Withdrawn: Prenatal thoraco-amniotic chest drain insertion to manage a case of fetal hydrops secondary to FOXC2

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Glucose control in the ICU

Purpose of review Critically ill patients usually develop hyperglycemia, which is associated with adverse outcome. Controversy exists whether the relationship is causal or not. This review summarizes recent evidence regarding glucose control in the ICU. Recent findings Despite promising effects of tight glucose control in pioneer randomized controlled trials, the benefit has not been confirmed in subsequent multicenter studies and one trial found potential harm. This discrepancy could be explained by methodological differences between the trials rather than by a different case mix. Strategies to improve the efficacy and safety of tight glucose control have been developed, including the use of computerized treatment algorithms. Summary The ideal blood glucose target remains unclear and may depend on the context. As compared with tolerating severe hyperglycemia, tight glucose control is well tolerated and effective in patients receiving early parenteral nutrition when provided with a protocol that includes frequent, accurate glucose measurements and avoids large glucose fluctuations. All patient subgroups potentially benefit, with the possible exception of patients with poorly controlled diabetes, who may need less aggressive glucose control. It remains unclear whether tight glucose control is beneficial or not in the absence of early parenteral nutrition. Correspondence to Greet Van den Berghe, MD, PhD, Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, B-3000, Leuven, Belgium. Tel: +32 16 344021; fax +32 16 344015; e-mail: greet.vandenberghe@kuleuven.be Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Thoracic trauma in military settings: a review of current practices and recommendations

Purpose of review To examine current literature on thoracic trauma related to military combat and to explore its relevance to the civilian population. Recent findings Damage control resuscitation (DCR) has improved the management of hemorrhaging trauma patients. Permissive hypotension below 110 mmHg and antifibrinolytic use during DCR is widely accepted, whereas the use of freeze-dried plasma and whole blood is gaining popularity. The Modified Physiologic Triaging Tool can be used for primary triage and it may have applications in civilian trauma systems. Although Tactical Combat Casualty Care protocol recommends the Cric-Key device for surgical cricothyroidotomies, other devices may offer comparable performance. Recommendations for regional anesthesia after blunt trauma are not well defined. Increasing amounts of evidence favor the use of extracorporeal membrane oxygenation for refractory hypoxemia and resuscitative endovascular balloon occlusion of the aorta (REBOA) for severe hemorrhage. REBOA outcomes are potentially improved by partial occlusion and small 7 Fr catheters. Summary The Global War on Terror has provided opportunities to better understand and treat thoracic trauma in military settings. Trauma registries and other data sources have contributed to significant advancements in the management of thoracic trauma in military and civilian populations. Correspondence to Robert Mansky, 545 First Ave, Apt 8I, New York, NY 10016, USA. Tel: +1 516 672 5589; e-mail: rmansky@gmail.com Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Noninvasive ventilation versus oxygen therapy in patients with acute respiratory failure

Purpose of review High-flow nasal cannula oxygen therapy (HFOT) is becoming an alternative to noninvasive ventilation (NIV) and standard oxygen in management of patients with acute respiratory failure. Recent findings Patients with de novo acute respiratory failure should be managed with HFOT rather than NIV. Indeed, the vast majority of patients with de novo respiratory failure meet the criteria for ARDS, and NIV does not seem protective, as patients generate overly high tidal volume that may worsen underlying lung injury. However, NIV remains the first-line oxygenation strategy in postoperative patients and those with acute hypercapnic respiratory failure when pH is equal to or below 7.35. During preoxygenation, NIV also seems to be more efficient than standard oxygen using valve-bag mask to prevent profound oxygen desaturation. In postoperative cardiothoracic patients, HFOT could be an alternative to NIV in the management of acute respiratory failure. Summary Recent recommendations for managing patients with acute respiratory failure have been established on the basis of studies comparing NIV with standard oxygen. Growing use of HFOT will lead to new studies comparing NIV versus HFOT in view of more precisely defining the appropriate indications for each treatment. Correspondence to Jean-Pierre Frat, Médecine Intensive Réanimation, CHU de Poitiers, 2 rue la Milétrie, 86021 Poitiers Cedex, France. Tel: +33 5 49 44 40 07; e-mail: jean-pierre.frat@chu-poitiers.fr Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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The effectiveness of noise interventions in the ICU

