We studied three children with severe forms of meningo coccic sepsis and intravascular coagulation having exten sive cutaneous necrosis during their acute illness. After 1 year, two of them showed epiphysiometaphyseal abnormal ities limited to the lower limbs with bowing of the legs and secondary dwarfism. In the third case, bilateral abnonmali ties appeared 4 months after the sepsis and involved the distal tibia, fibula, and talus, as well as the left tansal navic ular. These lesions are extremely rare and to our knowledge have not been reported previously. Case ReportsCase 1 A 7-month-oldboywasadmittedbecauseof 5 hr of restlessness and high fever. He was pale and responded only to painful stimuli.His temperature was 39.5°C; blood pressure, 75/30 mm Hg; white blood cell count, 3,000/mm3; platelets, 30,000/mm3; prothrombin time, 32%; hemoglobin, 1 1 g/dl; and hematocnit, 33%. A spinal puncture showed cloudy cerebrospinalfluid with 70 cells/mm3, 60% of which were neutrophils. In stained smears and cultures, Neisseria meningitidis was isolated.At 2 hr after admission extensive ecchymosis and petechiae appeared and the patient went into shock, recovering after intensive therapy. During his hospital stay, extensive skin necrosis required grafts,as well as amputationof severalphalangesof both hands. Case 2A 9-month-oldboy was admittedafter 12 hr of high fever and obtundation.Petechiaebegan developing3 hr before admission and on admission he was in shock with extensive ecchymosis and petechiae. His liver was palpable 6 cm below the costal margin. His neck was supple. His temperature was 38.5°C;hemoglobin, 11.5 gm/dI; hematocrit, 36%; white blood cell count, 1,25O/mm3; plate lets, 30,000/mm3; and prothrombin time, 14%. His cerebrospinal fluid wascloudyandcontained25 cells/mm3,mostof themneutro phils. In smears and cultures Neisseria meningitidis was isolated.Duringhis hospitalcourse, the extensivecutaneousnecrosisre quired skin grafts and amputation of several phalanges of hands and feet.At 1½ years after dischargehe developedlimpingon the left. Case 3A 4-year-old girl was admitted aften 1 day of vomiting, lethargy, fever of 39°C, and pallor. On admissionshe had extensivepete chiae and nuchal rigidity. Her blood pressure was 70/40 mm Hg; white blood cell count, 3,000/mm3; platelets, 30,000/mm3; pro thnombin time, 32%; hemoglobin, 8.1 g/dI; and hematocrit, 27%.Her cerebrospinal fluid was cloudy and contained100 cells/mm3, most of them neutrophils. In stained smears and cultures, Neisseria meningitidis was isolated. During her hospital stay she had exten sive hemorrhagicnecrosisof the skin, affecting mainlythe lower extremities. She also had pain in both knees and ankles. Radio graphswereunremarkableat that time.At 4 months after discharge she was seen with flexion deformity of the right knee and talipes equinovarus deformity of the feet. Aadiography showed mild irregularities of the distal tibial epiphy siometaphyseabareas but there was necrosis of the lateral aspect of the talar domes( fig. 3). Necrosisof the lef...

The rate of VTE in critically ill medical patients remains high despite standard chemoprophylaxis. Obesity is among 8 risk factors independently associated with 90-day VTE.

