Use of an Atriocaval Shunt in a Trauma Patient: First Reported Case in Hawai‘i

Background

Traumatic injuries to the retrohepatic vena cava are typically fatal. Emergent access to this area is difficult and patients typically exsanguinate before the injury can be identified and fixed.

Objective

To report the use of an atriocaval shunt in the repair of an injury to the retrohepatic vena cava from a gunshot wound.

Case Report

A 24-year-old man was shot in his right chest suffering a penetrating injury to the liver and inferior vena cava. Surgical repair was performed with the aid of an atriocaval shunt fashioned from a chest tube. He survived and recovered without incident.

Conclusion

Atriocaval shunting may be a life-saving option for uncontrolled hemorrhage from injuries to the retrohepatic vena cava.     

Emergency endovascular repair of acute descending thoracic aortic dissection

Background

Acute descending thoracic aortic dissection is a life-threatening emergency. It is not often considered as the initial diagnosis in patients presenting with epigastric pain and could easily be missed in a busy casualty department.

Aim

This case report is aimed to highlight the feasibility of the technique and the need for long-term surveillance following endovascular repair of acute thoracic aortic dissection.

Results

The patient presented with epigastric pain radiating to the interscapular region with a stable hemodynamic status. A computerized tomography (CT) scan demonstrated type B thoracic aortic dissection of the proximal descending thoracic aorta. A successful endovascular repair was carried out with uneventful recovery and follow-up CT scan six years after stent-grafting shows satisfactory position of the stent-graft, patent false lumen in the abdominal aorta perfusing the right kidney, and progressively enlarging diameter of the abdominal aorta.

Conclusion

Thoracic aortic dissection should be considered as a differential diagnosis in patients presenting with epigastric and interscapular chest pain. Emergency endovascular repair of acute thoracic aortic dissection is feasible and relatively safe. Regular follow-up with CT scan is required to evaluate the long-term efficacy and identify the need for re-intervention.     

Lower Mortality for Abdominal Aortic Aneurysm Repair in High‐Volume Hospitals Is Contingent upon Nurse Staffing

Objective

To determine whether and to what extent the lower mortality rates for patients undergoing abdominal aortic aneurysm (AAA) repair in high-volume hospitals is explained by better nursing.

Data Sources

State hospital discharge data, Multi-State Nursing Care and Patient Safety Survey, and hospital characteristics from the AHA Annual Survey.

Study Design

Cross-sectional analysis of linked patient outcomes for individuals undergoing AAA repair in four states.

Data Collection

Secondary data sources.

Principal Findings

Favorable nursing practice environments and higher hospital volumes of AAA repair are associated with lower mortality and fewer failures-to-rescue in main-effects models. Furthermore, nurse staffing interacts with volume such that there is no mortality advantage observed in high-volume hospitals with poor nurse staffing. When hospitals have good nurse staffing, patients in low-volume hospitals are 3.4 times as likely to die and 2.6 times as likely to die from complications as patients in high-volume hospitals (p < .001).

Conclusions

Nursing is part of the explanation for lower mortality after AAA repair in high-volume hospitals. Importantly, lower mortality is not found in high-volume hospitals if nurse staffing is poor.     

Relationship between patient safety and hospital surgical volume

Objective

To examine the relationship between hospital volume and in-hospital adverse events.

Data Sources

Patient safety indicator (PSI) was used to identify hospital-acquired adverse events in the Nationwide Inpatient Sample database in abdominal aortic aneurysm, coronary artery bypass graft, and Roux-en-Y gastric bypass from 2005 to 2008.

Study Design

In this observational study, volume thresholds were defined by mean year-specific terciles. PSI risk-adjusted rates were analyzed by volume tercile for each procedure.

Principal Findings

Overall, hospital volume was inversely related to preventable adverse events. High-volume hospitals had significantly lower risk-adjusted PSI rates compared to lower volume hospitals (p < .05).

