Sumedh S. Hoskote

MRI features of tuberculosis of the knee.

ObjectiveThe objective of this study was to describe the magnetic resonance imaging (MRI) features of tuberculosis (TB) of the knee joint.Materials and methodsThe MRI features in 15 patients with TB of the knee, as confirmed by histology of the biopsied joint synovium, were reviewed retrospectively. The images were assessed for intra-articular and peri-articular abnormalities.ResultsAll patients had florid synovial proliferation. The proliferating synovium showed intermediate to low T2 signal intensity. In the patients who were administered intravenous contrast, the hypertrophic synovium was intensely enhancing. Marrow edema (n = 9), osteomyelitis (n = 4), cortical erosions (n = 5), myositis (n = 6), cellulitis (n = 2), abscesses (n = 3), and skin ulceration/sinus formation (n = 2) were seen in the adjacent bone and soft tissue.ConclusionSynovial proliferation associated with tuberculous arthritis is typically hypointense on T2-weighted images. This appearance, in conjunction with other peri-articular MRI features described, can help in distinguishing TB arthritis from other proliferating synovial arthropathies.

Ketamine and Propofol Combination (“Ketofol”) for Endotracheal Intubations in Critically Ill Patients: A Case Series

Case series Patient: Male, 77 • Male, 25 • Male, 63 • Male, 70 • Male, 70 • Female, 61 Final Diagnosis: — Symptoms: Hypotension • respiratory failure Medication: Ketamine • Propofol • Etomidate Clinical Procedure: Endotracheal intubation Specialty: Critical Care Medicine Objective: Educational Purpose (only if useful for a systematic review or synthesis) Background: Endotracheal intubation is a common procedure performed for critically ill patients that can have immediate life-threatening complications. Induction medications are routinely given to facilitate the procedure, but most of these medications are associated with hypotension. While etomidate is known for its neutral hemodynamic profile, it has been linked with increased mortality in septic patients and increased morbidity in trauma patients. Ketamine and propofol are effective anesthetics with counteracting cardiovascular profiles. No data are available about the use of this combination in critically ill patients undergoing endotracheal intubation. Case Series: We describe 6 cases in which the combination of ketamine and propofol (“ketofol”) was used as an induction agent for endotracheal intubation in critically ill patients with a focus on hemodynamic outcomes. All patients received a neuromuscular blocker and fentanyl, while 5 patients received midazolam. We recorded mean arterial pressure (MAP) 1 minute before induction and 15 minutes after intubation with the combination. Of the 6 patients, 5 maintained a MAP ≥65 mmHg 15 minutes after intubation. One patient was on norepinephrine infusion with a MAP of 64 mmHg, and did not require an increase in the dose of the vasopressor 15 minutes after intubation. No hemodynamic complications were reported after any of the intubations. Conclusions: This case series describes the use of the “ketofol” combination as an induction agent for intubation in critically ill patients when hemodynamic stability is desired. Further research is needed to establish the safety of this combination and how it compares to other induction medications.

Improving the Quality of Handoffs in Patient Care Between Critical Care Providers in the Intensive Care Unit.

With the ever-increasing adoption of shift models for intensive care unit (ICU) staffing, improving shift-to-shift handoffs represents an important step in reducing medical errors. The authors developed an electronic handoff tool integrated within the existing electronic medical record to improve handoffs in an adult ICU. First, stakeholder (staff intensivists, fellows, and nurse practitioners/physician assistants) input was sought to define what elements they perceived as being essential to a quality handoff. The principal outcome measure of handoff accuracy was the concordance between data transmitted by the outgoing team and data received by the incoming team (termed as agreement). Based on stakeholder input, the authors developed the handoff tool and provided regular education on its use. Handoffs were observed before and after implementation of the tool. There was an increase in the level of agreement for tasks and other important data points handed off without an increase in the time required to complete the handoff.

Judgment of futile care in the ICU.

