Bradycardia Without Hypertension: Is It a Common Clinical Presentation of Ventriculoperitoneal Shunt Malfunction in Pediatric Patients?

BACKGROUND: Mechanical shunting of cerebrospinal fluid is an effective treatment for hydrocephalus. Some studies suggest that bradycardia without hypertension may also be observed in ventriculoperitoneal (VP) shunt malfunction; however, in our experience, this is not a common presenting sign. OBJECTIVE: The aim of this study was to evaluate whether bradycardia without hypertension was a common sign in patients presenting to the pediatric emergency department (ED) with a VP shunt malfunction. METHODS: A retrospective observational study, from May 2006 to April 2015, which included a random sample of children admitted to the ED with clinical features suggestive of possible VP shunt malfunction. Control patients were defined as those who arrived at our ED with suspected VP shunt malfunction that was later ruled out on further workup. RESULTS: A total of 65 patients were included in this study. A significantly greater number of patients with a confirmed shunt pathology presented with vomiting (P = 0.01) and lethargy/apathy (P = 0.01). In the control group, a significantly greater number of patients presented with fever (P = 0.004) and seizures (P = 0.02). The number of patients presenting with bradycardia was not significantly different between the shunt pathology and control groups (P > 0.05). CONCLUSIONS: Bradycardia is not a common presentation in patients with VP shunt malfunction. Bradycardia is often recognized as a significant sign; however, it is one of the last presenting signs. Educating patients about the early signs must be considered as part of the treatment for VP shunt malfunction.

Axillary-iliac bypass to protect a transplanted kidney during abdominal aortic aneurysm repair: case report.

Abdominal aortic aneurysms (AAA) are the most common type, even when compared to those involving other segments of the aorta. The prevalence and natural history of arterial aneurysms in abdominal organ transplant recipients remain uncertain. We report a case of abdominal aortic aneurysm in a kidney transplant patient with contrast allergy. Conventional abdominal aortic aneurysm repair was performed, constructing a bi-iliac aortic bypass. A temporary bypass was constructed from the right axillary artery to the right common iliac artery to maintain the renal graft. The patient was transferred to the intensive care unit, where he remained hemodynamically stable, and he was discharged on the 2nd postoperative day. Conventional open surgery with temporary extra-anatomic bypass is an alternative option for treatment of AAA in patients with transplanted kidneys.

Peer-Reviewed Journal Publication of Abstracts Presented at an International Emergency Medicine Scientific Meeting: Outcomes and Comparison With the Previous Meeting.

Scientific presentations at professional organization meetings have long been recognized as a method of providing up-to-date and novel information to both the medical and scientific community. After abstract presentation at a medical conference, the subsequent publication rate of full-text articles is variable, and few studies have examined this topic with respect to international emergency medicine conferences. This study's goals were to determine the publication rate of articles resulting from abstracts presented at the 12th International Conference on Emergency Medicine 2008 in San Francisco, Calif, and to compare this with data from the previous International Conference on Emergency Medicine 2006 conference in Halifax, Nova Scotia, Canada. We found a reduction in publication rate from 33.2% in 2006 to 22.8% in 2008 and that the host country furnished a greater proportion of the abstracts. It would be interesting to examine how these potential trends played out over more extended periods.

Unintentional oral beta agonist overdose: case report and review of the literature.

An 18-month-old male infant with oral albuterol intoxication was admitted to our pediatric emergency medicine unit with agitation, moderate hypokalemia (2.36 mEq/L), and hyperglycemia (180 mg/dL). His initial electrocardiogram showed sinus tachycardia with a low-amplitude T waves. He was admitted for observation, intravenous hydration was started with added potassium, blood glucose levels were closely monitored along with serum potassium and magnesium, and serial electrocardiography was performed. It should be stressed that as an oral bronchodilator, albuterol does not improve symptoms of asthma, and it can lead to severe complications, which can be avoided when this drug is delivered by inhalation or by a metered dose inhaler.

The role of physical examination in establishing the diagnosis of pneumonia.

