Clinical Features of Rickettsial Infection in Children in Tropical Australia-A Report of 15 Cases.

Rickettsial infections are an under-recognized cause of acute, undifferentiated fever in the tropics. In Asia, intensive care unit (ICU) admission rates as high as 21% and case-fatality rates of up to 5% have been reported. This 20-year retrospective audit of children and adults with serologically confirmed scrub typhus or spotted fever group (SFG) infection was performed at a tertiary-referral hospital in tropical Australia. There were 15 paediatric cases during the study period (11 scrub typhus, 3 SFG and 1 undifferentiated). Hypotension [5/15 (33%)], tachycardia [6/15 (40%)] and tachypnoea [6/15 (40%)] were common at presentation. Children were more likely to be hypotensive at admission than adults [5/15 (33%) vs. 5/118 (4%), p = 0.002]. However, no child died or was admitted to ICU, compared with 18/120 (15%) adults who required ICU support during the study period, one of whom died. Paediatric rickettsial infections have a relatively benign clinical course in tropical Australia with serious complications appearing far less frequently than have been reported in the Asian literature.

Is the Metronome-Paced Tachypnea Test (MPT) Ready for Clinical Use? Accuracy of the MPT in a Prospective and Clinical Study.

BACKGROUND: A simple technique to measure dynamic hyperinflation (DH) in patients with chronic obstructive pulmonary disease (COPD) is the metronome-paced tachypnea test (MPT). Earlier studies show conflicting results about the accuracy of the MPT compared to cardiopulmonary exercise testing (CPET). OBJECTIVES: The focus was to investigate the diagnostic accuracy of MPT to detect DH in a prospective and clinical study. METHODS: COPD patients were included; all underwent spirometry, CPET, and MPT. DH (ΔIC) was calculated as the difference in % between inspiratory capacity (IC) at the start and end of the test divided by IC at the start. A subject was identified as a hyperinflator, if ΔIC (% of ICrest) was smaller than -10.2 and -11.1% in CPET and MPT, respectively. With these values, sensitivity and specificity were calculated. Bland-Altman plots were made of ΔIC (% of ICrest). RESULTS: In the prospective and clinical study, 107 and 48 patients were included, respectively. Sensitivity of the MPT was 85% in both studies. The specificities were 33 and 27%, respectively. In the prospective study, B = +2.6%, L = 30.6, and -25.6%. In the clinical study, B = +0.8%, L = 31.0, and -29.1%. CONCLUSION: MPT seems to be a good replacement for CPET in group studies. The mean amount of DH was not different between CPET and MPT. On an individual level, MPT cannot be used to identify hyperinflators; it should be kept in mind that MPT overdiagnoses DH. The amount of DH should not be interchanged between CPET and MPT.

The autopsy and diagnosis of pulmonary thrombo-embolism.

Pulmonary thrombo-embolism (PTE) is a common cause of death but is frequently undetected by clinicians in spite of advanced diagnostic techniques. The autopsy has traditionally been used to identify the rate of PTE in hospital patients, but the decline in autopsy rates - especially in hospitals - has led to insufficient recent data from which to comment with confidence on the true rate of death from latent PTE. Widespread prophylactic anticoagulation regimens against venous thrombosis may induce complacency amongst clinicians. PTE continues to occur and to kill, and autopsies should be performed more frequently to better estimate the true prevalence of this condition.

A case of intracardiac echinococcosis.

We describe a case of multisystemic cystic echinococcosis exhibiting intracardiac involvement. A lesion inside the lateral wall of the left ventricle induced negative T waves on leads V5 and V6.

Thyroid Storm in a Patient with Trauma - A Challenging Diagnosis for the Emergency Physician: Case Report and Literature Review.

