Comparison of high flow oxygen therapy in children with respiratory distress due to bronchiolitis and pneumonia

Background: Respiratory support through high flow nasal cannula (HFNC) therapy has emerged as a new method to provide respiratory support with bronchiolitis. Aim was to study outcome of HFNC therapy in children with bronchiolitis and pneumonia.Methods: The study was a prospective observational study involving children admitted to pediatric intensive care unit with respiratory distress (RD) in the age group of 1 month to 6 years over a period of 3 months (February 2017 till April 2017). Severity was assessed by clinical respiratory score (CRS). Children with RD were initiated with high flow nasal cannula. During treatment various parameters including CRS were documented at baseline and at 15 min and then hourly in a carefully designed performa. The primary outcome was failure of HFNC and need for ventilation.Results: Sixty children were included in the study of which 22 (37%) were in the bronchiolitis group and 38 (63%) were in the pneumonia group. 38 children presented with severe RD and 19 children with moderate RD. There was significant decrease in heart rate (HR) (20%), respiratory rate (RR) (20%) and in CRS within 1 hour of HFNC with a clinical stabilization within 24 hours in 16 cases (27%), 24-48 hours in 35 cases (58%) and >48 hours in 5 (8%) cases. Therapy was successful in 55 (92%), and failed in 5 (8%).Conclusions: HFNC has better outcome in children with RD due to acute bronchiolitis when compared to pneumonia. HFNC can be safely commenced in RD in critically ill child with monitoring.

NCMP-19. RADIATION-INDUCED CRANIAL NEUROPATHY PRESENTING AS PROGRESSIVE BULBAR SYNDROME

Neuropathy is a well-known complication of radiation, especially when administered in proximity to the brachial plexus (BC), with symptoms usually appearing years after radiation. Pain is a less prominent feature when compared to neoplastic infiltration, with numbness and weakness being a more common and disabling complaint. Radiation-induced neuropathies tend to reach clinical stabilization after several months with por response to treatment. This is a case report of a 59 year-old Malaysian man who was diagnosed with nasopharyngeal carcinoma in 2002 treated with radiation to the nasopharynx in China. He has no evidence of disease to this date. In 2016 he started to develop progressive bulbar symptoms, such as hoarseness, hypophonia, and dysphagia. Symptoms worsened over the subsequent 18 months after presentation with clinical stabilization thereafter. Following the initial bulbar symptoms, he also developed bilateral hearing loss, atrophy of bilateral sternocleidomastoid muscles, significant tongue atrophy with fasciculations and tongue deviation. His clinical picture was consistent with bulbar amyotrophic lateral sclerosis. MRI brain and total spine did not show any intraparenchymal or nerve disease. An electromyography test was performed, which showed myokymia of the tongue and trapezius consistent with radiation-induced cranial neuropathy (CN). He received steroids without any clinical improvement, followed by hyperbaric oxygen with minimal improvement of his dysphagia, hoarseness and hypophonia. On last follow up his symptoms continued to be stable. Radiation to nasopharynx can cause radiation-induced CN with similar electromyographic findings to radiation-induced brachial plexopathy, such as myokymia. Symptoms can appear more than 10 years from radiotherapy, with progression over several months followed by clinical stabilization. Treatment with steroids, bevacizumab or hyperbaric oxygen only provide minimal benefit on this population.

Ascending Painful Paresthesias, Progressive Ataxia, and Bilateral Foot Drop

A 63-year-old woman had development of ascending paresthesias with lancinating and stabbing pain in all extremities. The symptoms began asymmetrically in the left leg and progressed to involve the right leg and both hands. She noticed progressive bilateral leg weakness, gait instability, and new numbness in the left middle back. She had recurrent falls and required the use of a cane and eventually a walker. She had 18.2 kg of weight loss. She had no autonomic symptoms or bladder or bowel dysfunction. Examination 1 year after symptom onset showed an emaciated, ill-appearing woman. On neurologic examination, she had marked gait ataxia with profound proprioceptive loss in all extremities, asymmetrically reduced pinprick sensation distal to the left thigh, right knee, and both forearms, as well as bilateral middle thoracic dermatomes. She had bilateral foot drop and mild weakness in bilateral hamstring and intrinsic hand muscles. Her deep tendon reflexes were globally absent. Toes were mute to plantar stimulation. Magnetic resonance imaging of the entire spine demonstrated subtle increased T2 signal in the posterior columns extending along cervical and thoracic segments and patchy gadolinium enhancement of the cervical and lumbosacral nerve roots. Electrodiagnostic testing demonstrated a length-dependent axonal sensorimotor peripheral neuropathy. Cerebrospinal fluid analysis showed an increased protein concentration, 9 cerebrospinal fluid-restricted oligoclonal bands, increased immunoglobulin G index and synthesis rate, and normal blood cell count. Paraneoplastic antibody evaluation showed high titers of collapsin-response mediator protein 5-immunoglobulin G autoantibodies in the serum and cerebrospinal fluid. Whole-body 18F-fludeoxyglucose–positron emission tomography indicated multiple hypermetabolic mediastinal and hilar lymph nodes. Biopsy of a mediastinal lymph node was consistent with small cell lung carcinoma. The patient was diagnosed with collapsin-response mediator protein 5- immunoglobulin G paraneoplastic myeloneuropathy associated with small cell carcinoma of the lung. The patient received a trial of intravenous methylprednisolone followed by chemotherapy, along with chest and prophylactic brain radiotherapy. She achieved a short period of clinical stabilization and mild improvement in gait and limb ataxia. Subsequently, her ataxia and bilateral leg weakness worsened. Her clinical condition rapidly deteriorated, and she became severely malnourished and bedridden, dying 12 weeks later, 2 years after symptom onset. Collapsin-response mediator protein 5- immunoglobulin G antibodies have been associated with asymmetric, painful polyradiculoneuropathy with coexisting myelopathy, often in the setting of thymoma or small cell lung cancer.

