Retardo na transferência do pronto-socorro para a unidade de terapia intensiva: impacto nos desfechos do paciente. Um estudo retrospectivo / Delayed intensive care unit admission from the emergency department: impact on patient outcomes. A retrospective study

RESUMO Objetivo: Estudar o impacto do retardo na admissão à unidade de terapia intensiva em mais do que 4 horas nos desfechos de pacientes críticos. Métodos: Este foi um estudo observacional retrospectivo, no qual pacientes adultos admitidos diretamente do pronto-socorro para a unidade de terapia intensiva foram divididos em dois grupos: Tempo Adequado, se admitidos dentro de 4 horas, e Admissão Retardada, nos casos em que a admissão demorou mais do que 4 horas para ocorrer. Compararam-se, entre os grupos, o tempo de permanência na unidade de terapia intensiva e a taxa de mortalidade na unidade de terapia intensiva e no hospital. Foi realizado pareamento por escore de propensão para correção de desequilíbrios. Utilizou-se uma análise de regressão logística para explorar retardo da admissão como fator independente de risco para mortalidade na unidade de terapia intensiva. Resultados: Durante o período do estudo, 1.887 pacientes foram admitidos diretamente do pronto-socorro para a unidade de terapia intensiva, sendo que 42% dessas admissões foram retardadas. Os pacientes com retardo tiveram permanências na unidade de terapia intensiva significantemente mais longas e maior mortalidade na unidade de terapia intensiva e no hospital. Esses resultados persistiram após pareamento dos grupos por escore de propensão. O retardo da admissão foi fator independente de risco para mortalidade na unidade de terapia intensiva (RC = 2,6; IC95% 1,9 - 3,5; p < 0,001). A associação de retardo e mortalidade na unidade de terapia intensiva surgiu após período de retardo de 2 horas e foi mais alta após período de retardo de 4 horas. Conclusão: O retardo da admissão do pronto-socorro para a unidade de terapia intensiva é fator de risco independente para mortalidade na unidade de terapia intensiva, sendo a associação mais forte após retardo de 4 horas.

Abstract Objective: To study the impact of delayed admission by more than 4 hours on the outcomes of critically ill patients. Methods: This was a retrospective observational study in which adult patients admitted directly from the emergency department to the intensive care unit were divided into two groups: Timely Admission if they were admitted within 4 hours and Delayed Admission if admission was delayed for more than 4 hours. Intensive care unit length of stay and hospital/intensive care unit mortality were compared between the groups. Propensity score matching was performed to correct for imbalances. Logistic regression analysis was used to explore delayed admission as an independent risk factor for intensive care unit mortality. Results: During the study period, 1,887 patients were admitted directly from the emergency department to the intensive care unit, with 42% being delayed admissions. Delayed patients had significantly longer intensive care unit lengths of stay and higher intensive care unit and hospital mortality. These results were persistent after propensity score matching of the groups. Delayed admission was an independent risk factor for intensive care unit mortality (OR = 2.6; 95%CI 1.9 - 3.5; p < 0.001). The association of delay and intensive care unit mortality emerged after a delay of 2 hours and was highest after a delay of 4 hours. Conclusion: Delayed admission to the intensive care unit from the emergency department is an independent risk factor for intensive care unit mortality, with the strongest association being after a delay of 4 hours.

Residual Lung Injury in Patients Recovering From COVID-19 Critical Illness: A Prospective Longitudinal Point-of-Care Lung Ultrasound Study.

