The management of acute supraglottitis patients at the intensive care unit

INTRODUCTION

Acute supraglottitis is a potentially life-threatening condition that often necessitates intensive care unit (ICU) admission for airway monitoring. The objective of this study was to identify clinical criteria that predict a benign course for patients with acute supraglottitis.

METHODS

A prospective observational study was performed. Adult patients hospitalized in the ICU between 2007 and 2019 diagnosed with acute supraglottitis were included. All patients were treated with antibiotics and corticosteroids. Fiber optic laryngoscopy (FOL) was performed every 12 h, with each exam defined as "improving", "no change" or "deteriorating" based on the presence of airway edema. Need for airway intervention was correlated to changes in the FOL exam.

RESULTS

Of 146 patients included, 14 (10%) required intubation, ten on admission, and four during the first 6 h of ICU admission. FOL follow-up was performed on 528 occasions-427 (81%) exams showed improvement, 16 (3%) deterioration, and 85 (16%) with no change. On no occasions was improvement in FOL followed by deterioration. The median ICU length of stay was 3 (IQR 2-3.5) vs. 1 (IQR 1.0-1.25) day for patients who did or did not require intubation (p < 0.001), respectively.

CONCLUSION

Improvement in FOL exam accurately predicted the absence of need for intubation and might represent a criterion for early ICU discharge.

Left Ventricular Assist Device Implantation in a COVID-19 Positive Patient

Introduction

Case Report

Summary

The management of cardiac implantable electronic device lead perforations: a multicentre study

AIMS

Lead perforation is a rare, well-known complication of cardiac implantable electronic device (CIED) implants, whose management is mostly not evidence-based. Main management strategies include conservative approach based on clinical and lead function follow-up vs. routine invasive lead revision approach. This study compared the complications of both strategies by composite endpoint, including recurrent perforation-related symptoms, recurrent pericardial effusion (PEf), lead dysfunction, and device infection during 12 month follow-up.

METHODS AND RESULTS

Multicentre retrospective analysis, inquiring data from imaging studies, device interrogation, pericardiocentesis, and clinical charts of patients with suspected perforating leads between 2007 and 2014 in five hospitals. All cases were reviewed by electrophysiologist and defined as definite perforations by suggestive symptoms along with lead perforation on imaging, bloody PEf on pericardiocentesis shortly after implant, or right ventricular (RV) lead non-capture along with diaphragmatic stimulation upon bipolar pacing. Clinical outcomes associated with both management approaches were compared, with respect to the composite endpoint. The study included 48 definitive perforation cases: 22 managed conservatively and 26 via lead revision. Conservative management was associated with an increased composite endpoint compared with lead revision (8/22 vs. 1/26; P = 0.007). The dominant complication among the conservative cohort was appearance of cardiac tamponade during follow-up; 5/6 occurring in cases which presented with no or only mild PEf and were treated by antiplatelets/coagulants during or shortly after CIED implantation.

CONCLUSION

A conservative management of CIED lead perforation is associated with increased complications compared with early lead revision. Lead revision may be the preferred management particularly in patients receiving antiplatelets/coagulants.

Diagnostic Accuracy of a Novel Mobile Phone Application for the Detection and Monitoring of Atrial Fibrillation

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia in adults, associated with significant morbidity, increased mortality, and rising health-care costs. Simple and available tools for the accurate detection of arrhythmia recurrence in patients after electrical cardioversion (CV) or ablation procedures for AF can help to guide therapeutic decisions. We conducted a prospective, single-center study to evaluate the accuracy of Cardiio Rhythm Mobile Application (CRMA) for AF detection. Patients >18 years of age who were scheduled for elective CV for AF were enrolled in the study. CRMA finger pulse recordings, utilizing an iPhone camera, were obtained before (pre-CV) and after (post-CV) the CV. The findings were validated against surface electrocardiograms. Ninety-eight patients (75.5% men), mean age of 67.7 ± 10.5 years, were enrolled. No electrocardiogram for validation was available in 1 case. Pre-CV CRMA readings were analyzed in 97 of the 98 patients. Post-CV CRMA readings were analyzed for 92 of 93 patients who underwent CV. One patient left before the recording was obtained. The Cardiio Rhythm Mobile Application correctly identified 94 of 101 AF recordings (93.1%) as AF and 80 of 88 non-AF recordings (90.1%) as non-AF. The sensitivity was 93.1% (95% confidence interval [CI] = 86.9% to 97.2%) and the specificity was 90.9% (95% CI = 82.9% to 96.0%). The positive predictive value was 92.2% (95% CI = 85.8% to 95.8%) and the negative predictive value was 92.0% (95% CI = 94.8% to 95.9%). In conclusion, the CRMA demonstrates promising potential in accurate detection and discrimination of AF from normal sinus rhythm in patients with a history of AF.