To the Editor: In a recent issue of Critical Care Medicine, Huynh et al (1) reported about the cost of futile treatment in the ICU. They make a valiant attempt to assess the impact of futile care provided in the ICU on patients awaiting ICU admission and costs to the healthcare system at large. With healthcare costs peaking toward the end of life and the aging demographic of ICU patients, the authors’ focus of research is certainly the need of the hour. We applaud their efforts in quantifying this difficult topic of futility and its related cost. However, we have several concerns about how such findings might be applicable to clinical practice. In particular, the authors highlight that futility was determined only from the point of view of the clinician and did not include the thoughts and opinions of patients and their families (1, 2). Schneiderman et al (3) describe a futile action as “one that cannot achieve the goals of the action, no matter how often repeated.” We contend that futility is often quantified in terms of probability, but this term should only be applied to those clinical situations where the probability of the desired outcome is close to zero. For many patients and their families, particularly during critical illness, a probability of even 5–10% is better than zero, and beginning a discussion describing the relative risks and benefits in terms of odds of success or likelihood of failure may mislead or confuse further, particularly as many activities done in the context of critical illness serve quite well initial physiological goals (maintenance of blood pressure, oxygen saturation, heart rate, etc.) but may not individually affect likelihood of survival. As a further example, we note that of the 123 patients deemed to be receiving futile care in this study, 20 patients (16%) survived up to 6 months following hospital discharge (though details of their medical conditions were not reported) (2). The remaining 84% of patients either died prior to discharge (84/123) or had terminal conditions and/or severe cognitive impairment (19/123). In clinical practice, it would not be considered appropriate to unilaterally make an assessment of futility based on these findings if 16% of patients with such a determination would be expected to survive up to 6 months. Whether that survival is meaningful, even if quality of life is debased, is a judgment reserved for patients and their families and may be unlikely considered futile in their minds (16% chance of survival is better than 0%). Indeed, futility judgments are often understood relative to specific clinical but value-laden goals (4). The same intervention may be considered futile with respect to one goal, for example, returning to premorbid quality of life, but may be effective in relation to another, for example, surviving critical illness. Therefore, any meaningful definition of futility must be context dependent. As one might imagine, input from patients would be of utmost importance in understanding their goals and expectations from medical care. As a result, patient-centered and physician-centered perceptions of futility may be vastly different (5, 6). The authors allude to this in their study by discussing indeed why care that is considered futile is still even provided when clinicians have a right not to provide such care. This highlights the fact that opinions of patients and families often differ from those of clinicians. Further studies are needed to assess aspects of futility beyond clinician perception and to examine the conflicts that can occur when clinician and family opinions differ. We believe that critical care providers should be extremely cautious when using the term “futile” especially because our ability to predict futility is currently limited. Future research in this field should focus on better models of medical prediction and methods of conflict resolution in order to have candid and open discussions with patients and families. To conserve precious healthcare resources, employ palliative care at the appropriate time, and provide a timely referral to hospice care as needed are important and lofty goals, but likely only possible when the goals and expectations of patients and their families are engaged and duly respected. This work was performed at the Mayo Clinic, Rochester, MN. The authors have disclosed that they do not have any potential conflicts of interest.

Imagen clínicaCuerpo extraño endobronquial que imitaba una neoplasia maligna pulmonar con tomografía por emisión de positrones positivaEndobronchial foreign body mimicking a positron emission tomography-positive lung malignancy

Un varón de 59 años de edad y fumador importante acudió por presentar tos no productiva de 6 meses de evolución. La tomografía computarizada (TC) torácica reveló una lesión endobronquial densa en el bronquio del lóbulo superior derecho (media: 220 unidades Hounsfield) y un infiltrado pulmonar separado en la periferia del lóbulo superior derecho. La tomografía por emisión de positrones (PET) confirmó un aumento de la captación en el infiltrado del lóbulo superior derecho y la lesión endobronquial (fig. 1A; SUVmáx 4,3). Se practicó una broncoscopia que mostró una masa no vascular blanda y amarillenta, que obstruía el bronquio del lóbulo superior derecho (fig. 1B). Se barajaron los posibles diagnósticos de cuerpo extraño, lipoma y tumor carcinoide endobronquial.

