Development and validation of a clinical score for early diagnosis of constipation in critically ill children

Constipation affects almost 50% of critically ill pediatric patients and is related to their morbidity and mortality. However, little attention is paid to it and it is diagnosed late and when there are already complications. The objective of this study is to develop and validate a score to identify critically ill children with high risk of constipation 48 h after admission. A single center two phase-study was carried out; the first one (retrospective observational study) to develop the score and the second one to validate it in another prospective observational study. Children between 15 days of life and 18 years old admitted to the PICU for more than 3 days were included. Demographic and clinical data during the first 48 h after PICU admission were collected. Univariate and multivariate analysis and ROC curves were used to develop and validate the score. Data from 145 patients (62.8% boys) with a mean age of 34.9 ± 7.3 months were used to develop the score. Independent factors identified to develop the score were: weight > 7 kg, admission to PICU after surgery, need of vasoconstrictors, doses of fentanyl ≥ 2 mcg/kg/h, and initiation of enteral nutrition later than 48 h after admission. Two cut-off values were identified to set low constipation risk (< 5.7 points) and high constipation risk (> 6.2 points). This score was validated in 124 patients showing a sensibility of 63.2%, specificity of 95.5% and a positive/negative predictive values (P/NPV) of 100% and 82.1% respectively to identify constipated patients. This is the first score to identify high constipation risk in critically ill children. This score is easy to apply, and internal validation has shown a PPV of 100%.

Frailty-Independent Undertreatment Negative Impact on Survival in Older Patients With Breast Cancer

Purpose

The management of older adults with breast cancer (BC) remains controversial. The challenging assessment of aging idiosyncrasies and the scarce evidence of therapeutic guidelines can lead to undertreatment. Our goal was to measure undertreatment and assess its impact on survival.

Methods

Consecutive patients with BC aged 70 years or older were prospectively enrolled in 2014. Three frailty screening tools (G8, fTRST, and GFI) and two functional status scales (Karnofsky performance score and Eastern Cooperative Oncology Group Performance Status) were applied. Disease characteristics, treatment options, and causes of mortality were recorded during a 5-year follow-up. In addition, we defined undertreatment and correlated its survival impact with frailty.

Results

A total of 92 patients were included in the study. The median age was 77 (range 70–94) years. The prevalence of frailty was discordant (G8, 41.9%; fTRST, 74.2%; GFI, 32.3%). Only 47.8% of the patients had a local disease, probably due to a late diagnosis (73.9% based on self-examination). Thirty-three patients (35.6%) died, of which 15 were from BC. We found a considerably high proportion (53.3%) of undertreatment, which had a frailty-independent negative impact on the 5-year survival (hazard ratio [HR], 5.1; 95% confidence interval [CI], 2.1–12.5). Additionally, omission of surgery had a frailty-independent negative impact on overall survival (HR, 3.9; 95% CI, 1.9–7.9).

Conclusion

BC treatment in older adults should be individualized. More importantly, assessing frailty (not to treat) is essential to be aware of the risk-benefit profile and the patient's well-informed willingness to be treated. Undertreatment in daily practice is frequent and might have a negative impact on survival, as we report.

Changes in hemodynamics, renal blood flow and urine output during continuous renal replacement therapies

Continuous renal replacement therapies (CRRT) affect hemodynamics and urine output. Some theories suggest a reduced renal blood flow as the cause of the decreased urine output, but the exact mechanisms remain unclear. A prospective experimental study was carried out in 32 piglets (2–3 months old) in order to compare the impact of CRRT on hemodynamics, renal perfusion, urine output and renal function in healthy animals and in those with non-oliguric acute kidney injury (AKI). CRRT was started according to our clinical protocol, with an initial blood flow of 20 ml/min, with 10 ml/min increases every minute until a goal flow of 5 ml/kg/min. Heart rate, blood pressure, central venous pressure, cardiac output, renal blood flow and urine output were registered at baseline and during the first 6 h of CRRT. Blood and urine samples were drawn at baseline and after 2 and 6 h of therapy. Blood pressure, cardiac index and urine output significantly decreased after starting CRRT in all piglets. Renal blood flow, however, steadily increased throughout the study. Cisplatin piglets had lower cardiac index, higher vascular resistance, lower renal blood flow and lower urine output than control piglets. Plasma levels of ADH and urine levels of aquaporin-2 were lower, whereas kidney injury biomarkers were higher in the cisplatin group of piglets. According to our findings, a reduced renal blood flow doesn’t seem to be the cause of the decrease in urine output after starting CRRT.