Amniotic fluid embolism: Then and now

BACKGROUND

The first case report to describe amniotic fluid embolism that appeared in 1926 in Basil-Medico is translated from Portuguese to English.

CASE

A patient with a dead fetus for several weeks, presented in labor and died suddenly with fetal squames evident in the maternal pulmonary vasculature at autopsy.

CONCLUSION

As can be seen from the translation, this case report is remarkably similar in many of its features to some of the eight patients described 15 years later in the first English language discussion of the disease by Steiner and Luschbaugh in JAMA. An enigma presented by this first case remains today: fetal material in the maternal pulmonary vasculature appears specific for amniotic fluid embolism at autopsy but not in living patients.

Alterações histológicas dos rins e expressão das metalotioneínas e das proteínas de choque térmico em ratos Wistar após exposição ao fungicida tirame

Avaliaram-se as alterações histológicas e a expressão das metalotioneínas (MTs) e das proteínas de choque térmico (Hsp70) nos rins de ratos Wistar após a exposição ao fungicida tirame. Os animais foram distribuídos em três grupos: grupo dieta-padrão; grupo dieta-padrão+óleo de milho; e grupo tirame. Foram encontradas diferenças significativas (P<0,05) na evolução do peso corporal entre os ratos do grupo tirame e os dos grupos controle e óleo de milho, e não foram verificadas lesões histológicas evidentes nos rins dos animais. Foram encontradas diferenças entre os animais do grupo exposto ao tirame e os dos grupos controle e óleo quanto às características histomorfométricas relativas ao corpúsculo renal - exceto para a proporção área da cápsula de Bowman:área do glomérulo - e relativas aos túbulos contorcidos proximal e distal - exceto para altura do epitélio dos túbulos distais. Nos ratos expostos ao tirame, foi observada imunomarcação positiva para as MTs, de moderada a forte, nos túbulos contorcidos da região cortical, diminuindo do córtex em direção à medula, e forte imunomarcação para as Hsp70 nas áreas do córtex e da medula, no glomérulo e nos túbulos contorcidos. Os resultados sugerem que o tirame pode ter toxicidade crônica nos mamíferos por afetar o seu crescimento e que a expressão das MTs e das Hsp70, provável resposta celular adaptativa ao estresse oxidativo causado pelo tirame, pode ser utilizada como biomarcador de exposição a este químico.

Comparison of different monoclonal antibodies against immunosuppressive proteins of Ascaris suum

The extract of Ascaris suum suppresses the humoral and cellular immune responses to unrelated antigens in the mouse. In order to further characterize the suppressive components of A. suum, we produced specific monoclonal antibodies which can provide an important tool for the identification of these proteins. The A. suum immunosuppressive fractions isolated by gel filtration from an extract of adult worms were used to immunize BALB/c mice. Popliteal lymph node cells taken from the immunized animals were fused with SP2/O myeloma cells and the cloned hybrid cells obtained were screened to determine the specificity of secreted antibodies. Three monoclonal antibodies named MAIP-1, MAIP-2 and MAIP-3 were selected and were shown to react with different epitopes of high molecular weight proteins from the A. suum extract. All antibody molecules have kappa-type light chains but differ in heavy chain isotype. MAIP-1 is a mouse IgM, MAIP-2 is an IgA immunoglobulin and MAIP-3 is an IgG1 immunoglobulin and they recognize the antigen with affinity constants of 1.3 x 10(10) M-1, 7.1 x 10(9) M-1 and 3.8 x 10(7) M-1, respectively. The proteins recognized by these monoclonal antibodies (PAS-1, PAS-2 and PAS-3) were purified from the crude extract by affinity chromatography and injected with ovalbumin in BALB/c mice in order to determine their suppressive activity on heterologous antibody production. It was demonstrated that these three proteins are able to significantly suppress anti-ovalbumin antibody secretion, with PAS-1 being more efficient than the others.

The use of contrast-enhanced magnetic resonance imaging to identify reversible myocardial dysfunction

BACKGROUND

Recent studies indicate that magnetic resonance imaging (MRI) after the administration of contrast material can be used to distinguish between reversible and irreversible myocardial ischemic injury regardless of the extent of wall motion or the age of the infarct. We hypothesized that the results of contrast-enhanced MRI can be used to predict whether regions of abnormal ventricular contraction will improve after revascularization in patients with coronary artery disease.

