Dangerous dog licks! - A rare case of epidural abscess secondary to Capnocytophaga.

We present a rare case of a 71-year-old female. She has a history of irritable bowel syndrome that is diet controlled. However she presented to the emergency department (ED) with a history of diarrhea, weakness, chills and right lower back pain for two days. She was found to have epidural abscesses secondary to Capnocytophaga bacteremia. To date, there has been only one case report of a sacral abscess secondary to Capnocytophaga sp. Capnocytophaga is a genus of facultative anaerobic gram-negative bacilli that are frequent commensals in the oral cavity of cats and dogs. It can be transmitted by bites, scratches or contact of saliva with exposed mucosa or skin. It is a rare but potentially fatal infection, that is known to cause severe septicemia and shock, especially in patients with splenectomy. Our case is a unique presentation of sepsis and epidural abscesses in an immunocompetent host due to Capnocytophaga. Given the slow growing and fastidious nature of the organism, it requires a high suspicion in a patient presenting with slow growing gram-negative rod bacteremia and diligent following of cultures and sensitivities to ensure correct antibiotic coverage.

Guideline-Directed Medical Therapy in Patients with Chronic Kidney Disease Undergoing Peripheral Vascular Intervention.

INTRODUCTION: Guideline-directed medical therapy (GDMT) is imperative to improve cardiovascular and limb outcomes for patients with critical limb ischemia (CLI), especially amongst those at highest risk for poor outcomes, including those with comorbid chronic kidney disease (CKD). Our objective was to examine GDMT prescription rates and their variation across individual sites for patients with CLI undergoing peripheral vascular interventions (PVIs), by their comorbid CKD status. METHODS: Patients with CLI who underwent PVI (October 2016-April 2019) were included from the Vascular Quality Initiative (VQI) database. CKD was defined as GFR <60 mL/min/1.73 m2. GDMT included the composite use of antiplatelet therapy and a statin, as well as an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker if hypertension was present. The use of GDMT before and after the index procedure was summarized in those with and without CKD. Adjusted median odds ratios (MORs) for site variability were calculated. RESULTS: The study included 28,652 patients, with a mean age of 69.4 ± 11.7 years, and 40.8% were females. A total of 47.5% had CKD. Patients with CKD versus those without CKD had lower prescription rates both before (31.7% vs. 38.9%) and after (36.5% vs. 48.8%) PVI (p < 0.0001). Significant site variability was observed in the delivery of GDMT in both the non-CKD and CKD groups before and after PVI (adjusted MORs: 1.31-1.41). DISCUSSION/CONCLUSION: In patients with CLI undergoing PVI, patients with comorbid CKD were less likely to receive GDMT. Significant variability of GDMT was observed across sites. These findings indicate that significant improvements must be made in the medical management of patients with CLI, particularly in patients at high risk for poor clinical outcomes.

Expansión maxilar rápida para pacientes pediátricos con síndrome de apnea obstructiva del sueño / Rapid maxillary expansion in pediatric patients with obstructive sleep apnea syndrome

RESUMEN: Introducción: El síndrome de apnea obstructiva del sueño (SAOS) es un trastorno respiratorio del sueño frecuente, caracterizado por episodios de obstrucción parcial o total de las vías respiratorias durante el sueño. La expansión maxilar rápida se ha propuesto como un posible tratamiento de esta patología en niños ya que su uso aumentaría el volumen de la vía aérea superior. Sin embargo, su uso para el tratamiento de apnea obstructiva del sueño es controvertido. Métodos: Realizamos una búsqueda en Epistemonikos, la mayor base de datos de revisiones sistemáticas en salud, la cual es mantenida mediante el cribado de múltiples fuentes de información, incluyendo MEDLINE, EMBASE, Cochrane, entre otras. Extrajimos los datos desde las revisiones identificadas, analizamos los datos de los estudios primarios, realizamos un metanálisis y preparamos una tabla de resumen de los resultados utilizando el método GRADE. Resultados y conclusiones: Identificamos seis revisiones sistemáticas que en conjunto incluyeron 23 estudios primarios. Concluimos que no es posible establecer con claridad el efecto del uso de la expansión maxilar sobre el índice de apnea-hipoapnea, eficiencia y tiempo del sueño, y microdespertares por causa respiratoria, debido a que la certeza de la evidencia existente ha sido evaluada como muy baja. No se encontraron estudios que evaluaran los efectos adversos ni la somnolencia diurna de los pacientes sometidos a expansión maxilar.

ABSTRACT: Introduction: Obstructive sleep apnea (OSA) is a frequent sleep disorder characterized by recurrent episodes of complete or partial obstruction of the upper airway during sleep. Since rapid maxillary expansion increases the volume of the upper airway, it has been proposed as a treatment option for OSA in children. However, its use is controversial. Methods: We searched in Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies, conducted a meta-analysis and generated a summary of findings table using the GRADE approach. Results and conclusions: We identified six systematic reviews including 23 studies overall. We are uncertain whether rapid maxillary expansion reduces apnea-hypopnea index and micro-awakenings, or improves sleep efficiency and total sleep time as the certainty of the evidence has been assessed as very low. No studies were found that looked at adverse effects or daytime sleepiness.

Clinical practice guidelines: Oral health care for children and adults living with epidermolysis bullosa.

