Thyroid Storm: A Forgotten Cause of Arrhythmias with Septic Feature

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Hyperthyroidism is the condition resulting from the effect of excessive amounts of thyroid hormones on body tissues. A dramatic extreme expression of thyrotoxicosis known as thyroid strom occurs rarely but requires prompt recognition and intervention to avoid the 90 percent mortality of untreated disease. Characteristically the patient present with fever, rapid tachyarrhythmias and atrial fibrillation. High output congestive heart failure can result from the tachycardia and severe hypermetabolic state. Frequently the clinical picture is clouded by a secondary infection such as pneumonia, a viral infection, or infection of the upper respiratory tract. Because of its variable presentation and because thyroid storm is rare condition, the correct diagnosis may be missed. We report two interesting cases of thyroid storm. The first was a lady who presented with a supraventricular tachycardia and atrial fibrillation initially misdiagnosed as septicemia with arrhythmias. The second case was a man with longstanding undiagnosed hyperthyroidism who presented with threatening thyroid storm and atrial fibrillation associated with cardiomyopathy. Both patients were subsequently managed successfully at our hospital. We hope misdiagnosis and late treatment of the similar cases will be avoided in the future.

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PMN and Lymphocyte Apoptosis in the Critically Ill: Different Means, Similar Outcome

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Accidental traumatic injury remains the fifth leading cause of death in America Behind heart disease, cancer, stroke and lung disease. Frequently, patients that survive the initial injury and do not succumb to major central nervous system or internal organ damage during the first day develop inflammatory complications, which result in morbidity and mortality due to multiple organ failure/dysfunction. These complications include non-septic inflammation of damaged tissue/organs, the adult respiratory distress syndrome (ARDS), and sepsis. While apoptosis, or programmed cell death, was initially understood as a mechanism by which cells of the immune system are cleared as a means of natural cell turnover or resolution of an inflammatory response, dysregulated apoptosis can be detrimental to the organism. Here we will briefly summarize data from both experimental animal models and critically ill patients that address (1) the suppression of neutrophil apoptosis in the critically ill, (2) the increase of lymphocyte (B and T cell) apoptosis, which leads to immunosuppression, (3) inflammatory mediators, such as cytokines, which appear to play predominant roles in neutrophil and lymphocyte apoptosis, and (4) the importance of the Bcl-2 familty in the regulation of apoptosis in the critically ill. These data clearly demonstrate the complexity of the apoptotic response and, thus, justify the need to increase our understanding of apoptosis in the critically ill. Such information will provide us with new insights, and possibly offer better therapeutic targets for the management of these devastating conditions.

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Cytopathic Dysoxia Revisited

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Most patients in septic shock die from the ensuing multi-organ dysfunction syndrome (MODS) rather than the acute inflammatory process per se. How systemic inflammation produces MODS remains unknown and many conundrums exist. It has been traditionally ascribed to tissue hypoxia secondary to microvascular shunting of blood away from nutrient capillaries. However, cell death, the expected corollary, is surprisingly absent in these failed organs despite gross biochemical and functional abnormality. With increasing severity of sepsis, tissue oxygen extraction falls with a decrease (relative or absolute) in tissue oxygen consumption. Nevertheless, tissue oxygen tensions rise, suggesting cellular availability but decreased utilisation, i.e. dysoxia. As mitochondrial oxygen consumption accounts for around 90% of total body oxygen utilisation, mitochondrial dysfunction leading to bioenergetic failure is a reasonable postulate to account for the biochemical and physiological perturbations witnessed in the septic patient. Importantly, nitric oxide and other reactive species, released in vast excess in sepsis, are potent inhibitors of mitochondrial oxidative phosphorylation. We review the increasing body of evidence derived from cell, animal and patient studies that implicate dysoxia as an important mechanism underlying the pathophysiology of multi-organ dysfunction.

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The Management of Head Trauma in Children

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In the United States, head trauma is a major cause of death and disability in children. There are significant epidemiological, anatomical and physiological differences in pediatric patients, which make them susceptible to additional complications and permanent brain injury. This article presents an over view of the initial assessment and management of pediatric head trauma in the acute care setting.

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A Prior Brain Microinjury Attenuates Hypermetabolism Induced by Brain Ischemia-Reperfusion in the Mouse

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We have previously shown that a prior brain microinjury improves survival of mice following brain ischemia, though the precise mechanism remains to be determined. The purpose of the present study was to examine the modulatory effects of the brain microinjury on postischemic brain metabolism. Sixty-eight DDY mice were divided into four groups: sham-operated non-ischemia, sham-operated ischemia, brain-injured non-ischemia, and brain-injured ischemia groups. Brain microinjury was induced by vertically inserting a 25-gauge needle into the brain at selected four sites. Seven days after the injury or sham-operation, animals in two ischemia groups were subjected to brain ischemia (60 min occlusion of bilateral carotid arteries). Using 2-[14C] deoxyglucose method, relative metabolic activity of brain regions was measured seven days after brain microinjury or sham operation in two non-ischemia groups and seven days after brain ischemia in the other two ischemia groups. There were no significant differences in relative metabolic activity of any brain region measured when compared between sham-operated and brain-injured animals without ischemia. In mice with sham operation, metabolic activity after ischemia was significantly higher in 8 of 22 brain regions examined that that measured without ischemia (p < .05). In mice with brain microinjury, metabolic activity remained unchanged following brain ischemia in any brain region examined except in the mammilary complex. The minor brain injury it self did not affect regional brain metabolism but attenuated postischemic increase in metabolic activity, suggesting that the ability of an antecedent brain microtrauma to attenuate postischemic hypermetabolism is involved in protection from subsequent ischemic-reperfusion injury.