Purpose of review Excessive noise has direct adverse physiological and psychological effects, and may also have indirect negative health consequences by reducing sleep quality and quantity. This review presents a synthesis of the epidemiology of noise in the ICU, and the potential interventions designed to attenuate noise and protect patients. Recent findings Noise increases cortisol release, oxygen consumption, and vasoconstriction. ICU noise levels are excessive throughout the 24-h cycle, irrespective of level of intervention or whether the patient is in a side room or open ward. Direct measurement suggests that noise is a substantial contributor to poor sleep quantity and quality in the ICU and is frequently recalled by survivors of critical illness as a negative experience of ICU admission. Noise abatement, environmental masking and pharmacological interventions may all reduce the impact of noise on patients. However, the sustainability of behavioural interventions remains uncertain and high-quality evidence demonstrating the benefit of any intervention on patient-centered outcomes is lacking. Summary Noise levels in the ICU are consistently reported to reach levels likely to have both direct and indirect adverse health consequences for both patients and staff. Noise reduction, abating the transmission of noise and pharmacological modulation of the adverse neural effects of noise are all potentially beneficial strategies, although definitive evidence of improved patient-centered outcomes is lacking. Correspondence to Lori Delaney, MIHM, MN, PGD Crit Care, PGC Ed, Faculty of Nursing, Queensland University of Technology, Kelvin Grove, QLD 4059, Australia. E-mail: Lori.delaney@qut.edu.au Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Telemedicine in the ICU: clinical outcomes, economic aspects, and trainee education

Purpose of review The evidence base for telemedicine in the ICU (tele-ICU) is rapidly expanding. The last 2 years have seen important additions to our understanding of when, where, and how telemedicine in the ICU adds value. Recent findings Recent publications and a recent meta-analysis confirm that tele-ICU improves core clinical outcomes for ICU patients. Recent evidence further demonstrates that comprehensive tele-ICU programs have the potential to quickly recuperate their implementation and operational costs and significantly increase case volumes and direct contribution margins particularly if additional logistics and care standardization functions are embedded to optimize ICU bed utilization and reduce complications. Even though the adoption of tele-ICU is increasing and the vast majority of today's medical graduates will regularly use some form of telemedicine and/or tele-ICU, telemedicine modules have not consistently found their way into educational curricula yet. Tele-ICU can be used very effectively to standardize supervision of medical trainees in bedside procedures or point-of-care ultrasound exams, especially during off-hours. Lastly, tele-ICUs routinely generate rich operational data, as well as risk-adjusted acuity and outcome data across the spectrum of critically ill patients, which can be utilized to support important clinical research and quality improvement projects. Summary The value of tele-ICU to improve patient outcomes, optimize ICU bed utilization, increase financial performance and enhance educational opportunities for the next generation of providers has become more evident and differentiated in the last 2 years. Correspondence to Christian D. Becker, MD, PhD, Division of Pulmonary and Critical Care Medicine, Department of Medicine, New York Medical College, Valhalla, NY 10595, USA. Tel: +1 914 493 1040; fax: +1 914 493 8373; e-mail: christian.becker@wmchealth.org Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Intra-atrial course of the right coronary artery: depiction of a potentially hazardous entity on dual-source CT

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Takotsubo cardiomyopathy triggered by status epilepticus: case report and literature review

Takotsubo cardiomyopathy (TC) is acute stress-induced cardiomyopathy with characteristic transient wall motion abnormalities. TC has a clinical presentation similar to an acute coronary syndrome, including chest pain or dyspnoea, ECG changes and elevated cardiac enzymes. TC often occurs after emotional stress. There are approximately 50 TC cases reported related to seizure activity, and our review revealed 15 articles which were associated with status epilepticus. This condition can be a serious complication of seizures. We report a case of TC after status epilepticus in a patient who had been seizure-free for 20 years.