Endobronchial foreign body mimicking a positron emission tomography-positive lung malignancy.

Un varón de 59 años de edad y fumador importante acudió por presentar tos no productiva de 6 meses de evolución. La tomografía computarizada (TC) torácica reveló una lesión endobronquial densa en el bronquio del lóbulo superior derecho (media: 220 unidades Hounsfield) y un infiltrado pulmonar separado en la periferia del lóbulo superior derecho. La tomografía por emisión de positrones (PET) confirmó un aumento de la captación en el infiltrado del lóbulo superior derecho y la lesión endobronquial (fig. 1A; SUVmáx 4,3). Se practicó una broncoscopia que mostró una masa no vascular blanda y amarillenta, que obstruía el bronquio del lóbulo superior derecho (fig. 1B). Se barajaron los posibles diagnósticos de cuerpo extraño, lipoma y tumor carcinoide endobronquial.

Cuerpo extraño endobronquial que imitaba una neoplasia maligna pulmonar con tomografía por emisión de positrones positiva

Un varón de 59 años de edad y fumador importante acudió por presentar tos no productiva de 6 meses de evolución. La tomografía computarizada (TC) torácica reveló una lesión endobronquial densa en el bronquio del lóbulo superior derecho (media: 220 unidades Hounsfield) y un infiltrado pulmonar separado en la periferia del lóbulo superior derecho. La tomografía por emisión de positrones (PET) confirmó un aumento de la captación en el infiltrado del lóbulo superior derecho y la lesión endobronquial (fig. 1A; SUVmáx 4,3). Se practicó una broncoscopia que mostró una masa no vascular blanda y amarillenta, que obstruía el bronquio del lóbulo superior derecho (fig. 1B). Se barajaron los posibles diagnósticos de cuerpo extraño, lipoma y tumor carcinoide endobronquial.

Precipitation of ventricular bigeminy by DMSO during autologous haematopoietic stem cell transplantation

A 69-year-old man with a history of multiple myeloma, peripheral neuropathy and intermittent palpitations presented to the infusion suite for an autologous peripheral blood stem cell transplant (PBSCT) after receiving 2 days of melphalan conditioning. Two months prior to presentation, he had completed nine cycles of lenalidomide, dexamethasone and bortezomib. For his palpitations, he had undergone 24-h Holter monitoring a day prior to presentation. Approximately 121 000 beats were recorded, with heart rates ranging from 61 to 123 (mean 83) beats per minute, which included 2133 (1·76%) supraventricular ectopics, 2 runs of supraventricular tachycardia, 773 (0·64%) ventricular premature depolarisations and 9 runs of ventricular bigeminy. He had no history of coronary artery disease, heart failure, chronic lung disease, renal or liver dysfunction. A comprehensive echocardiogram done 3 weeks prior to presentation was only notable for grade 1/4 left ventricular diastolic dysfunction. A 12-lead electrocardiogram (ECG) done 3 weeks prior to presentation showed sinus rhythm with first degree atrioventricular nodal block (PR interval 222 ms). During PBSCT infusion, the patient was noted to be bradycardic on the fingertip pulse rate monitor. The medical emergency response team was summoned, at which point the authors evaluated the patient. He denied chest pain, palpitations, lightheadedness, dizziness, abdominal pain, nausea, vomiting, tinnitus, dyspnoea or cough. His weight was 87·1 kg, temperature was 36·2 ∘C (97·2 ∘F), peripheral pulse was 47 beats per minute, blood pressure was 137/78 mmHg, respirations were 16 per minute and oxygen saturation was 99% on room air. He had been pre-medicated with hydrocortisone