Conclusion

These data support the relationship between hospital volume and quality health care delivery in select surgical cases. This study highlights differences between hospital volume and risk-adjusted PSI rates for three common surgical procedures and highlights areas of focus for future studies to identify pathways to reduce hospital-acquired events.     

Intussusception as a Cause of Bowel Obstruction in Adults from a Resource Limited Area,Cameroon

Background

Intussusception refers to the telescoping of a proximal segment of bowel into a distal segment. It is a rare cause of intestinal obstruction in adulthood.

Case Details

We report two cases of adult intussusception in a post-operative period following Caesarean Section (with no lead point) and Appendicectomy (due to colonic adenocarcinoma) respectively.

Conclusion

Though rare in adulthood, intussusception should be considered as a differential diagnosis to bowel obstruction in adults even in the post-operative period.     

Long-Term Inhalation Exposure to Nickel Nanoparticles Exacerbated Atherosclerosis in a Susceptible Mouse Model

Background

Because associations have been reported between inhaled ambient ultrafine particles and increased risk of cardiopulmonary disease, it has been suggested that inhaled engineered nanoparticles (NPs) may also induce adverse effects on the cardiovascular system.

Objective

We examined the long-term cardiovascular effects of inhaled nickel hydroxide NPs (nano-NH) using a sensitive mouse model.

Methods

Hyperlipidemic, apoprotein E-deficient (ApoE^−/−) mice were exposed to nano-NH at either 0 or 79 μg Ni/m³, via a whole-body inhalation system, for 5 hr/day, 5 days/week, for either 1 week or 5 months. We measured various indicators of oxidative stress and inflammation in the lung and cardiovascular tissue, and we determined plaque formation on the ascending aorta.

Results

Inhaled nano-NH induced significant oxidative stress and inflammation in the pulmonary and extrapulmonary organs, indicated by up-regulated mRNA levels of certain antioxidant enzyme and inflammatory cytokine genes; increased mitochondrial DNA damage in the aorta; significant signs of inflammation in bronchoalveolar lavage fluid; changes in lung histopathology; and induction of acute-phase response. In addition, after 5-month exposures, nano-NH exacerbated the progression of atherosclerosis in ApoE^−/− mice.

Conclusions

This is the first study to report long-term cardiovascular toxicity of an inhaled nanomaterial. Our results clearly demonstrate that long-term exposure to inhaled nano-NH can induce oxidative stress and inflammation, not only in the lung but also in the cardiovascular system, and that this stress and inflammation can ultimately contribute to progression of atherosclerosis in ApoE^−/− mice.     

Therapeutic implications of transesophageal echocardiography after transthoracic echocardiography on acute stroke patients

Background

The role of transesophageal echocardiography (TEE) in the evaluation of acute stroke patients is still ill-defined. We conducted a prospective observational study to find the prevalence of TEE findings that indicate anticoagulation as beneficial, in acute ischemic stroke patients without indication for anticoagulation based on clinical, electrocardiographic and transthoracic echocardiography (TTE) findings.

Methods

We prospectively studied all patients referred to our laboratory for TTE and TEE. Patients were excluded if the diagnosis was not acute ischemic stroke or if they had an indication for anticoagulation based on clinical, electrocardiographic, or TTE data. Patients with TEE findings that might indicate anticoagulation as beneficial were identified.

Results

A total of 84 patients with acute ischemic stroke and without indication for anticoagulation based on clinical and electrocardiographic or TTE data were included in the study. Findings indicating anticoagulation as beneficial were found in 32.1%: spontaneous echo contrast (1.2%), complex aortic atheroma (27.4%), thrombus (8.3%), and simultaneous patent foramen ovale and atrial septal aneurysm (2.4%).

Conclusions

The results of our study show that TEE can have therapy implications in 32.1% of ischemic stroke patients in sinus rhythm and with TTE with no indication for anticoagulation.     