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Fusobacterium necrophorum sepsis after tonsillitis/pharyngitis

Fusobacterium necrophorum is a rare infection most notable for causing Lemierre's syndrome. This consists of a primary oropharyngeal infection and septic thrombophlebitis, and one or more metastatic focus. Prior to the widespread use of antibiotics, Lemierre's syndrome commonly followed a rapidly progressing course, with a high mortality. We describe a case of a previously well 18-month-old boy who presented to the emergency department with a 3-week history of progressive, right-sided, painful neck swelling and systemic sepsis. He was initially treated conservatively with intravenous antibiotics, but ultimately required surgical drainage. Lemierre's syndrome is a rare condition with increasing incidence which can have significant adverse outcomes including death. Early recognition and treatment are essential, but identifying Lemierre's disease is challenging.

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Stroke or side effect? dofetilide associated facial paralysis after direct current cardioversion for atrial fibrillation

Dofetilide is a class III antiarrhythmic drug that has proven efficacious in maintaining sinus rhythm in up to 60% of patients with persistent atrial fibrillation. Dofetilide's most concerning adverse effect is QT prolongation and polymorphic VT, but providers should be aware of other rare significant side effects. We report a case of dofetilide associated Bell's palsy masquerading as stroke that developed shortly after a cardioversion. The patient's facial weakness, a side effect of dofetilide, resolved relatively quickly after discontinuation of the medication and a short course of oral corticosteroids.

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Proximal tibiofibular joint dislocation: a rare entity

A 37-year-old woman was diagnosed with an isolated proximal tibiofibular joint dislocation (PTJD) after an accident during gymnastic exercise. The dislocation has a low incidence rate and is often missed in the emergency department as physical and radiology signs are subtle. Treatment consists of closed or open reduction and immobilisation. When it is not recognised it is associated with significant peroneal nerve injury.

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Placental chorioangioma associated with polyhydramnios and hydrops fetalis

A 27-year-old multigravida woman was noted on routine growth scan at 27 weeks gestation to have a central placental hypoechoic area measuring 6.7x6.0x4.4 cm. A subsequent magnetic resonance scan confirmed a solid mass in the placenta lying anteriorly; therefore, a preliminary diagnosis of giant placental chorioangioma was made. A repeat ultrasound scan at 30 weeks gestation indicated that the mass had increased, with the presence of polyhydramnios. The patient experienced reduced fetal movements at 31 weeks gestation. There was persistent fetal tachycardia at 33 weeks gestation, and consequently the neonate was delivered by emergency caesarean section. The placenta revealed a large chorioangioma. The neonate's birth weight was 2.85 kg and non-immune hydrops fetalis was diagnosed. The neonate improved significantly in the neonatal intensive care unit and is currently well with no medical problems.

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Erythema ab igne as a complication of cannabinoid hyperemesis syndrome

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Bacteraemia and multiple liver abscesses due to Fusobacterium nucleatum in a patient with oropharyngeal malignancy

Fusobacterium infections can have a wide clinical spectrum, ranging from mild infections to severe sepsis and abscess formation. This range depends partly on the patient's underlying conditions, such as immunosuppression or malignancy. Fusobacteria are commensal rods in the oropharyngeal cavity and digestive tract, but should mucosal barrier disruption occur, in the presence of the above-mentioned predisposing conditions, fusobacteria can spread and cause infections in the soft tissues, liver and so on. An elderly woman was admitted with an altered level of consciousness (lethargy). The ensuing workup revealed a posterior oral cavity tumour (squamous cell carcinoma), Fusobacterium nucleatum bacteraemia and liver abscesses. Due to the severe sepsis, the patient was referred to our intensive care unit, but she passed away despite antibiotic treatment.

