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We propose an original method of postmortem computed tomography angiography of the body of a deceased newborn. The work is based on the analysis of the results of comprehensive postmortem computed tomography and pathological examination of 30 newborns, who died from congenital malformations. The key to a full-fledged postmortem radiation study using intravascular contrasting of deceased newborns and infants is the presence of vascular catheters established during life, as well as conducting it no earlier than 12 h and no later than 48 h after death. As a contrast agent, we recommend to use an iodine-containing water-soluble radiopaque drug containing at least 250 mg of iodine per 1 ml. The volume of contrast agent is calculated based on body weight, taking into account the general edema syndrome. The introduction of a contrast agent is carried out through vascular catheters in 3 stages in various positions of the body. The analysis of tomograms and 3D-reconstruction of blood vessels using their pseudocoloring allows accurate assessment of the topography of blood vessels with the possibility of separate study of the arterial and venous vessels, and to identify both congenital abnormalities of the heart and blood vessels, and their acquired pathology. CT angiography in some cases is superior to traditional autopsy in the diagnosis of blood vessel pathology. Postmortem CT angiography should be considered as an important stage of postmortem radiology in the structure of comprehensive pathological analysis of newborns and infants.

Background: Recent studies demonstrate that the edema index (ECW/TBW) may be a significant predictor of poor outcomes as a composite of overhydration and protein-energy wasting. There is no consensus regarding ECW/TBW cut-off values. We aimed to determine the performance of ECW/TBW in all-cause mortality prediction and to establish certain cut-off values in patients on chronic hemodialysis., Methods: Body composition of 158 hemodialysis patient was performed by using InBody S10 (Biospace, Seoul, Korea) analyzer. Demographic profile and laboratory data were collected. Subjective Global Assessment Scale (SGA) was used to assess nutrition status. In the mean follow up of 3.5 ± 1.15 years, two independent clinicians evaluated death cases and factors for all-cause mortality were established. Statistical analysis was performed with R software., Results: 73 of 158 hemodialysis patients were on kidney transplant waiting list. Mean age of study subjects was 53.6 ± 15.1 years, 51.9% were females, and 13.9% had diabetes. During the follow-up period, 17.72% of patients died. They had significantly higher ECW/TBW values 0.393 vs 0.408, p < 0.001. Subjects with lower edema index had better nutrition according to SGA (SGA A 0.391; SGA B 0.400; SGA C 0.413; p < 0.001). The calculated ECW/TBW cut-off point for all-cause mortality was 0.4055, with sensitivity of 84.6%, specificity of 69.8%. On the other hand, the cut-off point for SGA scores B and C was 0.396 with sensitivity of 72.7% and specificity of 68.7%., Conclusion: The manufacturer provided ECW/TBW cut-off point of 0.400 should be addressed carefully, because it varies depending on the selected outcome and population studied. InBody ECW/TBW reference values from 0.390 to 0.410 are the most promising in hemodialysis population to assess all-cause mortality, nutrition status and body composition., Competing Interests: Conflicts of interest All authors declared no conflict of interest., (Copyright © 2019 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.)

Background and Aim: The prognosis of cirrhotic patients with hepatic edema is poor. Although several short-term predictors of tolvaptan (novel diuretic agent) treatment for such patients have been reported, the factors related to long-term survival are still unclear., Methods: Among 459 patients with hepatic edema enrolled in a retrospective, multicenter collaborative study, we analyzed 407 patients who received tolvaptan., Results: Patients consisted of 266 men and 141 women, with the median age of 68 years (range, 28-93 years). The frequency of short-term responders to tolvaptan was 59.7% (243/407). In the Cox regression analysis, short-term response to tolvaptan, low average dosages of furosemide and spironolactone during tolvaptan treatment, Child-Pugh classification A and B, and absence of hepatocellular carcinoma were independent factors contributed to 1-year survival. The 1-year and long-term cumulative survival rates in short-term responders were significantly higher than those in non-responders (P = 0.011 and 0.010, respectively). Using a receiver operating characteristic curve analysis, the optimal cut-off values of average daily dosages of furosemide and spironolactone for predicting 1-year survival were 19 and 23 mg/day, respectively. The long-term cumulative survival rates in patients who received a mean dosage of spironolactone < 23 mg/day during tolvaptan treatment were significantly higher than those receiving a mean dosage of ≥ 23 mg/day (P = 0.001)., Conclusions: The present study suggests that the short-term response to tolvaptan and low dosages of conventional diuretics during tolvaptan treatment might improve the 1-year and long-term survival rates in cirrhotic patients with hepatic edema., (© 2019 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Background: Despite a reduction of child mortality in low-income countries, acutely ill undernourished children still have an elevated risk of death. Those at highest risk are children with severe acute malnutrition (SAM) who often show metabolic dysregulation that remains poorly understood., Objective: We performed a pilot study to examine changes in urinary organic acids during nutritional rehabilitation of children with SAM, and to identify metabolites associated with the presence of edema or with mortality., Methods: This study included 76 children aged between 6 and 60 months, hospitalized for SAM at the Moyo Nutritional Rehabilitation and Research Unit in Blantyre, Malawi. Urine was collected at admission and 3 days after clinical stabilization and metabolomics were performed using gas chromatography-mass spectrometry. Metabolite concentrations were evaluated with both uni- and multivariate approaches., Results: Most metabolites increased 3 days after clinical stabilization, and total urinary concentration changed from 1.2 mM (interquartile range [IQR], 0.78-1.7) at admission to 3.8 mM (IQR, 2.1-6.6) after stabilization ( P < .0001). In particular, 6 metabolites showed increases: 3-hydroxybutyric, 4-hydroxyhippuric, p -hydroxyphenylacetic, oxoglutaric, succinic, and lactic acids. Urinary creatinine was low at both time points, but levels did increase from 0.63 mM (IQR, 0.2-1.2) to 2.6 mM (IQR,1.6-4.4; P < .0001). No differences in urinary profiles were found between children who died versus those who survived, nor between children with severe wasting or edematous SAM., Conclusions: Total urinary metabolites and creatinine increase after stabilization and may reflect partial recovery of overall metabolism linked to refeeding. The use of urinary metabolites for risk assessment should be furthered explored., Trial Registration: TranSAM study (ISRCTN13916953).

