A 20-year-old woman with spinal cord injury without radiological abnormalities (SCIWORA)

Abstract

Spinal cord injury without radiological abnormalities (SCIWORA) has been defined as a direct trauma to the spinal cord, with no radiological or tomographic abnormalities, although there is a deficit, whether motor, sensory or both. (1) To establish the final diagnosis, shock, obstetrical complications, penetrating trauma to the spine and congenital malformations should be excluded. (2)


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Factors contributing to the accuracy of initial screening values measured by noninvasive spectrophotometric hemoglobin monitoring in an Emergency Department

Abstract

Objective: Spectrophotometric hemoglobin (SpHb) monitoring is a new noninvasive technology for measuring hemoglobin (Hb). However, few studies have assessed the usefulness of the initial screening SpHb values, especially when measured in an Emergency Department. In this study, we examined the correlation between the initial screening SpHb values and laboratory-measured hemoglobin (Hb) concentrations.

Design: This was a retrospective, single center study.

Setting: Emergency Department in a University hospital.

Patients: 105 cases between February and July 2016.

Interventions: The correlation between SpHb and Hb was determined in univariate analysis. Multiple regression analysis was then performed with ΔHb (defined as the absolute difference between SpHb and Hb [|SpHb-Hb|]) as the dependent variable to identify factors associated with reduced accuracy of SpHb.

Results: The initial screening SpHb value was only moderately correlated with Hb in univariate analysis (r=0.736, p<0.001). In multiple regression analysis, male sex and diastolic blood pressure were significantly associated with ΔHb (p=0.003 and p=0.022, respectively).

Conclusions: The initial screening SpHb value was only moderately correlated with Hb. SpHb might affected by patient factors, including male sex and diastolic blood pressure.


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Portal venous gas entrapment secondary to mesenteric ischemia after withdrawal of intra-aortic balloon pump: A case report with a rare ultrasound image

Abstract

After coronary artery bypass graft (CABG), mesenteric ischemia is a rare but dreadful complication with high mortality rates. Prophylactic use of intra-aortic balloon pump (IABP) is a common practice in patients with severe coronary artery disease awaiting CABG. During withdrawal of the IABP, there is a risk of dislodging atheromatous debris, thus causing peripheral and mesenteric emboli, which can cause mesenteric ischemia. Here we are reporting on a case where a patient had an IABP installed after a ST-elevation myocardial infarction (STEMI) while awaiting CABG surgery. After surgery, the IABP was eventually removed, but rising lactates led to further investigation. The abdominal computerized tomography (CT) scan showed extensive bowel pneumatosis and portal venous gas entrapment. The patient died despite aggressive non-surgical management. This case shows a fatal complication of IABP use in a high-risk patient undergoing CABG surgery and highlights the need for careful aorta and peripheral vascular assessment prior to IABP device insertion to avoid intestinal compromise.


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A fatal case of cerebral oedema and myocarditis associated with secondary dengue infection

Abstract

Background: Secondary dengue infection (SDI), in the form of two sequential infections by different serotypes, will lead to severe dengue. Concomitant organ failure in particular cardiovascular (CVS) and central nervous system (CNS) carries further rise in the mortality rate.

Case report: We report a confirmed SDI in a 27-year-old man who presented with hypovolemic shock due to persistent vomiting and diarrhoea. He was stabilized after fluid resuscitation. However, he developed sudden onset of seizure and myocarditis with unstable haemodynamic thereafter. After stabilization, his gag and cough reflexes were absent with dilated pupils. Imaging of the brain showed extensive cerebral oedema with poor flow beyond the internal carotid arteries and its branches above circle of Willis. He remained comatose with subsequent complications of diabetes insipidus, secondary bacterial infection, and acute kidney injury. He passed away after 19 days of admission.

Discussion: There is a higher risk of severe dengue with SDI as it is associated with antibodydependent enhancement (ADE) mechanism. The pre-existing dengue antibodies enhance virus replication by activating memory T-cells causing surges in inflammatory cytokines. The increased capillary permeability with massive vascular leak most likely led to the extensive cerebral oedema in this patient. The concomitant cardiovascular failure also led to his irreversible outcome.

