Recent innovations in wound dressings – case reports

Veterinary wound management can often fall short of the high standards which most of us aim to provide and which our clients have come to expect. Whilst it is commonplace for most practices to offer the most up-to-date drugs for medical conditions and referral of complicated cases to a specialist, it is still all too common for a cat, presenting with a burst abscess, to be sent home with a course of antibiotics, a bottle of chlorhexidine and a gaping hole in its face!     

Convalescent plasma therapy in B-cell-depleted and B-cell sufficient patients with life-threatening COVID-19 – A case series

ObjectiveTo investigate the effect of convalescent plasma therapy (CPT) on clinical courses of B-cell-sufficient and B-cell-depleted patients with life-threatening COVID-19.Patients and MethodsIn this case series, we retrospectively analysed clinical, laboratory and cardiopulmonary parameters of six patients with life-threatening COVID-19 receiving convalescent plasma (CP) as rescue therapy between April 11, 2020 to October 10, 2020. Clinical and laboratory parameters before and after transfusion were compared in two B-cell-depleted patients and four B-cell sufficient patients (control group).ResultsBoth B-cell-depleted patients cleared SARS-CoV-2 virus and survived, while all other patients died within 14 days from intervention despite maximal therapeutic efforts. D-dimer levels increased in both cohorts subsequent to CPT. In control patients, mean Interleukin-6 increased and platelet levels decreased as opposed to decreasing and stable levels in B-cell-depleted patients, respectively. Control patients required increased doses of vasopressor compared to decreasing doses in B-cell depleted patients subsequent to CPT. PO₂/FiO₂ decrease was more pronounced and respiratory deterioration required postinterventional extracorporeal membrane oxygenation in two control patients. Transpulmonary thermodilution revealed a further increase of the Extravascular Lung Water Index upon CPT in control patients.ConclusionUse of CP in late stages of life-threatening COVID-19 should be used with caution but may be beneficial in B-cell-depleted patients. Further studies are necessary to assess factors predicting potential therapeutic benefits as well as possible hazards.     

Can we predict septic shock in patients with hospital-acquired pneumonia?

Hospital-acquired pneumonia is a serious and potentially life-threatening complication, with reported pneumonia-attributable mortality rates as high as 50%. Rapid diagnosis and immediate institution of adequate empirical antimicrobial treatment are of paramount importance in patient management. Nevertheless, some patients deteriorate and develop respiratory insufficiency, septic shock and a multiorgan dysfunction syndrome. Early recognition of these patients might help in reducing morbidity and mortality. Elevated systemic levels of proinflammatory cytokines (IL-1β, IL-6, IL-8 and IL-10) at the time of diagnosis of hospital-acquired pneumonia appear to be indicative of subsequent progression to septic shock. Should this now become a part of patient management?     

Can we predict pneumococcal bacteremia in patients with severe community-acquired pneumonia?

Purpose

This study aimed to evaluate the role of biomarkers as markers of pneumococcal bacteremia in severe community-acquired pneumonia (SCAP).

Materials and Methods

A prospective, single-center, observational cohort study of 108 patients with SCAP admitted to the intensive care department of a university hospital in Portugal was conducted. Leucocytes, C-reactive protein (CRP), lactate, procalcitonin (PCT), d-dimer, brain natriuretic peptide (BNP), and cortisol were measured within 12 hours after the first antibiotic dose.

Results

Fifteen patients (14%) had bacteremic pneumococcal pneumonia (BPP). They had significantly higher levels of median CRP (301 [interquartile range, or IQR], 230-350] mg/L vs 201 [IQR, 103-299] mg/L; P = .023), PCT (40 [IQR, 25-102] ng/mL vs 8 [IQR, 2-26] ng/mL; P < .001), BNP (568 [IQR, 478-2841] pg/mL vs 407 [IQR, 175-989] pg/mL; P = .027), and lactate (5.5 [IQR, 4.5-9.8] mmol/L vs 3.1 [IQR, 1.9-6.2] mmol/L; P = .009) than did patients without BPP. The discriminatory power evaluated by the area under the receiver operating characteristic curve (aROC) for PCT (aROC, 0.79) was superior to lactate (aROC, 0.71), BNP (aROC, 0.67), and CRP (aROC, 0.70). At a cutoff point of 17 ng/mL, PCT showed a sensitivity of 87%, a specificity of 67%, a positive predictive value of 30% and a negative predictive value of 97%, as a marker of pneumococcal bacteremia.

Conclusions

In this cohort, significantly higher PCT, BNP, lactate, and CRP levels were found in BPP, and PCT presented the best ability to identify pneumococcal bacteremia. A PCT serum level lower than 17 ng/mL could identify patients with SCAP unlikely to have pneumococcal bacteremia.     