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Alports syndrome and intracranial aneurysm: mere coincidence or undiscovered causal relationship

A 44-year-old Caucasian man with a history of deceased donor renal transplant for end-stage renal disease from Alport's syndrome (AS), presented with a spontaneous subarachnoid haemorrhage and hydrocephalus. Following an external ventricular drain for the hydrocephalus, a CT angiography revealed a dissection of the left vertebral artery extending into vertebro-basilar junction necessitating a bypass between left occipital artery to left posterior inferior cerebellar artery. He had a posterior fossa Craniectomy, C1 laminectomy and coiling off, of the left vertebral artery. Postprocedure course was prolonged but uneventful with complete recovery and normal renal function 18 months postpresentation. AS, a disease caused by abnormalities in the synthesis of type IV collagen, can cause aneurysms with severe and permanent neurological sequalae. We present a case of AS with intracranial arterial dissection with potential life-threatening consequences and discuss the genetic and molecular basis of AS along with review of the relevant literature.

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Disseminated intestinal basidiobolomycosis with mycotic aneurysm mimicking obstructing colon cancer

Basidiobolomycosis is a rare fungal infection that may affect the gastrointestinal tract. It is caused by Basidiobolus ranarum and less than 80 cases have been reported in the literature. The incidence seems to be higher in the Middle East and in particular Saudi Arabia where most cases are diagnosed in the south-western region. An 18-year-old woman presented to the emergency department with an obstructing caecal mass initially suspected to be malignant. Surgical resection was complicated by bowel perforation, histology and cultures confirmed basidiobolomycosis infection. The postoperative course was complicated by an enterocutaneous fistula, fungal intra-abdominal abscesses, liver and lung abscesses, formation of mycotic hepatic artery aneurysm and meningoencephalitis. The patient eventually expired due to sepsis despite aggressive treatment. Diagnosis and management of such rare cases are very challenging and require a multidisciplinary approach. Complications are common and associated with a high mortality.

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Emergency management of massive haemoptysis

In this manuscript, we present a rare case of massive haemoptysis secondary to rupture of a pulmonary artery aneurysm, which was unusual for having occurred in the absence of tuberculosis or a vasculitis. We describe the emergency management of this that ultimately resulted in the patient's survival from both an anaesthetic and surgical perspective, as well as discuss the role of interventional radiology in this situation.

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Invasive aspergillosis complicating treatment with tyrosine kinase inhibitors

We describe three cases of pulmonary aspergillosis (PA) in three patients without traditional risk factors for invasive aspergillosis infection, such as prolonged neutropenia or high dose systemic corticosteroid therapy. All three patients developed PA while taking tyrosine kinase inhibitors (TKI) and sustained greater clinical improvement once TKI were withdrawn. Our case series supports the theory TKI treatment can increase susceptibility to PA without causing neutropenia. Recognition that TKI treatment may predispose to invasive aspergillosis will allow for rapid recognition of affected patients and more effective management of future cases.

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Tubulointerstitial nephritis and uveitis syndrome in a female adult

Tubulointerstitial nephritis and uveitis (TINU) syndrome is a rare disease characterised by the association of acutetubulointerstitial nephritis and uveitis. It affects mainly children and young women. Drugs and infections may be precipitating factors. It is a diagnosis of exclusion. The mainstays of treatment are topical and systemic corticosteroids. Prognosis is usually favourable. We report a case of TINU which occurred in our unit. A 37-year-old woman presented with an influenza-like illness, bilateral ocular pain and blurred vision. Ophthalmological evaluation revealed bilateral anterior uveitis and later renal involvement was seen as acute tubulointerstitial nephritis. A diagnosis of TINU was assumed after exclusion of other systemic diseases. She was treated with topical corticosteroids for the uveitis and evolved favourably, with resolution of ocular symptoms and normalisation of serum creatinine and proteinuria. This case highlights the importance of a high degree of clinical suspicion to make the diagnosis of TINU syndrome.