BACKGROUND: Community-acquired pneumonia (CAP) is an important cause of acute respiratory disease in ambulatory care settings. The objective of this study was to assess the accuracy of medical history and physical examination in diagnosing CAP. METHODS: Pediatric residents prospectively completed a questionnaire documenting patients' medical history and physical examination whenever a chest radiograph was ordered on patients 1 month to 16 years of age. Chest radiographs were read by a pediatric radiologist. RESULTS: Of 525 children participating in the study, 181 (34%) demonstrated findings of pneumonia. Thirty-four (19%) had no symptoms other than fever, and 51 (28%) had normal lung auscultation. Pediatric residents had the same interpretation in 85% of cases in which radiographic CAP was diagnosed by the radiologist, and in 76% of cases in which radiographic pneumonia was excluded by the radiologist. CONCLUSIONS: Results demonstrate the significant added value of chest radiography as an ancillary test for diagnosis of pneumonia in the emergency department setting.

Use of physostigmine for hallucinogenic plant poisoning in a teenager: case report and review of the literature.

The objective of this study was to utilize a case report to review the use of physostigmine for jimsonweed intoxication. A 15-year-old girl was found at school hallucinating and incoherent. Upon presentation to the emergency department, she was found to be tachycardic and confused with dilated pupils and dry, flushed, hot skin. She was admitted to our institution. Hallucinations and symptoms resolved after the use of physostigmine. She subsequently admitted to ingesting 'moonflower seeds,' which are derived from Jimsonweed (Datura stramonium). She was discharged when she got well. Jimsonweed is known to contain high concentrations of anticholinergic substances; hence, ingestion can result in the anticholinergic toxidrome. Signs and symptoms include hallucinations, tachycardia, dilated pupils, and disorientation. In our patient, the use of the physostigmine as an antidote resulted in a favorable outcome without any complications. Ingestion of the Datura species can result in severe toxicity. Each plant varies in the concentrations of alkaloid substances. For this reason, it is very important for individuals to become educated on the toxicities and potential risks associated with recreational use of these plants. The use of physostigmine can help in both the diagnosis and management of patients intoxicated with these substances.

Comparing human to electronic observers to monitor hand hygiene compliance in an intensive care unit.

Objective: We sought to determine whether an electronic hand hygiene (HH) system could monitor HH compliance at similar rates to direct human observation. Methods: This 4-year proof-of-concept study was conducted in an intensive care unit (ICU) of a private tertiary-care hospital in São Paulo, Brazil, where electronic HH systems were installed in 2 rooms. HH compliance was reported respectively using direct observation and electronic counter devices with an infrared system for detecting HH opportunities. Results: In phase 1, HH compliance by human observers was 56.3% (564 of 1,001 opportunities), while HH compliance detected by the electronic observer was 51.0% (515 of 1,010 opportunities). In phase 2, human observers registered 484 HH opportunities with a HH compliance rate of 64.7% (313 of 484) versus 70.6% (346 of 490) simultaneously detected by the electronic system. In addition, an enhanced HH electronic system monitored activity 24 hours per day and HH compliance without the presence of a human observer was 40.3% (10,642 of 26,421 opportunities), providing evidence for the Hawthorne effect. Conclusions: The electronic HH monitoring system had good correlation with human HH observation, but compliance was remarkably lower when human observers were not present due to the Hawthorne effect (25%-30% absolute difference). Electronic monitoring systems can replace direct observation and can markedly reduce the Hawthorne effect.

Comparison of two electronic hand hygiene systems using real-time feedback via wireless technology to improve hand hygiene compliance in an intensive care unit.

Background: Most hand hygiene (HH) intervention studies use a quasi-experimental design, are primarily uncontrolled before-and-after studies, or are controlled before-and-after studies with a nonequivalent control group. Well-funded studies with improved designs and HH interventions are needed. Objectives: To evaluate healthcare worker (HCW) HH compliance with alcohol-based hand rub (ABHR) through direct observation (human observer), 2 electronic technologies, a radio frequency identification (RFID) badge system, and an invasive device sensor. Methods: In our controlled experimental study, 2,269 observations were made over a 6-month period from July 1 to December 30, 2020, in a 4-bed intensive care unit. We compared HH compliance between a basic feedback loop system with RFID badges and an enhanced feedback loop system that utilized sensors on invasive devices. Results: Real-time feedback by wireless technology connected to a patient's invasive device (enhanced feedback loop) resulted in a significant increase in HH compliance (69.5% in the enhanced group vs 59.1% in the basic group; P = .0001). Conclusion: An enhanced feedback loop system connected to invasive devices, providing real-time alerts to HCWs, is effective in improving HH compliance.