Strategies to promote family–professional collaboration: two case reports

Purpose: Although research supports family–professional collaboration, challenges to implementation have been reported. The case reports describe the implementation of a 4-step practice model that incorporates specific strategies to facilitate family–professional collaboration.

Method: The participants were two mothers of children with physical disabilities and two physical therapists. Therapists received instruction in the strategies for collaboration including client-centred interview, visualising a preferred future, scaling questions, and family routine and activity matrix. The intervention was implemented during 6-weekly sessions. The 2nd and 5th sessions were videotaped to analyse the interactions between the parent and therapist using Response Class Matrix. Telephone interviews were conducted to explore participants’ experiences.

Results: Therapists were able to implement all strategies following 6 h of instruction. Analysis of the videotapes indicated that mother–therapist interactions were characterised by sharing information and open communication in a mutually supportive manner. Interviews with the mothers and therapists indicated that the therapists engaged the mothers in the intervention process and tailored interventions to child and family needs. The scaling questions were difficult to implement (therapists) and answer (parents).

Conclusion: The findings suggest that the strategies can be used by therapists to promote collaboration and involve parents in setting goals and the intervention process.

• Implications for Rehabilitation

• Strategies to promote parent–therapist collaboration include client-centred interview, visualising a preferred future, scaling questions, and family routine and activity matrix.

• Therapists with no previous instruction or training on family-centred services successfully implemented the strategies following 6 h of instruction.

• Interactions between two parent–physical therapist dyads were characterised by sharing information and open communication in a mutually supportive manner following therapist instruction in strategies for parent–therapist collaboration.

     

Factors associated with pneumonia in post–cardiac arrest patients receiving therapeutic hypothermia

Aim

The aim of this study is to investigate risk factors associated with the development of pneumonia during the first 7 days of admission in survivors of cardiac arrest receiving therapeutic hypothermia.

Methods

A total of 123 patients receiving therapeutic hypothermia after out-of-hospital cardiac arrest between January 2008 and December 2010 were enrolled. Study populations were categorized as “pneumonia present” [P (+)] and “pneumonia absent” [P (−)] contingent upon the development of pneumonia during the first 7 days of admission. Risk factors and outcomes related to development of pneumonia were determined.

Results

Fifty-nine patients (48.0 %) developed pneumonia, and P (+) patients had lower Acute Physiology and Chronic Health Evaluation II score (22 vs 26); longer durations of central venous catheter (8.9 vs 5.1 days), nasogastric tube (11.1 vs 3.8 days), mechanical ventilation (MV) (9.3 vs 3.7 days), and intensive care unit stay (10.0 vs 5.0 days); and higher rates of nasogastric feeding (66.1% vs 35.9 %), tracheostomy (52.5% vs 17.2 %), and postanoxic seizure (62.7% vs 39.1 %). In multivariate analyses, the occurrence of postanoxic seizure (odds ratio, 2.75; 95% confidence interval, 1.06-7.14; P = .04) and the length of MV (odds ratio, 1.33; 95% confidence interval, 1.15-1.52; P < .001) were independently associated with the development of pneumonia. The development of pneumonia had no significant association with survival (log-rank test, P = .15).

Conclusion

Postanoxic seizure and prolonged duration of MV are independently associated with development of pneumonia. It may be helpful that we give more attention to the development of pneumonia in patients with postanoxic seizure and provide prompt diagnosis and treatment of postanoxic seizure.     

Qualitative cultures in ventilator-associated pneumonia – can they be used with confidence?

The sensitivity and specificity of the radiographic and clinical evidence used to diagnose ventilator-associated pneumonia vary depending on the number of clinical criteria present. Bacteriological confirmation that rules out other diseases can be achieved by quantitative or qualitative cultures of tracheal aspirate. The rate of tracheal colonization in ventilated patients reduces the usefulness of qualitative cultures, but the absence of multiresistant micro-organisms in cultures from patients on prior antibiotics or a sterile culture in patients without prior antimicrobials may provide sufficient justification to stop or de-escalate antibiotics. However, more accurate guidance regarding whether antibiotics are unnecessary and should be stopped is provided by quantitative culture.     

