Background
The size of abnormal parathyroid glands in patients with primary hyperparathyroidism is highly variable, but the clinical significance of giant glands is unknown.
Methods
300 consecutive patients were reviewed following parathyroidectomy for primary hyperparathyroidism. We compared patients with giant parathyroid adenomas (weight ≥95th percentile) with the remaining patients.
Results
Giant adenomas were defined as weight ≥95th percentile or 3.5 grams (median 0.61 g, range 0.05–29.93). Patients with giant adenomas had a higher mean preoperative calcium level, higher mean parathyroid hormone level, and were less likely to have multiglandular or symptomatic disease. Giant adenomas were successfully localized on imaging in 87% of patients, which was not significantly increased over other patients (82%). There were no differences between the groups in age, gender, gland location, or the incidence of persistent or recurrent hyperparathyroidism. Finally, giant glands had an increased incidence of symptomatic post-operative hypocalcemia including one patient who required rehospitalization following removal of a giant gland.
Conclusions
Giant parathyroid adenomas have a distinct presentation characterized by single gland disease and lower incidence of symptoms despite increased levels of calcium and parathyroid hormone. Additionally, following resection of a giant adenoma, patients are more likely to develop symptomatic hypocalcemia.
Purpose
To describe current practice of ventilation in a modern air medical system, and to measure the association of ventilation strategy with subsequent ventilator care and acute respiratory distress syndrome (ARDS).
Materials and Methods
Retrospective observational cohort study of intubated adult patients (n=235) transported by a university-affiliated air medical transport service to a 711-bed tertiary academic center between July 2011 and May 2013. Low tidal volume ventilation was defined as tidal volumes ≤ 8 mL/kg predicted body weight (PBW). Multivariable regression was used to measure the association between prehospital tidal volume, hospital ventilation strategy, and ARDS.
Results
Most patients (57%) were ventilated solely with bag-valve ventilation during transport. Mean tidal volume of mechanically ventilated patients was 8.6 mL/kg PBW (SD 0.2 mL/kg). Low tidal volume ventilation was used in 13% of patients. Patients receiving low tidal volume ventilation during air medical transport were more likely to receive low tidal volume ventilation in the emergency department (p < 0.001) and intensive care unit (p = 0.015). ARDS was not associated with pre-hospital tidal volume (p = 0.840).
Conclusions
Low tidal volume ventilation was rare during air medical transport. Air transport ventilation strategy influenced subsequent ventilation, but was not associated with ARDS.
End-tidal CO has been advocated to improve safety of emergency department (ED) procedural sedation by decreasing hypoxia and catastrophic outcomes. This study aimed to estimate the cost-effectiveness of routine use of continuous waveform quantitative end-tidal CO monitoring for ED procedural sedation in prevention of catastrophic events. Markov modeling was used to perform cost-effectiveness analysis to estimate societal costs per prevented catastrophic event (death or hypoxic brain injury) during routine ED procedural sedation. Estimates for efficacy of capnography and safety of sedation were derived from the literature. This model was then applied to all procedural sedations performed in US EDs with assumptions selected to maximize efficacy and minimize cost of implementation. Assuming that capnography decreases the catastrophic adverse event rate by 40.7% (proportional to efficacy in preventing hypoxia), routine use of capnography would decrease the 5-year estimated catastrophic event rate in all US EDs from 15.5 events to 9.2 events (difference 6.3 prevented events per 5 years). Over a 5-year period, implementing routine end-tidal CO monitoring would cost an estimated $2,830,326 per prevented catastrophic event, which translates into $114,007 per quality-adjusted life-year. Sensitivity analyses suggest that reasonable assumptions continue to estimate high costs of prevented catastrophic events. Continuous waveform quantitative end-tidal CO monitoring is a very costly strategy to prevent catastrophic complications of procedural sedation when applied routinely in ED procedural sedations.
Study Objectives: The purpose of this study was to investigate the effect of common sources of infection on outcome in patients with severe sepsis and septic shock in the emergency department (ED).Methods: We conducted a retrospective observational study involving adult patients who were diagnosed with severe sepsis or septic shock in the ED of a tertiary care hospital during the period between August 2008 and March 2012. We categorized patients into four groups based on source of infection (pneumonia, intra-abdominal infection [IAI], urinary tract infection [UTI], and other sources [OS] group). The primary outcome was in-hospital mortality. Multivariable logistic regression analysis was used to adjust potential confounders including age, sex, serum lactate concentrations, the Sequential Organ Failure Assessment score, timely antibiotic use, and achievements of early resuscitation targets.Results: A total of 758 patients were included and overall in-hospital mortality was 16.6%. There were significant differences in mortality between four groups (27.5% for pneumonia, 12.1% for IAI, 2.6% for UTI, and 20.0% for other sources, P<0.01). In patients with IAI, adjusted odds ratios (ORs) for mortality were 0.53 (95% confidence interval [CI], 0.29 -0.98) compared with the OS group and 0.57 (95% CI, 0.36 -0.92) compared with non-IAI. For UTI, adjusted ORs were 0.07 (95% CI, 0.02 -0.28) compared with the OS group and 0.08 (95% CI, 0.02 -0.30) compared with non-UTI. For pneumonia, adjusted ORs were 1.52 (95% CI, 0.84 -2.76) compared with the OS group and 2.86 (95% CI, 1.80 -4.53) compared with non-pneumonia.Conclusions: Our study showed that source of infection was independently associated with in-hospital mortality in patients with severe sepsis and septic shock in the ED. In particular, UTI and IAI were significantly associated with in-hospital survival. Patients with pneumonia showed significantly higher mortality, compared with non-pneumonia patients.
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