Spontaneous Pneumomediastinum: Experience in 18 Adult Patients

Spontaneous pneumomediastinum (SPM) is defined as the presence of air in the mediastinum, developing in the absence of traumatic, iatrogenic, or preceding pulmonary pathologies (emphysema, chronic bronchitis, and lung cancer). The aim of this study was to review our experiences with SPM, underlining its symptomatology, diagnosis, treatment, and followup, and defining a reasonable course of assessment and management. A retrospective case series was conducted to identify adult patients with SPM who were diagnosed and treated in our institution between 1998 and 2005. Eighteen patients (10 males) were identified (average age = 25 ± 4.8 years). Acute onset of chest pain was the predominant symptom at presentation. All patients developed clinically evident subcutaneous emphysema and underwent chest computerized tomography. Fiber bronchoscopy and echocardiogram were used selectively (8 patients). The average hospital stay was 6 (±1.4) days. Sixteen patients were conservatively treated, and only two patients were treated with thoracic drainage due to a related pneumothorax. The disease followed a benign evolution in all patients and, as of today, no relapse has been reported. SPM is an uncommon pathology with a usually benign course. The authors discuss SPM. A diagnostic algorithmic approach is necessary to rule out severe secondary entities and consequences that need urgent treatment.     

Clinical experience of spontaneous pneumomediastinum: diagnosis and treatment

Background

Spontaneous pneumomediastinum (SPM) is a benign disease with a variety degree of severity but definite treatment modality is not clearly identified with its rarity. The purpose of this study was to review our experience and discuss the management of SPM according to the severity of disease.

Methods

From March 1996 to December 2012, total 64 patients were enrolled and classified as mild, moderate and severe groups and subsequent clinical courses were analyzed retrospectively.

Results

Fifty-one were males and 13 were females (M:F =3.9:1) with a mean age of 18 years old (range: 10-30 years old). Thirty-six patients were in mild, 22 in moderate and 6 in severe group. Chief complaints were chest pain (50 cases; 78.1%), neck pain (35 cases; 54.7%), dyspnea (18 cases; 28.1%), odynophagia (9 cases; 14.1%) and precipitating factors were coughing in 12 cases, feeding problems in 9 cases, and vomiting in 7 cases; however, 34 patients (53.1%) had no precipitating signs. All patients received oxygen therapy (100%), prophylactic antibiotics in 57 patients (89.1%), and pain medications in 47 patients (73.4%). The mean hospital stay was 4.6 days (range: 1-10 days). There was an increased linear trend according to time to visit (P=0.023) but clinical course demonstrated no significant trend between groups.

Conclusions

These data demonstrated that there was no difference in symptom, clinical course and SPM was adequately treated with conservative management regardless of the degree of severity of SPM.     

A narrative review of primary spontaneous pneumomediastinum: a poorly understood and resource-intensive problem

Primary spontaneous pneumomediastinum (PSPM) is a benign self-limited condition that can be difficult to discriminate from esophageal perforation. This may trigger costly work-up, transfers and hospital admissions. To better understand this diagnostic dilemma and current management, we undertook the most comprehensive and up to date review of PSPM. The PubMed database was searched using the MeSH term “Mediastinal Emphysema”[Mesh], to identify randomized controlled trials, meta-analyses and case series (including 10 or more patients) relevant to the clinical presentation and management of patients with PSPM. There were no relevant randomized controlled trials or meta-analyses. Nineteen case series met our criteria, including a total of 535 patients. The average mean age was 23 years with a 3:1 male predominance. Chest pain was the most common symptom, found in 70.9% of the patients. Dyspnea and neck pain were the second and third most common symptoms, found in 43.4% and 32% of the patients, respectively. Subcutaneous emphysema was the most common sign (54.2%). Common histories included smoking (29.6%), cough (27.7%), asthma (25.9%), physical exertion (21.1%) and recent retching or emesis (13%). Nearly all patients (96.9%) underwent chest X-ray (CXR). Other diagnostic studies included computed tomography (65%) and esophagram (35.6%). Invasive studies were common, with 13% of patients undergoing esophagogastroduodenoscopy and 14.6% undergoing bronchoscopy. The rate of hospital admission was 86.5%, with an average length of stay of 4.4 days. No deaths were reported. Notably, we identified a dearth of information regarding the vitals, laboratory values and imaging findings specific to patients presenting with PSPM. We conclude that PSPM is a benign clinical entity that continues to present a resource-intensive diagnostic challenge and that data on the vitals, labs, and imaging findings specific to PSPM patients is scant. An improved understanding of these factors may lead to more efficient diagnosis and management of these patients.     