BACKGROUND: Inherited epidermolysis bullosa (EB) is a genetic disorder characterized by skin fragility and unique oral features. AIMS: To provide (a) a complete review of the oral manifestations in those living with each type of inherited EB, (b) the current best practices for managing oral health care of people living with EB, (c) the current best practices on dental implant-based oral rehabilitation for patients with recessive dystrophic EB (RDEB), and (d) the current best practice for managing local anesthesia, principles of sedation, and general anesthesia for children and adults with EB undergoing dental treatment. METHODS: Systematic literature search, panel discussion including clinical experts and patient representatives from different centers around the world, external review, and guideline piloting. RESULTS: This article has been divided into five chapters: (i) general information on EB for the oral health care professional, (ii) systematic literature review on the oral manifestations of EB, (iii) oral health care and dental treatment for children and adults living with EB-clinical practice guidelines, (iv) dental implants in patients with RDEB-clinical practice guidelines, and (v) sedation and anesthesia for adults and children with EB undergoing dental treatment-clinical practice guidelines. Each chapter provides recommendations on the management of the different clinical procedures within dental practice, highlighting the importance of patient-clinician partnership, impact on quality of life, and the importance of follow-up appointments. Guidance on the use on nonadhesive wound care products and emollients to reduce friction during patient care is provided. CONCLUSIONS: Oral soft and hard tissue manifestations of inherited EB have unique patterns of involvement associated with each subtype of the condition. Understanding each subtype individually will help the professionals plan long-term treatment approaches.

Differentiating spontaneous echo contrast, sludge, and thrombus in the left atrial appendage: Can ultrasound enhancing agents help?

The accurate identification of thrombus in the left atrial appendage with transesophageal echocardiogram (TEE) in patients with atrial fibrillation (AF) before cardioversion is essential. Most of these patients have some grade of spontaneous echo contrast (SEC). Severe SEC is often called "sludge," and its prognosis and treatment are still controversial. Current guidelines suggest the use of ultrasound enhancing agents (UEAs) when significant SEC is present. However, little is known about the utility of the UEAs in the differentiation between sludge and less severe SEC.

Neurodevelopment of 24 children born in Brazil with congenital Zika syndrome in 2015: a case series study.

OBJECTIVE: To describe the neurodevelopment of children with congenital Zika syndrome during the second year of life. DESIGN: Case series study. SETTING: Instituto de Medicina Integral Professor Fernando Figueira (IMIP), Pernambuco, Brazil. PARTICIPANTS: 24 children with congenital Zika syndrome born with microcephaly during the Zika outbreak in Brazil in 2015 and followed up at the IMIP during their second year of life. MAIN OUTCOME MEASURE: Denver Developmental Screening Test II, head circumference and clinical neurological examination. RESULTS: All children presented neurodevelopmental delay: for an average chronological age of 19.9 months, language was equivalent to that of age 2.1 months, gross motor 2.7 months, fine motor/adaptive 3.1 months and personal/social 3.4 months. Head circumference remained below the third percentile for age and gender, and growth rate up to the second year of life was 10.3 cm (expected growth 13 cm). Muscle tone was increased in 23 (95.5%) of 24 children, musculotendinous reflexes were increased in the whole sample and clonus was present in 18 (77.3%) of 24 children. All children except one had epilepsy. CONCLUSION: Children born with microcephaly associated with congenital Zika virus have a significant neurodevelopmental delay.

Epileptic seizures in children with congenital Zika virus syndrome / Crises epilépticas em crianças com síndrome congênita do Zika vírus

Abstract Objectives: to describe preliminary data referred to epileptic seizures and the probability of occurring these epileptic seizures in the infants' first months of life with congenital Zika virus (ZIKV) syndrome. Methods: concurrent cohort study including newborns and infants with congenital Zika virus syndrome attended at the specialized outpatient clinic at IMIP, Recife, Pernambuco, from October 2015 to May 2016. Results: data on 106 infants were analyzed with confirmed or suspected association to ZIKV infection. Forty children (38.7%) presented an epileptic seizure, classified at 43.3% of the cases as being spasms, 22.7% as generalized tonic seizures, 20.5% as partial and 4.5% other types of seizures. The median of days until the first report on the occurrence of epileptic seizure was 192 days of life. Conclusions: children with congenital Zika virus syndrome presented a high incidence of epileptic seizures before the end of the first semester of life, and spasm was the epileptic seizure mostly observed.

Resumo Objetivos: descrever dados preliminares referentes às crises epilépticas e à probabilidade de ocorrência dessas crises nos primeiros meses de vida em crianças com síndrome congênita do Zika vírus (ZIKV). Métodos: estudo de coorte concorrente incluindo recém-nascidos e lactentes com síndrome congênita do Zika vírus, atendidos no ambulatório especializado do IMIP, Recife, Pernambuco durante o período de outubro 2015 a maio 2016. Resultados: foram analisados dados de 106 lactentes com diagnóstico confirmado ou provável associação da infecção pelo ZIKV. Quarenta crianças (38,7%) apresentaram crise epiléptica, classificada em 43,3% dos casos como sendo espasmo, 22,7% como crise generalizada tônica, 20,5% parcial e 4,5% crises epilépticas de outros tipos. A mediana dos dias até o primeiro relato de ocorrência de crise epiléptica foi 192 dias de vida. Conclusões: crianças com síndrome congênita do Zika vírus apresentaram elevada incidência de crises epilépticas de aparecimento precoce, antes do final do primeiro semestre de vida, sendo o espasmo o tipo de crise mais observado.