Imported Melioidosis in South Korea: A Case Series with a Literature Review

Objectives

Melioidosis is a potentially fatal infectious disease caused by the environmental anaerobic Gram-negative bacillus Burkholderia pseudomallei. Melioidosis is endemic to areas of northern Australia and Southeast Asia. With increasing international travel and migration, imported cases of melioidosis are being reported regularly. Here, we summarize the 11 cases of melioidosis reported in South Korea from 2003 to 2014.

Methods

Tracing epidemiological investigations were performed on every patient reported to the National Surveillance System since 2011. A systematic literature search was performed to identify melioidosis cases that occurred prior to 2011.

Results

The overall fatality rate was 36.4%. All the patients had visited Southeast Asia where melioidosis is endemic. The stay in the endemic region ranged from 4 days to 20 years. Of the seven patients who developed initial symptoms after returning to South Korea, the time interval between returning to South Korea and symptom onset ranged from 1 day to 3 years. The remaining four patients developed symptoms during their stay in the endemic region and were diagnosed with melioidosis in South Korea. Seven (63.6%) patients possessed at least one risk factor, all of whom were diabetic. Pneumonia was the most frequent clinical manifestation, but the patients showed a wide spectrum of clinical features, including internal organ abscesses, a mycotic aneurysm of the aorta, and coinfection with tuberculosis.

Conclusion

An early diagnosis and initiation of the appropriate antibiotics can reduce the mortality of melioidosis. Consequently, increased awareness of the risk factors and clinical features of melioidosis is required.     

Reaction of Medical Students to Experiences in Dissection Room

Background

As preclinical medical students start and/or enter the course, they go through the anatomy curriculum, which involves interaction with cadavers and cadaveric material. The objective of this study was to determine the reactions of preclinical medical students from year two and year three to the dissecting room.

Methods

Questionnaire was distributed to all second and third year medical students. The questionnaire was designed with the objective of identifying specific patterns of attitudes held and problems faced by the students in their first exposure to the human cadaver. The results are analyzed statistically using the SPSS 16.0 software and P< 0.05 was considered statistically significant.

Results

The commonest symptoms experienced were loss of appetite (43.29% year 2 and 34.86 % third year students). The commonest cause of their symptoms was studied and the result shows that it was the smell of the dissection room, as reported by 67.01% of year two students; and 54.12% for year 3 students.

Conclusion

The present study findings show that smell of the dissection room, touch and fear of cadaver were the commonest cause of their symptoms experienced while study in dissection room for the majority of students. Thus, instructors are should give awareness raising education before the commencement of the dissection session to the students both mentally and emotionally ready to do their work enthusiastically and confidently. Moreover, it is necessary to make the laboratory tidy for the students so that they develop a love for the dissection room.     

Incidental Chest Radiographic Findings in Adult Patients With Acute Cough

PURPOSE

Imaging may produce unexpected or incidental findings with consequences for patients and ordering of future investigations. Chest radiography in patients with acute cough is among the most common reasons for imaging in primary care, but data on associated incidental findings are lacking. We set out to describe the type and prevalence of incidental chest radiography findings in primary care patients with acute cough.

METHODS

We report on data from a cross-sectional study in 16 European primary care networks on 3,105 patients with acute cough, all of whom were undergoing chest radiography as part of a research study workup. Apart from assessment for specified signs of pneumonia and acute bronchitis, local radiologists were asked to evaluate any additional finding on the radiographs. For the 2,823 participants with good-quality chest radiographs, these findings were categorized according to clinical relevance based on previous research evidence and analyzed for type and prevalence by network, sex, age, and smoking status.

RESULTS

Incidental findings were reported in 19% of all participants, and ranged from 0% to 25% by primary care network, with the network being an independent contributor (P <.001). Of all participants 3% had clinically relevant incidental findings. Suspected nodules and shadows were reported in 1.8%. Incidental findings were more common is older participants and smokers (P <. 001).