Cardiac Amyloidosis Associated with Apolipoprotein A-IV Deposition Diagnosed by Mass Spectrometry-Based Proteomic Analysis

Amyloidosis is a group of disorders characterised by the accumulation of extracellular deposits of insoluble protein aggregates. Clinical management depends on the accurate identification of the amyloid precursor and underlying cause. We describe a rare case of apolipoprotein A-IV cardiac amyloidosis, the diagnosis of which required mass spectrometry-based proteomic analysis.

Multidisciplinary management of liver metastases in patients with colorectal cancer: a consensus of SEOM, AEC, SEOR, SERVEI, and SEMNIM

Colorectal cancer (CRC) has the second-highest tumor incidence and is a leading cause of death by cancer. Nearly 20% of patients with CRC will have metastases at the time of diagnosis, and more than 50% of patients with CRC develop metastatic disease during the course of their disease. A group of experts from the Spanish Society of Medical Oncology, the Spanish Association of Surgeons, the Spanish Society of Radiation Oncology, the Spanish Society of Vascular and Interventional Radiology, and the Spanish Society of Nuclear Medicine and Molecular Imaging met to discuss and provide a multidisciplinary consensus on the management of liver metastases in patients with CRC. The group defined the different scenarios in which the disease can present: fit or unfit patients with resectable liver metastases, patients with potential resectable liver metastases, and patients with unresectable liver metastases. Within each scenario, the different strategies and therapeutic approaches are discussed.

A Review of Commercial and Medical-Grade Physiological Monitoring Devices for Biofeedback-Assisted Quality of Life Improvement Studies

With the rise in wearable technology and "health culture", we are seeing an increasing interest and affordances in studying how to not only prolong life expectancy but also in how to improve individuals' quality of life. On the one hand, this attempts to give meaning to the increasing life expectancy, as living above a certain threshold of pain and lack of autonomy or mobility is both degrading and unfair. On the other hand, it lowers the cost of continuous care, as individuals with high quality of life indexes tend to have lower hospital readmissions or secondary complications, not to mention higher physical and mental health. In this paper, we evaluate the current state of the art in physiological therapy (biofeedback) along with the existing medical grade and consumer grade hardware for physiological research. We provide a quick primer on the most commonly monitored physiologic metrics, as well as a brief discussion on the current state of the art in biofeedback-assisted medical applications. We then go on to present a comparative analysis between medical and consumer grade biofeedback devices and discuss the hardware specifications and potential practical applications of each consumer grade device in terms of functionality and adaptability for controlled (laboratory) and uncontrolled (field) studies. We end this article with some empirical observations based on our study so that readers might use take them into consideration when arranging a laboratory or real-world experience, thus avoiding costly time delays and material expenditures.

Breast and Pectoralis Muscle Hypoplasia

Purpose:

Poland's syndrome is a congenital and unilateral aplasia of the pectoralis major muscle (PMM), with other anomalies of the ipsilateral upper extremity. We present 6 cases in which the only clinical expression was asymmetry of the breasts associated with partial absence of the PMM.

Material and Methods:

We reviewed 95000 mammograms (obtained 1985–1995) to find patients with asymmetrical breast size. Where the asymmetry could not be ascribed to any other cause, the patients were recalled for an examination of the PMM which was conducted at rest and with active contraction of the muscle.

Results:

Unilateral volume reduction of the PMM was found in 5 women of whom 2 were studied with MR. A 6th case was a fortuitous finding in a male patient.

Conclusion:

Mild forms of Poland's syndrome are more frequent than severe forms, and may go undiagnosed. Hypoplasia of one breast or a horizontal anterior axillary fold may be the sole clinical manifestation of this syndrome.

