Orbital infantile haemangioma: radiological features and treatment - case series and literature review.

AIM: The aim of this study is to report a retrospective case series on orbital infantile haemangiomas (OIH). Radiological features and treatment with oral propranolol (OP) are illustrated along with an updated literature review. METHODS: A retrospective chart review of six children, diagnosed with OIH from November 2015 to October 2016, was carried out. Only children with deep documented orbital involvement were included. All patients underwent magnetic resonance imaging (MRI) under general anaesthesia. OP was administered to the infants according to the Nottingham Children's Hospital guideline. As per the guideline, a preliminary paediatric assessment was performed and a 1 mg/kg test dose was administered, followed by definitive treatment at a dosage of 2 mg/kg in three divided doses. RESULTS: Average age at presentation was within the first 3 weeks of life. T1 hypointensity, T2 hyperintensity, avid enhancement with contrast, and the presence of flow-voids appear a fixed pattern of OIH on MRI. Response to treatment was noticed within 4 weeks in all children, and two of them (33.3%) responded within the first 7 days. In two children (33.3%), the haemangioma became clinically undetectable by the seventh month of treatment, while the other four (66.6%) experienced an almost complete regression of the OIH by the last follow-up. No complications were found. CONCLUSIONS: Our series strengthens the understanding that MRI is the preferred imaging modality in the investigation of OIH, showing vascular features, detailed orbital extension, and possible associated malformations. OP is the treatment of choice for OIH, and our study confirms its safety and effectiveness.

Genomic Investigations unmask Mycoplasma amphoriforme, a new respiratory pathogen.

BACKGROUND: Mycoplasma amphoriforme has been associated with infection in patients with primary antibody deficiency (PAD). Little is known about the natural history of infection with this organism and its ability to be transmitted in the community. METHODS: The bacterial load was estimated in sequential sputum samples from 9 patients by quantitative polymerase chain reaction. The genomes of all available isolates, originating from patients in the United Kingdom, France, and Tunisia, were sequenced along with the type strain. Genomic data were assembled and annotated, and a high-resolution phylogenetic tree was constructed. RESULTS: By using high-resolution whole-genome sequencing (WGS) data, we show that patients can be chronically infected with M. amphoriforme manifesting as a relapsing-remitting bacterial load, interspersed by periods when the organism is undetectable. Importantly, we demonstrate transmission of strains within a clinical environment. Antibiotic resistance mutations accumulate in isolates taken from patients who received multiple courses of antibiotics. CONCLUSIONS: Mycoplasma amphoriforme isolates form a closely related species responsible for a chronic relapsing and remitting infection in PAD patients in the United Kingdom and from immunocompetent patients in other countries. We provide strong evidence of transmission between patients attending the same clinic, suggesting that screening and isolation may be necessary for susceptible patients. This work demonstrates the critical role that WGS can play in rapidly unraveling the biology of a novel pathogen.

Why don't intensive care nurses perform routine delirium assessment? A discussion of the literature.

Delirium is a well recognised and serious problem in adult intensive care patients. With a reported incidence as high as 87%, it has been associated with increased length of stay, higher costs of care, ongoing cognitive impairment and increased mortality rates. The problem is so significant that routine, formal delirium assessment is recommended for all intensive care patients. However, there is evidence to suggest that few intensive care nurses are incorporating this screening into their daily practice. The aim of this paper is to discuss what is currently known about intensive care nurses' attitudes and beliefs in relation to caring for adults who are experiencing delirium, with a focus on identifying possible barriers to formal delirium assessment. It will be argued that intensive care nurses are well placed to perform regular delirium assessment and therefore have a responsibility to promote an improvement in delirium assessment practices.

Can a reduction in extracellular fluid volume result in increased serum albumin in peritoneal dialysis patients?

Serum albumin predicts survival in end-stage renal failure. The literature has emphasized the dependence of albumin on inflammation. We previously proposed an independent relationship with overhydration. To date, there is no proven therapy that increases serum albumin in dialysis patients. We investigated whether decreasing dry weight increases serum albumin in peritoneal dialysis patients. Twenty-one subjects (15 continuous ambulatory peritoneal dialysis patients and 6 continuous cycled peritoneal dialysis patients) were assessed at 0 and 4 weeks. Body weight, blood pressure, 4-site skin-fold thickness, subjective global assessment score, and use of antihypertensive medication were recorded. Fluid samples were collected for estimation of serum albumin, C-reactive protein, and 24-hour dialysate and urine volume. The extracellular fluid volume was estimated by multiple-frequency bioelectric impedance. Between the 0- and 4-week assessments, dialysis prescription was altered to increase the daily ultrafiltrate volume (1.00 +/- 0.71 L to 1.29 +/- 0.75 L; P = 0.04). Significant decreases were seen in body weight (70.7 +/- 12.1 kg to 69.9 +/- 12.2 kg; P = 0.0002), extracellular fluid volume (16.2 +/- 3.3 L to 15.5 +/- 3.2 L; P = 0.0006), systolic blood pressure (147.7 +/- 26.3 mm Hg to 124.2 +/- 20.9 mm Hg; P < 0.0001), diastolic blood pressure (84.2 +/- 14.5 mm Hg to 76.6 +/- 11.7 mm Hg; P = 0.01), and number of antihypertensive drugs (1.9 +/- 1.0 to 1.6 +/- 1.1; P = 0.02). Serum albumin increased (34.6 +/- 4.1 g/L to 35.9 +/- 3.6 g/L; P = 0.01). C-reactive protein did not change. Decreasing dry weight in peritoneal dialysis by an increase in ultrafiltration volume results in a decreased extracellular fluid volume, which is reflected by an improvement in blood pressure control. This improvement in blood pressure was associated with an increase in serum albumin. This finding strengthens the argument that overhydration is a cause of hypoalbuminemia in peritoneal dialysis and offers a therapeutic option in management of this patient group.

Is subjective global assessment a reliable measure of nutritional status in hemodialysis?

OBJECTIVE: Subjective global assessment (SGA) is recommended in US and European guidelines for the nutritional assessment of patients with end-stage renal failure (ESRF). SGA identifies patient groups with abnormal nutritional parameters, but may fail to identify patients with malnutrition as identified by other techniques, such as total body nitrogen. We sought to compare SGA with a composite nutritional score. METHODS: HD patients were assessed by SGA, anthropometry, 3-day food diary, serum albumin, Kt/V urea, and normalized protein catabolic rate (nPCR). A composite nutritional score was derived from SGA, body mass index, percent of reference weight, triceps skinfold, midarm muscle circumference, and serum albumin. RESULTS: In 72 HD patients an abnormal SGA identified a patient group with reduced midarm circumference, midarm muscle circumference and serum creatinine and an increased composite nutritional score. However, overlap of nutritional scores was considerable between the normal and abnormal SGA groups, suggesting that SGA misclassified a large number of subjects. Serum albumin correlated with C-reactive protein (r = -0.473, P <.0001), not nutritional status. The composite nutritional score correlated with all of its components except for serum albumin. CONCLUSIONS: SGA may not reliably identify hemodialysis patients with abnormal nutrition. Serum albumin is related to inflammation and not to nutrition status.