Sequential antimicrobial therapy in mediastinitis after cardiac surgery: An observational study of 81 cases

IntroductionMediastinitis is an infrequent but serious complication of cardiac surgery. Antimicrobial treatment guidelines are not well established. The aim was to describe the efficacy of sequential intravenous to oral therapy in selected post-surgical mediastinitis patients.MethodsA retrospective observational study including cases of mediastinitis after cardiac surgery, defined according to CDC criteria, at a third-level university hospital between January 2002 and December 2016. Sequential antimicrobial therapy was proposed in clinically stable patients. Rates of cure, relapse, and hospital stay were compared between patients who received sequential intravenous to oral therapy and those who received therapy exclusively by the intravenous route.ResultsEighty-one cases were included. Sequential intravenous to oral therapy was performed in 48 (59.3%) patients on median day 15. No differences in baseline characteristics or causal microorganisms were found between the two cohorts. The average duration of antibiotic therapy was 41.2 ± 10.09 days. The most commonly used drugs in sequential therapy were quinolones in 31 (64.6%) cases and rifampicin, always in association with another antibiotic, in 25 (52.1%). Hospital stay was shorter in the sequential therapy group (57.57 ± 34.03 vs. 84.35 ± 45.67; P = 0.007). Cure was achieved in 77 (92.8%) patients. Overall in-hospital mortality was less frequent in the group that received sequential therapy (2.1% vs. 15.2%; P = 0.039). There were no differences in relapse between the two cohorts (4.2% vs 9.1%; P = 0.366).ConclusionSequential antimicrobial treatment in selected patients with post-surgical mediastinitis may be as effective as exclusively intravenous treatment, reducing risks, hospital stay and associated costs.     

Clinical experience of a cardio-oncology consultation at a tertiary university hospital in Portugal: An observational study

IntroductionHeart disease and cancer are the two leading causes of morbidity and mortality worldwide. Advances in cancer screening and management have led to longer survival and better quality of life. Despite this progress, many cancer patients experience cardiovascular complications during and after cancer treatment. This study describes the experience of a cardio-oncology program at tertiary academic hospital.MethodsIn this retrospective observational study, cancer patients referred to the CHULN cardio-oncology consultation (COC) between January 2016 and December of 2019 were included. Data collected included: patient demographics, cancer type, reason for referral, cardiovascular risk factors, cardiac and oncologic treatments and clinical outcomes.ResultsA total of 520 patients (mean age: 65 ± 14 years; 65% women) were referred to the COC. The main reasons for referral were suspected heart failure (26%), pre-high risk chemotherapy assessment (20%) and decreased LVEF (15%). Pre-existing cardiovascular risk factors were common (79%) and 309 (59%) were taking cardiac medications. The most common type of malignancy was breast cancer (216, 41%) followed by gastrointestinal (139, 27%). More than half received anthracycline-based regimens (303, 58%). Most patients (401; 77%) successfully completed cancer therapy. At the time of last data collection, the majority of patients were alive (430, 83%). Cardiac-related mortality was observed in 16%.ConclusionsThe close collaboration between cardiology and oncology teams and timely cardiac monitoring was the key to the majority of patients to completing their prescribed cancer therapy.     