Use of hypoglycemic drugs during lactation.

QUESTION: My patient was taking glipizide (an oral sulfonylurea) for type 2 diabetes. Now she is pregnant and taking insulin instead. She is very anxious to return to her previous treatment immediately after delivery because of the pain and hurdles associated with the administration of insulin. Can sulfonylureas cross into human milk and, if so, is it safe for her to breastfeed her infant? ANSWER: The exposure of infants to second-generation sulfonylureas (eg, glipizide, glyburide) through breast milk is expected to be minimal, based on the limited data available. Women with type 2 diabetes treated with sulfonylureas should not be discouraged from breastfeeding. The benefits of breastfeeding greatly outweigh the risks of these medications, if any. The baby should, however, be monitored for signs of hypoglycemia.

Pharmacologic treatment of hyperthyroidism during lactation.

QUESTION: I have a patient who has hyperthyroidism due to Graves disease. She was taking methimazole but discontinued when she found out she was pregnant. She is currently close to delivery and might require antithyroid therapy in the postpartum period. Can methimazole cross into human milk, and is breastfeeding safe for her infant? ANSWER: The exposure of infants to methimazole or propylthiouracil through breast milk is minimal and not clinically significant. Women with hyperthyroidism using methimazole or propylthiouracil should not be discouraged from breastfeeding, as the benefits of breastfeeding largely outweigh the theoretical minimal risks.

Methadone exposure during lactation.

QUESTION: One of my patients is currently using methadone for maintenance of opioid dependence. She wants to breastfeed. Is breastfeeding safe for her infant? ANSWER: The exposure of infants to methadone through their mothers' breast milk is minimal. Women using methadone for treatment of opioid dependence should not be discouraged from breastfeeding. The benefits of breastfeeding largely outweigh any theoretical minimal risks.

Osteoarthritis model induced by intra-articular monosodium iodoacetate in rats knee.

PURPOSE:: To evaluate the usefulness of a knee osteoarthritis model through functional, radiological and microscopic changes of the synovial membrane. METHODS:: Forty eight rats were divided randomly into two groups. The first received 0.9% saline in the joint and corresponded to the control group. The second was submitted to experimental osteoarthritis of the right knee induced by monosodium iodoacetate and corresponded to the osteoarthritis group. All animals were subjected to comparative tests of forced ambulation and joint movements, inability to articulate and tactile allodynia on day 1 post-experiment by forced ambulation (Roto-rod test), joint assessment of disability (weight bearing test) and assessment of tactile allodynia (Von Frey test). After inflammatory induction they were divided into four sub-groups corresponding to the scheduled death in 7, 14, 21 and 28 days when they were submitted to radiographic examination of the knee, arthrotomy and collection of the synovial membrane. RESULTS:: The osteoarthritis group showed significant differences compared to control group on days 7 and 14 in Roto-rod, in weight bearing and Von Frey tests in all days, and in radiological evaluation. Microscopic examination of the synovial membrane showed abnormalities of inflammatory character at all stages. CONCLUSION:: The osteoarthritis induced by intra-articular monosodium iodoacetate in rats knee is a good model to be used in related research, because it provides mensurable changes on joint movements, tactile allodynia, progressive radiological degeneration and microscopic inflammation of the synovial membrane, that represent markers for osteoarthritis evaluation.