Background: The relationship between longitudinal clinical congestion pattern and heart failure outcome is uncertain. This study was designed to assess the prevalence of congestion over time and to investigate its impact on outcome in chronic heart failure., Methods: A total of 588 patients with chronic heart failure older than 60 years of age with New York Heart Association (NYHA) functional class ≥II from the TIME-CHF study were included. The endpoints for this study were survival and hospitalization-free heart failure survival. Orthopnea, NYHA ≥III, paroxysmal nocturnal dyspnea, hepatomegaly, peripheral pitting edema, jugular venous distension, and rales were repeatedly investigated and related to outcomes. These congestion-related signs and symptoms were used to design a 7-item Clinical Congestion Index., Results: Sixty-one percent of patients had a Clinical Congestion Index ≥3 at baseline, which decreased to 18% at month 18. During the median [interquartile range] follow-up of 27.2 [14.3-39.8] months, 17%, 27%, and 47% of patients with baseline Clinical Congestion Index of 0, 1-2, and ≥3 at inclusion, respectively, died (P <.001). Clinical Congestion Index was identified as an independent predictor of mortality at all visits (P <.05) except month 6 and reduced hospitalization-free heart failure survival (P <.05). Successful decongestion was related to better outcome as compared to persistent congestion or partial decongestion (log-rank P <0.001)., Conclusions: The extent of congestion as assessed by means of clinical signs and symptoms decreased over time with intensified treatment, but it remained present or relapsed in a substantial number of patients with heart failure and was associated with poor outcome. This highlights the importance of appropriate decongestion in chronic heart failure., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Introduction: Most household and body soaps have an alkaline pH (9-12). In addition to their foaming effect, they irritate the skin. This study aims to review soap exposure reported to the Angers Poison Control Centre., Method: A retrospective study of accidental or deliberate oral exposure to solid soaps reported to the Angers Poison Control Centre between 1 January 2000 and 1 April 2015. Poisoning severity was reassessed for each case according to the Poisoning Severity Score (PSS)., Results: 553 cases of exposure were recorded. In more than 40% of cases (n = 226), exposure occurred in community settings (retirement homes, nursing homes). Patients had a history of dementia in 220 cases (40%). The most common symptoms were labial oedema (28%, n = 153), oropharyngeal irritation (10%, n = 56), salivation (10%, n = 53), vomiting (9%, n = 48) and cough (8%, n = 45). Among symptomatic patients (n = 276), one patient died from aspiration pneumonia and one patient died from a cardiogenic shock following oropharyngeal oedema, vomiting, cough and bronchial obstruction. Patients with dementia were more often symptomatic (75% vs 34%, p < .001) and more frequently hospitalised (22% vs 0.8%, p < .001). They experienced more moderate to severe symptoms (8% vs 0%, p < .001). Mildly severe (PSS2, n = 14), highly severe (PSS3, n = 1) and fatal (PSS4, n = 2) poisoning were observed only in patients with dementia., Conclusion: Ingestion of soap bars is potentially serious, especially in patients with dementia. This type of soap should not be available to them in community settings and close monitoring should be considered in the event of oral exposure.

Background: Fluid overload and interdialytic weight gain (IDWG) are discrete components of the dynamic fluid balance in haemodialysis patients. We aimed to disentangle their relationship, and the prognostic importance of two clinically distinct, bioimpedance spectroscopy (BIS)-derived measures, pre-dialysis and post-dialysis fluid overload (FOpre and FOpost) versus IDWG., Methods: We conducted a retrospective cohort study on 38 614 incident patients with one or more BIS measurement within 90 days of haemodialysis initiation (1 October 2010 through 28 February 2015). We used fractional polynomial regression to determine the association pattern between FOpre, FOpost and IDWG, and multivariate adjusted Cox models with FO and/or IDWG as longitudinal and time-varying predictors to determine all-cause mortality risk., Results: In analyses using 1-month averages, patients in quartiles 3 and 4 (Q3 and Q4) of FO had an incrementally higher adjusted mortality risk compared with reference Q2, and patients in Q1 of IDWG had higher adjusted mortality compared with Q2. The highest adjusted mortality risk was observed for patients in Q4 of FOpre combined with Q1 of IDWG [hazard ratio (HR) = 2.66 (95% confidence interval 2.21-3.20), compared with FOpre-Q2/IDWG-Q2 (reference)]. Using longitudinal means of FO and IDWG only slightly altered all HRs. IDWG associated positively with FOpre, but negatively with FOpost, suggesting a link with post-dialysis extracellular volume depletion., Conclusions: FOpre and FOpost were consistently positive risk factors for mortality. Low IDWG was associated with short-term mortality, suggesting perhaps an effect of protein-energy wasting. FOpost reflected the volume status without IDWG, which implies that this fluid marker is clinically most intuitive and may be best suited to guide volume management in haemodialysis patients.

Background: Prognosis in light-chain (AL) and transthyretin (ATTR) amyloidosis is influenced by cardiac involvement. ATTR amyloidosis has better prognosis than AL amyloidosis despite more amyloid infiltration, suggesting additional mechanisms of damage in AL amyloidosis., Objectives: The aim of the study was to assess the presence and prognostic significance of myocardial edema in patients with amyloidosis., Methods: The study recruited 286 patients: 100 with systemic AL amyloidosis, 163 with cardiac ATTR amyloidosis, 12 with suspected cardiac ATTR amyloidosis (grade 1 on 99m Tc-3,3-diphosphono-1,2-propanodicarboxylic acid), 11 asymptomatic individuals with amyloidogenic TTR gene mutations, and 30 healthy volunteers. All subjects underwent cardiovascular magnetic resonance with T1 and T2 mapping and 16 underwent endomyocardial biopsy., Results: Myocardial T2 was increased in amyloidosis with the degree of elevation being highest in untreated AL patients (untreated AL amyloidosis 56.6 ± 5.1 ms; treated AL amyloidosis 53.6 ± 3.9 ms; ATTR amyloidosis 54.2 ± 4.1 ms; each p < 0.01 compared with control subjects: 48.9 ± 2.0 ms). Left ventricular (LV) mass and extracellular volume fraction were higher in ATTR amyloidosis compared with AL amyloidosis while LV ejection fraction was lower (p < 0.001). Histological evidence of edema was present in 87.5% of biopsy samples ranging from 5% to 40% myocardial involvement. Using Cox regression models, myocardial T2 predicted death in AL amyloidosis (hazard ratio: 1.48; 95% confidence interval: 1.20 to 1.82) and remained significant after adjusting for extracellular volume fraction and N-terminal pro-B-type natriuretic peptide (hazard ratio: 1.32; 95% confidence interval: 1.05 to 1.67)., Conclusions: Myocardial edema is present in cardiac amyloidosis by histology and cardiovascular magnetic resonance T2 mapping. T2 is higher in untreated AL amyloidosis compared with treated AL and ATTR amyloidosis, and is a predictor of prognosis in AL amyloidosis. This suggests mechanisms additional to amyloid infiltration contributing to mortality in amyloidosis., (Copyright © 2018 American College of Cardiology Foundation. All rights reserved.)

