Staging and diagnosis in accidental hypothermia

Core body temperature below 35 degrees C is defining arbitrarily hypothermia. There is no worldwide consensus concerning the staging and resuscitation strategies in such a vital emergency, not even in rewarming strategy. Accidental hypothermia has its own "survival chain", modifying some steps or the timing in the common cardiopulmonary resuscitation protocol, according to some particularities of the metabolism in such an accident. Taking into account the two major events during hypothermic conditions (ventricular fibrillation and coma), we have proposed a better borderline between the three severity classes, based on clinical, paraclinical and prognostic arguments. The interest in this special environmental emergency situation is coming not only from its incidence, but especially from its particular long time period in which the resuscitation maneuvers could be effective, so that a literature review mixed with our practical observations may be of didactical and legal benefit also.     

Anatomical and surgical considerations concerning the segmentation of the pancreas

Pancreatic vascularization, especially the right segment (the head of the pancreas) has great surgical importance, due to its anatomical variety. From this practical point of view, establishing the type of the patient's pancreatic vascular pattern is highly recommended not just diagnosis purposes, but especially for its indispensable role in surgical decision. Selecting the appropriate technique, based on the imagistic evidences must consider the anatomical studies, which propose a systematic vision of the cephalic area vascularization, detecting two major types of arterial distribution. The first type is especially anastomotic; meanwhile the second one is terminal, these two varieties leading to a different surgical technique, best adapted for avoiding hemorrhages or ischemic necroses. Between the classic two segments of the pancreas (cephalic and caudal parts) there is a less vascularized area, which includes just an intersegmentary artery and the pancreatic duct, surgically sectioned during the separation operation of the two pancreatic segments. Vascular variety of the pancreas may be related to both embryological development of the pancreatic tissue, and that of the abdominal aortic branches.     

Successful treatment of an adult with Amanita phalloides-induced fulminant liver failure with molecular adsorbent recirculating system (MARS)

Despite significant advances in intensive care management of Amanita phalloides-induced fulminant liver failure (FLF), patients with this condition still have a high mortality rate in the absence of orthotopic liver transplantation. Molecular Adsorbent Recirculating System (MARS) is a new, cell-free, extracorporeal liver assistance method utilizing an albumin dialysate for the removal of albumin-bound toxins, and a highly effective depurative therapy in adults with wild mushroom-induced FLF. We report the case of a 39 year old woman with Amanita phalloides-induced FLF, admitted to our intensive care unit (ICU) and treated with MARS. Our patient had severe hepatic dysfunction: hepatic encephalopathy (grade II), ALT = 5022 (2475-10098) IU/L, bilirubin = 7.18 (4.8-10.1) mg/dL, prothrombin time (PT) = 90.4 (29.3-140.4) s. MARS sessions had an immediate impact on liver tests: statistically significant decrease in ammonia, ALT and PT. Hepatic encephalopathy was successfully reduced. The patient survived and the hepatic function completely recovered. MARS appears to be a safe and highly effective depurative therapy in adults with Amanita phalloides-induced FLF.     

A rare cause of non-Q myocardial infarction--acute carbon monoxide poisoning

Myocardial infarction is a rarely reported complication of acute carbon monoxide (CO) poisoning. We report the case of a 77 years old woman who presented to our emergency department with altered consciousness as a consequence of exposure to CO. The patient didn't experience any chest pain, but the electrocardiogram showed a non-Q-wave antero-septal acute myocardial infarction, with typical elevation in troponin T and creatine-phosphokinase MB levels. The patient recovered completely after specific treatment of poisoning with no major cardiac complication. We consider that careful electrocardiographic and enzymatic monitoring of all patients, especially elderly patients, in the first hours after CO exposure is important for early diagnosis and treatment of this rare complication of CO poisoning, and can improve the outcome of these patients.     

Anatomic and physiopathologic basis for the diagnosis and treatment of intestinal ischemia

Changes of circulatory parameters in splanchnic territory lead to gut ischemia in an acute or chronic form (postprandial abdominal stroke). The implicated factors in intestinal ischemia are the timing and kind of onset, countercurrent vascularization and the eventuality of anastomotic subsystems for becoming hypertrophic. Superior mesenteric artery (SMA) is the "key" blood vessel implicated in the production of chronic intestinal ischemia, the atherosclerotic lesion being localized more frequent near SMA's ostium or even at ostium itself. Nonoclusif ischemia is induced by another stimulus that provokes mesenteric vasoconstriction, status that affects more the antimesenteric intestinal border, with a larger expansion at mucosa level. The most reseed diagnostic methods are selective angiographies and ultrasound examination. Usually chronic intestinal ischemia is clinically asymptomatic and becomes clinical evident just in the presence of an acute superposed factor or when at least two digestive arteries are affected. Revascularization methods are different, based on the type, mechanism and site of obstruction, each with its advantages and disadvantages. The most used method is retrograde aortomesenteric by-pass, at infrarenal aortic level (that is more accessible than the supraceliac aorta) and SMA reimplantation.     

