[Show abstract][Hide abstract] ABSTRACT: We present a case of a 27-year-old man with recurrent episodes of angioedema since he was 19, who responded well to treatment with medical grade cannabis. Initially, he responded to steroids and antihistamines, but several attempts to withdraw treatment resulted in recurrence. In the last few months before prescribing cannabis, the frequency and severity of the attacks worsened and included several presyncope events, associated with scrotal and neck swelling. No predisposing factors were identified, and extensive workup was negative. The patient reported that he was periodically using cannabis socially and that during these periods he was free of attacks. Recent data suggest that cannabis derivatives are involved in the control of mast cell activation. Consequently, we decided to try a course of inhaled cannabis as modulators of immune cell functions. The use of inhaled cannabis resulted in a complete response, and he has been free of symptoms for 2 years. An attempt to withhold the inhaled cannabis led to a recurrent attack within a week, and resuming cannabis maintained the remission, suggesting a cause and effect relationship.
[Show abstract][Hide abstract] ABSTRACT: Evidence of various cardiac arrhythmias in septic patients has been demonstrated by multiple clinical reports and observations. Most cardiac arrhythmias in sepsis are new-onset and may be related to sepsis-induced myocardial dysfunction. We propose to investigate and analyze data of new-onset paroxysmal atrial fibrillation (AF) in a critically ill septic population.
This is a retrospective epidemiologic study. We collected clinical data from two hundred septic patients who developed a new episode of atrial fibrillation during their hospitalization in General Intensive Care Unit (GICU) between January 2007 and June 2013.
Of these 200 septic patients, 81 septic patients developed a new episode of AF and included in the present study. Thirty-seven patients had no past medical history of atrial fibrillation (AF) or antiarrhythmic therapy (new episode of atrial fibrillation, Group 1) and 44 had previously known episodes of atrial fibrillation and were prescribed antiarrhythmic therapy at home (Group 2). Group 2 patients had longer duration of recurrent episodes of atrial fibrillation compared to patients in Group 1 (11.07 ± 8.7 vs. 7.4 ± 6.1 days; P = 0.013). The overall ICU and in-hospital mortality rate was similar in both study groups. There was no significant difference in new stroke and pulmonary embolism (PE) between both study groups (P > 0.05).
In the present study we demonstrated no difference in morbidity and mortality rate in-ICU and after discharge between septic patients who had previous AF episodes and patients who had no previous past medical history of any cardiac arrhythmias.
[Show abstract][Hide abstract] ABSTRACT: Herniation of the urinary bladder into the inguinal canal is an uncommon finding, observed in 0.5-4% of inguinal hernias (Curry (2000)). It is usually associated with other conditions that increase intra-abdominal pressure such as bladder neck obstruction due to prostatic hypertrophy. Consequently, in men, it is usually associated with some degree of urinary retention. We present a 42-year-old man in whom herniation of the urinary bladder was the cause of urinary retention, and not vice versa. The patient was on tumor necrosis factor alpha antagonist (TNFA) (Etanercept) for severe Ankylosing spondylitis. Initially, the urinary retention was thought to be a side effect of the medication, but after the drug was discontinued, urinary retention persisted. CT and MRI demonstrated huge herniation of the urinary bladder into the inguinal canal. Immediately after the hernia was repaired, bladder function was restored. TNF treatment was restarted, and no further urinary symptoms were observed in the next two years of follow-up. In this case, the primary illness and its treatment were distracting barriers to early diagnosis and treatment. In younger patients with a large hernia who develop unexpected urinary retention, herniation of the urinary bladder should be highly considered in the differential diagnosis.
[Show abstract][Hide abstract] ABSTRACT: Optimal oxygen supply is the cornerstone of the management of critically ill patients after extubation, especially in patients at high risk for extubation failure. In recent years, high flow oxygen system devices have offered an appropriate alternative to standard oxygen therapy devices such as conventional face masks and nasal prongs.
To assess the clinical effects of high flow nasal cannula (HFNC) compared with standard oxygen face masks in Intensive Care Unit (ICU) patients after extubation.