Conclusion: Severe cardiovascular and neurological manifestations can occur in SDI with resultant in the fatality. Therefore, early recognition of risk factors in the early phase of severe dengue is important to prevent the irreversible outcome.


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Blood plasma plasmalogens and fatty acids in multiple organ dysfunction syndrome

Abstract

Introduction: Changes in fatty acid composition as well as in a level of blood plasma plasmalogens in cases of various pathological conditions are evidences of lipid metabolism disorders and can indicate their reasons and degree. The objective of this study was to analyze fatty acids and plasmalogens of blood plasma in patients with multiple organ dysfunction syndrome (MODS).

Methods: Fatty acid ethyl esters and diethyl acetals of fatty aldehydes obtained during sample preparation were analyzed by capillary gasliquid chromatography.

Results: Marked changes in the plasma fatty acid composition and plasmalogen levels in pa tients with MODS were detected.

Conclusions: Based on the detected significant reduction in the plasmalogen levels of blood plasma, a conclusion was made about possible presence of peroxisome dysfunctions in patients with MODS. Peroxisome dysfunction may be one of the reasons of violation of detoxification processes, fatty acids oxidation disorder, prolongation and intensification of the inflammatory process, neurological disorders, and decreased blood antioxidant capacity. The assumption was made about an important role of fatty acids in disturbance of systemic hemodynamics, assessment of a degree of lipid metabolism disorders and activity of сatabolic response.


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The effect of selective COX-2 inhibitor on blood glutamate in moderate traumatic brain injury

Abstract

Head injury is the leading cause of death and disability in adolescence, children and the elderly. Post-traumatic brain damage is determined by combination of primary and secondary head injuries. Neuroinflammation is one mechanism of secondary brain injury. Selective cyclooxygenase (sCOX-2) inhibitors are drugs commonly used in treatment of postoperative pain but also possess an anti-inflammatory effect. The aim of this study is to determine the role of sCOX-2 inhibitors to inhibit the inflammatory processes in patients with head injury by measuring the glutamate levels.

This is a double blind randomized controlled study involving patients with moderate head injuries who underwent surgery at Dr. Hasan Sadikin Hospital Bandung since December 2013 until December 2015. After obtaining study approval from the Research Ethics Committees of School of Medicine Padjadjaran University/Dr. Hasan Sadikin Hospital, samples were clustered randomly into 5 groups: the control group, the COX2-group I (given sCOX-2 inhibitor once/day), the COX2-group II (given sCOX-2 inhibitor twice/day), the COX2-group III (given sCOX-2 inhibitor thrice/day), and the COX2-group IV (given sCOX-2 inhibitor four times/day), and each group consisted of 6 patients. All patients received standard therapy as recommended by Brain Trauma Foundation Guidelines 2007 as well as performed monitoring of blood pressure, pulse rate, respiratory rate, oxygen saturation, temperature and blood sugar during pre and postoperative stages. The data were analyzed using paired samples t-test and one-way Anova, which p<0.05 is considered as statistically significant.

Results showed that there was a significant reduction in glutamate level in COX2-group II with the p-value of 0.035. The study concluded that sCOX-2 inhibitor has a brain protective effect by lowering the levels of glutamate as neuroinflammatory biomarkers in patients with head injury.


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Albumin level as a predictor of shock and recurrent shock in children with dengue hemorrhagic fever

Abstract

Background: The severity of dengue hemorrhagic fever (DHF) can be seen from bleeding and plasma leakage manifestations. Albumin level is one of the markers of plasma leakage in dengue infection. Whether albumin can be used as a predictor of shock in DHF patients or of recurrent shock in dengue shock syndrome (DSS) patients still need to be further evaluated.

Objective: To determine serum albumin level as a predictor of shock in DHF and of recurrent shock in DSS.