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Acute ischaemic stroke-related choreoathetosis treated with arterial thrombectomy

A rare case of acute choreoathetosis after acute stroke is presented. This 66-years-old, right-handed Caucasian woman presented with weakness of her right arm and right leg with dysarthria, which resolved by the time she arrived in the emergency department. No obvious focal sign apart from the abnormal choreoathetoid movement of the right arm and leg and of the neck was present. Her medical history included atrial fibrillation without anticoagulation. CT head was nil acute (Alberta Stroke Program Early CT Score of 10). CT angiography of the carotids showed a hyperdense M2 segment of the left middle cerebral artery. Intravenous thrombolysis immediately followed by thrombectomy was decided. Using the Penumbra aspiration device (ACE 68) two clots were removed with two aspirations. A small distal clot remained but partial recanalisation (Thrombolysis in Myocardial Infarction/Thrombolysis in Cerebral Infarction 2b) was achieved. 30 seconds after restoring blood flow, the choreoathetoid movements ceased. The patient was brought to intensive care for further monitoring, which was uneventful.

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Persistent sciatic artery resembles a soft-tissue sarcoma in presentation

Persistent sciatic artery (PSA) is a rare vascular anomaly with estimated incidence of 0.03%–0.06%. It has high incidence of complications including aneurysmal formation and ischaemia that may lead to amputation. During early embryonic development, the sciatic artery (which usually supply fetal lower buds and caudal part) disappears when the superficial femoral artery develops properly and the lower limbs grow. On clinical examination, usually a pulsating gluteal mass (the aneurysm) is appreciated with weak or absent femoral artery (Cowie's sign). However, our patient had presented in a different way. She was referred from peripheral clinic as a case of possible liposarcoma in the gluteal region. On examination, there was obvious asymmetry between both buttocks. The affected side was hard, firm in consistency with no appreciable pulsation. Nevertheless, on auscultation there was a bruit of low grade. Peripheral pulses were palpable. Our clinical impression was towards a sarcoma namely a liposarcoma. MRI was requested to evaluate the mass. The radiology report suggested that most probably it is an angiosarcoma with slim possibility of being a cavernous haemangioma. The trucut biopsy was deferred, in view of the high vascular nature of the lesion. The plan was as follow: To do angiography and embolisation of the main feeding vessels, with the possibility of biopsy in a second incident if indicated.During the conventional angiography, the pathology revealed itself. The patient was type 3 according to Pillet-Gauffre classification (PSA is limited to gluteal area and the popliteal artery arising from the femoral artery) associated with huge arteriovenous malformation. Embolisation with different materials including coils, beads and foam was ineffective. Finally, the radiologist excluded the root of the sciatic artery by a stent bridging from common iliac to external iliac artery. This successfully occluded the PSA.

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Congenital lateral cleft palate with unilateral craniofacial microsomia and lateral ankyloglossia

Craniofacial microsomia is a group of anomalies that occur due to developmental defects in the first and second branchial arches during the embryological period. The disease has various craniofacial and extracraniofacial presentation patterns. Lateral cleft palate is distinct from the most common palate clefts because it is located lateral to the uvula. The presence of a lateral cleft palate has been very rarely reported in the literature, and the aetiopathogenesis of the disease is still not well understood. We aimed to report a case of the coexistence of lateral cleft palate and craniofacial microsomia and discuss the aetiopathogenesis of these diseases.

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Headache and inflammatory bowel disease: think cerebral vein!

Cerebral vein thrombosis is a severe complication of inflammatory bowel disease, can cause non-specific symptoms and hence lead to delay in diagnosis. We report the case of an adolescent with inflammatory bowel disease who developed extensive cerebral vein thrombosis requiring a ventriculoperitoneal shunt. Diagnosis was markedly delayed due to repeated misinterpretation of clinical signs and laboratory findings and the lack of reconsidering the working diagnosis despite the involvement of several medical subspecialties. The patient does not suffer from any neurological impairment. This case report highlights the need for clinicians to maintain vigilance for complications of chronic disease and encourages to cast doubt on the working diagnosis constantly.

