Sunkaru Touray

Acute inflammatory demyelinating polyradiculopathy in Legionella pneumonia

lomatous, non-eczematous eruptions (Fig. 1). The disposable concentric needle electrodes used in the EMG examination consisted of stainless-steel, platinum, and palladium. Patch testing was performed on the upper back with the German Contact Dermatitis Research Group (DKG) standard series and the DKG dental metal series. Positive reactions to palladium chloride (1.0% pet.) and ammonium tetrachloroplatinate (0.25% pet.) were observed at 72and 168-hour readings. No positive reactions were observed to any of the other 36 test substances. Sensitization may have occurred some years ago, when she wore a platinum piercing in the left eyebrow, which was removed due to persistent local inflammation. EMG and nerve conduction studies with needle electrodes may be associated with iatrogenic complications such as bleeding, infection, nerve injury, pneumothorax, urticaria, and complex regional pain syndrome. Although metal allergies are a well-known problem, they are probably rare after EMG. We could only find a single report of an EMG-associated allergic contact dermatitis, in which nickel could be identified as the allergen. In our patient, clinical signs of a delayed-type hypersensitivity reaction occurred at all needle electrode insertion points. They appeared as painful swelling and subsequent prominent granulomatous eruptions that persisted for several weeks. It is noteworthy that, unlike typical allergic contact dermatitis, the skin lesions were non-eczematous. Allergic reactions to 2 metals contained in the needle electrodes, platinum and palladium, were proven by patch testing. Delayed-type hypersensitivity reactions are T-cell driven and can include several metals due to crossreactivity, as in our patient. Because metal ions are haptens and are considered to be incomplete antigens, protein or peptide binding is needed for immunogenicity. Persistent local inflammation may have facilitated the generation of a metal-specific T-cell response in this patient. Treatment of contact dermatitis includes local steroid therapy and strict allergen avoidance. In conclusion, an allergic contact dermatitis to EMG needle electrodes should be considered in patients with previous sensitization and eczematous skin reactions or atypical granulomatous eruptions.

An assessment of critical care capacity in the Gambia

Purpose: Critical illnesses are a major cause of morbidity and mortality in The Gambia, yet national data on critical care capacity is lacking. Materials and methods: We surveyed eight of the eleven government‐owned health facilities providing secondary and tertiary care in The Gambias public health sector. At each hospital, a designated respondent completed a questionnaire reporting information on the presence of an intensive care unit, the number of critical care beds where available, monitoring equipment, and the ability to provide basic critical care services at their respective hospitals. Results: The response rate was 88% (7/8 hospitals). Only one hospital had a dedicated intensive care unit with eight ICU beds, resulting in an estimated 0.4 ICU beds/100,000 population in the country. All hospitals reported treating more than 50 critically ill patients a month, with trauma, obstetric emergencies, hypertensive emergencies and stroke accounting for the leading causes of admission respectively. The country lacks any trained specialists and resources to diagnose and treat critically ill patients. Conclusions: The Gambia has a very low ICU bed capacity and lacks the human resources and equipment necessary to diagnose and treat the large number of critically ill patients admitted to public hospitals in the country. Highlights What is already known on this topicMost low‐income countries lack any published data on critical care capacity. What this study addsThe Gambia currently has only 1 ICU with 8 beds in the public health system with an estimated 0.4 ICU beds/100,000 population.Critical illnesses account for a large number of adult emergency admissions in Gambian public hospitals with an estimated 3,000 cases annually.Using the World Health Organization target of 1 physician per 1000 population, the physician deficit in The Gambia stands at 1,866 physicians.

PS01.14: Diagnostic Yield in Patients Undergoing Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration: A Single Center Experience: Topic: Pulmonology

Background: Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration (EBUS-TBNA) is an established diagnostic tool in the evaluation of lung cancer with a variable diagnostic yield, ranging from 62 % 93 %. Although the procedure can be performed under moderate sedation (MS) or general anesthesia (GA) , the impact of sedation type on the diagnostic yield has yielded variable results with some authors reporting a higher yield with deep sedation, whereas others note no difference between MS and GA. We present findings of a retrospective study that looked at the diagnostic yield using an artificial airway under GA compared to conscious sedation through a natural airway in patients undergoing EBUS-TBNA. Methods: Demographic information on age, sex, race and co-morbidities were used to compute an age adjusted Charlson Co-morbidity index for each of 88 patients. Pathology reports were reviewed and an EBUS-TBNA was determined to be diagnostic if any of the sampled lymph nodes yielded a diagnosis. Assessment of the impact of using an artificial airway under GA on diagnostic yield was determined using multivariate logistic regression. Continuous variables are presented as means (± SD) and categorical variables are reported as counts and percentages. For all tests, two-sided P values < 0.05 were considered statistically significant. Results: Patients in the GA group were older (65 years versus 57.6, p1⁄4 0.005), had a higher age-adjusted Charlson comorbidity index, (3.7 versus 1.9, p < 0.001) and a higher ASA classification (3 versus 2 p1⁄4 0.004). Average lymph node size was smaller in the artificial airway group (16.2 mm versus 20.7mm, p1⁄4 0.01). Despite these differences, the diagnostic yield was the same (61.4 % in each group). In multivariate analyses, female sex and lymph node size were the only predictors of a diagnostic EBUS-TBNA. OR 3.3, 95 % CI, 1.23 e 9.1 for female gender, (p1⁄4 0.02) and 1.1, 95 % CI, 1.00 e 1.18 for lymph node size (p1⁄4 0.04). Diagnoses made were: adenocarcinoma of the lung 42.6 %, Sarcoidosis 16.7 %, Small cell lung cancer 14.8 %, Squamous cell carcinoma 11.1 %. Conclusion: EBUS-TBNA performed under general anesthesia through an artificial airway was not associated with an increased diagnostic yield, and therefore conscious sedation should be considered where appropriate, with general anesthesia reserved for those patients who are older, and with a higher perioperative risk. More research assessing the determinants of a positive diagnosis including physician pretest likelihood and PET/ CT avidity are needed to improve diagnostic outcomes.

