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Carotid artery dissection in the paediatric population is uncommon and in rare cases it can be due to intraoral blunt trauma associated with a stick-like object such as pen or chopstick in the mouth at the time of injury. Given the rarity of the condition, there is significant knowledge gap in evidence-based diagnosis and management of paediatric blunt cerebrovascular injury (BCVI). This case report presents a rare case of asymptomatic carotid artery dissection due to intraoral blunt trauma in a young patient and the successful conservative management. This report also demonstrated the sonographic progression of the carotid artery dissection on follow up imaging.

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Objectives: Adherence to Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines in acute exacerbation of chronic obstructive pulmonary disease (AECOPD) treatment is variable in the inpatient setting. This study evaluates appropriateness of therapy in patients admitted to an academic medical center for AECOPD. Methods: This was a single-center, retrospective, observational study. The primary endpoint was proportion of patients who received appropriate AECOPD treatment within 24 h. Secondary endpoints included mean length of stay (LOS) and time to administration (TTA) of pharmacotherapy, 30-day readmission rates, and proportions of various ancillary care received. Data were analyzed using descriptive and inferential statistics. Results: Of 533 screened admissions, 163 were included. Of those included, 55% (n = 90) received guideline-based therapy within 24 h of presentation. This group had significantly shorter mean LOS (3.48 ± 2.61 vs 4.53 ± 3.40 days, p = .026), fewer COPD-related readmissions (7 vs 14, p = .036), and numerically fewer all-cause readmissions (14 vs 19, p = .11). Mean LOS and TTA were 3.95 ± 3.02 days and 8.47 ± 12.77 h, respectively. Discussion: Timely and guideline-based delivery of medications was associated with shorter length of stay and fewer COPD-related readmissions. Establishing a standardized care plan through order set implementation may be one strategy to improve care and outcomes in AECOPD patients.

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Anomalous vascular anatomy was detected in the neck of a 52-year-old female with a Klippel-Feil anomaly. Ultrasound identified three separate arteries in the left carotid sheath without any branching or bifurcations. The vascular waveforms were used to identify the vessels as the internal carotid artery, external carotid artery and vertebral artery. This rare vascular anomaly was confirmed with CT angiography.

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Background Pregnancy-related venous thromboembolism (VTE) is a leading preventable cause of maternal mortality in the United States; however, American guidelines for pharmacologic VTE prophylaxis remain less aggressive than other developed countries. The Safe Motherhood Initiative (SMI) combines aspects of American and international guidelines to increase utilization of prophylaxis and thereby decrease incidence of pregnancy-related VTE. Objectives To evaluate the prescribing and administration rates of pharmacologic VTE prophylaxis for women undergoing cesarean section (c-section) when retrospectively applying the SMI recommendations. Setting Large academic medical center in Sacramento, California, USA. Method This was a single-center retrospective cohort study of pregnant women undergoing c-section who would have met criteria for pharmacologic prophylaxis according to the SMI. Main outcome measures Prescribing and administration rates of mechanical and pharmacologic VTE prophylaxis. Secondary outcomes included incidence of thromboembolism within 6 weeks after c-section and thromboembolic associated mortality. Results A total of 616 charts were analyzed. When applying the SMI guidelines for VTE prophylaxis, the prescribing rates for mechanical and pharmacologic prophylaxis were 94.3% and 4.71% of patients, respectively, and 94.9% of ordered pharmacologic prophylaxis doses were administered. The incidence of 6-week post-partum VTE was 0.49%. There were no cases of VTE-associated mortality. Conclusion This study demonstrated that a large population of c-section patients fit the SMI criteria for pharmacologic VTE prophylaxis but did not receive it. We observed a 0.49% rate of VTE, which was slightly higher than the nationally reported average rate of 0.3%. With growing rates of pregnancy-associated VTE in the United States, perhaps a more aggressive guideline is warranted.