We retrospectively analyzed 67 consecutive ventilated critical care patients in the ICU over a period of 1 year. The patients were allocated to two treatment groups: HFNC (34 patients, group 1) and non-rebreathing oxygen face mask (NRB) (33 patients, group 2). Vital respiratory and hemodynamic parameters were assessed prior to extubation and 6 hours after extubation. The primary clinical outcomes measured were improvement in oxygenation, ventilation-free days, re-intubation, ICU length of stay, and mortality.
The two groups demonstrated similar hemodynamic patterns before and after extubation. The respiratory rate was slightly elevated in both groups after extubation with no differences observed between groups. There were no statistically significant clinical differences in PaCO2. However, the use of HFNC resulted in improved PaO2/FiO2 post-extubation (P < 0.05). There were more ventilator-free days in the HFNC group (P< 0.05) and fewer patients required reintubation (1 vs. 6). There were no differences in ICU length of stay or mortality.
This study demonstrated better oxygenation for patients treated with HFNC compared with NRB after extubation. HFNC may be more effective than standard oxygen supply devices for oxygenation in the post-extubation period.
No preview · Article · Nov 2014 · The Israel Medical Association journal: IMAJ
[Show abstract][Hide abstract] ABSTRACT: Fat embolism syndrome (FES) is a life-threatening condition in which multiorgan dysfunction manifests 48-72 hours after long bone or pelvis fractures. Right ventricular (RV) failure, especially in the setting of pulmonary hypertension, is a frequent feature of FES. We report our experience treating 2 young, previously healthy trauma patients who developed severe hypoxemia in the setting of FES. Neither patient had evidence of RV dysfunction on echocardiogram. The patients were treated with inhaled nitric oxide (NO), and their oxygenation significantly improved over the subsequent few days. Neither patient developed any cardiovascular compromise. Patients with FES that have severe hypoxemia and evidence of adult respiratory distress syndrome (ARDS) are likely at risk for developing RV failure. We recommend that these patients with FES and severe refractory hypoxemia should be treated with inhaled NO therapy prior to the onset of RV dysfunction.
[Show abstract][Hide abstract] ABSTRACT: Percutaneous bedside tracheostomy (PBT) is a one of the common and safe procedures in intensive care units through the world. In the present paper we published our clinical experience with a performance of PBTs in the regular ward by intensive care physicians' team. We found it safe and similar outcome in comparison to open surgical tracheostomy method in operation room by ENT team. The performance of PBT in the regular ward showed potential economic advantages in saving medical staff and operating room resources.
Full-text · Article · Jan 2014 · Critical care research and practice
[Show abstract][Hide abstract] ABSTRACT: Page kidney is a well-known phenomenon causing hypertension, due to compression of renal parenchyma by a subcapsular hematoma, of either traumatic or non-traumatic origin. The main therapeutic approach is based on surgical approach (nephrectomy or hematoma evacuation) and antihypertensive treatment. In this paper we present a post-traumatic case of Page Kidney in a Critical Care unit. We discuss different therapeutical opportunities to extremely elevated systemic blood pressure resistant to traditional drug therapy.
[Show abstract][Hide abstract] ABSTRACT: Objective. Hyperthyroidism has been described as elevated serum free T3 and/or free T4 levels with decreased thyrotropin (TSH) concentrations. The main causes are related to autoimmune and neoplastic pathology. However, it might be caused due to a long-term topical exposure (iodine solution dressing) or by intravenous administration of iodine-containing substances. Both clinical and laboratory features might be presented. The main management is based on interruption of all exposures with iodine solutions and also antithyroid medicine in case of severe laboratory and clinical disturbances. Data Sources. We present a case of iodine-induced hyperthyroidism in a critically ill ICU patient caused by excessive iodine containing antiseptic solution washes and contrast agent administration. The patient was successfully treated by discontinuing iodine exposure and beta-blocker administration. Conclusions. In patients with underlying thyroid gland pathology, thyroid-function tests and clinical observation in the ICU are of critical importance.