CONCLUSIONS

Clinically relevant incidental findings on chest radiographs in primary care adult patients with acute cough are uncommon, and prevalence varies by setting.Key words: cough, lung/radiography, primary care, incidental findings     

Influence of thoracic aortic inflammation and calcifications on arterial stiffness and cardiac function in older subjects

Background

Vascular aging is accompanied by gradual remodeling affecting both arterial and cardiac structure and mechanical properties. Hypertension is suggested to exert pro-inflammatory actions enhancing arterial stiffness.

Objectives

To determine the influence of thoracic aortic inflammation and calcifications on arterial stiffness and cardiac function in hypertensive and normotensive older subjects.

Design

A prospective study.

Setting

An acute geriatrics ward of the University Hospital of Nancy in France.

Subjects

Thirty individuals ≥ 65 years were examined, including 15 hypertensive subjects and 15 controls well-matched for age and sex.

Measurements

Applanation tonometry was used to measure aortic pulse wave velocity (AoPWV) and carotid/brachial pulse pressure amplification (PPA). Left ventricular parameters were measured with magnetic resonance imaging. Local thoracic aortic inflammation and calcification were measured by 18 F-fluorodeoxyglucose positron emission tomography/computed tomography imaging. Biomarkers of low-grade inflammation were also quantified.

Results

AoPWV was higher in elderly hypertensive subjects comparatively to normotensive controls (15.5±5.3 vs. 11.9±2.5, p=0.046), and hypertensives had a higher calcification volume. In the overall population, calcifications of the thoracic descending aorta and inflammation of the ascending aorta accounted for respectively 18.1% (p=0.01) and 9.6% (p=0.07) of AoPWV variation. Individuals with high levels of calcifications and/or inflammation had higher AoPWV (p=0.003). Inflammation had a negative effect on PPA explaining 13.8% of its variation (p<0.05).

Conclusions

This study highlights the importance of local ascending aortic inflammation as a potential major actor in the determination of PPA while calcifications and hypertension are more linked to AoPWV. Assessment of PPA in the very elderly could provide complementary information to improve diagnostic and therapeutic strategies targeting ascending aortic inflammation.

     

A cross sectional study of the respiratory health of workers handling printing toner dust

Background

Although recent case reports have suggested possible respiratory effects of solid toner dust inhalation, this hypothesis has not been verified by epidemiological studies.

Objectives

To conduct a cross sectional study to evaluate the association between the biological indices of lung fibrosis and toner dust exposure in an occupational cohort handling solid toner dust in their work life.

Methods

A total of 600 male toner workers and 212 control subjects were surveyed in terms of their subjective respiratory symptoms, pulmonary functions, and chest radiographic findings. In addition to the exposure history, the current working conditions and personal exposure levels to toner dust were also examined.

Results

Although subjects handling toner for more than 20 years tended to show a higher prevalence of respiratory symptoms and minimal chest x ray abnormalities, there was no consistent relation between the exposure to toner dust and the biological responses of the respiratory system.

Conclusion

Deterioration of respiratory health related to toner dust exposure is less likely to occur in current well controlled work environments, especially if the powdered toner is handled carefully. Nonetheless, it is important to collect further epidemiological evidence on the biological effects of toner dust inhalation, preferably using a longitudinal study design.     

Medical Students' Attitudinal Changes Towards Cadaver Dissection: A Longitudinal Study

Background

Recently, not only the medical school curriculum but also medical students'' attitude towards cadaver-based learning of anatomy has changed. This investigation is therefore designed to analyse students'' attitudes towards human cadaveric dissection before and after exposure to dissection.

Methods

A longitudinal survey was conducted among second year medical students in 2010 at the college of Medicine and Health Sciences, University of Gondar. All second year medical students (n=147) were included in the study where their attitudes were surveyed at three time points (one week prior to dissection session, a week after the initiation of dissection and eight weeks after the second survey). Three standardized and pretested questionnaires prepared in English were used to collected relevant data from the subjects.