Caudal Regression Syndrome

Caudal Regression Syndrome (CRS) is a rare malformation syndrome associating to varying degrees agenesis of the coccygeal or lumbosacral vertebrae.This vertebral anomaly can therefore be reduced clinically to a simple coccygeal agenesis without any deficit or even lumbosacral agenesis accompanying a clinical picture with sphincter disorders associated or not with transit disorders and various deficits involving the lower limbs.This syndrome is accompanied by other orthopedic malformations such as shortening of the lower limbs, and / or gastrointestinal abnormalities, see also genitourinary as well as cardiovascular.Its incidence is 1 to 5 cases per 100,000 births. Its precise cause has not yet been identified, but its relationship to maternal diabetes is well established. We report in our study 5 patients with CRS from different clinics whose sphincter disorders were found in the foreground in all our patients and whose results vary according to the inaugural clinical picture. MRI made it possible to refine and confirm the diagnosis highlighting the congenital anomaly and the associated lesions.We have obtained 75% good results and 25% clinical stabilization; nor do we deplore any case of aggravation or death. The interest is to suspect the diagnosis of CRS; document it at the start of the prenatal period and determine its severity and associated abnormalities in order to present options for patient management; because once the diagnosis is made, surgical treatment becomes imperative due to the formidable neurological sequelae compromising the functional prognosis.

Urinothorax, another complication of bladder tumor: case report

Background Rupture of the fornix is a rare and serious urological complication of obstructive pathologies. The main cause is ureteral stone, but rarely a bladder tumor. Described complications of fornix rupture are superinfection, perirenal abscesses and even sepsis, but not urinothorax. Case presentation Patient of 56 years old, active and chronic smoker, was hospitalized for anemia and obstructive renal failure on a non-documented bladder tumor; clinically, he was presented with hematuria and an intense right loin pain associated with homolateral basithoracic pain and dyspnea. The CT scan without injection showed a right perirenal collection with bilateral renal dilatation on endo-vesical tumor and a right pleural effusion of less abundance. The ratio of pleural fluid creatinine to blood creatinine was greater than 1, confirming urinothorax. As an emergency, a percutaneous nephrostomy was performed. After clinical stabilization, the patient underwent a trans-urethral resection of the bladder and derivation by a double j stent. The ultimate evolution was favorable. Conclusions Beyond the metabolic complications secondary to obstructions, mechanical complications, which can also be fatal, must be included.

Radiation Necrosis with Proton Therapy in a Patient with Aarskog-Scott Syndrome and Medulloblastoma

Purpose Medulloblastoma is known to be associated with multiple cancer-predisposition syndromes. In this article, we explore a possible association among a patient's Aarskog-Scott syndrome, development of medulloblastoma, and subsequent brainstem radiation necrosis. Case Presentation A 5-year-old male with Aarskog-Scott syndrome initially presented to his pediatrician with morning emesis, gait instability, and truncal weakness. He was ultimately found to have a posterior fossa tumor with pathology consistent with group 3 medulloblastoma. After receiving a gross total resection and standard proton beam radiation therapy with concurrent vincristine, he was noted to develop brainstem radiation necrosis, for which he underwent therapy with high-dose dexamethasone, bevacizumab, and hyperbaric oxygen therapy with radiographic improvement and clinical stabilization. Conclusion Based on several possible pathologic correlates in the FDG1 pathway, there exists a potential association between this patient's Aarskog-Scott syndrome and medulloblastoma, which needs to be investigated further. In patients with underlying, rare genetic syndromes, further caution should be taken when evaluating chemotherapy and radiation dosimetry planning.

