Studies have showed that nearly 100% of morbidly obese men and 60–70% of women have obstructive sleep apnea (OSA). A polysomnography (PSG) study is used to establish the diagnosis and parameters for continuous positive airway pressure (CPAP) therapy. PSG is commonly recommended prior to bariatric surgery to assess for the presence of OSA and possible anesthetic complications. After surgery patients are to continue CPAP until a repeat sleep study is done to re-evaluate the need for CPAP. Currently there are not many studies that look at the prevalence of CPAP in the pre/post-op period in minority patients in an urban tertiary care center. Observational cohort study of morbidly obese patients who had polysomnography (PSG), received diagnosis of OSA and were prescribed CPAP treatment prior to bariatric surgery. Follow-up was done at 5 years post procedure. From 2010–2011, 121 patients had PSG prior to bariatric surgery at Brookdale Hospital. 100 patients were female and 21 were male. 70 of patients were black, 42 patients were Hispanic, and 8 were other ethnicities. 61 patients used CPAP consistantly prior to surgery. In the group using CPAP average age was 36.7 years and BMI was 49.8. The non-compliant group had an average age of 39.7 years and BMI of 48.0. None of the patients in the study had immediate complications post-surgical procedure. After 5 years, 15 patients continued to use CPAP and 2 patients in this group had a repeat PSG after surgery. Chi-squared and student t-test were used to analyze sex, age, ethnicity, BMI and there were no statistically significant differences between the two groups. Our study showed that there was no correlation between OSA and post-op complications which calls into question the need for PSG prior to bariatric surgery. Roughly half of the patients were compliant with CPAP prior to surgery and only 2 patients followed up for a repeat PSG. Possible reasons for lack of compliance with therapy include nasal discomfort, cost and lack of knowledge. More studies need to be done regarding the utility of PSG before and after bariatric surgery. None.
Crohn disease is an immune-mediated inflammatory condition with gastrointestinal and extraintestinal manifestations in patients. Pulmonary involvement of Crohn disease is one manifestation. There have been case reports which have shown Crohn disease and lung nodules which were noted to be histopathological as cryptogenic organizing pneumonia (COP). In our case, a 22-year-old woman with Crohn disease was seen with complaints of chest pain and cough. Computed tomographic scan of chest showed multiple bilateral lung nodules, for which biopsy was done, which showed COP. The case study is followed by a deeper discussion of COP and the extraintestinal manifestation seen in inflammatory bowel disease.
To determine predictors of need for transfusion of blood and blood products and create a clinical predictive model to reduce indiscriminate use of blood products during surgery.We conducted a retrospective chart review of 485 patients who underwent coronary artery bypass surgery from January 2004 to December 2004 at a Tertiary Care Hospital in Karachi, Pakistan. Independent predictors associated with transfusion were identified and a clinical prediction model developed.The transfusion rate was 37.1%. A predictive model was created based on the presence of pulmonary disease, diabetes mellitus, low ejection fraction and recent/ongoing myocardial infarction.The study identifies some predictors of need for blood transfusion in patients undergoing Coronary Artery Bypass Grafting. However, prospective studies with a larger sample of patients are needed to determine other predictors and their applicability in patient selection across institutions.
To evaluate the role of ultrasound during initial fluid resuscitation along with clinical guidance in reducing the incidence of fluid overload on day 3 in children with septic shock.It was a prospective, parallel limb open-labeled randomized controlled superiority trial done in the PICU of a government-aided tertiary care hospital in Eastern India. Patient enrolment took place between June 2021 and March 2022. Fifty-six children aged between 1 month and 12 years, with proven or suspected septic shock, were randomized to receive either ultrasound-guided or clinically guided fluid boluses (1:1 ratio) and subsequently followed up for various outcomes. The primary outcome was frequency of fluid overload on day 3 of admission. The treatment group received ultrasound-guided fluid boluses along with the clinical guidance and the control group received the same but without ultrasound guidance upto 60 mL/kg of fluid boluses.The frequency of fluid overload on day 3 of admission was significantly lower in the ultrasound group (25% vs 62%, p = 0.012) as was the median (IQR) cumulative fluid balance percentage on day 3 [6.5 (3.3-10.3) vs 11.3 (5.4-17.5), p = 0.02]. The amount of fluid bolus administered was also significantly lower by ultrasound [median 40 (30-50) vs 50 (40-80) mL/kg, p = 0.003]. Resuscitation time was shorter in the ultrasound group (13.4 ± 5.6 vs 20.5 ± 8 h, p = 0.002).Ultrasound-guided fluid boluses were found to be significantly better than clinically guided therapy, in preventing fluid overload and its associated complications in children with septic shock. These factors make ultrasound a potentially useful tool for resuscitation of children with septic shock in the PICU.Kaiser RS, Sarkar M, Raut SK, Mahapatra MK, Uz Zaman MA, Roy O, et al. A Study to Compare Ultrasound-guided and Clinically Guided Fluid Management in Children with Septic Shock. Indian J Crit Care Med 2023;27(2):139-146.