Derivação axilo-ilíaco para proteção de rim transplantado durante a correção de aneurisma de aorta abdominal: relato de caso / Axillary-iliac bypass to protect a transplanted kidney during abdominal aortic aneurysm repair: case report

Resumo Os aneurismas de aorta abdominal (AAA) são os mais frequentes, mesmo quando comparados a outros segmentos da aorta. A prevalência e a história natural de aneurismas arteriais em receptores de transplante de órgão abdominal permanecem incertas. Relatamos a abordagem de um caso de aneurisma de aorta abdominal em um paciente transplantado renal e com alergia ao contraste. Foi realizado o tratamento convencional do aneurisma de aorta abdominal com um by-pass aorto bi-ilíaco. Para manutenção do enxerto renal, foi confeccionado um by-pass temporário da artéria axilar direita até a artéria ilíaca comum direita. O paciente foi encaminhado para a unidade de terapia intensiva, onde permaneceu estável hemodinamicamente e recebeu alta no 2º pós-operatório. A cirurgia convencional aberta com derivação extra-anatômica temporária é uma alternativa para o tratamento do AAA em pacientes com transplante renal.

Abstract Abdominal aortic aneurysms (AAA) are the most common type, even when compared to those involving other segments of the aorta. The prevalence and natural history of arterial aneurysms in abdominal organ transplant recipients remain uncertain. We report a case of abdominal aortic aneurysm in a kidney transplant patient with contrast allergy. Conventional abdominal aortic aneurysm repair was performed, constructing a bi-iliac aortic bypass. A temporary bypass was constructed from the right axillary artery to the right common iliac artery to maintain the renal graft. The patient was transferred to the intensive care unit, where he remained hemodynamically stable, and he was discharged on the 2nd postoperative day. Conventional open surgery with temporary extra-anatomic bypass is an alternative option for treatment of AAA in patients with transplanted kidneys.

Program for the epidemiological evaluation of stroke in Tandil, Argentina (PREVISTA) study: rationale and design.

The availability of population-based epidemiological data on the incident risk of stroke is very scarce in Argentina and other Latin American countries. In response to the priorities established by the World Health Organization and the United Nations, PREVISTA was envisaged as a population-based program to determine the risk of first-ever and recurrent stroke and transient ischemic attack incidence and mortality in Tandil, Buenos Aires, Argentina. The study will be conducted according to Standardized Tools for Stroke Surveillance (STEPS Stroke) methodology and will enroll all new (incident) and recurrent consecutive cases of stroke and transient ischemic attack in the City of Tandil between May 1st, 2013 and April 30, 2015. The study will include patients with ischemic stroke, non-traumatic primary intracerebral hemorrhage, subarachnoid hemorrhage, and transient ischemic attack. To ensure the inclusion of every cerebrovascular event during an observation period of two years, we will instrument an 'intensive screening program', consisting of a comprehensive daily tracking of every potential event of stroke or transient ischemic attack using multiple overlapping sources. Mortality would be determined during follow-up for every enrolled patient. Also, fatal community events would be screened daily through revision of death certificates at funeral homes and local offices of vital statistics. All causes of death will be adjudicated by an ad-hoc committee. The close population of Tandil is representative of a large proportion of Latin-American countries with low- and middle-income economies. The findings and conclusions of PREVISTA may provide data that could support future health policy decision-making in the region.

[Bacteriological study of bronchoalveolar lavage in the antibiotic management of suspected ventilator-associated pneumonia of patients in surgical intensive care units]. / Estudo bacteriológico do lavado broncoalveolar na gestão de antibióticos na pneumonia associada à ventilação mecânica de pacientes em unidades de terapia intensiva cirúrgica.

OBJECTIVE: To determine the correlation of Gram staining with the culture of bronchoalveolar lavage in patients with clinical features of ventilator-associated pneumonia from two adult trauma and surgical intensive care units. METHODS: We conducted a retrospective study of 252 samples of bronchoalveolar lavage from patients with clinical ventilator-associated pneumonia in trauma or surgical postoperative care. Gram staining samples were classified as Gram-positive cocci and Gram-negative bacilli, all other results being excluded. Cultures from bronchoalveolar lavage were compared with Gram staining results. RESULTS: The correlation between Gram staining and culture from the bronchoalveolar lavage showed a kappa index of 0.27. The sensitivity of Gram staining was 53.9% and the specificity, 80.6%. Considering the identification of Gram-positive cocci against other results (negative and Gram-negative bacilli), the negative predictive value was 94.8%. The evaluation of Gram-negative bacilli against other results (negative and Gram-positive cocci) rendered a sensitivity of 27.1% and a specificity of 95.4%. CONCLUSION: It appears that the negative predictive value for Gram-positive cocci is acceptable, but the sensitivity of Gram staining in the etiology of ventilator-associated pneumonia was not able to identify the microorganism before culture.