Preview · Article · Apr 2013 · Case Reports in Endocrinology
[Show abstract][Hide abstract] ABSTRACT: Unrecognized severe pseudomembranous colitis may become life threatening. A typical Clostridium difficile infection is associated with involvement of the colon; however, small bowel disease has also been described. Here, we present a case of a 48-year-old man with Clostridium difficile colitis of an isolated segment in the descending colon treated by a novel catheter intraluminal antibiotic irrigation. The intraluminal antibiotic irrigation was performed through a Foley catheter inserted into the isolated mucus fistula. The patient recovered after three weeks of intraluminal vancomycin (250 mg diluted in 150 ml of normal saline x Q6) and metronidazole (500 mg x Q8). Both antibiotics were given into the mucus fistula over 30 min. The patient was discharged from the unit four weeks after admission. This novel technique, in which the antibiotic was administered through an inserted intraluminal Foley urinary catheter, may be an efficient and safe alternative when conventional routes cannot be implemented.
[Show abstract][Hide abstract] ABSTRACT: An outbreak of varicella occurred in an internal medicine ward. The outbreak comprised 3 nurses, 2 of whom were directly exposed to an immunocompetent patient with localized herpes zoster. Our observation provides an argument for airborne precautions in hospitalized patients with localized herpes zoster.
No preview · Article · Aug 2010 · Scandinavian Journal of Infectious Diseases
[Show abstract][Hide abstract] ABSTRACT: Tracheostomy is a surgical procedure, frequently used in patients with respiratory failure requiring prolonged mechanical ventilation. It is associated with fewer complications and may facilitate weaning from mechanical ventilation. Over the past 15 years, bedside percutaneous tracheostomy (PDT) has been widely employed as the primary method for performing tracheostomy in intensive care units. However, the ideal technique and timing for this procedure is still controversial.
To characterize the patients who underwent bedside percutaneous tracheostomy (PDT) in the Medical Intensive Care Unit (MICU) in terms of complications, clinical characteristics upon admission, short and long term outcome.
This retrospective cohort study included all patients hospitalized at the MICU from January 2003 to December 2007 who underwent bedside PDT. The patients' demographic data, past diagnosis, reason for admission to the ICU and a wide variety of data regarding procedure performance and complications were retrieved from the patients' charts. The information was subsequently computerized and analyzed.
The study population included 126 patients who underwent bedside PDT. Overall, 63.5% were men and the average age was 59.8 years. Patients who survived for 30 days after the procedure had a lower burden of background morbidity as reflected by their Charlson score. The one year mortality rate was 56.6%, of which 70% of the patients died in the first month following the procedure. Overall complication rate was low and occurred in 9 patients (7.1%). There was no procedure-related mortality. The most common pathogens isolated from patients' sputum were Acinetobacter spp. and Pseudomonas aeruginosa. The survival rate was highest among the group of patients who underwent tracheostomy during the first 10 days after initiation of mechanical ventilation.
Bedside PDT is a simple, safe and readily available procedure with low morbidity rates when performed by an experienced operator. However, long term outcome remains poor Survival rates were lower among patients who underwent the procedure within ten days of mechanical ventilation.
[Show abstract][Hide abstract] ABSTRACT: To determine if statin therapy reduces the incidence of severe sepsis and the levels of inflammatory cytokines in patients with acute bacterial infection.
Double-blind placebo controlled randomized clinical trial.
Department of medicine and medical intensive care unit in a tertiary university medical center.
A total of 83 patients with suspected or documented bacterial infection were enrolled. We randomly assigned 42 patients to receive 40 mg of simvastatin orally, followed by 20 mg of simvastatin, and 41 to receive matching placebo.
The study was prematurely terminated due to slow recruitment rate. Here we report the analysis of the secondary outcome: change in cytokines levels at 72 h. Both groups were evenly matched in terms of co-morbidity and severity of illness on admission. Four of the 83 patients enrolled developed severe sepsis, two in each group. No difference was observed in other clinical variables and there were no mortalities. Cytokine levels were randomly assessed in 40 patients (20 in each group). Both TNF-alpha and IL-6 levels were significantly reduced in the simvastatin group (p = 0.02 and p = 0.02, respectively), while no such difference was observed in the placebo group (p = 0.35 and 0.39, respectively).
Statin therapy may be associated with a reduction in the levels of inflammatory cytokines in patients with acute bacterial infections. Large controlled trials will determine if this reduction will translate into a clinical benefit.
Full-text · Article · Mar 2009 · Intensive Care Medicine