conclusion. This case illustrates difficulties of differential diagnosis between system lupus erythematosus and infective endocarditis, especially in the early stages, when there are still no data of additional examinations.

'Jaws of steel' after rocuronium.

Sir, A 60-year-old lady was admitted to the Intensive Care Unit of our hospital with complaints of shortness of breath. She was a diagnosed case of dilated cardiomyopathy with left ventricular failure. Arterial blood gas analysis revealed severe hypoxia with metabolic acidosis. Adrenaline infusion was started to optimise blood pressure. Intravenous frusemide was administered to relieve pulmonary oedema. Bilevel positive airway pressure was applied to improve oxygenation. After 1 h, patient was still hypoxic with laboured respiration; hence, it was decided to intubate patient electively and start mechanical ventilation. Her airway assessment revealed Mallampati class of 2 with good mouth opening. Intravenous midazolam 1 mg and fentanyl 50 µg were given; as bag and mask ventilation was adequate, rocuronium intravenous 50 mg was administered to facilitate muscle relaxation for intubation. After 1 min, an attempt was made to open the mouth, but severe jaw stiffness did not allow it. Injection rocuronium 20 mg was repeated, and bag and mask ventilation was continued for another 2 min. Oxygen saturation was maintained at 95% on 100% oxygen with bag and mask ventilation. Again, intubation attempt was made; however, jaw could not be opened with any force. As last resort, blind nasal intubation was done. Bilateral chest auscultation confirmed tracheal intubation. Except for the jaw muscle rigidity, other muscle spasm or rigidity in the body was not observed. The patient's body temperature was 36°C. End tidal expired CO2 was 32 mm Hg with tidal volume of 400 ml and respiratory rate of 12/min on mechanical ventilation. Haemodynamics were deteriorating despite maximal inotropic therapy with progressively increasing metabolic acidosis. The patient had repeated episodes of ventricular fibrillation and received multiple defibrillatory shocks. The patient could not be revived despite all efforts. Masseter muscle rigidity (MMR) also referred as ‘jaw of steel’ is severe stiffness of the jaw, with inability to open the mouth causing difficult or impossible laryngoscopy.[1] MMR is commonly seen after administration of succinylcholine and volatile agents.[2] MMR has also been quoted as an early sign of malignant hyperthermia (MH).[3] Muscle spasm following succinylcholine causing masseter spasm can lead to clinical MH in 30% of cases.[4] However, implications related to non-depolarising muscle relaxants have also been reported.[5] Jenkins reported a case of MMR after vecuronium.[6] Masseter spasm after pancuronium administration in a patient undergoing aortic valvulotomy has been reported.[7] A similar case of persistent masseter spasm during anaesthesia has been reported, where the authors attributed the spasm to increased extreme pre-operative anxiety rather than rocuronium.[8] Fentanyl in high dose can cause rigidity but in the present case, it was used in a low dose. Masseter spasm has the potential to complicate airway management, but no reported case has been shown to progress to generalised rigidity and MH. In the present case, we did not observe any signs of MH such as raised temperature, raised EtCO2 and generalised muscle rigidity. Non-depolarising muscle relaxants can be used safely in MH patients. Failed intubation in such scenario can be an important cause of morbidity and mortality. Nasopharyngeal airways can be placed and ventilation carried out and can be life saving. Sporadic case reports have suggested different techniques for airway management after MMR like fibreoptic nasotracheal intubation, retrograde endotracheal intubation, surgical cricothyrotomy and use of Trachlight®.[9] Though rare, one must be aware of MMR after using muscle relaxants. In case of any incident of masseteric spasm, the aim should be to maintain adequate oxygenation by any means. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

A case of primary adrenal diffuse large B cell lymphoma presenting with severe hyponatremia.

We herein report a case of primary adrenal lymphoma with severe hyponatremia. The patient was admitted for an evaluation of severe hyponatremia and an enlarged bilateral adrenal mass, which were found in a previous examination for causes of general fatigue and anorexia. Laboratory data, including the serum levels of sodium (115mEq/L), osmolality (239mOsm/kgH2O), ADH (5.8pg/mL), cortisol (11.6μg/dL), free T3 (2.42pg/mL), urinary Na (117mEq/L) and urine osmolality (490mOsm/kgH2O), fulfilled the diagnostic criteria for the syndrome of inappropriate secretion of ADH (SIADH). An abdominal computed tomography scan revealed a large bilateral adrenal mass. A biopsy of the enlarged left adrenal mass revealed diffuse large B cell lymphoma, which was negative for ADH protein. Hydrocortisone treatment normalized the patient's body temperature and serum sodium concentration. In this case, hyponatremia developed when both adrenal glands were involved and was normalized with hydrocortisone. These findings suggest that adrenal insufficiency was the cause of hyponatremia, although the basal serum cortisol was normal. The current case suggests that the administration of hydrocortisone is recommended if suspicious clinical signs or symptoms are found in severe hyponatremia, even if hyponatremia is associated with a normal serum cortisol level and fulfills the diagnostic criteria for SIADH.