Non-palpable breast lesions marked with coal suspension: evaluation of anatomopathological aspects, viability of interpretation and inflammatory response.

OBJECTIVE: To analyze the efficiency of labeling impalpable breast lesions with inert charcoal suspension; to evaluate the morphological alterations associated with its use and to determine whether the use of charcoal labeling hampers the diagnostic interpretation of the pathologist. METHODS: Was evaluated a total of 135 cases of impalpable breast lesions previously labeled with charcoal suspension. Histological H&E stained slides containing charcoal pigments were analyzed using optical microscopy, by which both quantitative and qualitative evaluations with regards to inflammatory response and interference in diagnosis were performed. Lymphocyte, giant cells and neutrophils were evaluated and quantified. Moreover, the distribution of the charcoal suspension present in the lesions was evaluated. RESULTS: As to the quantitative and qualitative evaluation of the inflammatory response caused by the use of charcoal labeling, granulomas were present in all samples regardless of the quantity of injected charcoal. Lymphocytic inflammatory response was absent in only 5.19% of the samples, 82.22% exhibited discrete intensity and 12.59% were moderate. With regards to acute inflammatory response, 42.96% showed total absence of neutrophilic exudate, whereas 42.22% contained discrete and 11.11% moderate neutrophilic exudate, and only 3.7% of cases had intense neutrophilic exudate. CONCLUSION: This study corroborates the utility and easiness of the charcoal method as a mean of efficient labeling of impalpable breast lesions; this technique is easy to use, has a low cost, high efficiency and does not interfere with the histological analysis. Moreover, it is comfortable for the patient and is of great help in finding and localizing the lesions for both the surgeon and pathologist.

Aplicação da citopatologia em meio líquido no diagnóstico diferencial das leveduras cervico/vaginais / Citopathology application in liquid medium in differential diagnosis of cervical/vaginal yeast

Objetivos: Analisar em preparados em base líquida a percentagem de diagnósticos de Candida sp., diferenciar e analisar a prevalência das espécies em relação à faixa etária das pacientes e verificar se há relação entre elas. Método: Foi realizado um estudo longitudinal retrospectivo de 174 amostras com diagnóstico de Candida sp. em material de citologia cérvico-vaginal colhidas em base líquida. Foi analisada a eficácia na detecção de Candida sp. através do método de citologia, dentre 5543 amostras realizadas. Resultados: Houve na amostra 176 (3,2%) diagnósticos de Candida sp., das 174 amostras 159 (91,4%) corresponderam a Candida albicans, 8 (4,6%) o Geotrichum candidum e 7 (4%) a Candida glabrata. Conclusão: A citologia detectou 3,2% de Candida sp, foi possível diagnosticar as espécies de Cândida em todos os casos estudados observando-se predomínio da Candida albicans (91,4%). Não houve relação entre a espécie de Candida sp. e a faixa etária das pacientes

Objectives: Annalise how prevalent each Candida sp. species is in different age groups and if there is any relation between age group and Candida sp. species. Methods: Retrospective longitudinal analysis of 174 liquid base exams with diagnosis of Candida sp. At the same time, the efficiency of liquid base method was evaluated, considering 5543 exams. Results: 176 (3,2%) cases of the total were diagnosed as Candida sp. It was possible to recognize Candida sp. species in Papanicolaou. In this study, a total of 174 liquid based smears were evaluated, 159 (91,4%) of this total were Candida albicans, 8 (4,6%) were diagnosed as Geotrichum candidum and 7 (4%) were Candida glabrata. Conclusion: The cytology detected 3,2% of Candida sp., it was also possible to differ Candida sp. species in all cases, observing a prevalence of Candida albicans (91,4%). It was not possible to relate Candida sp. species to patients' age group

Avaliação da capacidade funcional para atividades diárias dos pacientes tratados cirurgicamente das fraturas bicondilares de planalto tibial / Assessment of functional ability for daily activities of the surgically treated patients of tibial plateau fractures bicondylar