Introduction: The extremity edema of advanced disease is a common, multifactorial feature, which impairs patients' activities and quality of life. The most frequently chosen management is based on combined decongestive physiotherapy or pharmacotherapy (with diuretics or steroids). Subcutaneous lymphatic drainage in refractory edema may decrease the swelling, prevent spontaneous lymphorrhea, but also increase the risk of infection. Safe and effective conservative management in diuretics-resistant edemas is lacking. The objective of this prospective, observational study was to assess the effectiveness and tolerability of combined physiotherapeutic and diuretic therapy in edemas refractory to parenteral diuretics., Methods: A group of 19 patients with advanced disease and severe bilateral leg edema resistant to parenteral diuretic therapy were treated for three days with a combination of multilayer short-stretch compression bandaging and furosemide in hypersaline intravenous infusion., Results: A clinically meaningful decrease in mean limb volume (of 1.52 L; 20.6%; P < 0.0001)-strongly correlating with patients' weight loss (ρ = 0.71; P = 0.0001), with a lowering of the intensity of complaints-was achieved. The treatment was well tolerated, without decreasing the performance status in any patient. Stable levels of blood pressure, laboratory kidney profile (potassium, sodium, creatinine clearance), and serum albumin were observed. Maintenance of the achieved results with a good compliance was seen during an informal follow-up at the hospice., Conclusion: The combination of compression therapy with hypersaline diuretics could be considered as a valuable option for refractory cases of limb edema in advanced disease., (Copyright © 2017 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Objective: To describe our experience implementing decompressive hemicraniectomy (DH) for eligible patients with malignant middle cerebral artery (MCA) infarcts., Methods: We retrospectively collected data of malignant MCA infarction patients requiring DH at King Abdulaziz University Hospital & King Faisal Specialist Hospital & Research Center, Jeddah, Kingdom of Saudi Arabia between October 2010 and July 2015. Clinical outcome was assessed immediately postoperatively using Glasgow Coma Score (GCS), and at 12 months using the modified Rankin scale (mRS) and Barthel index. Survival was evaluated at thirty-days and one year after surgery., Results: Six out of 10 patients diagnosed with malignant MCA infarction underwent DH. Among the surgically treated patients (n=6), 4 were males (66%), and the median age was 22.5 years. The median time from admission to surgery was 35.5 hours. The median post-operative GCS was 6.5. Three patients (50%) died within 30 days of DH. In those who survived, the median mRS was 4.5 and BI was 7.5., Conclusion: Decompressive hemicraniectomy saves life and has the potential of improving survival functional outcome when done fast and in carefully selected patients. We call for national awareness of the management of such cases and early intervention.

Objective: To characterize the clinical and epidemiological profiles of patients with visceral leishmaniasis (VL) treated with liposomal amphotericin B (LAmB) and to identify prognostic factors for death from VL in 2008-2012 in the state of Minas Gerais, Brazil., Methods: A historical cohort study was conducted using data obtained from treatment requests forms, Brazilian Notifiable Disease Information System and the Mortality Information System. Case-fatality rates of patients with VL treated with LAmB were compared with patients treated with other therapies. Logistic regression analysis was used to identify prognostic factors for death., Results: The overall case-fatality rate of the 577 patients treated with LAmB was 19.4%. Prognostic factors for death from VL were age between 35 and 49 years (OR 2.7; 95% CI 1.3-5.4) and above 50 years (OR 2.6; 95% CI 1.3-4.9), jaundice (OR 2.2; 95% CI 1.2-3.7), kidney disease (OR 2.8; 95% CI 1.6-4.9), presence of other infections (OR 2.4; 95% CI 1.5-4.1), edema (OR 2.0; 95% CI 1.1-3.4), platelet count below 50.000/mm3 (OR 3.6; 95% CI 2.1-6.0), AST higher than 100 U/L (OR 2.2; 95% CI 1.3-3.8), and assistance in non-specialized institutions (OR 1.9; 95% CI 1.0-3.5)., Conclusions: Case-fatality rates were higher than that observed among patients with VL treated with other therapies. Identification of prognostic factors of death from VL may allow early diagnosis of patients prone to such outcome and prompt an expeditious and appropriate management of VL to reduce fatality rates., (© The Author 2017. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Proper monitoring for volume overload is important to improve prognosis in peritoneal dialysis (PD) patients. The association between volume status and residual renal function (RRF) remains an unresolved issue. The aim of the present study was to evaluate the association between the edema index and survival or RRF in incident PD patients., Patients and Methods: We identified all adults who underwent PD. The edema index was defined as the ratio of extracellular fluid to total body fluid. Participants with available data regarding survivorship or non-survivorship during the first year after PD initiation were included in the area under the receiver operating characteristic curve analysis. The cutoff value of the edema index for 1-year mortality was >0.371 in men and >0.372 in women. Participants were divided into two groups according to the cutoff value of their baseline edema indices: High (>cutoff value) and Low (≤ cutoff value). Survivors during the first year after PD initiation were divided into two groups according to the initial and 1-year edema index: Non-improvement (maintenance of criteria in the initial Low group during the year) and Other (all participants except those in the Non-improvement group)., Results: In total, 631 patients were enrolled in the present study. The cutoff value of the edema index for 1-year mortality was >0.371 in men and >0.372 in women. The respective mean initial RRF values (mL · min(-1) · 1.73 m(-2)) in the Low and High groups, respectively, were 4.88 ± 4.09 and 4.21 ± 3.28 in men (P = 0.108), and 3.19 ± 2.57 and 2.98 ± 2.70 in women (P = 0.531). There were no significant differences between groups in either sex. The respective mean RRF values at 1 year after PD initiation in the Low and High groups, respectively, were 3.56 ± 4.35 and 2.73 ± 2.53 in men, and 2.80 ± 2.36 and 1.85 ± 1.51 in women. RRF at 1 year after PD initiation was higher in the Low group than in the High group (men: P = 0.027; women: P = 0.001). In men, the cumulative 5-year survival rates were 78.7% and 46.2% in the Low and High groups, respectively, whereas in women, rates were 77.2% and 58.8% in the Low and High groups, respectively. For survivors during the first year after PD initiation, the Non-improvement group was associated with a poor survival rate compared with the Other group for both sexes., Conclusion: A high edema index was associated with mortality in incident PD patients at baseline and follow-up. The edema index may be used as a new marker for predicting mortality in PD patients.

Background: Congestion is the most frequent cause for hospitalization in acute decompensated heart failure. Although decongestion is a major goal of acute therapy, it is unclear how the clinical components of congestion (eg, peripheral edema, orthopnea) contribute to outcomes after discharge or how well decongestion is maintained., Methods and Results: A post hoc analysis was performed of 496 patients enrolled in the Diuretic Optimization Strategy Evaluation in Acute Decompensated Heart Failure (DOSE-AHF) and Cardiorenal Rescue Study in Acute Decompensated Heart Failure (CARRESS-HF) trials during hospitalization with acute decompensated heart failure and clinical congestion. A simple orthodema congestion score was generated based on symptoms of orthopnea (≥2 pillows=2 points, <2 pillows=0 points) and peripheral edema (trace=0 points, moderate=1 point, severe=2 points) at baseline, discharge, and 60-day follow-up. Orthodema scores were classified as absent (score of 0), low-grade (score of 1-2), and high-grade (score of 3-4), and the association with death, rehospitalization, or unscheduled medical visits through 60 days was assessed. At baseline, 65% of patients had high-grade orthodema and 35% had low-grade orthodema. At discharge, 52% patients were free from orthodema at discharge (score=0) and these patients had lower 60-day rates of death, rehospitalization, or unscheduled visits (50%) compared with those with low-grade or high-grade orthodema (52% and 68%, respectively; P=0.038). Of the patients without orthodema at discharge, 27% relapsed to low-grade orthodema and 38% to high-grade orthodema at 60-day follow-up., Conclusions: Increased severity of congestion by a simple orthodema assessment is associated with increased morbidity and mortality. Despite intent to relieve congestion, current therapy often fails to relieve orthodema during hospitalization or to prevent recurrence after discharge., Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifiers: NCT00608491, NCT00577135., (© 2015 American Heart Association, Inc.)

