Inhalation Injury, Respiratory Failure, and Ventilator Support in Acute Burn Care

Sustaining an inhalation injury increases the risk of severe complications and mortality. Current evidential support to guide treatment of the injury or subsequent complications is lacking, as studies either exclude inhalation injury or design limit inferences that can be made. Conventional ventilator modes are most commonly used, but there is no consensus on optimal strategies. Settings should be customized to patient tolerance and response. Data for pharmacotherapy adjunctive treatments are limited.

Everolimus induced organizing pneumonia in a patient with tuberous sclerosis complex

Organizing pneumonia is characterized by a distinct histologic pattern in the lung interstitium and presents clinically as hypoxemia, fever, cough, and dyspnea that is not attributable to concurrent infection. Typical etiologies of this condition include inflammatory disease, malignancy, toxic inhalation, and an array of medications including the mTOR inhibitor everolimus. In this report, we describe the case of a female with tuberous sclerosis complex on everolimus therapy for renal angiomyolipomas who presented to the hospital with persistent cough, dyspnea, and fevers and bilateral lower lobe opacities on chest X-ray despite multiple courses of antibiotic therapy. Bronchoscopy was performed with transbronchial biopsies, and results demonstrated a lymphocytic predominance and pathologic findings of intraluminal plugs composed of fibroblasts and myofibroblasts consistent with organizing pneumonia. Everolimus therapy was discontinued and patient completed a steroid course with resolution of symptoms. To our knowledge, this is the first published case of organizing pneumonia secondary to everolimus in a patient with tuberous sclerosis complex.

Optimization of an empiric vancomycin dosing algorithm for improved target concentration attainment in patients with thermal injury

OBJECTIVE

Vancomycin empirical dosing studies in thermally injured patients have netted low successful target attainment and most excluded renal dysfunction, limiting applicability. In a previous study, the authors performed a retrospective analysis of 124 patients' measured pharmacokinetic parameters to calculate optimal dose and interval for intermittent infusion regimens and find predictors of clearance and total daily dose. The objective of this study was to improve the accuracy of attaining goal therapeutic targets with initial vancomycin regimens in patients with thermal injury through retrospective modeling.

METHODS

In this phase 2 study, variables collected and calculated regimens in phase 1 were utilized to try and create an improved empiric vancomycin dosing algorithm in patients with thermal injury. Logistic regression was utilized to determine best predictors of dosing vancomycin every 6 and 8h. The strongest models were built as individual algorithms and tested for accuracy of target attainment. Each algorithm produced a regimen for each patient that was then tested utilizing each patient's actual measured pharmacokinetic parameters.

RESULTS

Univariable logistic regression of 41 variables identified 27 and 23 to be predictive of dosing every 8 or 6h, respectively. The most predictive multivariable model for dosing every 8h consisted of creatinine clearance (CrCl)≥80ml/min, Acute Kidney Injury Network classification <1, and total body surface area burned≥10 percent. For dosing every 6h, CrCl≥80ml/min, age≤40years old, days since injury≤6, and serum creatinine (SCr)≤0.8 were most predictive. Based on the top 5 multivariable models for each dosing interval, 7 algorithms were built to produce recommended regimens. The highest performing algorithm resulted in trough concentrations of <10mg/L (23%), 10-20mg/L (65%), 15-20mg/L (26%), and >20mg/L (11%); area under the concentration curve (AUC)>400mghr/L (83%); and AUC >400mghr/L without having a trough >20mg/L (72%).

CONCLUSIONS

The algorithm that resulted in the highest target attainment without overdosing recommended 15mg/kg dosed every 24h for CrCl≥30, every 12h for CrCl 31-79, every 8h for patients with CrCl≥80ml/min, and every 6h only if the patient with a CrCl≥80ml/min is also≤40 years old and has a SCr≤0.8. Caution is warranted for groups underrepresented in this study, such as those with very low CrCl, a low BMI, or receiving renal replacement therapy. This algorithm should be validated in other centers for patients with thermal injuries.

Pulmonary Air Embolism: An Infrequent Complication in the Radiology Suite

Patient: Female, 64

Final Diagnosis: Pulmonary air embolism

Symptoms: Shortness of breath

Medication: —

Clinical Procedure: —

Specialty: Critical Care Medicine

Systemic lupus erythematosus associated with type 4 renal tubular acidosis: a case report and review of the literature

Introduction

Type 4 renal tubular acidosis is an uncommon clinical manifestation of systemic lupus erythematosus and has been reported to portend a poor prognosis. To the best of our knowledge, this is the first case report which highlights the successful management of a patient with systemic lupus erythematosus complicated by type 4 renal tubular acidosis who did not do poorly.

Case presentation

A 44-year-old Hispanic woman developed a non-anion gap hyperkalemic metabolic acidosis consistent with type 4 renal tubular acidosis while being treated in the hospital for recently diagnosed systemic lupus erythematosus with multi-organ involvement. She responded well to treatment with corticosteroids, hydroxychloroquine and mycophenolate mofetil. Normal renal function was achieved prior to discharge and remained normal at the patient's one-month follow-up examination.

Conclusion

This case increases awareness of an uncommon association between systemic lupus erythematosus and type 4 renal tubular acidosis and suggests a positive impact of early diagnosis and appropriate immunosuppressive treatment on the patient's outcome.

Variation in the prevalence of gastric cancer in Perú

Most cases of gastric cancers occur in non-industrialized countries but there is scarce information about the epidemiology of this illness in these countries. Our study examined whether there was a variation in the prevalence of gastric cancer in Lima, Perú over the last 2 decades. Subjects older than 29 years of age were included. They underwent an esophagogastroduedonoscopy at 3 socioeconomically different health facilities in Lima: a county hospital (7,168 subjects), a Peruvian-Japanese Clinic (14,794 individuals) and a private hospital (4,893 individuals). Birth cohort prevalence of gastric cancer was used. Regression models were calculated to predict the future prevalence of gastric cancer. It was found that the birth cohort prevalence of gastric cancer decreased in Perú from 22.7 to 2% (p < 0.001), from 12 to 0.5% (p < 0.001), and from 6.5 to 0.1% (p < 0.001) in the low, middle and high socioeconomic group, respectively. The prevalence of intestinal metaplasia decreased from 44.3 to 12.5% (p < 0.001), from 28.4 to 5% (p < 0.001), and from 19.4 to 2.2% (p < 0.001) in the low, middle and high socioeconomic status, respectively. These trends will likely persist over the future decades. Nevertheless, the prevalence of gastric cancer remains high in subjects older than 59 years of age in the low socioeconomic status. It is concluded that the prevalence of gastric cancer is decreasing in Perú, similar to the current trend undergoing in industrialized nations. However, there are still specific groups with high prevalence that might benefit from screening for early detection and treatment.