Concept: Medical emergencies
Colonoscopy is a widely used diagnostic and therapeutic modality with a relatively low morbidity. However, given the large volume of procedures performed, awareness of the infrequent complications is essential. Perforation is an established complication of colonoscopy, and can range from 0.2%-3% depending on the series, population and modality of colonoscopy. Acute appendicitis after colonoscopy is an extremely rare event, and a cause-effect relationship between the colonoscopy and the appendicitis is not well documented. In addition, awareness of this condition can aid in prompt diagnosis. Relatively mild symptoms and exclusion of bowel perforation by contrast studies do not exclude appendicitis from the differential diagnosis for post-colonoscopy pain. In addition to the difficult diagnosis inherent to postcolonoscopy appendicitis, treatment strategies have varied greatly. This paper reviews these approaches. We also expand upon prior articles by giving guidance for the role of nonoperative management in these patients. This case and review of the literature will help to create awareness about this complication, and guide optimal treatment of pericolonoscopy appendicitis.
Localised infections, and burn wound sepsis are key concerns in the treatment of burns patients, and prevention of colonisation largely relies on biocides. Acetic acid has been shown to have good antibacterial activity against various planktonic organisms, however data is limited on efficacy, and few studies have been performed on biofilms.
- JAMA : the journal of the American Medical Association
- Published almost 6 years ago
Blunt abdominal trauma often presents a substantial diagnostic challenge. Well-informed clinical examination can identify patients who require further diagnostic evaluation for intra-abdominal injuries after blunt abdominal trauma.
Prior to 2001 there was no standard for early management of severe sepsis and septic shock in the emergency department. In the presence of standard or usual care, the prevailing mortality was over 40-50 %. In response, a systems-based approach, similar to that in acute myocardial infarction, stroke and trauma, called early goal-directed therapy was compared to standard care and this clinical trial resulted in a significant mortality reduction. Since the publication of that trial, similar outcome benefits have been reported in over 70 observational and randomized controlled studies comprising over 70,000 patients. As a result, early goal-directed therapy was largely incorporated into the first 6 hours of sepsis management (resuscitation bundle) adopted by the Surviving Sepsis Campaign and disseminated internationally as the standard of care for early sepsis management. Recently a trio of trials (ProCESS, ARISE, and ProMISe), while reporting an all-time low sepsis mortality, question the continued need for all of the elements of early goal-directed therapy or the need for protocolized care for patients with severe and septic shock. A review of the early hemodynamic pathogenesis, historical development, and definition of early goal-directed therapy, comparing trial conduction methodology and the changing landscape of sepsis mortality, are essential for an appropriate interpretation of these trials and their conclusions.
Dextran hydrogel scaffolds enhance angiogenic responses and promote complete skin regeneration during burn wound healing.
- Proceedings of the National Academy of Sciences of the United States of America
- Published about 6 years ago
Neovascularization is a critical determinant of wound-healing outcomes for deep burn injuries. We hypothesize that dextran-based hydrogels can serve as instructive scaffolds to promote neovascularization and skin regeneration in third-degree burn wounds. Dextran hydrogels are soft and pliable, offering opportunities to improve the management of burn wound treatment. We first developed a procedure to treat burn wounds on mice with dextran hydrogels. In this procedure, we followed clinical practice of wound excision to remove full-thickness burned skin, and then covered the wound with the dextran hydrogel and a dressing layer. Our procedure allows the hydrogel to remain intact and securely in place during the entire healing period, thus offering opportunities to simplify the management of burn wound treatment. A 3-week comparative study indicated that dextran hydrogel promoted dermal regeneration with complete skin appendages. The hydrogel scaffold facilitated early inflammatory cell infiltration that led to its rapid degradation, promoting the infiltration of angiogenic cells into the healing wounds. Endothelial cells homed into the hydrogel scaffolds to enable neovascularization by day 7, resulting in an increased blood flow significantly greater than treated and untreated controls. By day 21, burn wounds treated with hydrogel developed a mature epithelial structure with hair follicles and sebaceous glands. After 5 weeks of treatment, the hydrogel scaffolds promoted new hair growth and epidermal morphology and thickness similar to normal mouse skin. Collectively, our evidence shows that customized dextran-based hydrogel alone, with no additional growth factors, cytokines, or cells, promoted remarkable neovascularization and skin regeneration and may lead to novel treatments for dermal wounds.