Evaluation of immune response to Hepatitis B vaccine in health care workers at a tertiary care hospital in Pakistan: an observational prospective study

Background  

Seroconversion rates reported after Hepatitis B virus (HBV) vaccination globally ranges from 85–90%. Health care workers (HCWs) are at high risk of acquiring HBV and non responders' rates after HBV vaccination were not reported previously in Pakistani HCWs. Therefore we evaluated immune response to HBV vaccine in HCWs at a tertiary care hospital in Karachi, Pakistan.     

Current practice of management of bacteremic sepsis: a study in a tertiary care teaching hospital in Japan

OBJECTIVE: To investigate how patients with bacteremic sepsis are managed in a tertiary care teaching hospital. PATIENTS AND METHODS: Prospective observational study on patients with bacteremic sepsis. Clinical and microbiological characteristics of bacteremic sepsis were analyzed in relation to prognosis. Severity of the illness was quantitatively analyzed by the APACHE (Acute Physiology, Age, Chronic Health Evaluation) III scoring system. Also investigated was how closely physicians paid attention to acute physiological alterations in patients. RESULTS: The 28-day mortalities in fifty hemodynamically stable patients and in twenty-three septic shock patients were 26% and 52%, respectively (p=0.028). Gram-positive organisms accounted for 54% of all organisms, with the mortality and incidence of septic shock being the same as with Gram-negative infections. The mean APACHE III score was 42.9 in survivors, and 76.5 in non-survivors (p < 0.001). Although serum levels of C-reactive protein and acute physiology score (APS) was significantly higher in non-survivors than in survivors, the correlation with APACHE III score was more prominent in APS. The number of vital signs recorded was 1.67 in physicians and 3.6 in nurses (p < 0.001). CONCLUSIONS: The present study proved that the APACHE III score accurately discriminates between survivors and non-survivors of patients with sepsis. By addressing the need for an objective evaluation of severity of illness, it strongly recommends that physicians should be made aware of physiologically defined sepsis and that they should pay closer attention to patients' physiological alterations to identify the development of sepsis in critically ill patients.     

Mortality in diabetes: a retrospective analysis from a tertiary care hospital in North India

Cause(s) of death in patients with diabetes mellitus (DM) admitted to a tertiary care hospital in North India was analysed from classified information in patients' death records and case file. Of the 306652 total admissions from 1991 to 1999, 21584 patients died (7.04%), 592 of whom (355 men and 237 women) had DM (2.7%). Information from 92 patients with diabetes could not be retrieved and six patients with hyperglycemia of short duration (two with gestational DM, three with post-transplant diabetes and one with stress hyperglycemia) were excluded. Of the 494 patients, 456 (92.3%) had T2DM and 38 (7.7%) had T1DM. Four hundred and forty patients had diabetes related mortality: infections (230, 46.5%), cardiovascular events (86, 17.4%), chronic renal failure (CRF) (48, 9.7%), stroke (30, 6%), diabetic ketoacidosis (DKA) (15, 3%), hyperosmolar coma (11, 2.2%), and hypoglycemia (5, 1%), while others (54 patients) had diabetes unrelated deaths. Cause of death could not be ascertained in six patients (1.2%). Death was attributed to a single cause in 301 (60.9%), to two causes in 175 (35.4%) and to three or more causes in 12 (2.4%) patients. Analysis of the cause of death in DM versus hospital in-patients in general, showed infection (P<0.02), coronary artery disease (CAD) (P<0.001), and CRF (P<0.001) to be more frequent in diabetes.     