Mushroom poisoning in an autoimmune hepatitis patient

Mushroom poisoning is responsible for initiation of severe life threatening syndromes, especially hepatic cytolysis. We are describing a case in which the helvelian syndrome induced by mushroom meal was masking the preexistent autoimmune hepatitis type 1. The course of disease under corticoids was satisfactory after one month of surveillance.     

Benefits of butyrylcholinesterase reactivability testing in organophosphate poisoning

Organophosphate (OP) poisoning continues to represent an important medical issue through its high prevalence among toxic pathologies and through its severity. In diagnosing this toxicological disorder, the most frequently utilized and available laboratory test remains the assessment of plasma cholinesterase - butyrylcholinesterase (BChE) - activity. Despite the reluctance of many researchers on the usefulness of serum BChE for kinetic analysis in OP intoxications, we have tested a recently proposed protocol, which is safe, non-expensive, easy to perform, appropriate to distinguish between an aged cholinesterase and a still reactivable one. Our aim was to validate the usefulness of this protocol, studying a series of 23 consecutive patients acutely intoxicated with OP, admitted in a regional Emergency Hospital, over a 1-year period. Introducing the proposed test in the routine of monitoring OP-intoxicated patients has resulted in the identification of a pattern with a funnel aspect, consequence of the initial possibility to increment the degree of BChE activity. This funnel shape defines the presence of reactivability, while its absence demonstrates the lack of obidoximes effect, due to cholinesterase's ageing process. This method consisted in an advantage for the diagnosis, having the potential of improving prognostic evaluation and therapeutic orientation in OP intoxications.     

Epidemiology of acute drug poisoning in a tertiary center from Iasi County, Romania

The aim of this retrospective epidemiological study was to investigate the demographical, etiological and clinical characteristics of acute drug poisonings in Iasi County, Romania. All patients were referred and admitted in the Toxicology Clinic of "Sf. Ioan" Emergency Clinic Hospital Iasi, Romania. Between 2003 and 2009, 811 cases of acute drug poisonings were recorded, counting for 28.43% from the total number of poisonings. The majority of these poisonings resulted in mild (51.94%) and medium (28.35%) clinical forms, while 19.71% were coma situations. In all, 63.51% of patients originated from urban areas, 39.94% were unemployed and the patients were predominantly women (66.46%). A high percentage (97.27%) were suicide attempts, using only one type of drug (65.88%) and the 21-30 years group (29.8%) records the highest incidence, for both women and men. The most frequently involved drugs were benzodiazepines 13.69%, anticonvulsive drugs 8.63%, barbiturates 8.51% and cardiovascular drugs 5.92%. Drugs combinations were recorded in 32.92% of cases and 1.2% were combinations between drugs and other substances. Mortality was the outcome in 0.3% of the total registered number of acute drug poisonings. This study underlines that in order to provide a proper management of these situations, a Regional Poison Information Center is absolutely necessary.     

Effectiveness of a serious game on the self-concept of children with visual impairments: A randomized controlled trial

BackgroundYoung children with visual impairments (VIs) are at high risk for mental disorders, due to victimization and subsequent social withdrawal. Children with VIs have been shown to have a poorer self-concept and lower general psychosocial well-being compared with peers without VIs.ObjectiveThe objective of this study was to examine the effectiveness of a serious game to improve psychosocial outcomes in children with VIs.MethodsA randomized controlled trial was conducted to evaluate the effectiveness of the computer game See for children with VIs. The game was developed based on rational-emotive behavioral therapy principles, with the aim of addressing self-concept (academic, social, and general), psychosocial well-being (social inclusion, exclusion, and emotions), and coping strategies (approach, avoidance). Sixty-four children aged 6–8 years were randomized to the intervention group, who played the game, or a control group, who received care-as-usual (CAU).ResultsOur results showed that children with VIs who played the serious game scored significantly higher on academic self-concept and social inclusion compared with the control group. Furthermore, children rated the game positively, suggesting the desirability, validity, and feasibility of the intervention.ConclusionsThe results provide preliminary evidence that a serious game can enhance psychosocial outcomes in children with VIs. This approach might also promote positive educational outcomes, such as academic achievement, and reduce the stigma of therapy for children with VIs. Implications and future directions are discussed.