Design: A cohort prospective study.

Setting: Department of Child Health, Prof. Dr. RD Kandou Hospital, Manado, Indonesia.

Patients and participants: Sixty-seven DHF patients and 58 DSS patients aged 1- to 14-yearold were enrolled in our study. Sampling was done with consecutive sampling method. The inclusion criteria were patients diagnosed with DHF/DSS based on World Health Organization (WHO) criteria (2011). The exclusion criteria were patients who received corticosteroids, blood transfusion, albumin infusion and patients with severe malnutrition. The dependent variables were shock and recurrent shock. The independent variable was serum albumin level. The relation between serum albumin level and shock or recurrent shock were analyzed using logistic regression test, power 0.80, α 0.05 and was significant if p<0.05. We used receiver operating characteristic (ROC) curve to determine prognostic factors. Data was analyzed using software SPSS v 21.0.

Results: There was significant correlation between albumin level and shock in DHF patients (p=0.0001, area under the curve (AUC) 0.865, cut-off 3.05, odds ratio (OR) 17.4, sensitivity 79%, specificity 81%), but there was no correlation between albumin level and recurrent shock in DSS patients.

Conclusions: Serum albumin level can be used as a predictor of shock in DHF patients but it cannot be used as predictor of recurrent shock in DSS patients.


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Levamisole tainted cocaine induced vasculitis

Abstract

Levamisole has been implicated in the vasculitis and aganulocytosis. It has been pulled from the United States market for human use. Due to its euphoric and bulking properties, it has been used as a bulking agent in cocaine.
We hereby present a case of a 56-year-old Hispanic male, who developed vasculitis due to cocaine use adulterated with levamisole.


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Peripherally-inserted central catheters: Watch for retained wires!

An increasing number of patients are being admitted to critical care units with multiple chronic medical conditions. In some of these patients, intravenous access is a challenge. With a concern for indwelling catheter infections, peripherally inserted central catheters (PICC). These lines have been advocated due to their lower rate of complications and comfort to the patients. PICC are routinely inserted by physicians and trained nurses. Complications such as pneumothorax and infections are lower than in central venous lines and the incidence of retained guide wire is minimal and in some cases unrecognized.
We recently had one such case. An elderly man with sepsis required a PICC placement. A trained nurse attempted to place it when she recognized that the guidewire was missing, as the vessel dilator was being used. A chest radiograph confirmed that the guidewire remained in the patient’s chest cavity. Interventional radiology successfully retrieved the missing wire. Vigilance and frequent refresher courses are required to evaluate the competency among health care workers placing these catheters to help avoid complications.


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Prognostic value of serum cholinesterase activity in the septic shock due to bacterial infections

Abstract
Context: Kinetics of SChE activity analyses, in our knowledge, was not previously studied in the prediction of prognosis of patients with septic shock.
Objective: We aimed to analyse kinetics of SChE activity in 4 patients with septic shock.
Materials and methods: Prospective study.
Results: The kinetics analyses of SChE activity showed that SChE activity was correlated with the prognosis (decrease in deads and increase in survivors).
Discussion and conclusion: The kinetics of SChE activity can be used as a biomarker to
predict the prognosis of patients with septic shock.


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The association between delta shock index and mortality in children with shock

Abstract
Background: Shock remains one leading cause of morbidity and mortality in hospitalized children. Delta shock index is a simple tool to assess and evaluate shock.
Objective: To investigate whether delta shock index might be related to mortality in children with shock.
Methods: Prospective cohort study.
Setting: Emergency Room (ER) and Pediatric Intensive Care Unit (PICU) of Sanglah University Hospital, Bali from March 2015 to March 2016.
Patients and participants: Children aged 1- month to 12-year-old that were diagnosed with shock during admission or during hospitalization. Subjects were divided into delta shock index (DSI)≤0 group and DSI>0.
Results: From March 2015 to March 2016 a total of 80 subjects were recruited. There were 40 cases with DSI≤0 and 40 cases with DSI>0. Mortality was found in 28 (70%) patients with DSI≤0 group. Chi-square analysis showed significant association between DSI and mortality (RR 1.9, 95%CI:1.2-2.9; p=0.004). Survival analysis showed median time survival was 5 days for the group with DSI≤0 and 7 days for the group with DSI>0 (log-rank 0.03). Cox regression analysis showed that DSI≤0 (RR 1.895, 95%CI:0.989-3.623; p=0.037) and age (RR 0.988, 95%CI:0.979-0.997; p=0.015) were risk factors for mortality in children with shock.
Conclusion: DSI≤0 was associated with mortality in children with shock.