Atypical hemolytic uremic syndrome (aHUS) is a kidney disorder that is frequently unrecognized during its progression, and misdiagnosed with more common etiologies of microangiopathic hemolytic anemia (MAHA): hemolytic uremic syndrome, disseminated intravascular coagulation, and thrombotic thrombocytopenic purpura (TTP). During pregnancy, the diagnosis of aHUS is furthermore challenging. The clinical presentation of aHUS may mimic pre-eclampsia as it occurred to the patient described in the case report. However, the persistence of thrombocytopenia in the patient after dilatation of the cervix and surgical evacuation of the contents of the uterus has led to consider aHUS. The pathogenesis of aHUS provides clues to understanding the insidious progression and the variability of clinical presentations of the disease. aHUS is primarily a kidney disorder that results from genetic defects of the alternative complement pathway (AP). Consequently, Eculizumab, a monoclonal antibody that targets the AP, induced remission in the patient. A single gene defect of the AP cannot cause the clinical manifestation of aHUS alone. Most of aHUS patients have a combination of mutation, haplotype, and single nucleotide polymorphism. Often, an identifiable environmental factor or a physiological change triggers the onset of the disease. We report the first case of aHUS in a pregnant woman with chronic kidney disease.
Objectives:The diagnosis of Bipolar II disorder (BD-II) is currently based on patients' description of symptoms and clinical behavioral observations.This study explored the possibility of miRNA in peripheral blood (serum) as a specific blood-based biomarker for BD-II.Methods: We developed six miRNA profiles using next-generation sequencing from samples taken from three randomly picked controls and patients with BD-II each from a total of 102 BD-II patients and 118 controls.We further selected six differential expression miRNA candidates in the first cohort (as training group) of 79 BD-II and 95 controls and examined them using realtime PCR.Results: We found that serum expression levels of miR-7-5p, miR-23b-3p, miR-142-3p, miR-221-5p, and miR-370-3p significantly increased in patients with BD-II compared with controls in the first cohort.The diagnostic power of identified miRNAs was analyzed using receiver-operating characteristic (ROC) curves; results revealed miR-7-5p (area under the curve [AUC], 0.728; p < 0.0001), miR142-3p (AUC: 0.896; p < 0.0001), miR-221-5p (AUC: 0.824; p < 0.0001), and miR-370-3p (AUC: 0.703; p < 0.0001) to be good biomarkers for diagnosis of BD-II.Support vector machine (SVM) measurements revealed that a combination of four miRNAs may further improve the diagnostic accuracy (AUC: 0.907).We further examined an independent testing group (BD-II, n = 20; control, n = 20); the diagnostic power reached fair for BD-II (specificity = 90% and sensitivity = 85%). Conclusion:We constructed miRNA panels using SVM, which may aid in the development of objective diagnostic tools for BD-II.
Transfusion-associated hyperkalemic cardiac arrest is a serious complication in patients receiving packed red blood cell (PRBC) transfusions. Mortality from hyperkalemia increases with large volumes of PRBC transfusion, increased rate of transfusion, and the use of stored PRBCs. Theoretically, hyperkalemia may be complicated by low cardiac output, acidosis, hyperglycemia, hypocalcemia, and hypothermia. In this study, we focus on transfusion-related hyperkalemia involving only medical intensive care unit (MICU) patients.This prospective observational study focuses on PRBC transfusions among MICU patients greater than 18 years of age. Factors considered during each transfusion included patient's diagnosis, indication for transfusion, medical co-morbidities, acid-base disorders, K(+) levels before and after each PRBC transfusion, age of stored blood, volume and rate of transfusion, and other adverse events. We used Pearson correlation and multivariate analysis for each factor listed above and performed a logistic regression analysis.Between June 2011 and December 2011, 125 patients received a total of 160 units of PRBCs. Median age was 63 years (22 - 92 years). Seventy-one (57%) were females. Sixty-three patients (50%) had metabolic acidosis, 75 (60%) had acute renal failure (ARF), and 12 (10%) had end-stage renal disease (ESRD). Indications for transfusion included septic shock (n = 65, 52%), acute blood loss (n = 25, 20%), non-ST elevation myocardial infarction (NSTEMI) (n = 25, 20%) and preparation for procedures (n = 14, 11%). Baseline K(+) value was 3.9 ± 1.1 mEq/L compared to 4.3 ± 1.2 mEq/L post-transfusion respectively (P = 0.9). During this study period, 4% of patients developed hyperkalemia (K(+) 5.5 mEq/L or above). The mean change of serum potassium in patients receiving transfusion ≥ 12 days old blood was 4.1 ± 0.4 mEq/L compared to 4.8 ± 0.3 mEq/L (mean ± SD) in patients receiving blood 12 days or less old. Sixty-two patients (77.5%) that were transfused stored blood (for more than 12 days) had increased serum K(+); eight (17.7%) patients received blood that was stored for less than 12 days. In both univariate (P = 0.02) and multivariate (P = 0.04) analysis, findings showed that among all factors, transfusion of stored blood was the only factor that affected serum potassium levels (95% CI: 0.32 - 0.91). No difference was found between central and peripheral intravenous access (P = 0.12), acidosis (P = 0.12), ARF (P = 0.6), ESRD (P = 0.5), and multiple transfusions (P = 0.09). One subject developed a sustained cardiac arrest after developing severe hyperkalemia (K(+) = 9.0) following transfusion of seven units of PRBCs. Multivariate logistic regression showed linear correlation between duration of stored blood and serum K(+) (R(2) = 0.889).This study assesses factors that affect K(+) in patients admitted to MICU. Results from the study show that rise in serum K(+) level is more pronounced in patients who receive stored blood (> 12 days). Future studies should focus on the use of altered storage solution, inclusion of potassium absorption filters during transfusion and cautious use of blood warmer in patients requiring massive blood transfusions.
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