Effect of superior trunk block on diaphragm function and respiratory parameters after shoulder surgery

BackgroundThe interscalene brachial plexus block has been used effectively for intraoperative and postoperative analgesia in patients undergoing shoulder surgery, but it is associated with high rates of diaphragmatic dysfunction. Performing the block more distally, at the level of the superior trunk, may reduce the incidence of phrenic nerve palsy. We hypothesized that superior trunk block would result in diaphragmatic paralysis rate of less than 20%.Methods30 patients undergoing arthroscopic shoulder surgery received superior trunk block under ultrasound guidance. Measurements of diaphragm excursion were determined with ultrasound prior to the block, 15 min after the block, and postoperatively in phase II of postanesthesia care unit, in conjunction with clinical parameters of respiratory function.Results10 patients (33.3%, 95% CI 17.3% to 52.8%) developed complete hemidiaphragmatic paralysis at the postoperative assessment. An additional eight patients (26.7%) developed paresis without paralysis. Of the 18 patients with diaphragm effects, seven (38.9%) reported dyspnea. 83.3% of patients with abnormal diaphragm motion (56.7% of the total sample) had audibly reduced breath sounds on auscultation. Oxygen saturation measurements did not correlate with diaphragm effect and were not significantly reduced by the postoperative assessment.ConclusionAlthough injection of local anesthetic at the superior trunk level is associated with less diaphragmatic paralysis compared with traditional interscalene block, a significant portion of patients will continue to have ultrasonographic and clinical evidence of diaphragmatic weakness or paralysis.

Clinical and laboratory features of the lower respiratory pathology caused by COVID-19 and bacterial pneumonia in children

Objective: Conducting comparative analysis of the clinical and laboratory features of the course of community-acquired bacterial pneumonia and pneumonia in the presence of laboratory-confirmed coronavirus infection (COVID-19) in children in Krasnoyarsk.Methods: A retrospective clinical and laboratory analysis of 68 medical histories of children having a laboratory-confirmed diagnosis of a new coronavirus infection (COVID-19) complicated by pneumonia (2020), as well as 52 medical histories of children having community-acquired bacterial pneumonia (2019) is presented.Results: More than half of the cases fall on children older than 7 years. Boys prevailed in both groups. The majority of children in group 1 had a moderate form of COVID-19 course. Cough is the most common symptom in children having bacterial pneumonia. Children having COVID-19 pneumonia had symptoms that were not present in children of group 2: headache – in 19.1% of cases, myalgia – 7.4%, various dyspeptic disorders. In more than 80% of cases of bacterial pneumonia, there were percussion sound dullness and local decreased breath sounds, and more frequent detection of adverse respiratory noises. Changes in the peripheral blood in children with COVID-19 were non-specific.Conclusions: Clinical course of pneumonia in the presence of laboratory-confirmed coronavirus infection (COVID-19) in children has its specific clinical features. The most common symptoms are headache, myalgia, dyspeptic disorders. Children with bacterial pneumonia were more likely to suffer from cough and a strongly marked intoxication syndrome.

Evaluation of therapeutic efficacy of oxytetracycline against caprine respiratory mycoplasmosis using clinical score card method

Mycoplasmosis in goats is one of the challenging and continuous threats to small ruminant farming causing huge economic losses. This study was carried out to evaluate the therapeutic efficacy of oxytetracycline against caprine respiratory mycoplasmosis. Nasal swabs collected from fourteen goats showing clinical signs like cough, nasal discharge and abnormal breath sounds were screened for the presence of Mycoplasma spp. by polymerase chain reaction. The severity of the disease as well as the clinical improvement was recorded using a clinical score card. Oxytetracycline was administered intravenously at 15 mg/kg/day for 5 days along with supportive medications. Significant reduction in clinical score was observed after treatment and complete recovery was attained in 62.5 per cent animals.

A Prediction Model for Pediatric Radiographic Pneumonia

BACKGROUND: Chest radiographs (CXRs) are frequently used in the diagnosis of community-acquired pneumonia (CAP). We sought to construct a predictive model for radiographic CAP based on clinical features to decrease CXR use. METHODS: We performed a single-center prospective study of patients 3 months to 18 years of age with signs of lower respiratory infection who received a CXR for suspicion of CAP. We used penalized multivariable logistic regression to develop a full model and bootstrapped backward selection models to develop a parsimonious reduced model. We evaluated model performance at different thresholds of predicted risk. RESULTS: Radiographic CAP was identified in 253 (22.2%) of 1142 patients. In multivariable analysis, increasing age, prolonged fever duration, tachypnea, and focal decreased breath sounds were positively associated with CAP. Rhinorrhea and wheezing were negatively associated with CAP. The bootstrapped reduced model retained 3 variables: age, fever duration, and decreased breath sounds. The area under the receiver operating characteristic for the reduced model was 0.80 (95% confidence interval: 0.77–0.84). Of 229 children with a predicted risk of <4%, 13 (5.7%) had radiographic CAP (sensitivity of 94.9% at a 4% risk threshold). Conversely, of 229 children with a predicted risk of >39%, 140 (61.1%) had CAP (specificity of 90% at a 39% risk threshold). CONCLUSIONS: A predictive model including age, fever duration, and decreased breath sounds has excellent discrimination for radiographic CAP. After external validation, this model may facilitate decisions around CXR or antibiotic use in CAP.

