AIMTo study the prevalence, characteristics, risk factors and mortality at 28 d of acute-on-chronic liver failure (ACLF).METHODSA total of 100 cirrhotic patients admitted to our hospital for more than one day were included during the period between June 2013 and December 2015. We used the European Association for the Study of the Liver-Chronic Liver Failure-Consortium diagnostic criteria for ACLF, considering it as the acute decompensation of cirrhosis associated with the presence of one or more organ failure. For the diagnosis of organic failure the Chronic Liver Failure-Sequential Organ Failure Assessment score was used. Our population was divided into patients with and without ACLF. Clinical characteristics, presence of precipitating events, potential risk factors for developing ACLF and causes of mortality were analyzed. Mortality at 28 d was evaluated.RESULTSTwenty-nine patients (29%) developed ACLF criteria. Alcoholism, detected in 58 patients (58%), was the major etiological agent of cirrhosis. Bacterial infections were recognized as a precipitating event in 41.3% of cases and gastrointestinal bleeding in 27.5%. No precipitating event was identifiable in 27.5% of patients with ACLF. Comparing patients with and without ACLF, statistically significant risk factors were: Child Pugh score 10.2 ± 2.1 vs 8.4 ± 1.6 (P ˂ 0.0001), MELD score 20.7 ± 8.5 vs 12.3 ± 4 (P ˂ 0.0001), presence of ascites 27 (93%) vs 43 (60.5%) (P = 0.001), leukocytosis 15300 ± 8033 per cubic millimeter vs 10770 ± 5601 per cubic millimeter (P ˂ 0.0001), and high plasma levels of C reactive protein values 50.9 ± ​​46.4 mg/L vs 28.6 ± 23.4 mg/L (P ˂ 0.0019). Mortality rate was 62% (18 patients) vs 5.6% (4 patients), respectively (P < 0.0001).CONCLUSIONWe observed that the ACLF is a frequent entity in this group of patients and has a significantly higher mortality rate.

Patient: Male, 63Final Diagnosis: Cytomegalo virus (CMV) infectionSymptoms: DiarrheaMedication:—Clinical Procedure:—Specialty: Infectious DiseasesObjective:Unusual clinical courseBackground:Coinfection with cytomegalovirus in a patient with Clostridium difficile persistent diarrhea and colitis can lead to a delay in diagnosis and treatment.Case Report:A 63-year-old man with squamous cell carcinoma of the lower lip, status post surgical resection and currently on chemoradiation presented with intractable diarrhea and abdominal pain. Initial workup showed Clostridium difficile diarrhea with pancolitis. Diarrhea persisted despite being on antibiotics and bacteriological cure for C. difficile. Further noninvasive work up revealed associated cytomegalovirus infection, and patient had a dramatic response to ganciclovir without any relapse.Conclusions:Physicians should be cognizant about other causes of diarrhea and colitis in immunocompromised patient when treatment for primary diagnosis fails to resolve their symptoms.

PurposeTo determine the accuracy of knee examination under anesthesia (EUA) and develop a prognostic score for partial anterior cruciate ligament (ACL) tears.Materials and MethodsA total of 229 patients with an ACL injury were included. Knee EUA was performed using the Lachman test, pivot shift test and arthrometric maximum manual side-to-side difference (AMMD) test. The arthroscopic examination is the gold standard for the diagnosis of partial and complete ACL tears, which was compared with EUA findings. Multivariate logistic regression was estimated, and the significant variables were used to develop a predictive score.ResultsThe relative risk for a complete tear with Lachman 2+ was 8.55 (range, 3.5 to 20.7) and 53.04 (range, 6.7 to 417) with Lachman 3+, compared to Lachman 1+. Negative pivot shift was reported in 23 cases in the partial tear group (76.7%) and in 22 in the complete tear group (11.1%). The AMMD was 3.5 mm in the partial tear group and 5.4 mm in the complete tear group (p<0.05). A prognostic score of less than five suggested the presence of a partial ACL tear. The score showed 81.1% sensitivity and 68.7% specificity.ConclusionsPartial ACL tears can be differentiated from complete tears with Lachman test, pivot shift test, and AMMD test.

Background The purpose of this study was to identify nerves at risk when using a minimally invasive plate osteosynthesis precontoured long proximal humerus locking plate and to evaluate the risk of injury to deltoid insertion and brachialis muscle. Methods Ten cadaveric upper limb specimens were used. A transdeltoid anterolateral approach was performed proximally and a second anterior approach was performed distally. A 14-hole “low” long precountored ALPS locking plate (Biomet Trauma; Zimmer Biomet, Warsaw, IN, USA) was used. Subsequently, anatomic dissection to measure the anatomic relationship of the plate with the deltoid insertion, with the brachialis muscle, and with the axillary, radial, and musculocutaneous nerves was performed. Results The mean humeral length was 302 mm (standard deviation 52.3, 99% confidence interval: 259.3-344.6). In 6 specimens, the axillary nerve was located at the level of the third row of holes of the plate; in 3 specimens, at the level of the fourth row; and in one specimen, at the level of the second row. The distance between the plate and the musculocutaneous nerve was on average 10.2 mm (standard deviation 4, 99% confidence interval: 6.9-13.5) and between the plate and the radial nerve was on average 7.9 mm (standard deviation 4.7, 99% confidence interval: 4-11.8). The plate pierced the anterior distal fibers of the deltoid in all specimens. In 8 specimens, no brachialis muscle fibers were located under the plate. Conclusions The use of the long precontoured 14-hole ALPS locking plate with the minimally invasive plate osteosynthesis technique, previously identifying the axillary and musculocutaneous nerves, is feasible; however, the distances between the plate and the nerves remain low, so caution should be maintained. Despite the curved design of the plate, the deltoid insertion is partially compromised in all cases.

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