Тhe uncharted middle ground – when the patient asks, but the guideliness don’t answer

Heart failure takes up an increasing portion of everyday cardiology practice. The accumulation of knowledge about the range of phenotypes and the therapeutic responses across the spectrum of heart failure leads to dynamic reconsideration of the best classifi cation schemes and also of the offi cially recommended therapeutic guidelines. At the moment the lack of clearly structured therapy recommendations for patients with heart failure with mid-range ejection fraction (HFmrEF) poses a lot of questions before the clinician. Their answers, as well as the patient’s clinical stabilization, require a high level of fl uency in latest clinical practices, creative usage of diagnostics and available therapeutics, and competent interdisciplinary long-term follow up. We present a case report of a patient with a relatively typical clinical profi le and suggest a possible therapeutic strategy.

Management of pressure ulcers in palliative care patients: nurses' view

Objective: to understand the management of pressure ulcers in palliative care patients from the perspective of nurses. Methods: qualitative study, in which 17 care nurses participated through semi-structured interviews. Data were submitted to thematic categorical analysis. Results: two categories were listed: Nursing management of pressure ulcers in palliative care patients and Outcome of pressure ulcers in palliative care patients. Their management occurs by means of individualized assistance and may vary according to the different moments in which the individual is and should be malleable. The possibility of three outcomes was also observed: complete healing, clinical improvement and clinical stabilization. Conclusion: despite all the frailty of these patients in palliative care, it was perceived that the clinical improvement of the lesions occurs, although it is a slow path, by means of handling the lesions in an individualized manner and focused on the search for comfort.

Pneumothorax and pneumomediastinum in COVID-19 acute respiratory distress syndrome

COVID-19 has involved numerous countries across the globe and the disease burden, susceptible age group; mortality rate has been variable depending on the demographical profile, economic status, and health care infrastructure. In the current clinical environment, COVID-19 is one of the most important clinical differential diagnoses in patients presenting with respiratory symptoms. The optimal mechanical ventilation strategy for these patients has been a constant topic of discussion and very importantly so, since a great majority of these patients require invasive mechanical ventilation and often for an extended period of time. In this report we highlight our experience with a COVID-19 patient who most likely suffered barotrauma either as a result of traumatic endotracheal intubation or primarily due to COVID-19 itself. We also aim to highlight the current literature available to suggest the management strategy for these patients for a favorable outcome. The cases described are diverse in terms of age variance and other comorbidities. According to the literature, certain patients, with COVID-19 disease and spontaneous pneumothorax were noted to be managed conservatively and oxygen supplementation with nasal cannula sufficed. Decision regarding need and escalation to invasive mechanical ventilation should be taken early in the disease to avoid complications such as patient self-inflicted lung injury (P-SILI) and barotrauma sequelae such as pneumothorax and pneumomediastinum Recent systematic review further supports the fact that the use of non-invasive ventilation (NIV) in certain patients with COVID-19 pneumonia may give a false sense of security and clinical stabilization but has no overall benefit to avoid intubation. While invasive mechanical ventilation may be associated with higher rates of barotrauma, this should not mean that intubation and invasive mechanical ventilation should be delayed. This becomes an important consideration when non-intensivists or personnel with less experience provide care for this vulnerable patient population who may rely too heavily on NIV to avoid intubation and mechanical ventilation.

Paliperidone Palmitate Every Three Months (PP3M) 2-Year Treatment Compliance, Effectiveness and Satisfaction Compared with Paliperidone Palmitate-Monthly (PP1M) in People with Severe Schizophrenia

Paliperidone palmitate every three months (PP3M) is expected to facilitate patient’s treatment compliance and satisfaction. The objective here was to compare PP3M treatment compliance and satisfaction, effectiveness and tolerability, with paliperidone palmitate-monthly (PP1M) in patients with severe schizophrenia. A 24-month prospective, open-label study of patients with severe schizophrenia treated with PP3M after at least 2 years of stabilization with PP1M (n = 84) was carried out. Treatment satisfaction was assessed with the Treatment Satisfaction Questionnaire for Medication (TSQM) and with a Visual Analogue Scale (VAS). Effectiveness was measured with psychiatric hospital admissions and the Clinical Global Impression-Severity (CGI-S) scale. Tolerability assessments included laboratory tests, weight and adverse effects. Reasons for treatment discontinuation were recorded. CGI-S significantly improved after 24 months. Three patients changed back to PP1M due to adverse effects, and four were hospitalized. There were neither abandoning nor significant changes in weight or biological parameters, and lower incidence of side effects, with PP3M treatment. TSQM and VAS scales increased. No differences were found related to doses. Apart from somewhat improvement in treatment adherence, effectiveness, and tolerability, patients with severe schizophrenia lengthy treated with PP1M showed more satisfaction with PP3M, even those who needed high doses to get clinical stabilization.