Scarce data exist regarding the natural history of lung lesions detected on ultrasound in those who survive severe COVID-19 pneumonia. OBJECTIVE: We performed a prospective analysis of point-of-care ultrasound (POCUS) findings in critically ill COVID-19 patients during and after hospitalization. METHODS: We enrolled 171 COVID-19 intensive care unit patients. POCUS of the lungs was performed with phased array (2-4 MHz), convex (2-6 MHz) and linear (10-15 MHz) transducers, scanning 12 lung areas. Chest computed tomography angiography was performed to exclude suspected pulmonary embolism. Survivors were clinically and sonographically evaluated during a 4 month period for evidence of residual lung injury. Chest computed tomography angiography and echocardiography were used to exclude pulmonary hypertension (PH) and chest high-resolution-computed-tomography to exclude interstitial lung disease (ILD) in symptomatic survivors. RESULTS: Cox regression analysis showed that lymphocytopenia (hazard ratio [HR]: 0.88, 95% confidence intervals [CI]: 0.68-0.96, p = .048), increased lactate (HR: 1.17, 95% CI: 0.94-1.46, p = 0.049), and D-dimers (HR: 1.21, 95% CI: 1.03-1.44, p = .03) were mortality predictors. Non-survivors had increased incidence of pulmonary abnormalities (B-lines, pleural line irregularities, and consolidations) compared to survivors (p < .05). During follow-up, POCUS with clinical and laboratory parameters integrated in the semi-quantitative Riyadh-Residual-Lung-Injury scale had sensitivity of 0.82 (95% CI: 0.76-0.89) and specificity of 0.91 (95% CI: 0.94-0.95) in predicting ILD. The prevalence of PH and ILD (non-specific-interstitial-pneumonia) was 7% and 11.8%, respectively. CONCLUSION: POCUS showed ability to monitor the evolution of severe COVID-19 pneumonia after hospital discharge, supporting its integration in clinical predictive models of residual lung injury.

Clinical Characteristics and Predictors of 28-Day Mortality in 352 Critically Ill Patients with COVID-19: A Retrospective Study.

BACKGROUND: Since the first COVID-19 patient in Saudi Arabia (March, 2020) more than 338,539 cases and approximately 4996 dead were reported. We present the main characteristics and outcomes of critically ill COVID-19 patients that were admitted in the largest Ministry of Health Intensive Care Unit (ICU) in Saudi Arabia. METHODS: This retrospective study, analyzed routine epidemiologic, clinical, and laboratory data of COVID-19 critically ill patients in King Saud Medical City (KSMC), Riyadh, Saudi Arabia, between March 20, 2020 and May 31, 2020. Severe acute respiratory syndrome coronavirus-2 infection was confirmed by real-time reverse transcriptase polymerase chain reaction assays performed on nasopharyngeal swabs in all enrolled cases. Outcome measures such as 28-days mortality, duration of mechanical ventilation, and ICU length of stay were analyzed. RESULTS: Three-hundred-and-fifty-two critically ill COVID-19 patients were included in the study. Patients had a mean age of 50.63 ± 13.3 years, 87.2% were males, and 49.4% were active smokers. Upon ICU admission, 56.8% of patients were mechanically ventilated with peripheral oxygen saturation/fraction of inspired oxygen (SpO2/FiO2) ratio of 158 ± 32. No co-infections with other endemic viruses were observed. Duration of mechanical ventilation was 16 (IQR: 8-28) days; ICU length of stay was 18 (IQR: 9-29) days, and 28-day mortality was 32.1%. Multivariate regression analysis showed that old age [Odds Ratio (OR): 1.15, 95% Confidence Intervals (CI): 1.03-1.21], active smoking [OR: 3, 95% CI: 2.51-3.66], pulmonary embolism [OR: 2.91, 95% CI: 2.65-3.36), decreased SpO2/FiO2 ratio [OR: 0.94, 95% CI: 0.91-0.97], and increased lactate [OR: 3.9, 95% CI: 2.4-4.9], and D-dimers [OR: 2.54, 95% CI: 1.57-3.12] were mortality predictors. CONCLUSION: Old age, active smoking, pulmonary embolism, decreased SpO2/FiO2 ratio, and increased lactate and D-dimers were predictors of 28-day mortality in critically ill COVID-19 patients.

Tocilizumab in the treatment of rapidly evolving COVID-19 pneumonia and multifaceted critical illness: A retrospective case series.