The Evolving Art of Fluid Resuscitation

The maintenance of fluid and electrolyte homeostasis is an important treatment objective during the management of critically ill patients; the association of the administration of resuscitation fluids with attaining hemodynamic stability for patients has led to recommendations for its timely administration for injured, bleeding, burned, hypovolemic and septic patients [1, 2]. During the last centuries resuscitation principles were based on a classical compartmental model eloquently described by Ernst Starling which placed great importance on preserving the plasma oncotic and hydrostatic pressures as a means of restoring intravascular volume. Some of the assumptions of this model are being questioned by recent research findings because studies have found it difficult to demonstrate significant differences of plasma oncotic pressure (COP) among septic and non-septic patients [3, 4]. Additionally, measures of COP has not been robustly associated with clinical outcomes of critically ill patients and randomized trials of the infusion of HES or plasma substitutes to restore intravascular volume have not consistently demonstrated clinical benefit for disease states including hypoalbuminemia [5, 6] acute respiratory distress syndrome [7] and pulmonary edema [8]. Research exploring novel concepts of fluid physiology culminated in the identification of an endothelial glycocalyx layer (EGL) on the luminal aspect of the vascular endothelium [9]. This layer is now recognized as a major determinant of membrane permeability and it can be disrupted by mediators that are known to be present during sepsis, trauma, diabetes and surgery [10-12]. The combined Starling-Endothelial glycocalyx model appears to better account for the clinical responses to fluid resuscitation.

Cost-effectiveness of Fluid Resuscitation of Critically Ill Adults: New Insights From Uncharted Territory

The importance of resuscitation for surviving critical illness and injury has long been recognized and is now a standard and integral part of critical care practice. Our approach to resuscitation has evolved over the past century, encouraged by intense research efforts that have led to clinical trials of alternative resuscitation fluids including hydroxyethyl starch (HES). One of the key understudied aspects of resuscitation is its effect on the duration of illness or injury in relation to the costs of care. It is estimated that each year, 20 to 30 million patients worldwide will receive resuscitation as part of their care. For an integral aspect of commonly delivered care, there is considerable variation in clinical practice regarding the choice of fluid, in part influenced by product availability, local preferences, and costs.

Legionella pneumophila cases in a community hospital: A 12-month retrospective review

Background: Legionella pneumonia has long been recognized as an important cause of community-acquired pneumonia associated with significant morbidity and mortality; however, the description of the incidence of this disease is restricted to sporadic cases in the literature. With the advent of an inexpensive and rapid urine antigen test, routine testing has become more common. We report findings of a retrospective review of 266 patients who were admitted with a clinical diagnosis of community-acquired pneumonia over a 12-month period and were tested for Legionella pneumophila serogroup 1, reporting the prevalence and determinants of Legionella infection. Methods: Chart reviews of 266 patients admitted for community-acquired pneumonia and who underwent urine antigen testing for Legionella pneumophila during a 1-year time period were conducted, looking at demographic information as well as clinical and laboratory presentation, reporting on the prevalence and determinants of urine antigen positivity using multivariate logistic regression analysis. Results: Legionella pneumophila serogroup 1 was found in 2.3% of cases of community-acquired pneumonia. We also found that altered mental status, diarrhea, history of lung disease, and alcohol intake were significantly associated with pneumonia associated with Legionella. The presence of these four factors had a low sensitivity in predicting Legionella infection (33%); however, they had a positive predictive value of 98%, with a specificity of 100. All the Legionella-infected patients in our study required admission to the intensive care unit, and one of them developed Guillain–Barré syndrome, which to our knowledge represents the only reported case of this syndrome related to Legionella infection in an adult in the English scientific literature. Conclusion: Legionella pneumophila serogroup 1 is a common cause of sporadic cases of community-acquired pneumonia associated with a high morbidity and protean manifestations. Clinical features have a poor sensitivity in identifying cases, and routine urine antigen testing in patients with suggestive clinical symptoms appears to be a rational approach in the evaluation of community-acquired pneumonia.