BACKGROUND: Thyroid storm, an endocrine emergency, remains a diagnostic and therapeutic challenge. It is recognized to develop as a result of several factors, including infection, surgery, acute illness, and rarely, trauma. Recognition of thyroid storm in a trauma patient is difficult because the emergency physician usually focuses on managing more obvious injuries. OBJECTIVE OF THE REVIEW: We present a case of trauma-related thyroid storm and review the previous literature on posttraumatic thyroid storm to delineate risk factors of the disease. The case occurred in a 32-year-old man after a motorcycle accident. DISCUSSION: Careful investigation of patient history and risk factors of trauma-related thyroid storms and utilization of the scoring system may facilitate early diagnosis. Traumatically induced thyroid storm usually responds to medical treatment developed for hyperthyroidism. Surgical intervention may be needed for patients who failed medical treatment or those with direct thyroid gland injuries. The outcome is usually fair under appropriate management. CONCLUSION: We present a case of trauma-related thyroid storm to illustrate the diagnostic and therapeutic approach with a summary of the previous literature. Emergency physicians should be aware of the clinical presentation and risk factors of patients with trauma-related thyroid storm to reduce the rate of misdiagnosis and prevent catastrophic outcomes.

Oral amoxicillin compared with injectable procaine benzylpenicillin plus gentamicin for treatment of neonates and young infants with fast breathing when referral is not possible: a randomised, open-label, equivalence trial.

BACKGROUND: WHO recommends referral to hospital for possible serious bacterial infection in young infants aged 0-59 days. We aimed to assess whether oral amoxicillin treatment for fast breathing, in the absence of other signs, is as efficacious as the combination of injectable procaine benzylpenicillin-gentamicin. METHODS: In a randomised, open-label, equivalence trial at five sites in DR Congo, Kenya, and Nigeria, community health workers followed up all births in the community, identified unwell young infants, and referred them to study nurses. We randomly assigned infants with fast breathing as a single sign of illness or possible serious bacterial infection, whose parents did not accept referral to hospital, to receive either injectable procaine benzylpenicillin-gentamicin once per day or oral amoxicillin treatment twice per day for 7 days. A person who was off-site generated randomisation lists using computer software. Trained health professionals gave injections, but outcome assessors were masked to group allocations. The primary outcome was treatment failure by day 8 after enrolment, defined as clinical deterioration, development of a serious adverse event including death, persistence of fast breathing on day 4, or recurrence up to day 8. The primary analysis was per protocol and we used a prespecified similarity margin of 5% to assess equivalence between regimens. This study is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12610000286044. FINDINGS: From April 4, 2011, to March 29, 2013, we enrolled 2333 infants aged 0-59 days with fast breathing as the only sign of possible serious bacterial infection at the five study sites. We assigned 1170 infants to receive injectable procaine benzylpenicillin-gentamicin and 1163 infants to receive oral amoxicillin. In the per-protocol analysis, from which 137 infants were excluded, we included 1061 (91%) infants who fulfilled predefined criteria of adherence to treatment and adequate follow-up in the injectable procaine benzylpenicillin-gentamicin group and 1145 (98%) infants in the oral amoxicillin group. In the procaine benzylpenicillin-gentamicin group, 234 infants (22%) failed treatment, compared with 221 (19%) infants in the oral amoxicillin group (risk difference -2·6%, 95% CI -6·0 to 0·8). Four infants died within 15 days of follow-up in each group. We detected no drug-related serious adverse events. INTERPRETATION: Young infants with fast breathing alone can be effectively treated with oral amoxicillin on an outpatient basis when referral to a hospital is not possible. FUNDING: Bill & Melinda Gates Foundation grant to WHO.

Clinical predictors of hospital admission in acute lower respiratory tract infection in 2 months to 2-year-old children.

BACKGROUND AND OBJECTIVE: Acute lower respiratory tract infections (ALRI) are a common cause of paediatric emergency visits in young children. We studied risk factors for hospitalization and developed a clinical score for predicting hospitalization among 2 months to 2-year-old children with ALRI. METHODS: We conducted this prospective cohort study in the paediatric emergency department of a tertiary-care teaching hospital in India. Consecutive children, aged 2 months to 2 years with ALRI were enrolled from 15 December 2011 to 14 December 2012. A total of 26 a priori identified, putative risk factors were studied among enrolled children. We determined independent predictors of hospital admission (primary outcome) through multi-variable logistic regression analysis and assimilated them into a clinical risk score using regression coefficients. RESULTS: A total of 240 children (130 admissions) with ALRI were enrolled. Eleven clinical risk factors, which displayed association with hospital admission on univariate analysis (P < 0.1), were entered into multi-variable logistic regression analysis. Five factors retained independent association and were incorporated in a predictive score for hospitalization: tachypnoea (score of 5), chest retractions (score of 3), temperature > 37.8°C (score of 3), SpO2 < 92% at room air (score of 4), GCS < 15 (score of 6). Area under the receiver operator characteristic curve was 0.80 (95% CI: 0.75-0.85, P < 0.001). CONCLUSION: Five clinical risk factors-tachypnoea, chest retractions, fever > 37.8°C, SpO2 < 92% and GCS < 15-independently predicted hospital admission in infants with ALRI. A novel clinical score predicting hospital admission is presented.