BACKGROUND: COVID-19 associated critical illness characterized by rapidly evolving acute respiratory failure (ARF) can develop, especially on the grounds of hyperinflammation. AIM AND METHODS: A case-series of 61 patients admitted to our intensive care unit (ICU) between August 12 and September 12, 2020 with confirmed COVID-19 pneumonia and rapidly evolving ARF requiring oxygen support therapy and/or mechanical ventilation was retrospectively analyzed. We examined whether intravenous administration of tocilizumab, a monoclonal interleukin-6 receptor antibody, was associated with improved outcome. All patients received empiric antivirals, dexamethasone 6 mg/day for 7 days, antibiotics, and prophylactic anticoagulation. Tocilizumab was administered at a dosage of 8 mg/kg [two consecutive intravenous infusions 12 h apart]. Outcome measures such as mortality on day-14, ICU length of stay, and rate of nosocomial acquired bacterial infections were also analyzed. Results: Patients were males (88.2%) aged 51 [interquartile range (IQR): 42.5-58.75)], with admission Acute Physiology and Chronic Health Evaluation (APACHE) 4 score of 53 (IQR: 37.75-72.5), and had more than one comorbidity (62.3%). On admission, twenty nine patients (47.5%) were mechanically ventilated, and thirty two patients (52.5%) were receiving oxygen therapy. No serious adverse effects due to tocilizumab therapy were recorded. However, twelve patients (19.6%) developed nosocomial acquired infections. ICU length of stay was 13 (IQR: 9-17) days, and mortality on day-14 was 24.6%. Six patients were shifted to other hospitals but were followed-up. The overall mortality on day-30 was 31.1%. Non-mechanically ventilated patients had higher survival rates compared to mechanically ventilated patients although results were not significant [hazards ratio = 2.6 (95% confidence intervals: 0.9-7.7), p = 0.08]. Tocilizumab did not affect the mortality of critically ill COVID-19 patients. CONCLUSION: Tocilizumab could be an adjunct safe therapy in rapidly evolving COVID-19 pneumonia and associated critical illness.

Co-infection of SARS-CoV-2 and Bordetella bronchiseptica in a young man with idiopathic non-cystic bronchiectasis and vitamin D3 deficiency.

This is the first reported case, to our knowledge, of co-infection of Bordetella bronchiseptica and SARS-CoV-2 in a young patient with underlying idiopathic bronchiectasis and vitamin D3 deficiency that was treated successfully with a combination therapeutic regime integrating doxycycline, empiric therapies for COVID-19, vitamin D supplementation, and supportive ICU care. Large prospective studies are required to investigate further the role of co-infections in COVID-19 patients with bronchiectasis. Randomized control trials should examine the putative beneficial role of vitamin D supplementation in patients with COVID-19.

Therapeutic plasma exchange in adult critically ill patients with life-threatening SARS-CoV-2 disease: A pilot study.

PURPOSE: We investigated the effect of therapeutic plasma exchange (TPE) on life-threatening COVID-19; presenting as acute respiratory distress syndrome (ARDS) plus multi-system organ failure and cytokine release syndrome (CRS). MATERIALS AND METHODS: We prospectively enrolled ten consecutive adult intensive care unit (ICU) subjects [7 males; median age: 51 interquartile range (IQR): 45.1-55.9 years old] with life-threatening COVID-19 infection. All had ARDS [PaO2/FiO2 ratio: 110 (IQR): 95.5-135.5], septic shock, CRS and deteriorated within 24 h of ICU admission despite fluid resuscitation, antibiotics, hydroxychloroquine, ARDS-net and prone position mechanical ventilation. All received 5-7 TPE sessions (dosed as 1.0 to 1.5 plasma volumes). RESULTS: All of the following significantly normalized (p < 0.05) following the TPE completion, when compared to baseline: Sequential Organ Function Assessment score, PaO2/FiO2 ratio, levels of lymphocytes, total bilirubin, lactate dehydrogenase, ferritin, C-reactive protein and interleukin-6. No adverse effects from TPE were observed. Acute kidney injury and pulmonary embolism were observed in 10% and 20% of patients, respectively. The duration of mechanical ventilation was 9 (IQR: 7 to 12) days, the ICU length of stay was 15 (IQR: 13.2 to 19.6) days and the mortality on day-28 was 10%. CONCLUSION: TPE demonstrates a potential survival benefit and low risk in life-threatening COVID-19, albeit in a small pilot study.

Lung Injury in COVID-19-An Emerging Hypothesis.

Lung injury with COVID-19 may be due to a complex underlying pathophysiology. Cytokine release syndrome appears to be a catalyst of different inflammatory pathways promoting lung parenchymal injury and thromboembolic phenomena ("dual hit" injury). Recently, severe neurological manifestations such as acute disseminated encephalomyelitis, which may be not linked to lung pathology, have been identified in COVID-19, contributing thus further to the versatility of its clinical features.

A pilot study of therapeutic plasma exchange for serious SARS CoV-2 disease (COVID-19): A structured summary of a randomized controlled trial study protocol.