Osteopontin – a fibrosis-related marker – in dilated cardiomyopathy in patients with Emery-Dreifuss muscular dystrophy

Abstract

Background: As osteopontin (OPN) may be assumed to have diagnostic/prognostic value in heart diseases, it is worth assessing whether it is also involved in the pathogenesis and can be applied in the diagnosis of the dilated cardiomyopathy (DCM) in Emery-Dreifuss muscular dystrophy (EDMD). Methods: Serum levels of osteopontin were quantified by means of sandwich immunoassay in 25 EDMD patients (10 laminopathies AD-EDMD and 15 emerinopathies – X-EDMD), eight carriers of X-EDMD, nine disease controls (patients with dystrophinopathy) and 20 age-matched healthy controls. Results: The levels of circulating OPN were elevated in all AD-EDMD and X-linked EDMD patients, as well as in X-EDMD carriers and patients suffering progressive muscular dystrophy. There was no correlation between the osteopontin level and different cardiac parameters, including left-ventricular end-diastolic diameter, left atrial diameter, the left ventricular ejection fraction and the CK-MB level. There was a slight negative correlation with the ages of the patients. Conclusions: The presented results indicate that assessments of circulating OPN levels may help to identify EDMD patients at risk of dilated cardiomyopathy and might be therefore included among the set of biomarkers referred to with a view to appropriate early cardiologic diagnosis and therapy being commenced with in time.     

Can magnetocardiography detect patients with non-ST-segment elevation myocardial infarction?

BACKGROUND AND AIM: Magnetocardiography (MCG) has been proposed as a noninvasive diagnostic tool to risk-stratify patients with myocardial infarction (MI) and ischemia. The purpose of this study is to find the MCG parameters that are sensitive enough to detect the non-ST-segment elevation myocardial infarction (NSTEMI) patients. METHODS: MCG data were recorded and analyzed from 165 young controls (mean age = 27.2 +/- 9.0 years), 57 age-matched controls (mean age = 55.9 +/- 10.5 years) and 83 NSTEMI patients (mean age = 59.7 +/- 11.1 years). The MCG recordings were obtained using a 64-channel MCG system in a magnetically shielded room. Statistical analyses were performed for 24 parameters derived from QRS-, R-, T-wave, and ST-T period. Binary boundaries to detect NSTEMI patients out of control subjects were found using the receiver operating characteristic (ROC) curve for each parameter. RESULTS: Fifteen parameters showed a significant difference (P < 0.05 and P < 0.01) between NSTEMI and both of the control groups. For detection of NSTEMI, the angle of the maximum current and the filed map angle on T-wave peak showed the highest diagnostic performance from 75% to 92% including accuracy, sensitivity, specificity, positive predictive value, and negative predictive value (area under ROC curve = 0.87 approximately 0.93). CONCLUSIONS: Our study showed that MCG has potential clinical application for detection of NSTEMI and should be further investigated.     

Efficacy of therapeutic plasma exchange in a patient with coagulation inhibitors (acquired haemophilia A) – A case report

Acquired haemophilia A (AHA) is a rare disorder with mostly idiopathic aetiology that leads to factor VIII (FVIII) deficiency due to coagulation inhibitors formation. Treatment protocol includes immunosuppression and Factor VIII bypassing agents including activated Prothrombin Complex Concentrates (PCC). Nevertheless, the role of plasma exchange is not clear in the treatment of AHA. We report a case of 73 year old male who presented with haematuria, prolonged activated partial thromboplastin time (APTT) and a very high titres of Factor VIII inhibitors of 98 Bethesda units (BU) and was diagnosed with acquired haemophilia A. He failed to respond to multiple immunosuppressive therapies including rituximab. Therefore, therapeutic plasma exchange (TPE) therapy was planned due to persistence of haematuria despite immunosuppressive therapies. After five cycles of plasma exchange, APTT became normal, haematuria subsided and Factor VIII inhibitors became negative. Patient was discharged without any bleeding and in a stable condition. In this index case, plasma exchange played a very crucial role, resulting in recovery of the patient. These results advocate that therapeutic plasma exchange is an effective therapy for acquired haemophilia A.     

Personalized treatment with immunoadsorption and intravenous immunoglobulin in a case of severe Rh alloimmunization during pregnancy unresponsive to plasma – exchange

Introduction

Despite prophylaxis, a small proportion of RhD-negative women may develop anti-D antibodies after a sensitizing event occurring during pregnancy or delivery of a D-positive baby. Intrauterine transfusion (IUT) is the treatment of choice in case of fetal anemia, but it cannot be performed early during pregnancy. Combined treatment with therapeutic plasma-exchange (TPE) and intravenous immunoglobulin (IVIG) can avoid or delay IUT. Immunoadsorption (IA) could represent a more effective treatment in selected cases.

Imaging of intracranial aneurysm by three-dimensional contrast enhanced duplex sonography—two case reports

We report two cases of intracranial aneurysms to give an impression of the use of three-dimensional (3-D) transcranial duplex sonography in combination with the application of a transpulmonary stable contrast agent. Data acquisition was performed with a free-hand scanning of the transducer (2 MHz) and a prototype of a new magnetic sensor system to track the spatial orientation of the ultrasound probe while scanning the volume of interest. The 3-D data were stored and afterwards 3-D reconstructions performed. Three-dimensional transcranial color duplex system with power Doppler mode showed an exact spatial orientation of the intracranial arteries. The three-dimensional system lets the reader retrospectively choose the section plane through the 3-D data set, and the reconstructions through the data set allowed us to localize aneurysms in both cases. The increased freedom of movement of the transducer allows the sonographer to maintain transducer contact with the skin, while offering the freedom to move the transducer as needed to remain on the acoustic window.     