Ketoacidosis in a non-diabetic woman who was fasting during lactation.

Ketoacidosis is a potential complication of type 1 diabetes. Severe ketoacidosis with a blood pH below 7.0 is only rarely seen in other diseases.Three weeks after delivery, a young woman was admitted because of tachypnoe and tachycardia. Blood gas analysis showed a severe metabolic acidosis with a high anion gap. Further workup revealed the presence of ketone bodies in the urine with normal blood glucose and no history of diabetes. The patient reported that she had not eaten for days because of abdominal pain. After initial treatment in the ICU and immediate re-feeding, the patient's condition rapidly improved.While under normal circumstances fasting causes at most only mild acidosis, it can be dangerous during lactation. Prolonged fasting in combination with different forms of stress puts breast feeding women at risk for starvation ketoacidosis and should therefore be avoided.

Optogenetic stimulation of adrenergic C1 neurons causes sleep state-dependent cardiorespiratory stimulation and arousal with sighs in rats.

RATIONALE: The rostral ventrolateral medulla (RVLM) contains central respiratory chemoreceptors (retrotrapezoid nucleus, RTN) and the sympathoexcitatory, hypoxia-responsive C1 neurons. Simultaneous optogenetic stimulation of these neurons produces vigorous cardiorespiratory stimulation, sighing, and arousal from non-REM sleep. OBJECTIVES: To identify the effects that result from selectively stimulating C1 cells. METHODS: A Cre-dependent vector expressing channelrhodopsin 2 (ChR2) fused with enhanced yellow fluorescent protein or mCherry was injected into the RVLM of tyrosine hydroxylase (TH)-Cre rats. The response of ChR2-transduced neurons to light was examined in anesthetized rats. ChR2-transduced C1 neurons were photoactivated in conscious rats while EEG, neck muscle EMG, blood pressure (BP), and breathing were recorded. MEASUREMENTS AND MAIN RESULTS: Most ChR2-expressing neurons (95%) contained C1 neuron markers and innervated the spinal cord. RTN neurons were not transduced. While the rats were under anesthesia, the C1 cells were faithfully activated by each light pulse up to 40 Hz. During quiet resting and non-REM sleep, C1 cell stimulation (20 s, 2-20 Hz) increased BP and respiratory frequency and produced sighs and arousal from non-REM sleep. Arousal was frequency-dependent (85% probability at 20 Hz). Stimulation during REM sleep increased BP, but had no effect on EEG or breathing. C1 cell-mediated breathing stimulation was occluded by hypoxia (12% FIO2), but was unchanged by 6% FiCO2. CONCLUSIONS: C1 cell stimulation reproduces most effects of acute hypoxia, specifically cardiorespiratory stimulation, sighs, and arousal. C1 cell activation likely contributes to the sleep disruption and adverse autonomic consequences of sleep apnea. During hypoxia (awake) or REM sleep, C1 cell stimulation increases BP but no longer stimulates breathing.

Early Detection Tool of Intestinal Dysfunction: Impact on Necrotizing Enterocolitis Severity.