OBJECTIVES: To evaluate the safety of therapeutic plasma exchange (TPE) in adult patients with serious/life-threatening COVID-19 requiring intensive care unit (ICU) admission, and associated 28-day mortality. Serious and life threatening COVID-19 are defined as per published literature (please, refer to the full protocol, Additional file 1). The rationale is that TPE can remove interleukins-3, 6, 8, 10, interferon-gamma and tumor necrosis factor-alpha. Thus, it may reduce the cytokine release syndrome associated with fulminant COVID-19 disease. TRIAL DESIGN: Pilot, interventional, open-label, randomized controlled multicenter trial. PARTICIPANTS: Inclusion criteria are: 1) age ≥ 18 years old; 2) intubation and intensive care unit (ICU) admission; 3) serious and/or life-threatening COVID-19 (please, refer to the full protocol, Additional file 1). SARS-CoV-2 infection is confirmed by Real-Time-Polymerase-Chain-Reaction (RT-PCR) assays using QuantiNova Probe RT-PCR kit (Qiagen) in a Light-Cycler 480 real-time PCR system (Roche, Basel, Switzerland). Exclusion criteria are: 1) previous allergic reaction to plasma exchange or its ingredients (i.e., sodium citrate), 2) two consecutive negative RT-PCR tests for SARS-CoV-2 at least 24 hours apart, 3) mild COVID-19 not requiring ICU admission and 4) terminally ill patients receiving palliative care. The primary site will be King Saud Medical City (KSMC), Riyadh, Kingdom of Saudi Arabia (KSA). Also, the study will run in ICUs (Ministry of Health Cluster 1; Riyadh) and other centers in KSA pending their institutional review board (IRB) approval. INTERVENTIONS AND COMPARATOR: The intervention group will receive TPE, plus empiric treatment for COVID-19. TPE is administered using the Spectra Optia TM Apheresis System equipped with the Depuro D2000 Adsorption Cartridge (Terumo BCT Inc., USA). The first dose is 1.5 plasma volumes, followed by one plasma volume on alternate days or daily for five to seven total treatments. Spectra Optia TM Apheresis System operates with acid-citrate dextrose anticoagulant (ACDA) as per Kidney Disease Improving Global Outcomes (KDIGO) 2019 guidelines. Plasma is replaced with albumin 5% or fresh frozen plasma in patients with coagulopathy (prothrombin time >37 seconds; international normalized ratio >3; activated partial thromboplastin time >100 or fibrinogen level <100 mg/d). TPE sessions are performed daily over four hours and laboratory markers measured daily. The comparators are controls not receiving TPE but usual empiric treatment for COVID-19 as per institutional, national and international recommendations. Both groups will receive standard ICU supportive care. MAIN OUTCOMES: Primary study end-point is 28-day mortality and safety of TPE in serious and/or life-threatening COVID-19. Safety will be evaluated by the documentation of any pertinent adverse and/or serious adverse effects related to TPE as per institutional, national and international (Food and Drug Administration) guidelines. Secondary outcomes are: i) improvement in Sequential Organ Function Assessment (SOFA) score ; ii) changes in inflammatory markers: serum C-reactive protein, lactate dehydrogenase, ferritin, d-dimers and interleukin-6; iii) days on mechanical ventilation and ICU length of stay. RANDOMIZATION: Eligible consented patients are randomized (1:1 allocation) after stratification by ICU center and two PaO2/FIO2 ratio categories (> 150 and ≤ 150). Randomization occurs in variable block sizes of four to eight patients. A web-based randomization service, randomize.net, is used to allocate patients to their respective strata prior to the intervention or control therapy. BLINDING (MASKING): Given the visibility of TPE machinery, the intervention will be unblinded; hence, no enrollment concealment will be expedited. The lack of allocation concealment will be mitigated by several measures (please, refer to the full protocol, Additional file 1). NUMBERS TO BE RANDOMIZED (SAMPLE SIZE): This pilot randomized trial aims to recruit a convenience sample of patients with serious and/or life-threatening COVID-19. Therefore, at least 20 patients are to be randomized to each group per participating center. We are hoping to consent and randomize approximately 60 patients in each group over a 3 to 6 months period giving a total of 120 participants. TRIAL STATUS: The protocol version 1 was approved 29/04/2020. Recruitment is ongoing, and began on 01/05/2020. We estimate completion by 29/10/2020. TRIAL REGISTRATION: Registered at ISRCTN on 18/05/2020 (ISRCTN21363594; doi.10.1186/ ISRCTN21363594). FULL PROTOCOL: The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest of expediting dissemination of this material, the familiar formatting has been eliminated; this letter serves as a summary of the key elements of the full protocol.