Objetivo: Analisar a capacidade funcional, durante as atividades de vida diária, de indivíduos que sofreram fraturas do planalto tibial e foram submetidos a tratamento cirúrgico. Métodos: Foram analisados os prontuários de 168 pacientes após essa análise preliminar os pacientes selecionados foram submetidos a aplicação do questionário ADLS (Activities of Daily Living Scale). Resultados: Dos 168 prontuários analisados, 44 atenderam aos critérios de inclusão, destes 16 responderam ao questionário, onde encontramos que 75% apresentaram resultado próximo ao normal. Conclusões: Concluímos que 12 dos indivíduos apresentaram capacidade funcional próximo ao normal, de acordo com a pontuação estabelecida pela escala utilizada

Objective: Analyze the functional capacity during daily life activities of individuals who experienced tibial plateau fractures and underwent surgery. Methods: 168 patient records were analyzed after this preliminary analysis the selected patients underwent application of ADLS questionnaire (Activities of Daily Living Scale). Results: Of the 168 records analyzed, 44 met the inclusion criteria, 16 of these responded to the questionnaire, which found that 75% had results close to normal. Conclusions: We concluded that 12 of the subjects had near-normal functional capacity, according to the scores established by the scale used

Perfil clínico-epidemiológico e evolução de pacientes com fratura diafisária de tíbia atendidos no Hospital Universitário Evangélico de Curitiba - HUEC / Clinical epidemiological profile and evolution of patients with fracture of tibia served diaphyseal in University Hospital Evangelic of Curitiba - HUEC

Objetivo: Descrever um perfil clínico-epidemiológico de pacientes com fratura de diáfise da tíbia. Metodologia: Estudo longitudinal, retrospectivo e descritivo, através da avaliação de prontuários de 72 pacientes atendidos no Hospital Universitário Evangélico de Curitiba no período de março de 2014 a abril de 2015. O acompanhamento da evolução clínica foi feito até a última alta ambulatorial. Resultados: Houve predomínio do sexo masculino, com 64 pacientes (88,89%), em relação ao sexo feminino, com 8 pacientes (11,11%). As fraturas fechadas ocorreram em 48 pacientes (66,67%), enquanto que as fraturas expostas foram observadas em 24 pacientes (33,33%). A maior incidência foi na faixa etária entre 21 e 40 anos, representando 41,67% dos pacientes. As principais causas de fratura foram por acidentes de trânsito, com 40 casos (55,56%), seguida de quedas, com 16 casos (22,22%). O tempo médio de consolidação da fratura foi de 19,95 semanas. As complicações mais comuns foram: infecção (35,56%), retardo de consolidação (22,22%) e pseudoartrose (20%). O tempo médio de acompanhamento ambulatorial foi de 6,5 meses. Conclusão: Foi possível confirmar a importância dos estudos epidemiológicos para a melhor caracterização dos pacientes com fratura diafisária de tíbia, sendo úteis para aprimorar a conduta terapêutica

Objective: describe a clinical and epidemiological profile of patients with tibial shaft fracture. Methods: A longitudinal, retrospective and descriptive study through epidemiological evaluation of the records of 72 patients treated at Hospital Universitário Evangélico de Curitiba from March 2014 to April 2015. The monitoring of clinical progress was made until the medical release. Results: There was a predominance of males, with 64 patients (88.89%) compared to females, with 8 patients (11.11%). The closed fractures occurred in 48 patients (66.67 %), while the exposed fractures was observed in 24 patients (33.33 %). The highest incidence was in the age group between 21 and 40 years representing 41.67% of the patients. The main fracture causes were due to traffic accidents, with 40 cases (55,56%), followed by falls, with 18 cases (22,22%). The average time of fracture healing was 19.95 weeks. The most common complications: infection (35.56 %), delayed consolidation (22.22%) and pseudoarthrosis (20%). The average time of outpatient follow-up was 6.5 months. Conclusion: It was possible to confirm the importance of epidemiological studies to better characterization of the patients with diaphyseal fractures of the tibia, being useful to guide the best therapeutic approach