Results

Out of the 147 students 85.7% were males. The subjects'' age ranged between 18 and 23 with a mean and standard deviation of 19.5±1 years. This study has revealed that among majority of the students fear and nausea have decreased while their interest and excitement has increased on subsequent exposure to dissection (P<0.05). About 75% of students considered the dissection room as slightly or highly stressful. Smell of the cadaver and eye irritation as a result of the chemicals in it were the major aspects identified as making the dissecting room stressful. The result also showed that almost all (99%) considered cadaver dissection had very important educational value for anatomy learning.

Conclusion

In the majority of the students fear and nausea had decreased while interest and excitement had increased on subsequent exposure to dissection. It also showed that chemical odour and eye irritations were the leading factors which create discomfort in the dissection room even though anatomical dissection by itself was not considered as a stressor. Thus, instructors are recommended to adequately prepare students mentally and emotionally before the commencement of the dissection session for an exciting and stress free anatomy learning though dissection.     

Hypersensitivity pneumonitis in a cluster of sawmill workers: a 10-year follow-up of exposure,symptoms, and lung function

Background:

The long-term prognosis of repeated acute episodes of hypersensitivity pneumonitis (HP) is not well described. We report on a 10-year follow-up of a 10-person cluster from a Norwegian sawmill who had all experienced relapsing episodes of HP.

Objectives:

To evaluate the health symptoms, work-related sick-leave, and lung function of 10 workers exposed to mold in a Norwegian sawmill.

Methods:

Participants were evaluated at baseline and 10 years later at follow-up. A structured interview, measurement of serum IgG antibodies to Rhizopus microsporus (R. microsporus) antigens, lung function tests, high resolution computed tomography (HRCT) of the chest, and personal measurements of exposure to mold spores and dust were completed for each participant.

Results:

At baseline, nearly all workers reported acute episodes of HP more than twice a month. At follow-up, both the frequency and intensity of symptoms had declined. Sick-leave was reduced and gas diffusing capacity improved – paralleling the gradually reduced air levels of mold spores.

Conclusions:

In spite of an initially high occurrence of symptoms, long-term clinical and physiological outcome was good. With reduced exposure to mold spores, symptoms declined and lung function was restored.     

Compassion Practices and HCAHPS: Does Rewarding and Supporting Workplace Compassion Influence Patient Perceptions?

Objective

To examine the benefits of compassion practices on two indicators of patient perceptions of care quality—the Hospital Consumer Assessment of Healthcare Providers and systems (HCAHPS) overall hospital rating and likelihood of recommending.

Study Setting

Two hundred sixty-nine nonfederal acute care U.S. hospitals.

Study Design

Cross-sectional study.

Data Collection

Surveys collected from top-level hospital executives. Publicly reported HCAHPS data from October 2012 release.

Principal Findings

Compassion practices, a measure of the extent to which a hospital rewards compassionate acts and compassionately supports its employees (e.g., compassionate employee awards, pastoral care for employees), is significantly and positively associated with hospital ratings and likelihood of recommending.

Conclusions

Our findings illustrate the benefits for patients of specific and actionable organizational practices that provide and reinforce compassion.     

Music and 25% glucose pain relief for the premature infant: a randomized clinical trial

OBJECTIVE:

to analyze the total Premature Infant Pain Profile scores of premature infants undergoing arterial puncture during music and 25% glucose interventions, and to assess their association with neonatal and therapeutic variables.

METHOD:

a randomized clinical trial with 80 premature infants; 24 in the Experimental Group 1 (music), 33 in the Experimental Group 2 (music and 25% glucose), 23 in the Positive Control Group (25% glucose). All premature infants were videotaped and a lullaby was played for ten minutes before puncture in Experimental Groups 1 and 2; 25% glucose administered in Experimental Group 2 and the Positive Control Group two minutes before puncture.

RESULTS:

60.0% of premature infants had moderate or maximum pain; pain scores and intervention groups were not statistically significant. Statistically significant variables: Experimental Group 1: head and chest circumference, Apgar scores, corrected gestational age; Experimental Group 2: chest circumference, Apgar scores, oxygen therapy; Positive Control group: birth weight, head circumference.