Background: Fluid retention is a common complication of critical illness. It typically results from large-volume fluid infusions during acute resuscitation and is worsened by hypoalbuminemia. Recognized as edema, fluid retention is important for its association with delayed weaning and increased mortality. The standard treatment is the administration of diuretics, with or without albumin. We hypothesize that intravenous 25% albumin plus furosemide, by comparison with furosemide alone, improves diuresis, oxygenation, and hemodynamic stability in the deresuscitation of critically ill, hypoalbuminemic patients. We propose a pilot study to determine the feasibility of a trial to investigate this hypothesis., Methods/design: FADE is a single-center, parallel, pilot randomized controlled trial. We aim to allocate 50 hemodynamically stable, hypoalbuminemic adult patients receiving diuresis to treatment with either 100 ml of either 25% albumin or normal saline placebo twice daily, for a total of six doses. Diuretics are to be prescribed by the caregiving team at least twice daily, and administered within 2 hours following study treatment. Patients, intensive care unit (ICU) clinicians, data collectors, and outcome adjudicators will be blinded to treatment allocation. Feasibility outcome measures include the proportion of patients receiving albumin within 2 hours of diuretic, the proportion of patients receiving the full six doses of study treatment, the proportion of patients who receive open label 25% albumin, and the rate of recruitment. Physiologic, laboratory, and clinical data are collected until discharge from the ICU or until 30 days., Discussion: This is the first randomized trial to assess the use of hyperoncotic albumin in addition to diuretics in a general ICU population. Should this pilot study demonstrate feasibility, the primary outcome measure of the larger clinical trial will be the number of ventilator-free days, with secondary clinical outcome measures of duration of mechanical ventilation, length of ICU stay, episodes of hemodynamic instability and mortality. The addition of 25% albumin to standard diuretic therapy is a promising treatment in the post-resuscitation care of the critically ill patient., Trial Registration: ClinicalTrials.gov NCT02055872; ISRCTN70191881.

Background: Sacrococcygeal teratoma is the most common neonatal tumor. Fetuses with large tumors may develop hydrops from a high cardiac output state (HCOS) and progress rapidly to fetal demise. We postulate that the prenatal solid tumor volume index (STVI), or the ratio of solid tumor volume to the estimated fetal weight (EFW), has greater impact than the total tumor volume in outcome prediction., Methods: A retrospective chart review of all sacrococcygeal teratoma patients (n = 38) between 2005 and 2012 was conducted. Total tumor volume and percent of solid component were calculated by magnetic resonance imaging and then normalized by dividing them by either head circumference or EFW. Outcomes measured were survival, hydrops or high cardiac output state, defined as a combined ventricular output of >625 mL/min/kg with abnormal Doppler or echocardiogram findings., Results: Thirty-one patients were included in the study. All deaths (n = 7) had either high cardiac output state or hydrops. At a total tumor volume/EFW >0.16, the patient was 17 times more likely to develop HCOS/hydrops (P = 0.001) with 81.25% sensitivity and 86.67% specificity. At a STVI >0.09, the patient was 120 times more likely to develop HCOS/hydrops (P < 0.0001) with 81.25% sensitivity and 100% specificity., Conclusions: While total tumor volume aids in stratifying patients into high risk categories, STVI (solid tumor volume/EFW) is a better predictor of adverse outcomes. This data will allow us to identify patients who are high risk for cardiac compromise and guide appropriate therapy., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objective: To investigate the clinical characteristics of mirror syndrome., Methods: Retrospective analysis of cases with mirror syndrome. Data of clinical manifestations, laboratory examinations, placental morphology, treatment and prognosis of these patients were obtained and studied., Results: Five cases satisfying the inclusion criteria for mirror syndrome were identified from our hospital database. The incidence of the condition was 0.0154% in China. Mirror syndrome was associated with Rhesus isoimmunization, intrauterine parvovirus B19 infection, fetal neuroblastoma, fetal heart malformation and unknown cause respectively. Fetal symptoms were multi-hydrocele and fetal heart failure complicating fetal hydrops. All of the cases manifested maternal hydrops and hemodilution, the other most common symptoms included hypertension, proteinuria, hypoalbuminemia, anemia, thrombocytopenia and elevated uric acid levels. Fetal outcomes in this study were poor with a perinatal mortality rate of 100%. Placentomegaly was observed in most cases and placental morphology showed villous edema, increased intervillous fibrin deposition and one rare case of fetal adrenal neuroblastoma. Resolution of maternal symptoms was noted within 3-30 days after delivery., Conclusion: Mirror syndrome is associated with a substantially increased risk of fetal death and severe maternal complications. Early diagnosis of this condition during pregnancy is crucial for providing proper treatments and achieving better clinical outcomes.

Medical files of children with severe malnutrition admitted at New Halfa hospital, Sudan during 2007-2009 were reviewed. A total of 1097 children (54.9%, 602 male) with severe malnutrition were admitted during the three year period. Oedematous severe malnutrition was found in 179 (16.3%) children. Of these 1097, 796 (72.6%) patients with severe malnutrition were children <2 years old. Out of these 1097 children, 780 (71.1%) and 112 (10.2%) had diarrhoea and malaria, respectively. Sixty-one (5.5%) of these children died, 237 (21.6%) discharged against medical advice and 799 (72.8%) were discharged. Of the 61 children who died 11 (18.0%) had septicaemia following diarrhoea and respiratory tract infections. The case fatality rate was not different with sex or with presence/absence of oedema., (Copyright © 2011 Royal Society of Tropical Medicine and Hygiene. Published by Elsevier Ltd. All rights reserved.)

Edema acquired during the perioperative period has long been associated with increased mortality. Edema acquired during cardiopulmonary bypass (CPB) may contribute to this mortality. The intent of this retrospective study was to test the premise that edema in the form of a positive fluid balance change (FBC) acquired during CPB correlated to mortality. If so, FBC from the beginning of CPB (baseline; FBC = 0) to the end of CPB may need to be monitored, measured, and controlled on CPB with the same ardor as blood pressure and pH. This retrospective analysis reviewed the FBC of 1540 pediatric and congenital heart surgery patients at the end of CPB. Additions and subtractions of fluid to the combined patient/CPB circuit were routinely quantified during CPB procedures and during periods of modified ultrafiltration (MUF). The primary outcome assessed was mortality during hospitalization. The overall mortality of the 1540 patients was 5.65% from all causes. Eighty percent (n = 1226, mortality = 4.65%) of the patients had a zero or negative FBC immediately after CPB/MUF. Twenty percent (n = 314, mortality = 9.55%) had a positive FBC. Positive FBC patients tended to be in higher risk categories, weighed more, and had longer pump times (p < .05) with an adjusted odds ratio for mortality of 1.73 (1.01-2.96, 95% confidence interval). There is a correlation between edema acquired during CPB and increased mortality in pediatric and congenital heart surgery patients. The potential exists for the perfusionist to optimize the fluid balance changes while on CPB to reduce mortality rates.