Refining perforator selection for deep inferior epigastric perforator flap: the impact of the dominant venous perforator.

INTRODUCTION: This article aims to investigate the critical role of the venous-perforator in the decision-making process of choosing the best suitable perforator-complex in a deep inferior epigastric perforator (DIEP) flap. METHODS: Forty consecutive DIEP breast reconstructions were pre-operatively evaluated by CT-Angiography to identify the dominant and centrally located abdominal wall perforators. The CTA results were used as a guide to conduct a Color-Duplex-Ultrasound examination that was mainly focused on investigating the accompanying venous-perforator. In group-A (n = 20) perforator-complex selection was based on the size of the arterial-perforator, whilst in group-B (n = 20) it was based on the size of the venous-perforator. RESULTS: All single perforator-complex DIEP flaps survived. No significant differences were recorded concerning the size of arterial-perforator between the two groups; however the size of venous-perforator was significantly larger in group-B (P < 0.05). In group-A, four flaps showed vascular compromise intraoperative that was salvaged by flap supercharge with the superficial inferior epigastric system. In contrast, in group-B, all flaps were re-vascularized uneventfully (P < 0.05). Physical examination revealed a palpable mass in one patient and ultrasound investigation added three cases with a firm area of scar tissue in group-A, but no fat necrosis was detected in group-B (P < 0.05). CONCLUSIONS: The CTA-guided duplex ultrasonography could direct the perforator-complex selection according to the size of the venous-perforator, and may reduce the intraoperative problems and the incidence of fat necrosis.

Integrating imaging techniques in lower limb microsurgical reconstruction: focusing on ultrasonography versus computed tomography angiography.

Recent developments in the field of biomedical imaging have facilitated the use of various imaging techniques as adjunctive tools in microsurgical lower limb reconstructions. Frequently-used imaging modalities in reconstructive microsurgery are colour-Doppler ultrasound and computed tomography angiography. Here, we present basic principles of the above applied techniques and analyze the surgical rationale of integrating imaging techniques in lower limb reconstruction.

Sonographic and clinical features of upper extremity deep venous thrombosis in critical care patients.

Background-Aim. Upper extremity deep vein thrombosis (UEDVT) is an increasingly recognized problem in the critically ill. We sought to identify the prevalence of and risk factors for UEDVT, and to characterize sonographically detected thrombi in the critical care setting. Patients and Methods. Three hundred and twenty patients receiving a subclavian or internal jugular central venous catheter (CVC) were included. When an UEDVT was detected, therapeutic anticoagulation was started. Additionally, a standardized ultrasound scan was performed to detect the extent of the thrombus. Images were interpreted offline by two independent readers. Results. Thirty-six (11.25%) patients had UEDVT and a complete scan was performed. One (2.7%) of these patients died, and 2 had pulmonary embolism (5.5%). Risk factors associated with UEDVT were presence of CVC [(odds ratio (OR) 2.716, P = 0.007)], malignancy (OR 1.483, P = 0.036), total parenteral nutrition (OR 1.399, P = 0.035), hypercoagulable state (OR 1.284, P = 0.045), and obesity (OR 1.191, P = 0.049). Eight thrombi were chronic, and 28 were acute. We describe a new sonographic sign which characterized acute thrombosis: a double hyperechoic line at the interface between the thrombus and the venous wall; but its clinical significance remains to be defined. Conclusion. Presence of CVC was a strong predictor for the development of UEDVT in a cohort of critical care patients; however, the rate of subsequent PE and related mortality was low.

Impact of portable duplex ultrasonography in head and neck reconstruction.

We have reviewed the use of portable duplex ultrasonography (PDU) in 12 patients who underwent soft tissue/bone head and neck reconstruction, aiming to determine its role in the design and management of such complex cases. According to our data, there were modifications either of the surgical plan or of patient's management, based on PDU findings, in 9 (75%) of 12 patients. The use of ultrasound directed to subtle modifications in 3 patients (25%) but to significant changes of the surgical plan in the other 3 patients (25%). Also, the use of duplex ultrasound impacted significantly the postoperative management in 4 patients (33.33%). Thus, significant impact of PDU in patient's treatment was recorded in 58.33% of cases. Portable ultrasound represents generally available method for preoperative, intraoperative, and postoperative diagnosis and decision making in free tissue transfer, hence could replace in the future the unidirectional Doppler in the hands of head and neck surgeons.