CONCLUSION:

neonatal variables are associated with pain in premature infants. Brazilian Registry of Clinical Trials: UTN: U1111-1123-4821.     

Meta-Analysis: Identification of Low Birthweight by Other Anthropometric Measurements at Birth in Developing Countries

Background

Low birthweight should be identified early, even in developing countries where birthweight cannot be easily measured due to the absence of scales and trained staff. This meta-analysis evaluated and compared the use of other anthropometric measurements at birth to predict low birthweight.

Methods

All studies of medium to high quality (Quality Assessment of Diagnostic Accuracy Studies score ≥8) published in English were included. Bivariate random-effects meta-analysis and hierarchical summary receiver operating characteristic curves were used.

Results

A total of 69 studies evaluated foot length or the circumference of the chest, (mid-upper) arm, or thigh (n = 8, 25, 30, and 6, respectively). Chest circumference and arm circumference had areas under the curve >0.9 (0.95 for both), pooled positive likelihood ratios >5 (8.7 and 10.3, respectively), and negative likelihood ratios <0.2 (0.13 and 0.17, respectively); thigh circumference and foot length were less accurate. There was no substantial difference between chest and arm circumference with respect to pooled sensitivity (0.88 vs. 0.84, P = 0.505), specificity (0.90 vs. 0.92, P = 0.565), or diagnostic odds ratio (67 vs. 60, P = 0.552). However, as compared with arm circumference, chest circumference showed greater clustering of observations on the hierarchical summary receiver operating characteristic curve and narrower 95% confidence and prediction regions.

Conclusions

Chest circumference and arm circumference have similarly high, although not confirmative, accuracy in predicting low birthweight; however, chest circumference appears to be more precise.Key words: meta-analysis, low birth weight, anthropometry, sensitivity and specificity, newborn     

Cross-cultural adaptation and clinical validation of the Neonatal Skin Condition Score to Brazilian Portuguese

OBJECTIVE:

to describe the process of cross-cultural adaptation and clinical validation of the Neonatal Skin Condition Score.

METHODS:

this methodological cross-cultural adaptation study included five steps: initial translation, synthesis of the initial translation, back translation, review by an Committee of Specialists and testing of the pre-final version, and an observational cross-sectional study with analysis of the psychometric properties using the Adjusted Kappa, Intraclass Correlation Coefficient, and Bland-Altman Method statistical tests. A total of 38 professionals were randomly recruited to review the clarity of the adapted instrument, and 47 newborns hospitalized in the Neonatology Unit of the Clinical Hospital of Porto Alegre were selected by convenience for the clinical validation of the instrument.

RESULTS:

the adapted scale showed approximately 85% clarity. The statistical tests showed moderate to strong intra and interobserver item to item reliability and from strong to very strong in the total score, with a variation of less than 2 points among the scores assigned by the nurses to the patients.

CONCLUSIONS:

the scale was adapted and validated to Brazilian Portuguese. The psychometric properties of the Brazilian version of the Neonatal Skin Condition Score instrument were similar to the validation results of the original scale.     

A High‐Resolution Analysis of Process Improvement: Use of Quantile Regression for Wait Time

Objective

Apply quantile regression for a high-resolution analysis of changes in wait time to treatment and assess its applicability to quality improvement data compared with least-squares regression.

Data Source

Addiction treatment programs participating in the Network for the Improvement of Addiction Treatment.

Methods

We used quantile regression to estimate wait time changes at 5, 50, and 95 percent and compared the results with mean trends by least-squares regression.

Principal Findings

Quantile regression analysis found statistically significant changes in the 5 and 95 percent quantiles of wait time that were not identified using least-squares regression.

Conclusions

Quantile regression enabled estimating changes specific to different percentiles of the wait time distribution. It provided a high-resolution analysis that was more sensitive to changes in quantiles of the wait time distributions.