Objectives: The aim of this study was to define the prevalence and significance of myocardial edema in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS)., Background: Most patients with NSTE-ACS undergo angiography, yet not all have obstructive coronary artery disease (CAD) requiring revascularization. Identifying patients with myocardium at risk could enhance the effectiveness of an early invasive strategy. Cardiac magnetic resonance (CMR) can demonstrate edematous myocardium subjected to ischemia but has not been used to evaluate NSTE-ACS patients., Methods: One hundred consecutive patients with NSTE-ACS were prospectively enrolled to undergo 30-min CMR, including T2-weighted edema imaging and late gadolinium enhancement before coronary angiography. Clinical management including revascularization decision-making was performed without CMR results., Results: Of 88 adequate CMR studies, 57 (64.8%) showed myocardial edema. Obstructive CAD requiring revascularization was present in 87.7% of edema-positive patients versus 25.8% of edema-negative patients (p < 0.001). By multiple logistic regression analysis after adjusting for late gadolinium enhancement, perfusion, and wall motion scores, TIMI risk score was not predictive of obstructive CAD. Conversely, an increase in T2 score by 1 U increased the odds of subsequent coronary revascularization by 5.70 times (95% confidence interval: 2.38 to 13.62, p < 0.001). Adjusting for peak troponin-I, patients with edema showed a higher hazard of a cardiovascular event or death within 6 months after NSTE-ACS compared with those without edema (hazard ratio: 4.47, 95% confidence interval: 1.00 to 20.03; p = 0.050)., Conclusions: In NSTE-ACS patients, rapid CMR identifies reversibly injured myocardium due to obstructive CAD and predicts worse outcomes. Identifying myocardium at risk may help direct appropriate patients toward early invasive management.

Background: Current survival models for primary biliary cirrhosis have limited precision for medium and long-term survival. Aim To describe a prognostic model for the advent of complications in primary biliary cirrhosis as the first approach to a staged prognostic model., Methods: From an established database of 289 consecutive primary biliary cirrhosis patients referred to Royal Free Hospital over 12 years (mean follow-up of 4.1 years), baseline characteristics at referral were evaluated by Cox-proportional hazards regression modelling., Results: The following complications occurred de novo: 85 ascites/peripheral oedema, 40 oesophagogastric varices, 63 encephalopathy, 29 spontaneous bacterial peritonitis and/or septicaemia, 59 symptomatic urinary tract infections. Age, albumin, log(10)(bilirubin), presence of ascites at referral, variceal bleeding within 6 weeks before referral, detection of oesophagogastric varices at or before referral were significant at multivariate analysis with different combinations and coefficients for each complication. The model for predicting ascites and/or peripheral oedema best fitted the observed data (ROC = 0.7682, S.E. = 0.0385)., Conclusions: The known prognostic factors in primary biliary cirrhosis also model the advent of complications. In view of the prognostic importance of ascites and its more robust statistical model, ascites and/or peripheral oedema could represent, following validation, the most suitable staged model in primary biliary cirrhosis to improve precision in survival modelling.

Hereditary angioedema (HAE) is caused by complement factor 1 inhibitor (C1-INH) deficiency, and its mode of inheritance is autosomal dominant. We present a case of an 8-year-old patient who required emergency laparotomy after a traffic accident. General anesthesia with tracheal intubation was necessary. The patient's mother and maternal grandmother had been diagnosed with HAE. HAE is associated with high mortality when airway edema is caused by tracheal intubation. It was impossible to rule out HAE preoperatively in the patient. Therefore, we presumed that he had HAE and treated him with pasteurized C1-INH concentrate. The patient underwent laparotomy uneventfully. Several days after the operation, the laboratory data revealed that the perioperative plasma complement 1 q subunit (C1q) protein level and C1-INH function were not lowered. The diagnosis of HAE was not confirmed, but it was not possible to rule out the diagnosis either. The prophylactic use of a C1-INH in this case may be justified, because the procedure was an emergency and because of the high mortality associated with tracheal intubation in patients with HAE.

Fluid accumulation is associated with adverse outcomes in critically ill patients. Here, we sought to determine if fluid accumulation is associated with mortality and non-recovery of kidney function in critically ill adults with acute kidney injury. Fluid overload was defined as more than a 10% increase in body weight relative to baseline, measured in 618 patients enrolled in a prospective multicenter observational study. Patients with fluid overload experienced significantly higher mortality within 60 days of enrollment. Among dialyzed patients, survivors had significantly lower fluid accumulation when dialysis was initiated compared to non-survivors after adjustments for dialysis modality and severity score. The adjusted odds ratio for death associated with fluid overload at dialysis initiation was 2.07. In non-dialyzed patients, survivors had significantly less fluid accumulation at the peak of their serum creatinine. Fluid overload at the time of diagnosis of acute kidney injury was not associated with recovery of kidney function. However, patients with fluid overload when their serum creatinine reached its peak were significantly less likely to recover kidney function. Our study shows that in patients with acute kidney injury, fluid overload was independently associated with mortality. Whether the fluid overload was the result of a more severe renal failure or it contributed to its cause will require clinical trials in which the role of fluid administration to such patients is directly tested.

Background: Patients with chronic kidney disease (stage 5) who undergo hemodialysis treatment have similarities to heart failure patients in that both populations retain fluid frequently and have excessively high mortality. Volume overload in heart failure is associated with worse outcomes. We hypothesized that in hemodialysis patients, greater interdialytic fluid gain is associated with poor all-cause and cardiovascular survival., Methods and Results: We examined 2-year (July 2001 to June 2003) mortality in 34,107 hemodialysis patients across the United States who had an average weight gain of at least 0.5 kg above their end-dialysis dry weight by the time the subsequent hemodialysis treatment started. The 3-month averaged interdialytic weight gain was divided into 8 categories of 0.5-kg increments (up to > or =4.0 kg). Eighty-six percent of patients gained >1.5 kg between 2 dialysis sessions. In unadjusted analyses, higher weight gain was associated with better nutritional status (higher protein intake, serum albumin, and body mass index) and tended to be linked to greater survival. However, after multivariate adjustment for demographics (case mix) and surrogates of malnutrition-inflammation complex, higher weight-gain increments were associated with increased risk of all-cause and cardiovascular death. The hazard ratios (95% confidence intervals) of cardiovascular death for weight gain <1.0 kg and > or =4.0 kg (compared with 1.5 to 2.0 kg as the reference) were 0.67 (0.58 to 0.76) and 1.25 (1.12 to 1.39), respectively., Conclusions: In hemodialysis patients, greater fluid retention between 2 subsequent hemodialysis treatment sessions is associated with higher risk of all-cause and cardiovascular death. The mechanisms by which fluid retention influences cardiovascular survival in hemodialysis may be similar to those in patients with heart failure and warrant further research.