OBJECTIVE: The aim of this study is to determine the use of an early clinical signs and symptoms warning tool in early identification of intestinal dysfunction as a clinical strategy to decrease necrotizing enterocolitis (NEC) severity. DESIGN: Using signs and symptoms of 297 infants, of which 33 infants were diagnosed with stage II and III EC intestinal dysfunction, a five clinical category scoring tool (Neonatal Necrotizing Enterocolitis Early Detection Score [NeoNEEDS]) and strategy with abdominal X-ray alert was developed. The categories included behavior, cardiac, respiratory, gastrointestinal, and feeding tolerance. The strategy was tested in a prospective cohort of 72 infants < 1,500 g, utilizing 532 observations between 10/2012 and 9/1/2013. The statistical analysis utilized the Statistical Analysis Software (SAS). RESULTS: The earliest signs and symptoms of intestinal dysfunction (Stage I NEC) were cardiorespiratory baseline changes, p < 0.001. Abdominal distension and/or feeding intolerance were late findings associated with stage II or III NEC. Tool scores ≥ 5 predicted intestinal dysfunction (p < 0.00). Sensitivity was high (95%) with specificity of 82% and positive and negative predictive values of 76% and 95%, respectively. Use of the tool during the study period was associated with decreased NEC severity rates (Bell NEC stage II and III). CONCLUSION: Cardiorespiratory symptoms precede gastrointestinal symptoms of intestinal dysfunction. Targeting signs and symptoms in an early warning tool to identify intestinal dysfunction can impact NEC severity progression.

Prodromal illness before acute chest syndrome in pediatric patients with sickle cell disease.

BACKGROUND: Acute chest syndrome (ACS) is associated with morbidity and mortality in children with sickle cell disease. We hypothesize that children with sickle cell disease have a distinct prodromal illness before their ACS episode. MATERIALS AND METHODS: We performed a chart review of ICD-9-CM identified ACS episodes at a pediatric hospital from 2005 to 2010. Prodromal visits were defined as acute visits that resulted in a discharge from care and occurred within 2 weeks of a hospitalization that included ACS. We reviewed the documented history, examination, laboratory studies, and radiographs for each prodromal visit. RESULTS: We identified 196 ACS episodes. Children received prodromal care in 29% of the ACS episodes. Painful vaso-occlusive crisis was a common reason for seeking this care (61%) and was commonly located in the chest or back (81%). We also observed that patients were hypoxic (53%), tachypneic (29%), had a history of asthma (39%) or ACS (80%), and presented during the winter months (38%). CONCLUSIONS: These data suggest that nearly one third of patients who develop ACS seek care for a prodromal illness. Further research is needed to confirm and better define an ACS prodromal illness that may help to identify patients at high risk for developing ACS.

Early diagnosis of paroxysmal sympathetic hyperactivity in the ICU.

BACKGROUND: Paroxysmal sympathetic hyperactivity (PSH) is a complication of acquired brain injury manifesting with episodic tachycardia, tachypnea, hypertension, diaphoresis, hypertonia, and posturing. No universally accepted diagnostic criteria exist and diagnosis is often delayed until the rehabilitation phase. METHODS: Electronic records were screened to identify consecutive cases of PSH diagnosed in an intensive care unit (ICU) between 1/2006 and 8/2012 and assess the validity of early clinical diagnosis against formal diagnostic criteria. Data collected included patient demographics, brain injury etiology, symptoms noted by the clinician to support the diagnosis of PSH, PSH manifestations, therapeutic interventions, relevant brain imaging, and investigations to exclude alternative diagnoses. An operational set of diagnostic criteria based on previous literature was used for comparison. RESULTS: Fifty-three consecutive patients with PSH were identified. Mean age was 33.6 ± 14.5 years (range 16-67). Traumatic brain injury was the most common etiology (30 patients, 56.6 %) but causes were diverse. Mean time to diagnosis was 8.3 ± 11.0 days; 31 patients (59 %) were diagnosed within 7 days and 20 patients (38 %) within 3 days of admission. Tachycardia was almost uniformly present, and diaphoresis, fever, hypertension, and tachypnea were also present in most cases. Dystonia and posturing were present in less than half of patients. 89 % of clinically diagnosed cases met formal diagnostic criteria. CONCLUSIONS: Paroxysmal sympathetic hyperactivity can be diagnosed early in the ICU. Strict diagnostic criteria supported the clinician's diagnosis in the majority of cases. Diagnosis should not be rejected because of any particular sign's absence, especially dystonia and posturing.

