A Rare Report of Infectious Emphysematous Aortitis Secondary to Clostridium septicum without Prior Vascular Intervention.

The term "mycotic aneurysm" was first used by Osler in 1882 to describe a mushroom-shaped aneurysm in subacute bacterial endocarditis. Mycotic aneurysms account for only 2.6% of all aneurysms of the aorta. Rarer still are anaerobic infections secondary to organisms such as Clostridium septicum, which results in emphysematous aortitis. The vast majority of emphysematous aortic infections occur as a result of instrumentation; however, in this case we present an infection de novo. A 75-year-old male presented with a 2-week history of progressive fatigue and chest pain that then developed into constitutional symptoms. Chest radiograph demonstrated an obvious widened mediastinum. CT angiogram of his chest then confirmed this finding as well as significant periaortic gas and focal outpouching. Numerous diverticuli with inflammatory changes consistent with diverticulitis was observed on CT abdomen. Blood cultures returned positive for Clostridium septicum. Definitive treatment was discussed including debridement and graft insertion; however, patient decided on conservative management and was discharged on intravenous antibiotics. Unfortunately, as in most cases of emphysematous aortitis that do not undergo surgical management, the patient succumbed to his illness. The lesson provided will be the epidemiology of emphysematous aortitis, presentation, diagnosis, management, and prognosis through a case report.

Operator dependent factors implicated in failure of non-invasive positive pressure ventilation (NIPPV) for respiratory failure.

BACKGROUND: Non-invasive Positive Pressure Ventilation (NIPPV) is employed for the management of acute respiratory failure and studies have shown that it can prevent the need for endotracheal intubation, mechanical ventilation and associated complications. Given limited studies evaluating the factors, other than those related patient or underlying disease severity, that may lead to NIPPV failure, we performed this study to gain insight into current practices in terms of utilization of NIPPV and operator dependent factors that may possibly contribute to failure of NIPPV. METHOD: After institutional board review approval a retrospective chart review was performed of consecutive patients who were initiated on and failed NIPPV between January 2009 and December 2009. Data was recorded regarding baseline demographics, admission diagnosis, indications for NIPPV, presence of contraindications, type of NIPPV and initial settings, ABG analysis before and after initiation, whether a titration of the settings was performed or not, operator related factors that may have contributed to failure of NIPPV and clinical outcomes. RESULTS: Among 1095 patients screened, 111 failed NIPPV. The mean age was 60 years with 59% males. The most frequent indication for initiating NIPPV was COPD exacerbation (N = 27) followed by pneumonia (N = 26). CPAP was used in 5(6%) patients. Median inspiratory positive airway pressure (IPAP) and expiratory positive airway pressure (EPAP) setting were 10 and 5 cm of H2 O respectively. Three most common reasons for failure were an inappropriate indication (33%), Progression of underlying disease (30%) and lack of titration (23%). Overall mortality was 22%. Mortality was higher when NIPPV failure was seen among patients with an inappropriate indication or an overlooked contraindication compared to those with an appropriate indication (27% vs 17%). CONCLUSIONS: Excluding progression of underlying disease, operator dependent factors linked to NIPPV failure are; inappropriate indication, lack of adequate titration and an overlooked contraindication. Inappropriate utilization of NIPPV in respiratory failure is associated with higher mortality.

An unusual case of postpartum dyspnea.

A 40-year-old South Asian woman was admitted in active labor at 38 weeks' gestation. She had an unremarkable medical history with routine prenatal care, negative HIV testing results, and an uneventful pregnancy. She received a Bacillus Calmette-Guérin vaccine during childhood and reportedly had a subsequent positive purified protein-derivative test result 1 year prior to conception. She never smoked and had seven normal term pregnancies.

Predictors of repeat visits to the emergency room by asthmatic children in primary care.

BACKGROUND: Subsets of asthmatic children, particularly in the Caribbean, burden the health system through repeated emergency room (ER) visits. We examined children to determine predictors of repeated ER visits in Trinidad. METHODS: Caregivers of 300 asthmatic children in primary healthcare in Trinidad reported on perceived factors of exacerbated wheeze requiring ER services. RESULTS: Prevalence of ER utilization in the past 12 months was 59.7% and 40.3% for repeated visits. Average age of wheezing onset was 2.8 (SD = 2.5) years. From the logistic regression analyses, independent predictors of repeat ER visits were mothers with a history of asthma (OR = 2.0, 95%Cl = 1.0-4.0), exposure to perfumes/odors (OR = 2.4, 95% Cl = 1.4-4.2), using inhaled corticosteroids (ICS) (OR = 2.2, 95% Cl = 1.2-4.0), and young age group (1-5 vs. 13-16 years) (OR = 2.7, 95% Cl = 1.1-6.4). More 1-5 year-olds (63.8%) and 6-12-year-olds (60.2%) wheezed in the dry and wet seasons, respectively (p = 0.04). Follow-up was poor (32.3%), and disease management did not include educational interventions. CONCLUSIONS: Repeated ER use in pediatric asthma underscores a pressing need for health providers and caregivers to develop an asthma management plan noting the identified predictors to assist in reducing Trinidad's asthma burden.