Helicopter emergency medical services use of thoracic point of care ultrasound for pneumothorax: a systematic review and meta-analysis

Background Auscultating for breath sounds to assess for pneumothorax in the helicopter emergency medical services (HEMS) settings can be extremely challenging. Thoracic point of care ultrasound (POCUS) offers a seemingly more useful visual (rather than audible) alternative. This review critically and quantitatively evaluates the use of thoracic POCUS for pneumothorax in the HEMS setting. Methods A systematic literature review with meta-analysis was conducted. Only papers reporting on patients undergoing POCUS for pneumothorax in the helicopter or pre-hospital setting were included. Primary outcome was accuracy, focusing on sensitivity and specificity. Secondary outcome was practicality. PubMed, Embase and the Cochrane Library were searched. The Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) was used to assess validity of studies. Results Twelve studies reporting on n = 1,936 images from medical and trauma patients were included in qualitative synthesis. Studies were nearly all observational designs. Most images were acquired by nurses or paramedics who were previously novices to ultrasound. The reference standard was predominantly CT. Specificity results were unanimously precise and very high, whereas sensitivity results were imprecise and extremely variable. Meta-analysis of eight studies involving n = 1,713 images yielded pooled sensitivity 61% (95% CI: 27–87%; I2 = 94%) and pooled specificity 99% (95% CI: 98–100%; I2 = 89%). Six studies involving n = 315 images reported practicality. The highest or second highest categorisation of image quality was reported in around half of those images. Conclusion Thoracic POCUS is highly specific but has extremely variable sensitivity for pneumothorax when performed in the HEMS setting. This is from purely a diagnostic (not clinical) perspective. Sensitivity increases when only clinically significant pneumothoraces are considered. Case reports reveal thoracic POCUS can appropriately alter treatment and triage decisions, but only for a small number of patients. It appears predominantly useful in mitigating against unnecessary interventions. More research reporting patient focused outcomes is required. In the meantime, thoracic POCUS appears to offer a more appropriate visual alternative to auscultation for breath sounds when assessing for pneumothorax in the HEMS setting.

Improving Student Pharmacists' Learning Through the Use of Pediatric Simulation

OBJECTIVE The purpose of this study was to assess the effect of low-fidelity simulation on students' confidence, knowledge, and skills in pediatric physical assessments, and to compare students' interest ratings of topics and effectiveness of learning activities between students' who experienced simulation and those who did not. METHODS Within a pediatric elective, a vital signs and physical assessment activity was re-designed to incorporate a low-fidelity heart and breath sounds simulator. Students rated their confidence in completing 9 different physical assessment skills before and after the activity and assessment. Students' perspectives of the activity were also assessed. Course evaluation surveys were compared with prior course offerings (without simulation) to determine a change in students' interest ratings of the topic and effectiveness of learning activities. The Wilcoxon signed rank test, thematic analysis, and descriptive statistics were used to analyze outcomes. RESULTS All 106 second professional year students in the elective completed the pre- and post-simulation surveys and course evaluations for 3 offerings. Students' post-simulation average confidence scores increased statistically on all 9 skills compared with pre-simulation scores. All students agreed or strongly agreed “the lecture and simulation activity done in class helped me overcome challenges I had with learning the skill.” Students (98%) successfully demonstrated competency on the formal assessment. Compared with previous course offerings, students reported higher interest ratings in the topics and instruction effectiveness when simulation was incorporated into the activity. CONCLUSIONS Low-fidelity simulation is an effective teaching and learning approach to increase students' confidence, knowledge, and interest in pediatric vital signs and physical assessment.

Case Report: Bilateral Pneumothoraces Due To Targeted Tumor Therapy With Regorafenib in a Young Woman With Metastatic Colorectal Cancer

Background: Colorectal cancer is one of the most common cancer types, frequently metastasizing into the lungs. Treatment options have been vastly improved over the last years. With the increasing use of targeted therapies novel and rare adverse effects can be seen. In this report, we present the case of recurrent spontaneous bilateral pneumothorax due to fulminant tumor necrosis during the administration of regorafenib in a heavily pretreated patient with multiple lung metastases from colorectal cancer. Case presentation: A 43-year-old woman presented in our oncology department with chest pain and dyspnea. The patient was diagnosed with colorectal cancer seven years earlier and had received chemoradiation, surgery and multiple chemotherapies, before she was started on regorafenib because of progressive pulmonary metastases. Clinical examination revealed no breath sounds in the right hemithorax. The patient was tachycardic and orthopneic. Computed tomography scans demonstrated cavitation of former nodular bilateral pulmonary metastases. After drainage and resolution of the right-sided pneumothorax the patient returned eleven days later with recurrent dyspnea, chest pain and subcutaneous emphysema. Bilateral pneumothoraces were treated with chest tubes. Due to left-sided tension pneumothorax video-assisted thoracoscopy and bilateral pleurodeses were performed. Persistent air leaks with severe pain and pulmonary infiltrates led to the death of the patient. Conclusions: Our case illustrates the effectiveness of regorafenib in a highly pretreated patient. However, in our patient the ensuing cavitation of the multiple nodes led to recurrent pneumothoraces and associated infectious complications. Therefore, special surveillance should be implemented to detect potential transformation of solid pulmonary metastases during treatment with this multi-kinase inhibitor.