Background: In vitamin A-deficient populations, children hospitalized with infections and/or malnutrition are at particular risk of developing severe vitamin A (VA) deficiency. High-dose VA supplements are recommended as part of the treatment but results on its effect on recovery from morbidity and on prevention from nosocomial morbidity are conflicting., Objective: We aimed to assess the effect of a single high dose and daily low dose of VA on hospitalized malnourished children's morbidity., Design: We carried out a double-blind, randomized trial in 604 and 610 Senegalese hospitalized children. The first mentioned batch received a high-dose VA supplement (200,000 IU) on admission, the second a daily low-dose VA supplement (5000 IU per day) during hospitalization. Children were followed up until discharged. Data on all-cause morbidity were collected daily., Results: Survival analysis showed that the incidence of respiratory disease was significantly lower in the low-dose group than in the high-dose group, hazard ratios (HR): 0.26, 95% CI: 0.07-0.92. The duration of respiratory infection was also significantly lower in the low-dose group than in the high-dose group (HR of cure: 1.41, 95% CI: 1.05-1.89). Duration and incidence of diarrhoea were not significantly different between treatment groups. In children with oedema on admission, mortality was significantly lower in the low-dose group (Adjusted odds ratio: 0.21; 95% CI: 0.05-0.99)., Conclusions: Daily low dose of VA compared with single high dose significantly reduced duration and incidence of respiratory infection but not of diarrhoea in hospitalized children.

Background: The purpose of this study was to determine whether baseline physical examination and history are useful in identifying patients with cardiac edema as defined by echocardiography, and to compare survival for patients with cardiac and noncardiac causes of edema., Hypothesis: Physical examination and history data can help to identify patients with edema who have significant cardiac disease., Methods: We reviewed the medical records of 278 consecutive patients undergoing echocardiography for evaluation of peripheral edema. We classified cardiac edema as the presence of any of the following: left ventricular ejection fraction < 45%, systolic pulmonary artery pressure > 45 mmHg, reduced right ventricular function, enlarged right ventricle, and a dilated inferior vena cava., Results: The mean age of the 243 included patients was 67 +/- 12 years and 92% were male. A cardiac cause of edema was found in 56 (23%). Independent predictors of a cardiac cause of edema included chronic obstructive pulmonary disease (COPD, odds ratio [OR] 1.74, 95% confidence interval [CI] 1.14-2.60) and crackles (OR 1.98, 95% CI 1.26-3.10). The specificity for a cardiac cause of edema was high (91% for COPD, 93% for crackles); however, the sensitivity was quite low (27% for COPD, for 24% crackles). Compared with patients without a cardiac cause of edema, those with a cardiac cause had increased mortality (25 vs. 8% at 2 years, p < 0.01), even after adjustment for other characteristics (hazard ratio 1.55, 95% CI 1.08-2.24)., Conclusions: A cardiac cause of edema is difficult to predict based on history and examination and is associated with high mortality.

Objective: To evaluate the incidence of adverse cutaneous drug reactions in intensive care unit patients., Design: Cohort study., Setting: General adult intensive care unit of an institutional tertiary care hospital., Patients: Patients in the intensive care unit during a consecutive 8-month period were examined for adverse cutaneous drug reactions., Results: Patients in the intensive care unit have an incidence of 11.6% of adverse cutaneous drug reactions. Associated risk factors were female gender, obesity, age over 60 and immune dysregulation (systemic lupus erythematosus, dysthyroidism, and antiphospholipid antibodies syndrome). Few patients had previous history of adverse cutaneous drug reactions. Antimicrobials were the main drug involved. Morbilliform rash followed by urticary were the most frequently observed reactions. Interestingly, over 50% of patients with massive edema -independent of etiology- died., Conclusions: Intensive care unit patients are particularly at risk for developing an adverse cutaneous drug reaction.

Objective: Current prognostic models in primary biliary cirrhosis (PBC) have low precision, partly due to the restricted inclusion criteria of some cohorts used for modelling but also because of the prolonged natural course of the disease. It is hypothesized that better precision could be achieved with a staged model, using ascites or peripheral oedema as a new starting-point for prediction., Material and Methods: The study was based on an established database of 289 consecutive patients, followed between 1977 and 1998. Stepwise Cox regression was used to construct a staged model based on 143 patients who first developed ascites (n=111) or peripheral oedema (n=32) at entry or during subsequent follow-up. The model was compared with published models using graphical methods and receiver operating characteristics (ROCs)., Results: Mean time from clinical diagnosis of ascites or peripheral oedema to death was 3.1 years. The following variables had independent prognostic significance: log10(bilirubin) (p<0.001), albumin (p<0.001), age (p<0.001) and history of encephalopathy (p<0.001). Goodness of fit showed that the survival probabilities predicted by the Ascites Stage Model fitted well with the observed data. The Ascites Stage Model (ROC 0.8324 (SE 0.0348)) was a better predictor of survival than the Mayo long-term model (ROC 0.7833 (SE 0.0397)), the Mayo Repeated Patient Visits Model (ROC 0.7779 (SE 0.0399)) and the Royal Free PBC Prognostic Model (ROC 0.7785 (SE 0.0396))., Conclusions: The Ascites Stage Model gives a better survival estimate for PBC patients once they have developed ascites or peripheral oedema compared with the current models, and demonstrates an advantage of staged models in diseases with a prolonged natural history.

In this work, bioelectrical impedance vector analysis (BIVA) method is used in a sample of haemodialysis patients in stable (without oedema) and critical (hyperhydrated and malnutrition) states, in order to establish the relation between hyperhydration (oedema) and mortality. The measurements obtained were single frequency (50 kHz), tetrapolar (hand-foot) complex impedance measurements (vector components are: resistance R and reactance Xc). The impedance components were standardized by the height H of the subjects, (R/H and Xc/H) to obtain de impedance vector Z/H, that is represented in the RXc plot (abscise R/H, ordinate Xc/H). Measurements were performed on a sample of 74 patients (30 men and 44 women, 18-70 year, body mass index (BMI), 19-30 kg m(-2)) at the Saturnino Lora University Hospital in Santiago de Cuba. The 46 stable patients comprised 28 men and 18 women; the 28 critical patients 16 men and 12 women. The reference population consisted of 1196 healthy adult subjects living in Santiago de Cuba (689 men and 507 women, 18-70 year, BMI 19-30 kg m(-2)). We used the RXc plot with the BIVA method to characterize the reference population using the 50%, 75% and 95% tolerance ellipses. Student's t-test and Hotelling's T2-test were used to analyse the separation of groups obtained by means of clinical diagnosis and those obtained by BIVA. We obtained a significant difference (P < 0.05) in R/H, Xc/H and phase angle (PA) in men as in women between the location of Z/H vectors in the RXc graph and the separation made by the doctors between stable and critical patients. Critical (hyperhydrated) patients were located below the inferior pole of the 75% tolerance ellipse, whereas stable patients were within the tolerance ellipses. Some cases classified as stable by the clinic were classified as hyperhydrated by BIVA with 100% sensitivity and 48% specificity. In conclusion, the BIVA method could be used to classify patients by hydration state and to predict survival. Advantages of the method are its simplicity, objectivity and that it does not require the definition of patient dry weight.