Crit Care Med 2014 • Volume 42 • 12 (Suppl.) oxygenation and ventilation, using DLT and a bronchial blocker provides isolation of the diseased lung, while using the rest to maintain adequate gas exchange. This method can be useful in managing patients with respiratory failure and pneumothorax where less invasive methods are insufficient.Learning Objectives: Ibogaine is a naturally occurring alkaloid with hallucinogenic and psychedelic effects. It is classified as a schedule I controlled substance in the U.S., but is available in several countries and may also be purchased through the internet. It is promoted as an antiaddiction medication, but safety concerns include the risk of cardiac arrhythmias; the mechanism of which is unclear but may involve inhibition of hERG potassium or sodium channels. This case involved a 40 year old female with a history of cocaine and heroin abuse taking ibogaine to help decrease drug cravings. EMS was called when the patient was found unresponsive at home. Naloxone 1 mg was administered en route resulting in slight arousal and agitation. Upon arrival to the emergency department, the patient had continued agitation and received lorazepam 2 mg IV and haloperidol 5 mg IV. Shortly after, the patient became bradycardic and developed an episode of nonsustained ventricular tachycardia (VT) which selfresolved. A brief generalized tonic-clonic seizure ensued and the patient was subsequently intubated. Multifocal premature ventricular contractions (PVCs) were observed on telemetry and the patient was given 2 g of IV magnesium sulfate with resolution of PVCs. EKG results revealed a prolonged QTc interval of 599 msec and initial labs had notable derangements of serum magnesium (1.1 mg/ dL) and potassium (3.4 mEq/L). 10 hours after admission, the patient went into cardiac arrest due to polymorphic VT consistent with torsade de pointes. Chest compressions were performed with ROSC with sinus rhythm. An EKG revealed a prolonged QTc interval of 601 msec and 2 g of IV magnesium sulfate was administered. Over the 6-day admission, the patient's QTc trended downward with no further cardiac issues. The etiology of torsade de pointes is attributed to ibogaine use, concomitant haloperidol administration, and electrolyte abnormalities. This case correlates long-QT syndrome and torsade de pointes with the use of ibogaine, a compound being actively evaluated for its potential to treat substance addiction.

Introduction: Obesity increases the risk of venous thromboembolism (VTE) in hospitalized medical patients. Standard chemoprophylaxis in these patients may be suboptimal, potentially leading to increased VTE. The objective of this study was to compare the rate of VTE in obese (body mass index [BMI] ≤30 kg/m 2 ) medical patients receiving standard VTE prophylaxis with rates in non-obese patients (BMI 17-29.9 kg/m 2 ). Hypothesis: Obese patients will suffer from a higher incidence of VTE within 90 days of hospitalization. Methods: In a single-center retrospective cohort study, patients admitted to all medical units between November 2007 and November 2013 were evaluated for eligibility if they received an initial dose of VTE prophylaxis within 48 hours of admission. Appropriate prophylaxis was heparin 5000 units subcutaneously (SQ) every 8 to 12 hours or enoxaparin 30 mg SQ twice daily or 40 mg SQ once daily. Exclusion criteria included hypercoagulable states, therapeutic anticoagulation, and admission for trauma or surgery. The primary outcome was 90 day VTE defined as deep vein thrombosis or pulmonary embolism using ICD-9 codes. Secondary outcomes included in-hospital VTE, 30 day VTE, and 90 day mortality. Univariate and multivariate analyses were used in calculating p-values and odds ratios (OR) for the primary outcome. Results: There were 17,525 patients eligible for inclusion. The final cohort included 4,237 obese patients and 4,990 non-obese patients (median BMI 36 and 25 kg/m 2 , respectively). Obesity increased the risk of in-hospital VTE (5.6% vs. 4.4%; p=0.01), 30 day VTE (5.7% vs. 4.6%; p=0.013), and 90 day VTE (5.9% vs. 4.8%; p=0.028) on univariate analysis. However, using multiple logistic regression, obesity was not an independent predictor of 90 day VTE (OR 1.0; p=0.83). Variables which independently increased 90 day VTE were Charlson Comorbidity Index (OR 1.09; p=0.003), prior VTE (OR 36.35; p<0.001), congestive heart failure (OR 1.33; p=0.017), and surgery in 90 days following admission (OR 1.56; p=0.004). Mortality was lower at 90 days in obese patients (3.3% vs. 6.3% non-obese; p<0.001) Conclusions: The incidence of VTE at 90 days in hospitalized medical patients is significant, but it is uncertain if obesity independently contributes to this.

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