Changes in arterial blood flow of free flaps after the administration of sildenafil in swine.

We evaluated blood flow changes after experimental free tissue transfer and the potential hemodynamic effect of sildenafil on the free flap. Sixteen swine were used for free transfer of a latissimus dorsi myocutaneous flap to the chest that was anastomosed to the internal mammary vessels, and were randomized into controls and study group. The latter received a single dose of sildenafil, 6 hours following flap revascularization. Doppler ultrasonography revealed that arterial flow was mainly systolic postoperatively. Diastolic flow patterns were gradually restored after the first postoperative day. Pulsatility index (PI) significantly increased and flow volume decreased in all animals postoperatively. In the sildenafil group, PI significantly decreased and flow volume increased, while diastolic flow patterns were restored earlier on compared to controls, postoperatively. In conclusion, the administration of sildenafil after free tissue transfer increases flow volume and facilitates the restoration of diastolic blood flow patterns in the early critical postoperative period.

Robotic-assisted surgical removal of pelvic schwannoma: a novel approach to a rare variant.

BACKGROUND: Robotic-assisted excision of a pelvic schwannoma is presented. METHODS: A 27 year-old female presented with occasional numbness of the right thigh. Imaging studies revealed a large mass adjacent to the right ovary. Robotic surgery with adjunctive electrophysiological monitoring was performed. The mass was adhered to the L4, L5 roots and was displacing the iliac vessels and the ureter. The tumour bulk was decompressed and total excision was facilitated. RESULTS: Pathology revealed a neoplasm consisting of spindle cells. Immunochemistry revealed S-100(+) and a growth index Ki-67 < 1%. These findings were consistent with the diagnosis of ancient schwannoma. The intraoperative time was comparable to laparoscopy and the patient had an uneventful recovery. CONCLUSION: Ancient schwannoma is often diagnosed only when it is large enough to produce symptoms. Robotic surgery with adjunctive electrophysiological monitoring is a safe technique for the removal of large pelvic neurinomas.

Portable duplex ultrasonography: A diagnostic and decision-making tool in reconstructive microsurgery.

Unidirectional Doppler is a common diagnostic tool by the Reconstructive Microsurgeons; however, it may generate false signals and surely provides less imaging data as compared to duplex ultrasonography. We have reviewed the use of Portable Duplex Ultrasonography (PDU) in 16 patients who underwent complex soft-tissue/bone reconstruction, aiming to determine its role in the design and management of free tissue transfer. According to our data, there were modifications either of the surgical plan and/or of patient's management, based on PDU findings, in 10 out of 16 patients (62.5%). The use of ultrasound directed to subtle modifications in three patients (19%), but to significant changes of the surgical plan in four patients (25%). Also, the use of ultrasound improved significantly the postoperative management in three patients (19%). Thus, significant impact of PDU in patient's treatment was recorded in 44% of cases. Portable ultrasound represents generally available method for preoperative, intraoperative, and postoperative diagnosis and decision-making in free tissue transfer, hence could replace in the near future the unidirectional Doppler in the hands of Microsurgeons.

Peripheral T-cell lymphoma presenting as an ischemic stroke in a 23-year-old woman: a case report and review of the literature.

INTRODUCTION: Peripheral T-cell lymphoma of the unspecified variant is a highly aggressive subtype of T-cell non-Hodgkin's lymphoma. This is the first reported case of this type of lymphoma presenting as an ischemic stroke in a woman. CASE PRESENTATION: A previously healthy 23-year-old woman presented with fever and hemiplegia. She was subsequently intubated after scoring 7 out of 15 at the Glasgow Coma Scale. Brain computed tomography scans of the patient depicted a massive sylvian infarction while an abdominal computed tomography scan revealed multiple enlarged abdominal lymph nodes and a retroperitoneal mass adjacent to the left psoas muscle. A diagnostic work up for inherited thrombophilia yielded negative results. Blood and cerebrospinal fluid cultures for infectious agents also gave negative results. A biopsy of the retroperitoneal mass guided by computed tomography was inconclusive. A biopsy of an enlarged inguinal lymph node of the patient, combined with an immunophenotypic analysis, revealed an unspecified variant of peripheral T-cell lymphoma. The patient underwent chemotherapy but developed multiple organ failure. She died 26 days after she was admitted to our intensive care unit. CONCLUSION: Peripheral T-cell lymphoma of the unspecified variant is a highly aggressive subtype of peripheral T-cell lymphomas. The latter exhibit no consistent immunophenotypic, genetic, or clinical features. Clinicians should be aware of atypical clinical presentations of the above lymphomas such as ischemic stroke.