Ecology of blood stream infection and antibiotic resistance in intensive care unit at a tertiary care hospital in North India

ObjectiveTo analyse the prevalent microorganisms and their antimicrobial resistance among intensive care unit patients in a tertiary care centre in New Delhi.MethodsA retrospective study of all consecutive blood cultures from various intensive care unit patients in the hospital during four years (January 2008 to December 2011). Antibiotic consumption data in the intensive care units were also analysed during the same period.ResultsOut of the total 22,491 blood cultures processed, 2846 samples were positive and 3771 microorganisms were isolated. The blood culture positivity was estimated as 12.7% of which 67.5% were monomicrobial and 32.5% polymicrobial infections. Gram negative bacilli, Gram positive cocci, and fungi were isolated in 49%, 33%, and 18% cases, respectively. Coagulase negative staphylococcus was the commonest single isolate followed by Candida spp. A drastic shift in the distribution of Candida spp. towards nonalbicans along with high resistance to azole group of antifungals suggest echinocandins for the empiric therapy of candidemia. High penicillin resistance in Gram positive isolates suggest vancomycin, linezolid and tigecycline as the options for empiric therapy, whereas tigecycline and colistin are the only options remaining for highly resistant Gram negative isolates. Aminoglycosides were observed to have better sensitivity and reduced usage when compared with cephalosporins and β-lactam + β-lactam inhibitor combinations.ConclusionsHigh frequencies of multidrug resistant organisms were observed in intensive care units which is a warning as to use the only few effective antimicrobials wisely to reduce selective pressure on sensitive strains.     

Pneumorrhachis and pneumomediastinum in connective tissue disease-related interstitial lung disease: case series from a tertiary care teaching hospital in South India

Pneumomediastinum has been described as a rare complication of connective tissue diseases. Here, we report four cases of pneumomediastinum: three of which are associated with dermatomyositis and one with mixed connective tissue disease. All our patients had interstitial lung disease. The first case of dermatomyositis described below was complicated by epidural emphysema (pneumorrhachis) in addition to pneumomediastinum. Pneumorrhachis is reported in many isolated case reports and series in the setting of asthma, pneumothorax, blunt chest trauma, etc. Less than 10% of pneumomediastinum cases develop this complication and vast majority of cases resolve spontaneously. The mechanism behind this has been postulated to be the passage of air through the intervertebral foramen. Others suggest entrapment of air which dissects between paraspinal soft tissues and along the vascular and nerve sheaths into the epidural space. This is the first ever reported case of epidural emphysema in connective tissue disease to the best of our knowledge.     

Clinical profile of insulinoma: analysis from a tertiary care referral center in India

Objective  

To describe the clinical presentation, localization techniques, surgical procedures and outcome in patients with insulinoma.     

Clonal diversity of vancomycin-resistant enterococci from an outbreak in a tertiary care university hospital

Background: Enterococci have become important nosocomial pathogens and now account for approximately 12% of nosocomial infections. Enterococci can be transferred from patient to patient and from health care personnel to patient. We investigated the clonal diversity of vancomycinresistant enterococci (VRE) causing an outbreak of infections and attempted to determine the patterns of spread of these bacteria in a university hospital. Methods: Ribotyping was used to examine the clonal diversity of 50 VRE isolates, including 23 from wounds, 14 from urine, 8 from blood, 3 from the rectum, 1 from drainage, and 1 from the cornea. Results: Nine patients were infected with Enterococcus faecalis, 10 with Enterococcus faecium, 3 with both E faecalis and E faecium , and 1 with Enterococcus avium. The results suggest that the sources of the VRE infections included endogenous strains and strains acquired by transmission from attending staff or from the environment. Three patients were infected by both nosocomial and endogenous strains. Conclusions: These data suggest that the collection and analysis of several isolates from repeated specimens is necessary to obtain a fuller understanding of the epidemiology and population structure of antibiotic-resistant enterococci. (AJIC Am J Infect Control 1998;26:563-8)     

Spectrum of rheumatological disorders: an experience of 337 cases in a tertiary care hospital in Pokhara valley,Nepal