Inhibitor development in two patients with mild haemophilia A – spontaneous disappearance and no recurrence of the inhibitor after re-challenge

Inhibitors against factor VIII (FVIII) complicate the treatment of patients with haemophilia. In mild haemophilia, the development of antibodies against FVIII is rare. However, the occurrence of an inhibitor in mild haemophilia changes the bleeding phenotype from mild to severe, and thus becomes a major clinical problem. We report on two patients with mild haemophilia A (FVIII level 8 and 27%, respectively), who have a missense mutation in exon 16 (G to A transition in codon 1773) and exon 22 (T to C transition in codon 2096), respectively. Both mutations have not been described in the Haemophilia A Mutation, Structure Test and Resource Site. Our patients developed high titer inhibitors following an intensive FVIII replacement therapy due to a muscle bleeding and after a polytrauma. During the presence of the inhibitor, AICC or FVIIa was successfully used as bypassing agent. In both patients the inhibitor disappeared spontaneously. Years after the development of the inhibitor, the patients again received FVIII concentrates. Reappearance of the inhibitor was not observed in either patient. The reported cases indicate that inhibitors in patients with mild haemophilia might be transient and disappear spontaneously. Therefore, the necessity of immune tolerance therapy, which is costly and strenuous for the patients, should be critically examined for each individual patient and a watch and wait strategy might be advisable.     

Methicillin‐resistant Staphylococcus aureus among elderly patients with community-acquired pneumonia

IntroductionThe 2019 American Thoracic Society/Infectious Diseases Society of America guidelines for community-acquired pneumonia (CAP) recommend methicillin‐resistant Staphylococcus aureus (MRSA) coverage for patients with prior sputum isolation of MRSA. This study aimed to determine the impact of MRSA coverage on in-hospital mortality in elderly patients with CAP among whom MRSA was isolated.MethodsConsecutive elderly patients who were admitted for CAP and had positive sputum culture for MRSA were retrospectively included, and the association between MRSA coverage and in-hospital mortality was analyzed.ResultsTwenty (18%) of 111 patients received MRSA coverage. Although patients who received MRSA coverage tended to have more frequent prior isolation of MRSA compared to those who did not, no significant difference in in-hospital mortality was observed between both groups (2/20, 10% vs. 8/91, 9%). MRSA coverage was not associated with in-hospital mortality (odds ratio: 1.15; 95% CI: 0.23–5.89, p = 0.864); however, advanced age, hemoglobin level, a high A-DROP score, and C-reactive protein levels were associated with in-hospital mortality. MRSA coverage may not improve the prognosis of elderly patients with CAP who had positive sputum culture for MRSA.ConclusionsA randomized control study is required to determine the efficacy of MRSA coverage on the management of CAP in elderly patients.     

Excess mortality risk from sepsis in patients with HIV – A meta-analysis

PurposeDifferences in HIV prevalence, access to antiretrovirals and ICU resources may result in wide variation in sepsis mortality in HIV patients. The aim of this study was to perform a meta-analysis to quantify the excess risk of sepsis mortality in HIV patients.Materials and methodsA systematic review was performed using three databases. The systemic inflammatory response syndrome criteria was used for the presumptive diagnosis of sepsis. We only included studies that stratified sepsis mortality by HIV serostatus. A meta-analysis was performed using random effects models, with subgroup analyses performed using country income, sepsis severity, and time periods.Results17 studies were included, containing 82,905 patients. Sepsis mortality was found to be 28% higher in the HIV positive patients (95% CI 1.13–1.46, p < .01). Relative risk of mortality was higher in patients treated in low-income countries (RR 1.43 in low-income vs. 1.29 in high-income countries). Mortality was more pronounced in HIV patients with severe sepsis (RR 1.32 in severe sepsis vs. RR 1.15 in sepsis).ConclusionsHIV increases the risk of sepsis mortality compared to seronegative individuals across all time periods and geographic areas. We note that this effect is more pronounced in patients with organ dysfunction.     

Anxiety trait in patients with stress-induced cardiomyopathy: a case–control study

Background  

Stress-induced Tako-tsubo cardiomyopathy (TTC) is an acute cardiac syndrome, mimics ST elevation myocardial infarction (STEMI), largely confined to postmenopausal women, frequently precipitated by a stressful event. The pathogenesis of TTC is still unknown. Some authors hypothesized a possible connection between TTC and anxiety disease, but no previous study analyzed the relationship between anxiety trait and TTC. This study sought to assess the potential role of anxiety trait in the development and clinical course of TTC.