Tuberculous pleural effusion in a patient with sympathetic ophthalmia on immunosuppression: a case report

Background Tuberculous pleural effusion (TPE) is paucibacillary, making its diagnosis difficult based on laboratory investigations alone. We present a case of a patient with a TPE who was initially misdiagnosed to have azathioprine-induced lung injury. The diagnosis of TPE was arrived at with the help of clinical assessment, laboratory and radiological investigations. Case presentation A 25-year-old chronic smoker with sympathetic ophthalmia on long-term immunosuppression, latent tuberculosis infection and a significant family history of tuberculosis presented with a three-week history of productive cough, low-grade fever, night sweats and weight loss. Examination of the lungs showed reduced breath sounds at the right lower zone. Chest x-ray showed minimal right pleural effusion with a small area of right upper lobe consolidation. The pleural fluid was exudative with predominant mononuclear leukocytes. Direct smears of sputum and pleural fluid; polymerase chain reaction of pleural fluid; and sputum, pleural fluid and blood cultures were negative for M. tuberculosis (MTB) and other organisms. As he did not respond to a course of broad-spectrum antibiotics, he was then treated as a case of azathioprine-induced lung injury. However, his condition did not improve despite the cessation of azathioprine. A contrast-enhanced computed tomography of the thorax showed right upper lobe consolidation with tree-in-bud changes, bilateral lung atelectasis, subpleural nodule, mild right pleural effusion and mediastinal lymphadenopathy. Bronchoalveolar lavage was negative for malignant cells and microorganisms including, MTB. However, no pleural biopsy was done. He was empirically treated with anti-tubercular therapy for 9 months duration and showed complete recovery. Conclusion A high index of suspicion for TPE is required in individuals with immunosuppression living in regions endemic to tuberculosis. Targeted investigations and sound clinical judgement allow early diagnosis and prompt treatment initiation to prevent morbidity and mortality.

Cricopharyngeal Achalasia Presenting as Acute Dysphagia in a Pediatric Patient

Objective: To describe a case of idiopathic cricopharyngeal achalasia (CPA) in a pediatric patient with acute onset of dysphagia managed conservatively with supportive care. Methods: Sixteen-month-old boy presented with acute onset of gagging and coughing with feeding. His exam was notable for a well-appearing child with pooling of oral secretions and coarse breath sounds. Plain film series did not show radio-opaque foreign body (FB) and an esophagram demonstrated an endoluminal filling defect of the cervical esophagus and aspiration of contrast. He was taken to the operating room for urgent endoscopy but no FB or food impaction was observed. He had persistent symptoms that required further evaluation and a multidisciplinary team approach. Bedside laryngoscopy did not reveal any abnormalities. Modified barium swallow (MBS) study revealed upper esophageal sphincter (UES) dysfunction, consistent with cricopharyngeal achalasia. Repeat upper endoscopy with biopsies demonstrated mucosal irritation overlying the UES but histologic studies were negative for infectious causes. Results: He was treated with supportive care, including nasogastric feedings for nutrition supplementation as he was unable to tolerate oral feedings without aspiration. Over the course of 3 months after discharge, his symptoms resolved and repeat MBS was normal. Conclusion: CPA is a rare cause of dysphagia in the pediatric population. Conservative management with supportive care is a reasonable approach in cases with acute onset in otherwise healthy children without underlying medical problems.

Management of Local Anesthetics Systemic Toxicity In A 78 Year Old Man Undergoing Remove Of Inplate

Background: Local anesthetics have been widely used over the past 50 years in many clinical practices, ranging from emergency departments to operating rooms. Local anesthetics systemic toxicity (LAST) is a life-threatening condition when the effects of local anesthetics reach the systemic circulation with an incidence of 0.03% or 0.27 incidence of 1000 episodes of Peripheral nerve block (PNB). Case: We report a 78-year-old male who underwent of remove of inplate (ROI) and open reduction internal fixation (ORIF) reconstruction. Preoperative physical examination revealed GCS E4V5M6, blood pressure 195/76, other vital signs within normal limits, SpO2 99% in the supine position. On examination of the lungs, there were increased bronchial breath sounds and rough crackles, especially in the 2-5 left intercostal space. Other physical and laboratory examinations were within normal limits. The patient was hemodynamically stable after infusion lipid emulsion. The main principle of LAST management is to ensure adequate ventilation and organ perfusion with sufficient oxygen-rich blood to reach the brain, heart, and kidneys to prevent acidosis until lipid emulsion therapy. Conclusion: LAST management requires prompt and precise diagnosis and treatment to get a good outcome.