Aim: To reveal the commonly occurring important types of rheumatological disorders, as well as various clinico‐epidemiological aspects, concurrent medical illnesses, and the ancillary medications used, along with their side‐effects. Method: A total of 365 patients with various rheumatological disorders were studied at the Rheumatology Department of Manipal Teaching Hospital, Pokhara, Nepal from September 2001 to September 2004. The diagnosis was based on the criteria of the American College of Rheumatology (1988). A pro forma was prepared for 30 common rheumatological disorders, listing patient identification, clinical characteristics, disease duration, objective and subjective assessment of the progress of the diseases, monitoring the response of treatment and side‐effects of medications. Patients aged 15–75 years, men and women suffering from various musculoskeletal disorders, fulfilling the ACR criteria, were studied. Each patient was followed up at 1–3 monthly interval and data recorded systematically to monitor the progress of joint function and evaluating the effects of medications. Results: Out of the 365 patients recorded, only 337 fulfilled the criteria laid down by ACR. Most common rheumatological disorders in order of frequency were soft tissue rheumatism (40.0%), inflammatory arthritis (21.36%) and bone and cartilage diseases (21.06%). Connective tissue disorders were only 4.74%. Seronegative spondyloarthritis group was only 2.67% and least common disease was gout at 3.85%. Rheumatoid arthritis was the most common inflammatory arthritis observed in 20.17% of total cases. Fibromyalgia was the most common soft tissue rheumatism seen in 19.88%. Osteoarthritis of knee, hand and hip were the most common degenerative disorder of the bone and cartilage, constituting 10.38%. Lumbago, lumbar spondylolisthesis and spinal canal stenosis together comprised 14.24% of patients with low back pain. Cervical spondylosis and all types of shoulder joint pain syndromes comprised 5.93% and 5.34%, respectively. Patients were mostly in the age group 20–60 years. The most common type of drug used in all rheumatic conditions was non‐steroidal anti‐inflammatory drugs in 81.6% of cases followed by steroids in 26.7%, disease‐modifying and cytotoxic drugs in 18.6% and 17.2% of cases, respectively. Chronic obstructive airway disease and hypertension constituted the major concurrent illness in 23.63% and 18.78%, respectively. Conclusion: This unique type of clinico‐epidemiological study on rheumatological disorders, the first in Nepal, will provide a rich database for future investigations into rheumatology and would plan for all levels of prevention and therapy in the future.     

Profile of bacterial isolates from suspected cases of infective endocarditis (IE): a retrospective study in a north Indian tertiary care hospital

Infective Endocarditis (IE) is an emerging infection of the twenty-first century. This chronic Infection is mainly caused by bacteria, although fungi can also be associated with it. It is Important to know the profile of bacteria causing IE in a given region so as to suggest the empirical therapy for this serious illness. Blood culture isolates of clinically diagnosed or suspected cases of IE admitted to various wards of the All India Institute of Medical Sciences were analyzed retrospectively from January 2000 to June 2004. Standard techniques were used for the isolation and identification of the bacteria. Our study has demonstrated the predominance of Gram-negative bacilli, especially, Acinetobacter species and Pseudomonas aeruginosa, which are notorious for antimicrobial resistance, as the aetiological agents of IE. Amongst Gram-positive cocci, Enterococci exhibiting HLAR comprised the predominant species. Methicillin resistance among staphylococcal strains in this Tertiary care hospital is adding to the therapeutic challenge in the management of this serious illness. Although antimicrobial treatment should not be delayed in such cases, we cannot undermine the importance of isolation and identification of the etiological agents and the determination of the antimicrobial susceptibility for the management of these life-threatening conditions as well as for the formulation of guidelines for empirical therapy of these cases.     

Steroid-free remission in lupus: myth or reality; an observational study from a tertiary referral centre

Clinical Rheumatology - Whether maintaining steroid-free remission is feasible in Indian patients with systemic lupus erythematosus (SLE). In 148 patients with SLE including 78 lupus nephritis (LN)...