Pulmonary Embolism With Multiple Active Right Ventricular Thrombi in Transit Managed Using Anticoagulation With and Without Inferior Vena Cava Filter: A Report of Two Oncology Patients.

Pulmonary embolism (PE) in the context of a right ventricular (RV) thrombus in transit is a special situation requiring a quick response that differs according to many factors. It is a rare but alarming finding. There is no clear guide to date that outlines a common pathway for treatment, as many factors play a role in determining the treatment plan. The mere presence of a thrombus in transit in the right atrium or right ventricle with a concomitant PE carries a higher risk of morbidity and mortality than PE alone. We will examine two cases presenting with PE with concomitant RV multiple thrombi and a background of cancer and diffuse bilateral deep vein thrombosis. One case was treated with anticoagulation alone, and the other with an inferior vena cava (IVC) filter in addition to anticoagulation. They both had a stable course despite their high risks and the frightening appearance of the multiple floating and attached thrombi seen in their echocardiography, some of which newly appeared after the second day of anticoagulation. The cases reflect the effectiveness of echocardiography for detecting and guiding treatment even after starting anticoagulation as well as the good outcome in such cases with anticoagulation alone when no massive PE occurs.

Outcomes of Dual Mobility Bearings in Revision Total Hip Replacements.

Background Dual mobility bearings have gained attention in the prevention of instability in revision total hip replacement. This study aimed to evaluate the use of dual mobility bearings in revision total hip replacement. The primary outcome was the rate of dislocation. Secondary outcomes included the rate of re-operation for any reason, surgical complications, serious medical adverse events, and 90-day mortality rate. Methods A single-centre case series of 55 consecutive operations in 49 patients who underwent revision total hip replacement using dual mobility bearings with a minimum follow-up of three months was studied.  Results Early dislocation occurred in one case (2%), and there were no intra-prosthetic dislocations at a mean follow-up of 16 months. The rate of re-operation for any reason was 6/55 (11%) cases, and the post-operative infection rate was 2/55 (4%) cases. Serious medical adverse events occurred in 2/55 (4%) cases. The 90-day mortality rate was 1/55 (2%) cases. Two cases (2%) had cup abduction or anteversion angles outside of the safe zones although there were no dislocations in these patients. Conclusion This case series demonstrates a low dislocation rate in the early post-operative period for dual mobility bearings in revision total hip replacement. Dual mobility bearings show promise as an early low dislocation implant in revision total hip replacement. It remains to be determined whether dual mobility bearings are low-wear implants in the long term.

Understanding and managing a case of the omphalocele-exstrophy-imperforate anus-spinal defect complex.

The omphalocele-exstrophy-imperforate anus-spinal defects (OEIS) complex is a rare birth disorder involving a combination of gastrointestinal, musculoskeletal, renal, neural, and genitourinary system defects. We present a case report of a neonate with OEIS born by vertex spontaneous delivery to non-consanguineous parents. The major presenting defect was exstrophy of the cecum lying between two exstrophied halves of the bladder, an imperforate anus and spina bifida myelomeningocele. Explorative laparotomy revealed a duplex kidney system, attachment of the terminal ileum and cecum to the exstrophy, and a sausage-like atretic large bowel. Malrotation was also noted. Ladd's bands were released followed by ileostomy and ureterostomy. Patient was stable post-operatively and in the incubator on room air. OEIS remains a challenging anomaly that requires optimal treatment to facilitate the quality of life. With appropriate surgical intervention, the functional and social treatment goals for this unusual congenital defect can be met.

Correlation of transcranial Doppler based parameters with computed tomography assessed cerebral oedema score in patients with traumatic brain injury: A prospective observational study.

Background and Aims: Cerebral oedema and increased intracranial pressure are associated with poor neurological outcomes in traumatic brain injury (TBI). This study aimed to examine the correlation between transcranial doppler (TCD) derived indices and computed tomography assessed cerebral oedema score in patients with TBI. Methods: This prospective observational study was conducted between April 2021 and December 2021 after approval from the University Research Ethics Committee (R75/2021) and registration with the clinicaltrials.gov (NCT04834453). Cerebral oedema on computed tomography (CT) imaging of the brain was scored as (0 = no cerebral oedema, 1 = mild cerebral oedema, 2 = moderate cerebral oedema, and 3 = severe cerebral oedema). The daily neurological assessment was performed using Glasgow coma scale score. TCD-based parameters, mean flow velocity (MFV), and pulsatility index (PI) in middle cerebral arteries were simultaneously obtained. Results: There was a significant negative correlation between MFV and cerebral oedema score (r = - 0.840, P <.001) and a significant positive correlation between PI and cerebral oedema score (r = 0.825, P <.001) on the seventh day of assessment. Significant differences were noted in MFV [53.17 ± 7.52 cm/s vs. 34.55 ± 3.35 cm/s] and PI [1.02 ± 0.16 vs. 1.46 ± 0.07] in patients with improvement and no improvement in cerebral oedema after seven days of TBI management. Conclusion: Bedside assessments of TCD-based parameters of MFV and PI correlate well with CT-based assessment of cerebral oedema in patients with TBI.

The role of lung ultrasound in procalcitonin-guided antibiotic discontinuation in ventilator-associated pneumonia.