Liver cytolysis in acute heart failure: What does it mean? Clinical profile and outcomes of a prospective hospital cohort

Abnormal liver function tests (LFTs) are a common manifestation of heart failure (HF). Our purpose was to characterize patients hospitalized for acute HF (AHF) with liver cytolysis, analyze cytolysis predictors and explore its prognostic implications.

METHODS

In a prospective cohort study, we enrolled patients with AHF consecutively admitted to the Internal Medicine Department of University Hospital between January 2009 and December 2010, and recorded demographic, clinical, laboratory and echocardiogram parameters. A logistic regression was done to identify cytolysis predictors. In survival analysis primary endpoints were all-cause death, readmission due to AHF, and the combined event of all-cause death and readmission for AHF at 90days of follow-up.

RESULTS

Fifty-eight patients had cytolysis at admission. AHF attributed to atrial fibrillation (OR 3.235), higher heart rate at admission (OR 1.028), cold/wet profile at admission (OR 7.12) and ejection fraction <30% (OR 2.316) were independent predictors of cytolysis. Death occurred more frequently during follow-up in the cytolysis group (27.6 vs. 15.1%, p=0.014, respectively). On survival analysis, cytolysis remained an independent predictor of death at 90days when adjusted to age (HR 1.066), male gender (HR 1.884), valvular etiology (HR 2.365), neurologic status at admission (sleepy HR 3.854; confusion HR 3.176) and cardiac output (HR 0.762).

CONCLUSION

Cytolysis may be a marker of systemic hypoperfusion, so strategies to improve hemodynamic profile should be considered, especially in the presence of cold/wet clinical profile, AHF attributed to AF, tachycardia, and EF<30%. Cytolysis is associated with higher mortality at 90days in patients with AHF.

[Abdominal aneurism screening in Primary Care]

OBJECTIVES

To obtain the percentage of abdominal aortic aneurism (AAA) determined in men between 65-74 years old in a health centre using ultrasound, and to describe the distribution of risk factors in the whole sample and in patients with aneurism, as well as determining how many AAA are confirmed at the hospital and those cases of uncertain diagnosis.

PATIENTS AND METHOD

A cross-sectional study conducted on patients included from September 2014 to February 2015. From a total of 212 randomised patients, a clinical interview and abdominal ultrasound were performed on 115 men, aged 65 to 74, telephone-recruited from a total of 171 that fulfilled inclusion criteria.

RESULTS

An infra-renal AAA was found in 2.6% of the sample (95% CI 0.54-7.4). Just over half (51.3%) of the sample had arterial hypertension, and 76.1% were smokers or former smokers. The 3 AAA found, one of which had an initial doubtful diagnosis, were confirmed by the Hospital Universitario Fundación Jiménez Díaz. There were no losses. All of the patients with AAA were active smokers and had at least one other risk factor.

CONCLUSION

The percentage of infra-renal AAA in the sample was lower than expected, but higher than the percentage found in other studies that did not consider smoking in the inclusion criteria.

Impact of Chronic Nitrate Therapy in Patients With Ischemic Heart Failure

PURPOSE

There is a lack of knowledge on the effects of nitrates alone in heart failure (HF). We aimed to assess the impact of nitrates use in the occurrence of ischemic events in patients with ischemic HF attending an HF clinic.

METHODS

We performed a retrospective analysis of a cohort of 632 patients managed in an HF clinic between January 2000 and December 2011. Patients with ischemic etiology were selected (n = 290). Patients were classified according to chronic nitrates use (n = 83 nitrates users vs n = 194) and followed up for 5 years for the occurrence of fatal or nonfatal myocardial infarction or stroke.

RESULTS

Nitrates users had more frequently diabetes, dyslipidemia, and higher body mass index but were less frequently treated with statins. Thirty adverse events were recorded (n = 16 in nitrates group). Variables significantly associated with the occurrence of the end point in univariate analysis were arterial hypertension, diabetes, and nitrates use. Male gender, beta-blockers, statin, and clopidogrel use had a protective effect on the occurrence of the end point. In multivariate analysis, nitrates use remained an independent predictor of adverse outcome when adjusted for each of the variables: arterial hypertension, gender, diabetes, beta-blocker, and clopidogrel use; however, when adjusted for statin use, nitrates were no longer associated with the outcome.