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Is my patient really brain dead?

Abstract
The diagnosis of brain death can be fraught with multiple challenges ranging from the presence of complex motor movements to inappropriate patient screening, e.g. patient’s not meeting preconditions.
We describe two cases where complex motor movements persisted following clinical death by standard brain death criteria and caused uncertainty with regards to diagnosis of brain death.
We wish to highlight that complex motor movements are common and do not always preclude the diagnosis of brain death.


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MRSA pneumonia mucus plug burden and the difficult airway

An 80-year-old female with a past medical history of chronic obstructive pulmonary disease (COPD), diabetes, and hypertension was initially admitted to the hospital for surgical repair of an incarcerated inguinal hernia. She underwent successful herniorrhaphy with mesh placement. Her post-operative course was complicated by a pelvic hematoma requiring evacuation during an exploratory laparotomy. The patient subsequently developed worsening hypoxia and increased work of breathing. She was placed on supplemental oxygen and as part of her work-up, underwent chest-computed tomography (CT) (Figures A and B). Subsequently, she was admitted to the Intensive Care Unit (ICU).

MRSA pneumonia mucus plug burden and the difficult airway


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A randomized controlled trial: Changes of serum sodium levels in children with diarrhea moderate dehydration receiving rehydration therapy with standard hypotonic solution or balanced solution

Abstract
Background: Hyponatremia is a condition that may cause dangerous clinical manifestations. Diarrhea with dehydration is one of the most common causes for hyponatremia. Intravenous hypotonic fluid is used for children with moderate dehydration and isotonic Ringer lactate is used for severe dehydration in several therapy guidelines for diarrhea.
Aims: To investigate the difference in changes of serum sodium levels between rehydration therapy with standard hypotonic solution and balanced solution for children with diarrhea and dehydration.
Design: Randomized controlled clinical trial.
Setting: Emergency unit in Dr. Soetomo General Hospital, Surabaya, Indonesia.
Patients: Forty children aged between 3 months to 12 years old who were diagnosed with diarrhea with moderate dehydration based on Haroen Noerasid’s clinical criteria. Patients were randomly assigned into two groups: standard hypotonic solution therapy group (n=21) and balanced solution therapy group (n=19).
Interventions: Children in the standard therapy group received standard hypotonic solution (Na+ 50 mmol/L), while the other group received balanced solution (Na+ 145 mmol/L) as the main fluid during rehydration therapy.
Results: The mean initial serum sodium levels in the standard hypotonic solution and balanced solution group were 141 mmol/L and 141.4 mmol/L, respectively. The difference was found to be not statistically significant. There was a statistically significant difference between the post rehydration mean serum sodium levels of the standard hypotonic (138.3 mmol/L) and balanced solution group (141.7 mmol/L). The mean reduction of serum sodium levels was 2.48 mmol/L in the standard hypotonic solution group and there was a mean increase of 0.37 mmol/L in the balanced solution group. We found clinically a not significant difference of symptoms of hyponatremia in this study. There was no seizure, neurological inpairment in both treatment groups before and after rehydration.
Conclusions: There were difference changes in serum sodium levels post rehydration therapy by using two different solutions. Balanced solution was more stable and a safer choice to protects against hyponatremia.

A randomized controlled trial- Changes of serum sodium levels in children with diarrhea moderate dehydration receiving rehydration therapy with standard hypotonic solution or balanced solution


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