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BACKGROUND: There is inadequate guidance for clinicians on selection of the optimal dextrose 50% (D50W) dose for hypoglycemia correction in critically ill patients. OBJECTIVE: The purpose of this study was to determine the blood glucose (BG) response to D50W in critically ill patients. METHODS: A retrospective analysis was conducted of critically ill patients who received D50W for hypoglycemia (BG < 70 mg/dL) while on an insulin infusion. The primary objective of this study was to determine the BG response to D50W. The relationship between participant characteristics and the dose-adjusted change in BG following D50W was analyzed using simple and multiple linear mixed-effects models. RESULTS: There were 470 hypoglycemic events (BG < 70 mg/dL) corrected with D50W. The overall median BG response was 4.0 (2.53, 6.08) mg/dL per gram of D50W administered. Administration of D50W per protocol resulted in 32 episodes of hyperglycemia (BG > 150 mg/dL), resulting in a 6.8% rate of overcorrection; 49% of hypoglycemic episodes (230/470) corrected to a BG >100 mg/dL. A multivariable GEE analysis showed a significantly higher BG response in participants with diabetes (0.002) but a lower response in those with recurrent hypoglycemia (P = 0.049). The response to D50W increased with increasinginsulin infusion rate (P = 0.022). Burn patients experienced a significantly larger BG response compared with cardiac, medical, neurosurgical, or surgical patients. CONCLUSIONS: The observed median effect of D50W on BG was approximately 4 mg/dL per gram of D50W administered. Application of these data may aid in rescue protocol development that may reduce glucose variability associated with hypoglycemic episodes and the correction.

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AIM: The exact diagnostic role of temporal artery ultrasound (TAU) remains unclear. The aim of this study was to determine the sensitivity and specificity of a positive halo sign in patients undergoing TAU in a clinical setting, and to perform a review of existing evidence. METHOD: Patients who had undergone TAU at a single centre in Australia were included in the study. The presence or absence of a halo sign and whether it was unilateral or bilateral was determined retrospectively from radiology reports. Pathology results were used to determine which patients underwent a temporal artery biopsy and if the biopsy was positive or negative. A case note review was performed to determine presenting clinical features and if a clinical diagnosis of giant cell arteritis was made. The sensitivity, specificity and likelihood ratios of TAU compared to both biopsy and clinical diagnosis were calculated. RESULTS: Fifty patients were identified as having had a TAU (28% male, mean age 69). When compared to biopsy-proven cases, the sensitivity of a halo sign was 40%, specificity 81%, positive likelihood ratio 2.1 and negative likelihood ratio 0.7. When compared to clinical diagnosis, the sensitivity was 42%, specificity 94%, positive likelihood ratio 7.1 and negative likelihood 0.6. CONCLUSIONS: Sensitivity and specificity results were comparable to the literature. A halo sign may preclude the need for biopsy in cases of high clinical suspicion and contraindications to surgery. Biopsy remains necessary in most cases, irrespective of whether a halo sign is present.

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BACKGROUND: Aortic aneurysm repair in the presence of a functioning renal transplant carries significant risks of renal ischaemia. We describe the management of patients undergoing this treatment by using a temporary, externally sited axillofemoral bypass and discuss other treatment options. METHODS: Three patients underwent a temporary, externally sited axillary artery to common femoral artery bypass. The aneurysm was then dissected via a transperitoneal incision. When the aneurysm was clamped, the axillofemoral graft was opened allowing retrograde perfusion to the renal transplant. RESULTS: All three patients made a good recovery without postoperative deterioration of renal function. CONCLUSION: Numerous methods of protecting the transplanted kidney have been described, including expeditious surgery with no renal protection or some form of temporary shunt to perfuse the donor iliac artery. Temporary insertion of an axillofemoral bypass adds 45-60 min of extra operating time if two surgeons are present. However, this technique should completely avoid transplant ischaemia and is an excellent technique for dealing with abdominal aneurysms in patients with functioning transplants.

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