CONCLUSION

Long-term nitrates use in patients with ischemic HF was associated with higher occurrence of ischemic events, defined as fatal or nonfatal myocardial infarction or stroke. Our results, although from a retrospective analysis, do not support a role for chronic nitrate use in HF.

[Hemodynamic effects of intravenous omeprazole in critically ill children]

INTRODUCTION

Critical patients usually have hemodynamic disturbances which may become worse by the administration of some drugs. Omeprazole is a drug used in the prophylaxis of the gastrointestinal bleeding in these patients, but its cardiovascular effects are unknown. The objective was to study the hemodynamic changes produced by intravenous omeprazole in critically ill children and to find out if there are differences between two different doses of omeprazole.

MATERIAL AND METHODS

A randomized prospective observational study was performed on 37 critically ill children aged from 1 month to 14 years of age who required prophylaxis for gastrointestinal bleeding. Of these, 19 received intravenous omeprazole 0.5mg/kg every 12 hours, and 18 received intravenous omeprazole 1mg/kg every 12 hours. Intravenous omeprazole was administered in 20 minutes by continuous infusion pump. Heart rate, systolic, diastolic and mean arterial blood pressure, central venous pressure and ECG were recorded at baseline, and at 15, 30, 60 and 120 minutes of the infusion.

RESULTS

There were no significant changes in the electrocardiogram, heart rate, blood pressure and central venous pressure. No patients required inotropic therapy modification. There were no differences between the two doses of omeprazole.

CONCLUSIONS

Intravenous omeprazole administration of 0.5mg/kg and 1mg/kg is a hemodynamically safe drug in critically ill children.

[Effects of induced hypothermia in critically ill children]

OBJECTIVE

To study the efficacy of induced hypothermia (IH) in children, its effect on hemodynamic, hematological, and biochemical parameters and its side effects.

DESIGN

Retrospective, observational study.

SETTING

Pediatric intensive care unit.

PATIENTS

Pediatric patients requiring induced hypothermia.

INTERVENTIONS

None.

DATA COLLECTED

The following variables were recorded prior to the initiation of IH and after 4, 24, 48, 72, and 120 hours: heart rate, systolic blood pressure (SBP), diastolic blood pressure (DBP), diuresis, dose of inotropic, sedative, and muscle relaxant drugs, fluid balance, hematocrit, white cell count, white cell differential percentages, platelet count, blood levels of glucose, sodium, and potassium, C reactive protein, lactate, coagulation times, pressure ulcers, shivering, infections and death.

RESULTS

Thirty-one patients with a mean age of 20 months (SD: 39.8) were included in the study. The mean duration of IH was 3.97 days (range: 1 to 11 days). Among the IH effects, there was a significant fall in heart rate, with no changes in SBP, DBP, or diuresis. The blood tests revealed a progressive and significant fall in platelet count and an increase in C reactive protein levels. The fall in hematocrit and glucose and lactate levels was not significant. Positive cultures were detected in 25.8% of the patients during IH, most commonly from the bronchial aspirate (65%).

CONCLUSIONS

Induced hypothermia can be useful in some critically ill children. Tolerance is generally good and there are usually few side effects, which can be controlled through appropriate monitoring.

[Renal infarction and kidney rupture: complication of a massive cocaine intoxication in an intestinal carrier]

Major complications derived from the use of cocaine have been described, alter nasal or intravenous administration of the drug. These complications are related to vascular spasm and secondary organ damage. We present the case of an intestinal cocaine packer--in slang, "mule"--, who suffered massive absorption of the drug, resulting n bowel, liver and renal ischemia. This situation, previously undescribe in the literature, ended in kidney rupture. An attempt of embolization, was unsatisfactory, and nephrectomy was finally required. The patient recovered uneventfully, with progressive renal functional improvement. This case, albeit quite exceptional, is illustrative of several of the renal actions of cocaine, and reveals the effects of absorption of cocaine at the intestinal level.