Shivering suppression in therapeutic hypothermia

In Brief Therapeutic hypothermia uses methods such as ice packs and cooling blankets to reduce a patient's body temperature, which decreases cerebral oxygen consumption, and metabolic rate, improving survival and preventing neurologic damage.

Long-Term Fever After Hallux Valgus Surgery Secondary to Titanium Allergy: A Case Report and Review of the Literature

We present the case of a patient who had experienced a fever of unknown cause for >7months after surgical treatment for hallux valgus. A patch test revealed a positive reaction to a titanium alloy. All symptoms subsequently disappeared after we removed the implanted titanium screws. Histopathologic examination of the tissue surrounding the screws showed macrophage infiltration in the tissue. For >1year after removal of the titanium screws, the patient's body temperature remained <37°C. These results support a diagnosis of titanium allergy in our patient. To the best of our knowledge, a long-term fever caused by an allergic reaction to mini-titanium screws of such a small size has not been reported. A review of 16 cases of titanium allergy reported in the published data confirmed that titanium allergy is extremely rare and that the clinical symptoms can vary. Titanium allergy should be suspected when a patient presents with a fever of unknown cause, delayed wound healing, dermatitis, or impaired fracture healing after internal fixation with titanium materials. A patch test for titanium or the lymphocyte transformation test could offer guidance for the clinical diagnosis of titanium allergy. Finally, we recommend that all patients should be asked whether they have a history of an allergy to any metal before surgery.

The effectiveness of the newly designed thermal gown on hypothermic patients after spinal surgery.

To develop the newly designed thermal gown to test the effectiveness in relieving postoperative hypothermia as compared to traditional cotton cloth. Hypothermia is a common problem after spinal surgery. A patient's safety and comfort are significant. Currently, most research is focused on instruments that relieve a patient's hypothermia. Studies have rarely considered a patient's comfort while caring for their body temperature. This study employed an experimental design. The participants were assigned randomly to two groups: the experimental group (N=50) and the control group (N=50). The experimental group received the newly designed thermal gown intervention. The control group received the standard postanaesthesia care unit re-warming intervention. The material used to collect data included demographic data, postoperative management and comfort level. Nurses measured patients' vital signs and asked for patients' subjective comfort level on admission to the postanaesthesia care unit every 10minutes until their discharge from the postanaesthesia care unit. The accumulated percentage for thermal gown group patients in reaching 36°C during the first 20minutes of admission was significantly higher than that of the cotton cloth group. The thermal gown group individuals showed significantly higher comfort levels (score=4) at 10minutes, when compared to the cotton cloth group. Results suggested that the newly designed thermal gown had effectively improved postoperative temperature and comfort level with an evidence-based intervention. Maintaining a patient's body temperature is a major task for nurses working in the post-anaesthesia care unit. With the newly designed thermal gown, the duration of a patient's stay in the postanaesthesia care unit was shortened and the patient's comfort was increased.

Hip arthroscopy for the management of trauma: a literature review.

The first descriptions of the use of hip arthroscopy for traumatic injuries were presented in 1980. One paper described arthroscopy for the removal of a bullet fragment while others reported using hip arthroscopy to remove fragments following total hip arthroplasty. With the application of traction and modification of arthroscopic instruments, hip arthroscopy has become a useful tool in treating trauma to the hip. Most of the literature describes traumatic hip dislocation. Several studies have documented the successful use of arthroscopy for removal of loose bodies, but it has also been used to treat labral tears, chondral defects and acetabular rim fractures. Complications reported include fluid extravasation, the lowering of the patient's body temperature using cool saline irrigation and further injury due to unrecognized concomitant pathology.

Heterotopic ossification in a tetraplegic patient with prolonged fever

Prolonged fever is rare in patients with spinal cord injury. Fever has been shown to be associated with hetero-topic ossification, but prolonged fever is very rare. We report here a case of prolonged fever in a tetraplegic patient who was eventually diagnosed with heterotrophic ossification, and provide a review of the literature. Treatment with sodium etidronate resolved the fever. A 51-year-old man with C3 tetraplegia developed prolonged fever (37.5-39.4°C). Fever workup did not reveal a definite origin of the fever. Non-infectious disease was suspected. The patient was diagnosed with heterotopic ossification after 3-phase bone scintigraphy. Oral sodium etidronate treatment was started immediately at a dose of 20 mg/kg/day after diagnosis. On the 14th day of administration, the patient's body temperature decreased to the normal range and remained stable. Heterotopic ossification should be taken into consideration when examining patients with spinal cord injury who have prolonged fever. This case shows that hetero-topic ossification can be treated successfully with sodium etidronate.