Impact of late preterm birth on neonatal intensive care resources in a tertiary perinatal center.

OBJECTIVE: To examine delivery indications, short-term morbidities, and use of resources for late preterm infants admitted to the neonatal intensive care unit (NICU) at a tertiary perinatal center. STUDY DESIGN: Data for 1137 inborn infants 340/7 to 366/7 weeks' gestational age discharged between July 2004 and December 2009 were collected from an electronic NICU database. Birth information was obtained from maternal charts. RESULTS: Forty-two percent of late preterm infants were admitted to the NICU. Their mean ( ± standard deviation) birth weight was 2347 ± 569 g; 15.1% were small for gestational age, 35.5% were multiples, and 17.8% had an antenatally diagnosed anomaly. Most births (52%) occurred following spontaneous rupture of membranes or labor. Cesarean section rate was 56.8%. Mortality rate was 1.2%. Most frequent morbidities were transient tachypnea (18.8%), cardiac or other congenital anomaly (16.8%), and respiratory distress syndrome (7.4%). Although 41.5% received ventilatory support, duration was short (1.1 ± 3.1 days). Mean length of NICU stay was 8.1 ± 9.3 days with 38% transferred to community hospitals before discharge. CONCLUSION: For many late preterm infants admitted to the NICU, the duration of intensive therapy was short and some required no interventions. One impact of late preterm birth was bed occupancy.

Emergency department crowding and younger age are associated with delayed corticosteroid administration to children with acute asthma.

OBJECTIVE: This study aimed to identify factors associated with delayed or omission of indicated steroids for children seen in the emergency department (ED) for moderate-to-severe asthma exacerbation. METHODS: This was a retrospective study of pediatric (age ≤ 21 years) patients treated in a general academic ED from January 2006 to September 2011 with a primary diagnosis of asthma (International Classification of Diseases, Ninth Revision code 493.xx) and moderate-to-severe exacerbations. A moderate-to-severe exacerbation was defined as requiring 2 or more (or continuous) bronchodilators. We determined the proportion of visits in which steroids were inappropriately omitted or delayed (>1 hour from arrival). Multivariable logistic regression models were used to identify patient, physician, and system factors associated with delayed or omitted steroids. RESULTS: Of 1333 pediatric asthma ED visits, 817 were for moderate-to-severe exacerbation; 645 (79%) received steroids. Patients younger than 6 years (odds ratio [OR], 2.25; 95% confidence interval [CI], 1.19-4.24), requiring more bronchodilators (OR, 2.82; 95% CI, 2.10-3.79), initially hypoxic (OR, 2.78; 95% CI, 1.33-5.83), or tachypneic (OR, 1.52; 95% CI, 1.05-2.20) were more likely to receive steroids. Median time to steroid administration was 108 minutes (interquartile range, 65-164 minutes). Steroid administration was delayed in 502 visits (78%). Patients with hypoxia (OR, 1.91; 95% CI, 1.11-3.27) or tachypnea (OR, 1.82; 95% CI, 1.17-2.84) were more likely to receive steroids 1 hour or less of arrival, whereas children younger than 2 years (OR, 0.16; 95% CI, 0.07-0.35) and those arriving during periods of higher ED volume (OR, 0.79; 95% CI, 0.67-0.94) were less likely to receive timely steroids. CONCLUSIONS: In this ED, steroids were underprescribed and frequently delayed for pediatric ED patients with moderate-to-severe asthma exacerbation. Greater ED volume and younger age are associated with delays. Interventions are needed to expedite steroid administration, improving adherence to National Institutes of Health asthma guidelines.

Two isolated giant gastric duplication cysts in thorax in a newborn.

We report a case of a newborn with severe respiratory distress since birth with two giant intrathoracic and separate eneteric duplication cysts in right hemithorax. On day 19, the intrathoracic cysts were removed, and the baby was discharged on his 22nd day of life. Histologic findings confirmed the diagnosis of a gastric duplication cyst. This report is the first case of two isolated, separated and giant right intrathoracic gastric duplication cysts in literature. The diagnostic values of radiological evaluation and surgical and pathological management for precise diagnosis are discussed.