Superior mesenteric arterial embolism: local fibrinolytic treatment with urokinase

PURPOSE

To evaluate the efficacy of intraarterial urokinase in the treatment of superior mesenteric arterial (SMA) embolism.

MATERIALS AND METHODS

Within 3 years, 10 patients (six men, four women; aged 62-82 years) with angiographically proved SMA emboli were selected on the basis of absence of peritoneal signs of intestinal necrosis at physical examination and normal abdominal plain radiographs to undergo local lysis with urokinase.

RESULTS

The procedure was performed without complications in all 10 patients. The embolus was successfully lysed in nine patients (90%). Clinical success was achieved in seven patients (70%); however, in one patient laparotomy was required to confirm the clinical finding. None of these patients had recurrent embolism or postischemic intestinal stenosis during follow-up (mean, 11.2 months). The three remaining patients (30%) underwent laparotomy subsequent to failure of intraarterial treatment with urokinase.

CONCLUSION

Fibrinolytic treatment with urokinase may be an effective alternative to surgical embolectomy in patients with SMA embolism without clinical or radiologic signs of intestinal infarction. In this small series, abatement of abdominal pain in the 1st hour of fibrinolytic treatment was the best indicator of clinical success. Pain persisted in patients with intestinal infarction.

Lipoma-induced jejunojejunal intussusception: US and CT diagnosis

A case study of a patient who presented with abdominal pain and a palpable mesogastric mass is discussed. Ultrasound and computed tomography (CT) demonstrated that the palpable mass was jejunojejunal intussusception of the small intestine. The lead point of the intussusception was a lipoma that appeared in the CT scan as a small intramural mass with an attenuation coefficient of fat.

Breast and pectoralis muscle hypoplasia. A mild degree of Poland's syndrome

PURPOSE

Poland's syndrome is a congenital and unilateral aplasia of the pectoralis major muscle (PMM), with other anomalies of the ipsilateral upper extremity. We present 6 cases in which the only clinical expression was asymmetry of the breasts associated with partial absence of the PMM.

MATERIAL AND METHODS

We reviewed 95000 mammograms (obtained 1985-1995) to find patients with asymmetrical breast size. Where the asymmetry could not be ascribed to any other cause, the patients were recalled for an examination of the PMM which was conducted at rest and with active contraction of the muscle.

RESULTS

Unilateral volume reduction of the PMM was found in 5 women of whom 2 were studied with MR. A 6th case was a fortuitous finding in a male patient.

CONCLUSION

Mild forms of Poland's syndrome are more frequent than severe forms, and may go undiagnosed. Hypoplasia of one breast or a horizontal anterior axillary fold may be the sole clinical manifestation of this syndrome.

Local pathological findings in experimental dorsal root entry zone lesions performed by mechanical section, laser and radiofrequency. A comparative study

Dorsal root entry zone lesions are nowadays accepted as a first choice of treatment to alleviate certain types of chronic pain though it is still controversial to decide proper procedure for lesioning. Based on this last argument in 15 mongrel dogs different types of lesions using mechanical microsection, radiofrequency and laser were done. Under general anaesthesia a C-3 to C-7 laminectomy was performed in all animals and after open the dura mater the posterior nerve rootlets and posterolateral sulcus were identified using magnification. In 5 dogs, a longitudinal 1 mm deep incision from C-4 to C-6 spinal cord segments coinciding with the sulcus was carried out with a microknife; in other 5, a sequence of thermocoagulations produced by a radiofrequency current lower than 35 mA was done at same places and level with intervals of 2 mm; and in the rest of animals, an alike incision in depth, location and level was realised by carbon dioxide laser. Four days and three months after lesioning 2 and 3 animals of each group were sacrificed and spinal cord specimens submitted for histological and ultrastructural studies. Low-power microscopic examination showed that all lesioning methods were able to produce a reasonable well delimited necrotic area involving the whole dorsal root entry zone structures, slightly more diffuse with the laser. Acute perilesional changes as well as chronic ones were nevertheless more evident in mechanical and radiofrequency lesions, over all regarding oedema, perivascular haemorrhage, intraluminal thrombosis and ischaemic alterations.