Diverticulitis in the young.

BACKGROUND: Colonic diverticulitis is relatively uncommon in young patients, especially those younger than 40 years. We compared demographic data, clinical presentation, management, and clinical course of diverticulitis in patients ≤40 years old compared with patients >40 years old. METHODS: This study included all patients who presented to the emergency department with a diagnosis of diverticulitis between October 1, 2009 and September 30, 2010. Patients were divided into 2 groups: group 1 (≤40 years old) and group 2 (>40 years old). Demographic characteristics, clinical presentation and management, and short-term outcomes were compared. RESULTS: Ninety-four patients were included in the study (37 patients in group 1 and 57 patients in group 2). A higher percentage of obese and Hispanic men was found in group 1 (P > .05). The rate of discharge from the emergency department was significantly higher in group 1 (56.8% in group 1 vs 7.0% in group 2, P < .01). Group 2 patients had a shorter median length of stay than group 1 patients (3.1 vs 5.7 days, P = .16). There were no differences in vital signs, laboratory data (including complete blood count and basic metabolic panel), and in-hospital mortality rates between the 2 groups. CONCLUSIONS: This study demonstrates that young Hispanic men develop diverticulitis and that this diagnosis needs to be considered when they present to emergency rooms with abdominal symptoms. A longitudinal study is needed to determine the long-term outcomes in these patients and to investigate the pathogenesis.

Chiari syndrome and respiratory failure: a literature review.

BACKGROUND: Patients with failed extubation requiring reintubation have increased morbidity and mortality. This situation may reflect the severity of the underlying disorder or may reflect an undiagnosed condition that was not apparent at the time of the initial intubation. METHODS: Case report and literature review. RESULTS: A 49-year-old man developed acute hypercapneic respiratory failure during an episode of community-acquired pneumonia. This patient failed extubation 4 times. Routine neurological evaluation, including computed tomography of the head, was within normal limits. A magnetic resonance imaging revealed a severe Chiari malformation type I. The patient eventually required tracheostomy and prolonged mechanical ventilation. We identified 28 cases with Chiari malformations (CM) in the medical literature, who presented with respiratory failure. The mean age was 29.5 years, 46% of the cases were male, 50% had an associated syringomyelia, and 64% required a decompressive surgery. Twenty-five percent had recurrent symptoms postsurgery. CONCLUSIONS: Patients with CMs can have repeated extubation failures. Some of these patients have normal neurological examinations and studies and are not identified until they have an MRI study. Clinicians need to consider this possibility in patients who are difficult to wean.

The utilization of standardized order sets using AASLD guidelines for patients with suspected cirrhosis and acute gastrointestinal bleeding.

To improve the adherence to AASLD (American Association for the Study of Liver Diseases) guidelines for variceal bleeding, we developed and implemented standardized order sets for gastrointestinal bleeding in our hospital on October 1, 2009. We performed medical record reviews of hospitalized patients with gastrointestinal bleeding with suspected cirrhosis from October 2009 to October 2010 to determine the use of octreotide, prophylactic antibiotics, and endoscopy. We reviewed 300 Medical records and identified 26 patients with suspected cirrhosis and gastrointestinal bleeding who had adequate information to determine whether or not the order set was used. Antibiotic was used in 76% of patients, octreotide was used in 76% of patients, and upper endoscopy was completed in 94% of patients within 24 hours. The use of antibiotics was higher than that used in historical controls in our hospital. Implementation of standardized order sets appears to have improved adherence to standard recommendations. However, larger studies with longer follow-ups are needed to evaluate this effect on clinical outcomes and cost of care.

Progressive disseminated histoplasmosis in systemic lupus erythematosus-an unusual presentation of acute tenosynovitis and a literature review.

Progressive disseminated histoplasmosis is a disease where Histoplasma capsulatum affects multiple organs due to the inability of host cellular immunity to control the infection. Progressive disseminated histoplasmosis mainly involves the bone marrow, liver, and lungs. We report an unusual initial presentation of progressive disseminated histoplasmosis presenting as acute tenosynovitis in a systemic lupus erythematosus (SLE) patient. This report highlights the point that H. capsulatum may present as focal lesions and a high level of suspicion is needed to make the diagnosis, especially in SLE patients. We specifically reviewed reported cases of progressive disseminated histoplasmosis in SLE patients, and a review of the literature is presented.

Endoscopic ultrasound-guided versus conventional transmural techniques have comparable treatment outcomes in draining pancreatic pseudocysts.

We carried out the first meta-analysis comparing the technical success and clinical outcomes of endoscopic ultrasound-guided drainage (EUD) and conventional transmural drainage (CTD) for pancreatic pseudocysts. We searched PubMed, Embase, Scopus, and the Cochrane library to identify relevant prospective trials. The technical success rate, short-term (4-6 weeks) success, and long-term (at 6 months) success in symptoms and the radiologic resolution of pseudocysts, complication rates, and death rates were compared. Two eligible randomized-controlled trials and two prospective studies including 229 patients were retrieved. The technical success rate was significantly higher for EUD than for CTD [risk ratio (RR)=12.38, 95% confidence interval (CI): 1.39-110.22]. When CTD failed because of the nonbulging nature of pseudocysts, a crossover was carried out to EUD (n=18), which was successfully performed in all these cases. All patients with portal hypertension and bleeding tendency were subjected to EUD to avoid severe complications. EUD was not superior to CTD in terms of short-term success (RR=1.03, 95% CI: 0.95-1.11) or long-term success (RR=0.98, 95% CI: 0.76-1.25). The overall complications were similar in both groups (RR=0.98, 95% CI: 0.52-1.86). The most common complications were bleeding and infection. There were two deaths from bleeding after CTD. The short-term and long-term treatment success of both methods is comparable only if proper drainage modality is selected in specific clinical situations. For bulging pseudocysts, either EUD or CTD can be selected whereas EUD is the treatment of choice for nonbulging pseudocysts, portal hypertension, or coagulopathy.