Background and Aims: Starting antibiotic therapy at the proper time is the cornerstone of the management of ventilator-associated pneumonia (VAP). However, using antibiotics for a long duration of therapy in intensive care leads to increased bacterial resistance, financial burden and adverse drug reactions. We hypothesised that lung ultrasound may have a role in guiding antibiotic discontinuation in patients with VAP that will help to reduce the antibiotic duration and decrease the resistance. Methods: This was a prospective blinded cohort study from October 2020 to September 2021 in which 62 VAP patients were recruited. Antibiotics were started, procalcitonin (PCT) level and clinical pulmonary infection score were estimated and lung ultrasound (US) was performed on day 1 and repeated on day 7. On day 7, discontinuation of antibiotics was recommended if the PCT level was <0.25 µg/L. A lung reaeration score was recorded. Results: Based on the PCT levels, antibiotics were discontinued in 40 patients. The computed tomography findings of VAP had improved in all. The ultrasound reaeration score showed a highly significant negative correlation with the PCT on day 7 (-0.718, P < 0.001). A cut-off of 5 for the US score showed a sensitivity of 92.5%, specificity of 95.5%, positive predictive value of 97.4% and negative predictive value of 87.5% in detecting a low PCT score on day 7. Conclusion: Lung US is a non-invasive and safe method that can be used to guide antibiotic therapy in VAP.

Effect of extended infusion of meropenem and nebulized amikacin on Gram-negative multidrug-resistant ventilator-associated pneumonia.

BACKGROUND: Ventilator-associated pneumonia (VAP) due to multidrug-resistant organisms (MDROs) is associated with a significant mortality in the Intensive Care Unit (ICU). The aim of this study was to compare the efficacy and safety of extended infusion of meropenem and nebulized amikacin on VAP caused by Gram-negative MDRO versus intravenous (IV) meropenem and amikacin alone. METHODOLOGY: A randomized nonblinded controlled trial was performed on ninety patients with VAP. Patients were randomized into three equal groups: Group I received IV amikacin 20 mg/kg/24 h and meropenem 2 g over 30 min/8 h. Group II received the same as Group I in addition to nebulized amikacin 25 mg/kg/day every 8 h. Group III received IV amikacin 20 mg/kg/24 h, nebulized amikacin 25 mg/kg/day every 8 h, and meropenem 2 g diluted in 240 ml normal saline over 3 h/8 h. The primary outcome was the clinical outcome of VAP. Secondary outcomes were microbiological outcome, VAP-related mortality, duration of MV, ICU stay, and nephrotoxicity. RESULTS: Group II and Group III compared to Group I showed higher incidence of clinical cure (53.33% in Group II and 66.67% in Group III vs. 26.67% in Group I, P = 0.007). Group II compared to Group I showed significant reduction in ventilator days (5.32 ± 1.86 vs. 7.3 ± 2.1 days, respectively, P < 0.001) and reduction in ICU days (11.87 ± 2.6 vs. 15.3 ± 3.1 days, respectively, P < 0.001). Group III compared to Group II showed significant reduction in ventilator days (4.22 ± 1.32 vs. 5.32 ± 1.86, respectively, P = 0.011) and highly significant reduction in ICU days (9.21 ± 1.17 vs. 11.87 ± 2.6, respectively, P < 0.001). All groups were comparable as regards nephrotoxicity or mortality. CONCLUSIONS: Adding nebulized amikacin to systemic antibiotics in patients with VAP caused by Gram-negative MDRO may offer efficacy benefits, and the use of extended infusions of meropenem could improve the clinical outcomes in critically ill populations.

Combination of dexmedetomidine and remifentanil for labor analgesia: A double-blinded, randomized, controlled study.

BACKGROUND: Satisfactory analgesia is of great importance in the labor. The clinical efficacy and side effects of remifentanil in the management of labor pain had been evaluated. Dexmedetomidine (DMET) demonstrates an antinociceptive effect in visceral pain conditions. Aims of the study were to assess whether the combination of DMET with remifentanil would produce a synergistic effect that results in lower analgesic requirements. Furthermore, whether this combination would have less maternal and neonatal adverse effects. PATIENTS AND METHODS: Sixty American Society of Anesthesiologists physical status I-II pregnant women had been enrolled into this study. All were full term (37-40 weeks' gestation), singleton fetus with cephalic presentation in the first stage of spontaneous labor. They were divided into two groups group (I) Patient-controlled IV remifentanil analgesia (bolus dose 0.25 µg/kg, lockout interval 2 min) increased by 0.25 µg/kg to a maximum bolus dose 1 µg/kg in addition to a loading dose of DMET 1 µg/kg over 20 min, followed by infusion at 0.5 µg/kg/h group (II) Patient-controlled IV remifentanil analgesia (PCA) (bolus dose 0.25 µg/kg, lockout interval 2 min) increased by 0.25 µg/kg to a maximum bolus dose 1 µg/kg in addition to a the same volume of normal saline as a loading dose, followed by a continuous saline infusion. Visual analog scale score, maternal, and fetal complications and patients' satisfaction were recorded. RESULTS: Patients receiving a combination of PCA remifentanil and DMET had a lower pain score compared with remifentanil alone in the second stage of labor (P = 0.001). The Total consumption of remifentanil was reduced by 53.3% in group I. There was an increased incidence of maternal complications and a lower patient satisfaction score in group II. CONCLUSION: DMET has an opioid sparing effect; a combination of DMET and remifentanil produces a synergistic effect that results in lower analgesic requirements and less maternal and neonatal adverse events.