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Procalcitonin May be a Better Predictor of Interleukin-6 than Conventional Inflammatory Markers

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Objective: To determine the correlation and predictive accuracy of conventional inflammatory variables (body temperature, leukocyte count, neutrophil percentage, absolute neutrophil count [ANC], C-reactive protein [CRP]) and a new inflammatory marker, procalcitonin (PCT), with elevated levels of interleukin-6 (IL-6) in septic patients. Materials and Methods: Fifty-one patients were enrolled in the study. Systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis, and septic shock were diagnosed according to ACCP/SCCM criteria. Serum concentrations of PCT, IL-6 and CRP were determined within 24 hours after the clinical onset of sepsis or SIRS. Leukocyte count, neutrophil percentage, and ANC, as well as maximal body temperature were also recorded. Results: Among all investigated variables, PCT most significantly correlated with serum IL-6 levels. Based on area under the receiver operating characteristics curve, PCT exhibited the highest predictive capability (0.685 for IL-6 ¡Ý 500 pg/mL, and 0.858 for IL-6 ¡Ý 1000 pg/mL), body temperature (0.662 and 0.792, respectively) and CRP (0.625 and 0.727, respectively) offered moderate predictive accuracy, while leukocyte count, neutrophil percentage and ANC carried the lowest predictive capability. Sensitivity, specificity, positive and negative predictive values all followed the same pattern. Conclusion: Compared with conventional inflammatory variables, PCT may reflect more reliably the elevated IL-6 levels.

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Does Pulse Pressure Variation Correlate with Conventional Measures of Preload?

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Objective: Systolic pressure variation (SPV) and pulse pressure variation (PPV) are sensitive and specific predictors of cardiovascular response to fluid challenge, with PPV being slightly more accurate. SPV does not correlate well with conventional measure of preload such as pulmonary artery occlusion pressure (PPAO), central venous pressure (CVP) or echocardiographic measures such as end-diastolic area (EDA), especially in patients with decreased left ventricular (LV) function. Because PPV is a more sensitive and specific predictor of preload responsiveness, we questioned whether PPV would correlate with conventional measures of preload. Design: Prospective repeat measures series. Setting: University teaching hospital cardiac operating theatre. Patients: Eight anesthetized cardiac surgery patients before and after cardiopulmonary bypass. Interventions: Positive pressure ventilation with tidal volumes of 8-10 ml/kg. Measurements: PPAO, CVP, arterial pressure and 2-dimensional LV mid-axis cross-sectional areas with transesophageal echocardiography were measured both before and after bypass during a brief apneic period followed by a mechanical breath. All measures were performed with the chest closed. Main Results: Using linear regression modeling, neither SPV nor PPV correlated with PPAO, CVP or EDA. This suggests that preload responsiveness and estimates of LV end-diastolic volume reflect different physiologic concepts.

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The Addition of Trickle Feeds Reduces the Complications Associated with Parenteral Nutrition

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Background: “Trickle feeds” are frequently added to patients receiving parenteral nutrition on the assumption that providing small volumes of enteral nutrition reduces the complications associated with parenteral nutrition. This hypothesis, however, has not been tested. Objective: The aim of this study was to compare the incidence of ventilator-associated pneumonia and the Standardized Mortality Ratio in critically ill ICU patients receiving parenteral nutrition alone as compared to parenteral nutrition together with trickle feeds. Design: This was a non-randomized cohort study. The incidence of ventilator-associated pneumonia and the Standardized Mortality Ration was compared in critically ill ICU patients with an acute abdominal processes who had received at least 3 days of parenteral nutrition or parenteral nutrition together with trickle feeds. The diagnoses of pneumonia was made by protected specimen bruch sampling. Results: Thirty two patients received parenteral nutrition alone and 34 parenteral nutrition together with trickle feeds. The patients receiving trickle feeds had a loweer incidence of confirmed bacterial pneumonia (8 vs 28%; p=0.05) and a trend towards a lower hospital mortality. The Standardized Mortality Ratio was 1.4 in the patients receiving parenteral nutrition alone and 0.85 in patients receiving trickle feeds together with parenteral nutrition; a 44% reduction in mortality. Conclusion: This study suggests that the addition of “trickle” feeds to parenteral nutrition reduces infective complications and may reduce hospital mortality.

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Respiratory Distress in An Infant Induced By Respiratory Syncytial Virus Bronchiolitis Complicated By Bronchogenic Cyst

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A 3-month-old infant developed respiratory distress as a result of respiratory syncytial virus bronchiolitis. The patient was first treated for initial symptoms which were gradually improving, but mechanical ventilation was required for seven days. Upon extubation, rapid respiratory distress ensued, requiring reintubation. Chest computed tomograph examination revealed a mediastinal mass, which was surgically removed and the patient was successfully weaned from mechanical ventilation. Histological diagnosis was bronchogenic cyst.

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Interleukin 11 and Stem Cell Factor Levels in Patients with Disseminated Intravascular Coagulation: A Report of Four Cases

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Interleukin 11 (IL-11) and stem cell factor (SCF) stimulate platelet production. In this study, we examined serum IL-11 and SCF levels in 4 patients with disseminated intravascular coagulation (DIC) complicating massive trauma and infections. The serum concentrations of both IL-11 and SCF showed a marked increase coinciding with the development of DIC in these patients, regardless of the presence or absence of infections. Further studies are required to confirm whether the increase in levels of these two platelet- inducing cytokines with the onset of DIC reflects an enhancement of platelet production in order to maintain the biological system in balance, or simply an inflammatory biological response.

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