Acute respiratory distress syndrome (ARDS) is a disabling and potentially lethal syndrome requiring prompt recognition and urgent interventions to prevent morbidity and mortality[1]. Although constipation is not generally recognized as a cause for ARDS or usually listed within the differential diagnosis, there have been case reports describing such an association[2,3]. We present the case of a patient with history of intermittent constipation presenting with progressive abdominal pain and an acute abdomen that required emergent surgical fecal decompaction. This was followed by hypoxemic respiratory distress leading to respiratory failure in the setting of severe constipation and aspirated feculent material. To our knowledge, this is the first published case report describing aspirated feculent material in a child with respiratory failure due to ARDS.

BackgroundRespecting Choices (RC) is an advance care planning (ACP) model developed in La Crosse, WI, USA. Basic ACP via this model was demonstrated in previous studies: LADS I (1998) and LADS II (2008). RC has since developed ACP for persons beginning to suffer effects from progressive, life-limiting illnesses, known as Next Steps (NS). Kirchhoff (2010 and 2012) demonstrated that NS improves patient and surrogate understanding of patients’ treatment preferences. Whether NS decreases healthcare utilisation or cost is currently unknown.AimTo detail the findings of an analysis of the value of NS ACP compared to basic ACP, including its impact on resource utilisation and patient medical costs.MethodsA chart review of hospitalizations preceding death  (≤2 years) to determine in-patient days, hospital utilisation, and Hospice utilisation of decedents with and without NS ACP from 1/1/2010 to 4/7/2014, matched on insurance, age, comorbidities, and marital status.Results95% of variable group (n = 42) and ninety-three percent (n = 76) of control group had completed basic ACP at time of death. Those with NS ACP had fewer hospital encounters and greater Hospice utilisation compared with controls. Analysis of insurance costs shows that billed costs over the last two years of life decreased among the variable group but increased among the control group.DiscussionWe found that hospital encounters, intensity, and medical costs decrease with NS planning, while time in Hospice significantly increases.ConclusionStaged approaches to ACP are valuable. NS ACP can lower hospital utilisation and medical costs at the end of life for patients with life-limiting illnesses.

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Hereditary multiple exostoses (HME) is a syndrome characterized by presence of two or more osteochondromas (exostoses) in the appendicular or axial skeleton. Here, we present a case of an adolescent patient presenting with chest pain as the only symptom of an intrathoracic exostosis leading to the diagnosis of HME. CASE PRESENTATION:A previously healthy 15-year-old male presented to the pediatric pulmonary clinic for months-long history of recurrent left-sided chest pain, without any associated symptoms. Chest x-ray showed an ill-defined nodular opacity in the left upper lobe, with central calcification identified. Additional work-up with spirometry, complete blood count, fungal antibody panel, and Histoplasma urine antigen testing was normal. Family history was positive for pulmonary embolism and "blood clotting issues" with no specific syndromes identified. A chest computed tomography angiography (CTA) with contrast was ordered for further evaluation.Chest CTA revealed a large bony exostosis arising from the anterior aspect of the left third rib, with two areas of surrounding nodular soft tissue measuring 3 cm x 1.3 cm x 2.6 cm. There was extension into the lung abutting the pleura and lateral aspect of the mediastinum. Additional bony protuberances were noted along the left fifth rib, right second rib, and bilateral scapulae. A diagnosis of HME was made because of the presence of multiple exostoses. Due to continued chest pain he was referred to cardiothoracic surgery. The decision was made to monitor symptoms and obtain repeat imaging in six months to monitor growth or worsening lung impingement.DISCUSSION: HME is characterized by the presence of two or more exostoses in the appendicular or axial skeleton. The most common location of exostoses is in the appendicular skeleton. Though rare, involvement of the ribs can occur [1]. Previous case reports have identified presence of multiple costal exostoses in patients with known HME [1,2]. The patient presented here represents a case with chest pain as the only presenting complaint prior to diagnosis of HME being made. The presence of a costal exostosis should be considered in adolescents presenting with chest pain if other more common causes are ruled out. The presence of multiple exostoses supports the diagnosis of HME. Cases of HME with costal exostoses can be associated with intrathoracic complications, including hemothorax, pneumothorax, and pericardial effusion [3]. Supportive care and observation is the usual plan of care. However, if complications develop, surgical resection may be necessary and cardiothoracic surgery consultation is recommended.CONCLUSIONS: Chest pain may be the only presenting symptom in pediatric patients with HME.

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