Inter and intra-specific differences in sensitivity of early life stage salmonids to 2,3,7,8-TCDD exposure have been reported, but intra-strain differences have not been found in the literature. Our results indicate that intra-strain variability in terms of embryo mortality (LD50) is small in Eagle Lake strain of rainbow trout, LD50 values ranging from 285 to 457 pg TCDD egg g(-1). These results confirm Eagle Lake as a less sensitive strain within rainbow trout, and do not indicate overlap with reported LD50 values for brook or lake trout. Our results also demonstrate that although generalized edema in regions including the yolk-sac are frequently associated with mortality following dioxin exposure, not all edematous fish die. We detected dose-dependent decreases in cranial length, eye diameter, mass, and total length (P < 0.05) in viable swim-up rainbow trout. These effects are presumed to indicate more subtle dose-dependent disruptions of the viteline vein vasculature and, therefore, in access to energy sources. A tendency for dose-dependent decrease in liver glycogen reserves concurred with previous results on salmonids and with the well described TCDD-induced alterations in intermediate metabolism of rats and chicken embryos (wasting syndrome). This syndrome could be contributing to the reduced growth that we observed.

Objective: Markers of inflammation have recently been shown to be predictive of cardiovascular disease (CVD). Furthermore, the excess mortality in rheumatoid arthritis (RA), a disease characterized by chronic polyarthritis, is chiefly due to death from CVD. With this background, we studied the effect of inflammation, as reflected by the number of joints with soft tissue swelling, and rheumatoid factor (RF) seropositivity on CVD-related mortality., Methods: Mortality rates and rate ratios for all-cause and CVD-related deaths were computed in a longitudinal, population-based cohort of Pima Indians in Arizona from 1965 through 1994. Repeated health examinations were performed, involving systematic assessment of the features of RA, cardiovascular risk factors, serum titers of RF, as well as mortality. The cohort comprised 4,120 subjects (1,861 men, 2,259 women) who were examined an average of 3.5 times during a mean followup of 14 years., Results: During the followup period, 182 CVD-related deaths ocurred. The age- and sex-adjusted CVD-related mortality rates increased significantly with the presence of a higher number of joints with soft tissue swelling (Ptrend = 0.04), and were 2.07 (95% confidence interval [95% CI] 1.30-3.31) times as high in those subjects who had 2 or more swollen joints as in those who had none. There were no significant additional effects on CVD-related mortality when seropositivity for RF or a previous diagnosis of RA were considered. In age- and sex-adjusted proportional hazards analyses, which were controlled for possible confounders, the effect of swollen joints remained significant (mortality rate ratio 1.33, 95% CI 1.04-1.71 per category increase [no swollen joints, 1 swollen joint, at least 2 swollen joints])., Conclusion: Joint swelling is a significant risk factor for CVD-related death, independent of other known risk factors including a diagnosis of RA. This finding supports the hypothesis that inflammatory mechanisms are important for the development of CVD.

Objective: Starling's equation indicates that reduced oncotic pressure gradients will favor edema formation, and the current consensus definition of acute respiratory distress syndrome (ARDS) excludes only the hydrostatic pressure contribution. We hypothesized that low serum total protein levels might correlate with the likelihood of ARDS in at-risk patients because serum total protein is the chief determinant of oncotic pressure in humans., Design: Regression analysis to compare outcomes in patients with low serum total protein levels with outcomes in patients with normal serum total protein levels with respect to weight change, development of ARDS, and mortality., Setting: Intensive care units (ICUs) of seven clinical centers in North America., Patients: A total of 455 ICU patients who met consensus criteria for severe sepsis (178 of whom developed ARDS) from a recently completed prospective clinical trial., Intervention: None., Measurements and Main Results: We found that 92% of the patients developing ARDS had low or borderline serum total protein levels (<6 g/dL). Logistic and multiple regression analyses confirmed that of 18 clinical variables, initial serum total protein level and protein change over time were the most statistically significant predictors of weight gain, prolonged mechanical ventilation, ARDS development, and mortality in the study population. This correlation remained significant after adjustment for the other major predictors of outcome present at baseline (ie, Acute Physiology and Chronic Health Evaluation II score)., Conclusions: Hypoproteinemia is significantly correlated with fluid retention and weight gain, development of ARDS and poor respiratory outcome, and mortality in patients with sepsis. Prospective, randomized trials of serum protein manipulation are needed to establish whether there is a cause-effect relationship to this association.

Objective: To describe a method of rapid fluid removal in children with anasarca and the acute respiratory distress syndrome (ARDS) secondary to sepsis or the systemic inflammatory response syndrome., Design: Consecutive case series., Setting: Pediatric Intensive Care Unit of a children's hospital., Patients: Six patients with ARDS secondary to sepsis or systemic inflammatory response syndrome, who had persistent anasarca complicating their respiratory course despite intravenous diuretic therapy., Interventions: Continuous flow peritoneal dialysis (CFPD) was instituted after percutaneously inserting two Tenckhoff dialysis catheters into the peritoneal cavity of each patient and tunneling them through the subcutaneous tissue to exit from opposite lower abdominal quadrants. A dialysis solution with 2.5% dextrose was administered continuously via one of the catheters at a rate ranging from 10-30 mL/kg/hr, and concomitantly drained via the other catheter. The concentration of the dialysis solution and rate of inflow were adjusted as needed to achieve the desired peritoneal outflow rate. CFPD was discontinued when adequate weight loss had occurred and the patient's daily urine output exceeded their daily fluid intake. The patient's overall fluid balance and change in weight were recorded daily. The PaO2/FiO2 ratio, alveolar-arterial oxygen gradient, and oxygenation index were also calculated daily., Measurements and Main Results: Six patients with ARDS, mean age 18.7+/-37.0 months were mechanically ventilated for 8.0+/-4.0 days before CFPD, during which time average body weight increased to 63%+/-22% above admission body weight, despite the use of intravenous diuretic therapy. They underwent CFPD for 126.7+/-60.0 hrs, during which time their body weight decreased to 30%+/-12% above admission weight (p<.05). During dialysis, the dialysis outflow rate exceeded the inflow rate by 4.2+/-0.9 mL/kg/hr. When compared with values calculated immediately before starting CFPD, post-CFPD PaO2/FiO2 increased from 97.0+/-32.0 to 215.0+/-40.4 mm Hg (12.9+/-4.3 to 28.7+/-5.4 kPa) (p<.05), post-CFPD alveolar-arterial oxygen gradient decreased from 390.7+/-85.8 to 206.7+/-72.8 mm Hg (52.1+/-11.4 to 27.6+/-9.7 kPa) (p<.05), and post-CFPD the oxygenation index decreased from 29.6+/-9.8 to 11.8+/-5.6 (p<.05). There were no complications associated with dialysis catheter insertion or CFPD therapy. Four patients survived. Two patients had an irreversible course of infections and septic shock and died., Conclusion: Severe anasarca in the course of ARDS can be effectively treated in pediatric patients with continuous flow peritoneal dialysis, resulting in a significant improvement in respiratory status.