Comparison of standard polyvinyl chloride tracheal tubes and straight reinforced tracheal tubes for tracheal intubation through different sizes of the Airtraq laryngoscope in anesthetized and paralyzed patients: a randomized prospective study.

BACKGROUND: The authors compared the intubation success rate of straight reinforced tracheal tubes emerging from the Airtraq laryngoscope (Prodol Meditec S.A., Vizcaya, Spain) with standard preformed polyvinyl chloride tracheal tubes in anesthetized patients. METHODS: The authors randomly allocated 347 adult patients to be intubated with standard polyvinyl chloride tracheal tubes, standard straight wire-reinforced tracheal tubes, or silicone straight wire-reinforced tubes, through either the larger or the smaller adult laryngoscope sizes. The possible influence of laryngoscope size, tube size, and tube type on intubation failure was examined. RESULTS: Success rates were 100% for polyvinyl chloride tracheal tubes, 78.5% for standard wire-reinforced tracheal tubes, and 75.4% for silicone wire-reinforced tubes (P < 0.01). Compared with the former, patients in the straight standard and silicone wire-reinforced tube groups required more optimization maneuvers (4.1% vs. 42.1%; P < 0.01) and more attempts at successful intubation (0% vs. 7.3%; P < 0.01). The angle created by the tube emerging from the Airtraq guiding channel was inversely correlated to the ratio of the endotracheal tube OD to the width of the channel in the standard and silicone wire-reinforced tube groups (r = -0.95 and r = -0.82, respectively; P < 0.01). Finally, a decrease in 0.1 of the above ratio was associated with a 3.1 (95% confidence interval, 1.9-5.2; P < 0.01) times increase in the odds ratio of intubation failure. CONCLUSIONS: Standard polyvinyl chloride tracheal tubes were found to be superior compared with standard and silicone straight wire-reinforced tubes for intubation through the Airtraq laryngoscope. In the latter groups, a decrease of the ratio of their OD to the width of the Airtraq guiding channel resulted in increased intubation failure.

Sclerosing mesenteritis affecting the small and the large intestine in a male patient with non-Hodgkin lymphoma: a case presentation and review of the literature.

INTRODUCTION: Sclerosing mesenteritis is a rare disease resembling a mesenteric tumour. We present here a case of sclerosing mesenteritis that affected both the large and the small intestine of the patient. Therapeutic and diagnostic issues are discussed. CASE PRESENTATION: A 62-year-old man with a history of non-Hodgkin lymphoma presented with fatigue, a palpable tender abdominal mass and clinical signs of progressing intestinal obstruction. The preoperative evaluation failed to prove recurrence of the lymphoma or any other definite diagnosis. A laparotomy was performed through a midline incision. The mesentery resembled a tumour-like thickened and fibrotic mass. Abundant, rigid intestinal loop adhesions were observed. Diffuse fibrotic infiltration of the ileum and of the sigmoid colon, which obviously affected the intestinal vascular supply, were identified. A right colectomy and partial sigmoidectomy were performed. Pathological evaluation revealed extensive myofibroblastic reaction of the mesentery with accompanying loci of fat necrosis and areas of inflammation. A diffuse fibrotic infiltration that focally showed a ground-glass appearance was observed. The post-operative course was complicated by respiratory insufficiency and infections and the patient died 2 months after the operation. CONCLUSION: Sclerosing mesenteritis that affects both the small and the large intestine is extremely rare. The disease is characterized by myofibroblastic reaction, fat necrosis and diffuse fibrosis of the mesentery. Pathological confirmation may be required for definite diagnosis. If the disease is characterized by severe and diffuse fibrosis, then the application of surgical therapy may be problematic.