The present study was designed to determine the role of topical treatment with curcumin (Cur) on burn wound healing in rats. The Wistar-albino rats were randomly allotted into one of three experimental groups: 4th, 8th and 12th day (post burn) and all groups include subgroups which Burn and Burn + Cur. Each group contains 12 animals. Burn wounds were made on the back of rat and Cur was administered topically. At the end of the study, all animals were sacrificed and the wound tissues removed for analyse to biochemical and histopathological changes. There was a significant increase in the hydroxyproline levels in the skin of the Cur groups. Cur treated wounds were found to heal much faster as indicated by improved rates of inflammatory cells, collagen deposition, angiogenesis, granulation tissue formation and epithelialization which were also confirmed by histopathological and biochemical examinations. Our data also indicate that there is a rise in the expression of proliferating cell nuclear antigen in skin tissues of Cur-treated rats in the Burn group. The results clearly substantiate the beneficial effects of the topical application of Cur in the acceleration of wound healing.
We report a unique case of diabetic ketoacidosis in which a relatively low potassium level on admission was associated with consequent life-threatening and refractory arrhythmia secondary to inappropriate use of intravenous insulin and bicarbonate therapy. The latter was reversed by rapid bolus potassium injection. Although we do not advocate this approach in every case, we emphasise that a bolus injection of potassium may be life saving in such cases. The lessons from this case have led to multidisciplinary meetings and modification of the institute’s diabetic ketoacidosis clinical pathway.
Patients on antithrombotic therapy (ATT) have the highest risk of ongoing bleeding and mortality. Hemospray (Cook Medical, Winston-Salem, North Carolina, USA) is a novel hemostatic agent for the treatment of upper gastrointestinal bleeding (UGIB). Initial reports on its use appear promising in terms of initial hemostasis and rebleeding rates. It is unknown whether this also pertains to patients on ATT. The aim of the current study therefore was to evaluate the efficacy of Hemospray in the treatment of UGIB in patients taking ATTs. A total of 16 unselected consecutive patients with UGIB who were treated with Hemospray were analyzed (eight taking ATT for various indications and eight not on ATT). Initial hemostasis was achieved after Hemospray application in 5 /8 patients on ATT (63 %) and in all eight patients not on therapy (P = 0.20). Rebleeding rates were similar in both groups. These preliminary data on the use of Hemospray in the management of UGIB are promising in both patients with and without ATT; however, caution should be exercised for its use in patients on ATT with spurting arterial bleeding.
Several changes in the way patients with hemorrhagic shock are resuscitated have occurred over the past decades, including permissive hypotension, minimal crystalloid resuscitation, earlier blood transfusion, and higher plasma and platelet-to-red cell ratios. Hemostatic adjuncts, such as tranexamic acid and prothrombin complex, and the use of new methods of assessing coagulopathy are also being incorporated into resuscitation of the bleeding patient. These ideas have been incorporated by many trauma centers into institutional massive transfusion protocols, and adoption of these protocols has resulted in improvements in mortality and morbidity. This article discusses each of these new resuscitation strategies and the evidence supporting their use.
Object There has been an increase in civilian gun violence since the late 1980s, with a disproportionately high increase occurring within the pediatric population. To date, no definite treatment paradigm exists for the management of these patients, nor is there a full understanding of the predictors of favorable clinical outcome in this population. Methods The authors completed a retrospective review of all victims of intracranial gunshot injury from birth to age 18 years at a major metropolitan Level 1 trauma center (n = 48) from 2002 to 2011. The predictive values of widely accepted adult clinical and radiographic factors for poor prognosis were investigated. Results Eight statistically significant factors (p < 0.05) for favorable outcome were identified. These factors include single hemispheric involvement, absence of a transventricular trajectory, < 3 lobes involved, ≥ 1 reactive pupil on arrival, systolic blood pressure > 100 mm Hg on arrival, absence of deep nuclei and/or third ventricular involvement, initial ICP < 30 mm Hg when monitored, and absence of midline shift. Of these 8 factors, 5 were strong predictors of favorable clinical outcome as defined by Glasgow Outcome Scale score of 4 or 5. These predictive factors included absence of a transventricular trajectory, < 3 lobes involved, ≥ 1 reactive pupil on arrival, absence of deep nuclei and/or third ventricular involvement, and initial ICP < 30 mm Hg. These findings form the basis of the St. Louis Scale for Pediatric Gunshot Wounds to the Head, a novel metric to inform treatment decisions for pediatric patients who sustain these devastating injuries. Conclusions The pediatric population tends to demonstrate more favorable outcomes following intracranial gunshot injury when compared with the adult population; therefore some patients may benefit from more aggressive treatment than is considered for adults. The St. Louis Scale for Pediatric Gunshot Wounds to the Head may provide critical data toward evidence-based guidelines for clinical decision making.