METHODS

Gadolinium-enhanced MRI was performed in 50 patients with ventricular dysfunction before they underwent surgical or percutaneous revascularization. The transmural extent of hyperenhanced regions was postulated to represent the transmural extent of nonviable myocardium. The extent of regional contractility at the same locations was determined by cine MRI before and after revascularization in 41 patients.

RESULTS

Contrast-enhanced MRI showed hyperenhancement of myocardial tissue in 40 of 50 patients before revascularization. In all patients with hyperenhancement the difference in image intensity between hyperenhanced regions and regions without hyperenhancement was more than 6 SD. Before revascularization, 804 of the 2093 myocardial segments analyzed (38 percent) had abnormal contractility, and 694 segments (33 percent) had some areas of hyperenhancement. In an analysis of all 804 dysfunctional segments, the likelihood of improvement in regional contractility after revascularization decreased progressively as the transmural extent of hyperenhancement before revascularization increased (P<0.001). For instance, contractility increased in 256 of 329 segments (78 percent) with no hyperenhancement before revascularization, but in only 1 of 58 segments with hyperenhancement of more than 75 percent of tissue. The percentage of the left ventricle that was both dysfunctional and not hyperenhanced before revascularization was strongly related to the degree of improvement in the global mean wall-motion score (P<0.001) and the ejection fraction (P<0.001) after revascularization.

CONCLUSIONS

Reversible myocardial dysfunction can be identified by contrast-enhanced MRI before coronary revascularization.

Evaluation research in public health: barriers to the production and dissemination of outcomes data

Health outcomes are becoming the currency of health care exchange, and a call for evidence dominates decision making at all levels. This discussion paper reviews methodological and sociopolitical barriers that impede the production and dissemination of outcome research in public health, with particular reference to nursing. Barriers to the production of high-quality research evidence include inaccessible graduate education and inadequate research funding. Also, randomized controlled trials (the ideal design for interventions studies) are uniquely difficult to implement for public health services. Practical and ethical difficulties arise in defining the intervention, implementing random allocation methods, selecting and measuring outcomes, and articulating adequate theoretical frameworks. When health care activity is defined as output, there is a tendency to exclude the ethical standing of preventive, supportive and communitarian functions. The production and interpretation of research results must remain part of a social, political and ethical debate, not a purely scientific one.

A systematic overview of the effectiveness of home visiting as a delivery strategy for public health nursing interventions

The purpose of this systematic overview was to assess the evidence for the effectiveness of public health nursing interventions when carried out by the strategy of home visiting. A search of published and unpublished literature resulted in retrieval of 108 articles; 77 articles were judged to be relevant. Validity criteria included method of allocation to the study groups, level of agreement to participate in the study, control for confounders, method of data collection (pretesting of data collection tools, blinding of data collectors to group allocation of study participants), quantitative measure of effect and percentage of participants available at follow-up. Using these criteria, 9 articles were judged to be strong, 5 moderate and 63 weak. There were no reported negative effects of home visiting in the 9 strong articles. Positive outcomes included improvement in children's mental development, mental health and physical growth; reduction in mother's anxiety, depression, and tobacco use; improvement in maternal employment, nutrition and other health habits; government cost saving; and reduced level of care required for the elderly.

Prolactin and cortisol levels in various paroxysmal disorders in childhood

The hormonal response of the anterior pituitary to various epileptic and nonepileptic events in children was studied. Postictal serum prolactin and cortisol levels were measured in 17 children with epilepsy, 23 with febrile seizures, and 10 with syncope or breath-holding spells. The levels were compared with those of 30 children with nonspecific fever, and 23 afebrile children served as control subjects. Significantly higher (P less than .01) prolactin levels (26.5 +/- 3.3 ng/mL, mean +/- SEM) were found in the epileptic group, compared with levels in children with febrile seizures (13.2 +/- 1.0 ng/mL), fever (11.2 +/- 0.9 ng/mL), syncope (7.3 +/- 0.9 ng/mL), and the control group (7.9 +/- 0.6 ng/mL). In contrast, serum cortisol levels were nonspecifically elevated in the epileptics and patients with febrile seizures or fever only. These findings suggest that elevated prolactin levels may be found after epileptic seizures and much less after febrile seizures, but not after breath-holding spells or syncopal events. Cortisol secretion appears to be nonselectively triggered by all stressful events, such as epileptic and febrile seizures, and fever. Elevated prolactin levels (greater than 15 ng/mL) associated with seizures may help in differentiating epileptic from febrile seizures or syncope.