Peripheral neuropathy of the extremity after hyperbaric exposure.

BACKGROUND: Neurological deficits occurring after diving or hyperbaric exposure are typically due to central nervous system decompression illness (DCI). However, consideration of alternate diagnoses is sometimes warranted. CASE REPORT: A 47-yr-old female hyperbaric technician developed foot drop 2 d following her last hyperbaric exposure. She had worked in chamber once daily at 45 fsw for 90 min. The breathing gas was air until the last 15 min, during which she breathed oxygen. Her history was complicated by a gastric bypass and weight loss totaling 160 pounds within the preceding 9 mo. She was treated for presumed neurological DCI without improvement. The adherence to safe hyperbaric protocols, delayed presentation, ongoing medical issues, and lack of response to therapy brought the diagnosis into question. Extensive neurological evaluation, including nerve conduction studies, revealed a common peroneal mononeuropathy. We concluded that her neuropathy was more likely due to extreme weight loss and malnutrition than peripheral nervous system DCI. DISCUSSION: There are rare reports of DCI affecting the peripheral nerves of the extremities. A literature search revealed only three such cases. Two further reports describe peripheral neuropathy in the extremities of divers that were attributed to other causes: compression by a weight belt and vasculitis. However, peroneal neuropathy is one of the most common focal mononeuropathies of the lower extremity and has been reported in association with extreme weight loss and malnutrition. We attributed our diver's neuropathy to extreme weight loss and malnutrition rather than DCI.

Course and Outcome of Children with Convulsive Status Epilepticus Admitted to a Pediatric Intensive Care Unit.

Introduction The objective of this study was to describe the course and the outcomes of children with convulsive status epilepticus and to evaluate the differences between two groups of children with new-onset seizures and known seizure disorders. Methods This is a retrospective, single-center study. Children with convulsive status epilepticus admitted to our tertiary care pediatric intensive care unit were included in the study. Medical records were reviewed to obtain the demographic- and seizure-related variables. Results Among 139 children with status epilepticus, 69.7% (n = 99) had a known seizure disorder. Focal seizures were present in 23.9% of children, and 34.6% required intubation; there was an overall mortality rate of 1.2%. The children with new-onset seizures were younger and received electroencephalography (EEG) and neuroimaging more often compared to children with known seizure disorders (p < 0.05). However, an abnormal EEG was more common among children with known seizure disorders (p < 0.001). Conclusions Sub-therapeutic anti-epileptic drugs levels were common among children with known seizure disorders presenting with status epilepticus. Gender, race, insurance status, type of seizures, intubation requirement, lengths of stay, and mortality were not significantly different between the two groups.

What Is the Utility of Routine Complete Blood Count, Liver Function Tests, and Chest X-ray in the Evaluation of Patients with Clinically Node-Negative Breast Cancer?

National Comprehensive Cancer Network guidelines suggest a selective workup of early-stage breast cancer with complete blood count (CBC) and liver function tests (LFTs) and no longer recommend chest X-ray (CXR) to screen for occult metastasis. We evaluated the utility of routine preoperative screening tests in patients with clinically node-negative (cN0) breast cancer. We identified 1611 patients with cN0 breast cancer treated at our institution between October 1998 and December 2015; 94.4 per cent of the patients underwent at least one preoperative screening test: 90.8 per cent CBC, 89.4 per cent LFTs, and 63.6 per cent CXR. Thirty-six per cent of CBCs, 13.1 per cent of LFTs, and 6.7 per cent of CXRs were abnormal. Abnormalities led to 17 CT scans, and one found an occult metastasis. Eleven patients (0.7%) were diagnosed with metastatic disease postoperatively, but only half had abnormal preoperative screening tests. Positive predictive values of preoperative CBC, LFTs, and CXR for occult metastasis are 1.3 per cent, 1.1 per cent, and 1.5 per cent, respectively. Preoperative screening in cN0 breast cancer is of low yield. Even when abnormalities are found, metastasis is present in less than 1 per cent of patients, and a normal study does not rule out metastasis. Routine preoperative determination is not warranted, and staging studies should be limited to patients with signs or symptoms.

Umbilical Negative Pressure Dressing for Transumbilical Appendectomy in Childern.

BACKGROUND AND OBJECTIVES: Transumbilical laparoscopic-assisted appendectomy (TULAA) carries a high risk for surgical site infection. We investigated the effect of a bio-occlusive umbilical vacuum dressing on wound infection rates after TULAA for patients with acute appendicitis and compared to it with a conventional 3-port appendectomy with a nonvacuum dressing. METHODS: This study was a retrospective chart review of 1377 patients (2-20 years) undergoing laparoscopic appendectomy for acute appendicitis in 2 tertiary care referral centers from January 2007 through December 2012. Twenty-two different operative technique/dressing variations were documented. The 6 technique/dressing groups with >50 patients were assessed, including a total of 1283 patients. RESULTS: The surgical site infection rate of the 220 patients treated with TULAA and application of an umbilical vacuum dressing with dry gauze is 1.8% (95% CI, 0.0-10.3%). This compares to an infection rate of 4.1% (95% CI, 1.3-10.5%) in 97 patients with dry dressing without vacuum. In the 395 patients who received an umbilical vacuum dressing with gauze and bacitracin, the surgical site infection rate was found to be 4.3% (95% CI, 2.7-6.8%). CONCLUSIONS: Application of an umbilical negative-pressure dressing with dry gauze lowers the rate of umbilical site infections in patients undergoing transumbilical laparoscopic-assisted appendectomy for acute appendicitis.