Changes in serum and intrapancreatic enzyme content and protein synthesis in pancreas were studied in acute oedematous pancreatitis (AOP). Male Wistar rats (n = 111) were divided into 2 groups, controls with a sham operation and those with AOP. Serum amylase levels rose immediately after the procedure causing AOP and then fell gradually, while serum lipase and ribonuclease levels remained higher than control values over 48 h. (p < 0.05, 0.01). Serum deoxyribonuclease (DNase) II levels were unchanged. Intrapancreatic enzyme levels were scarcely affected by AOP. 3H-leucine uptake into pancreatic tissue of rats with AOP was decreased throughout the study (p < 0.001), but some protein synthesis continued. Intrapancreatic enzyme contents are maintained despite diffusion into the blood because the pancreas retain its ability to synthesize enzymes.

Objective: To measure the prognostic value of clinical, anthropometric, and biological indicators of protein energy malnutrition in hospitalised children., Design: Hospital based follow up study from admission to discharge or death of a cohort of children. SETTING-Paediatric hospital in Zaire., Subjects: 1129 children consecutively admitted between August 1986 and October 1988., Main Outcome Measures: Height, weight, arm circumference, skinfold thicknesses, serum albumin concentration, and mortality., Results: Mortality was higher in wasted children and in those with a mid-upper arm circumference < 125 mm, a serum albumin concentration < 16 g/l, and oedema. After multivariate analysis, serum albumin concentration was the best predictor of subsequent risk of dying. Mid-upper arm circumference and oedema, however, still contributed considerably to evaluation of mortality., Conclusions: In this specific environment of central Africa an isolated clinical sign such as oedema is not enough to detect children with a high risk of dying among those admitted to paediatric wards with severe protein energy malnutrition. Measurement of additional indicators such as arm circumference and serum albumin concentration seems to be of crucial importance.

During the decade to 1979, 203 hydropic infants died in the State of Victoria, Australia. Non-immune hydrops fetalis (NIHF) became more common than immune hydrops fetalis as a cause of fetal hydrops, and its contribution to the total perinatal mortality increased from 0.1% to 3%. The perinatal mortality rate of infants with NIHF was virtually 100%. The most consistent finding at post-mortem was pulmonary hypoplasia which was probably due to compression from serous cavity effusions. Survival may be improved by early diagnosis and termination of the pregnancy in selected patients with viable infants before the development of gross serous cavity effusions. The most constant clinical sign associated with hydrops fetalis was polyhydramnios which is an indication for ultrasonography and cardiotocography to detect cases of NIHF and to select the optimum time for delivery.

A case of fatal massive edema of the head and neck secondary to subgaleal involvement from a scalp laceration has been presented. Subgaleal infections have been rare since the advent of antibiotics. The unusual and serious nature of the condition is made evident, with considerations of differential diagnosis included.

Twenty-two cases of nonimmune hydrops fetalis (NIHF) seen over a three-year period are described. Eight cases were associated with major congenital anomalies, seven cases with minor anomalies or other disease entities, and seven idiopathic cases. The overall mortality rate was 50%, greatest in those cases complicated by major anomalies. The clinical problems commonly encountered in management of these patients are reviewed, and include prenatal detection, perinatal asphyxia, disseminated intravascular coagulopathy, fluid and electrolyte imbalance, and respiratory difficulty. A review of the literature for those entities found in association with NIHF is also included. The case studies of three consecutive siblings with NIHF born to the same parents are briefly analyzed.

Eight cases of nonimmunologic hydrops fetalis (HF) were seen at Cedars-Sinai Medical Center over a 3.5-year period. The etiology of the HF included 2 cases of fetal-maternal hemorrhage and 1 each of sacral teratoma, tachyarrhythmia, diaphragmatic hernia, neuroblastoma, and heart disease. For 1 infant, the cause was never found. These cases involved various diagnostic and therapeutic dilemmas. Only 4 were anticipated ant partum by ultrasound scanning. Two of the 8 fetuses died in utero, whereas 4 others died in the neonatal period. Earlier diagnosis and evaluation are likely to improve these outcomes.

Reported is a maternal death associated with bilateral postpartum vulvar edema. Data are reviewed for this patient and four other patients who were previously reported to have had a syndrome of unilateral postpartum vulvar edema associated with maternal death. Overall, an 80% mortality rate has been observed.

Arterial blood gas tensions were studied for six years in 85 patients (59 men, 26 women, mean age 58.8 years) with hypoxaemia associated with chronic bronchitis. All patients who died had a precipitous fall of arterial oxygen tension (PaO2) breathing air. In patients dying within two years of the first appearance of ankle oedema the mean rate of fall of PaO2 was 0.11 kPa/month. Patients who survived two years appeared to deteriorate more slowly (0.017 kPa/month) until some months before death, when they too deteriorated rapidly. Hypoxaemic patients with obstructive airways disease suffer a terminal rapid decline in arterial oxygen tension, which probably indicates real pathological change in the lungs and has important implications for long-term domiciliary oxygen treatment.

The probability procedure of Neuman -Pearson (method of maximal credibility) was used for the quantitative description of factors of prognosis of edematous form of breast cancer in terms of specific gravities . A complex evaluation of these factors was carried out. The reliability of prognosis made on the basis of the factors under study was as high as 79%.

Reported are three maternal deaths in four patients who presented with a similar syndrome following a normal antepartum course and normal labor and delivery managed by regional or local anesthesia and midline or proctoepisiotomy. Beginning about the second postpartum day, the patients developed unilateral perineal edema and induration which progressed to generalized vulvar, vaginal, perineal, and gluteal edema and induration. These patients developed marked leukocytosis, fever, and ultimately vascular collapse; three of them died. The one patient who survived had a similar course except for vascular collapse. Unilateral vulvar induration and edema associated with fever and marked leukocytosis are ominous signs. Aggressive treatment should include the use of multiple antibiotic, crystaloid, colloid, and steroid drugs and appropriate monitoring. By this report we hope to bring attention to this rare but lethal syndrome.

Two feeding bioassays were conducted to study the mortality pattern, incidence of edema and ascites formation and plasma composition of turkey poults fed diets containing varying levels of toxic fat (fat contaminated with polychlorinated dibenzo-p-dioxins) and/or salt. No significant changes in plasma concentrations of electrolyte and total protein and packed cell volume were observed in slaughtered poults fed diets containing toxic fat compared with poults fed a normal diet. However, a positive dose-response relationship between levels of dietary toxic fat (0,2 and 5%) and incidence of mortality with edema, ascites and hydropericardium was observed in poults fed diets containing 1% salt. The toxic effects of polychlorinated dibenzo-p-dioxins were accentuated by increasing the level of salt (0.5, 1 and 3%) in the diet. Mortality started at nine days of age and increased on days 10 and 11. The present experiments demonstrated that gross pathological changes similar to those reported for "chick edema disease" caused by feeding polychlorinated dibenzo-p-dioxins, could also be produced in young turkey poults. The etiology of the toxic effects of these organic compounds in edema formation is discussed.