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Rivaroxaban-related acute kidney injury in a patient with IgA vasculitis

Anticoagulants have recently been recognised as a cause of acute kidney injury (AKI). We describe the case of a 75-year-old man with IgA vasculitis and atrial fibrillation treated with rivaroxaban, who presented with macroscopic haematuria and an acute decline in renal function. Two months before referral, he noted palpable purpuric lesions and was diagnosed with IgA vasculitis based on skin biopsy findings; the skin lesion disappeared following treatment with a steroid external preparation. Renal biopsy revealed glomerular haemorrhage and red blood cell casts. Although rivaroxaban was withdrawn, his kidney function worsened and he was started on haemodialysis. His renal function did not recover. To the best of our knowledge, this is the first case of direct oral anticoagulant (DOAC)-related AKI in systemic vasculitis. During DOAC therapy, close monitoring of a patient's urinalysis results and their renal function may be required for patients with systemic vasculitis to avoid AKI.

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Synovial sarcoma in an HIV-positive pregnant woman and review of literature

We present a first case of synovial sarcoma in an HIV-positive pregnant woman. This 28-year-old woman was diagnosed with synovial sarcoma, a high-grade malignant soft tissue sarcoma, involving her left thigh during the first trimester of her pregnancy. She underwent surgical treatment in the form of hip disarticulation at 30 weeks' gestation. She was subsequently delivered by emergency caesarean section (CS) at 34 weeks' gestation when she presented with wound sepsis and a scan revealed static growth in a small for gestational age fetus. Prompt diagnosis and treatment of this aggressive tumour is important and should involve a multidisciplinary approach, with a balanced consideration of the maternal and fetal outcomes.

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Gross anterior segment ischaemia following vitreoretinal surgery for sickle-cell retinopathy

We report the case of a 32-year-old Afrocaribbean man with known stage 3 proliferative sickle-cell retinopathy who presented with a mixed picture of tractional and rhegmatogenous macula off detachment. He underwent left primary 25 g vitrectomy with silicone oil, delamination and endolaser photocoagulation under a general anaesthetic. He, however, presented 48 hours postoperatively with gross anterior segment ischaemia. His pain and ocular signs settled over the course of a few days following administration of supplemental oxygen, oral steroids, analgesia and intravenous hydration. Examination showed resolution of his proptosis and orbital signs as well as anterior segment inflammation. He remains under follow-up.

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Treatment of Ethylene Glycol Poisoning with Oral Ethyl Alcohol

Ethylene glycol poisoning is not uncommon in India. The ill effects are primarily caused by its toxic metabolites: glycolic acid and oxalic acid. A 70-year-old female presented to our hospital with ataxia after ingestion of ethylene glycol. The reported case describes the management of ethylene glycol poisoning using oral ethyl alcohol as an alternative to the recommended intravenous ethyl alcohol and fomepizole that are not available for use in India. The need for high degree of clinical suspicion, targeted investigations, and early instigation of treatment is of prime importance in cases of ethylene glycol poisoning as it can lead to long-term complications or even death.

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Trousseau syndrome in a patient with advanced oral squamous cell carcinoma: a case report

Trousseau syndrome is known as a variant of cancer-associated thrombosis. Trousseau syndrome commonly occurs in patients with lung or prostate cancer. Hypercoagulability is thought to be initiated by mucins pr...

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EBV Infection Unmasking a Choledochal Cyst in an Infant

Hepatic involvement is common in acute Epstein–Barr virus (EBV) infection in children. It usually manifests as a transitory elevation of transaminases in up to 80% to 90% of patients, and they normalize by 2 to 6 weeks. A cholestatic pattern with elevated gamma-glutamyl transferase (γGT) and alkaline phosphatase (ALP) is common, in up to 60% in young adults. However, jaundice is very rare occurring in only 5% of pediatric patients. We report here an 8-month-old female with EBV infection who developed obstructive jaundice 2 weeks after the initial infection. Radiologic investigations were compatible with choledochal cyst type IVa complicated by stone formation in the common bile duct. In case of clinical exacerbation or nonamelioration of liver function tests in EVB infection, another diagnosis should be addressed. This highlights the importance of close follow-up in these patients in order not to miss a serious underlying condition such as choledochal malformation.

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