Aortoenteric fistulae and their multidisciplinary approach.

Aortoenteric fistula is an uncommun life-threatening condition which remains associated with significant morbidity and mortality. It can be primary (aneurysm, neoplasms, radiation therapy, infection) or secondary to vascular prosthesis. Early diagnosis and aggressive surgical treatment are very important to achieve optimal outcomes in these patients. The aim of this article is to highlight the importance of early diagnosis and multidisciplinary approach of aortoenteric fistula through the presentation of a clinical case.

La fístula aortoentérica es una patología poco frecuente, pero de riesgo vital, asociada a alta morbimortalidad. Puede ser primaria (aneurisma, neoplasia, radioterapia, infección) o secundaria a prótesis vascular. El diagnóstico precoz y el tratamiento quirúrgico agresivo son los pilares fundamentales para lograr buenos resultados en estos pacientes. El objetivo de este trabajo es destacar la importancia del diagnóstico precoz de la fístula aortoentérica y su manejo multidisciplinar, mediante la presentación de un caso clínico.

Deploying a novel custom mobile application for STEMI activation and transfer in a large healthcare system to improve cross-team workflow. STEMIcathAID implementation project.

BACKGROUND: ST-segment elevation myocardial infarction (STEMI) is a high-risk patient medical emergency. We developed a secure mobile application, STEMIcathAID, to optimize care for STEMI patients by providing a digital platform for communication between the STEMI care team members, EKG transmission, cardiac catherization laboratory (cath lab) activation and ambulance tracking. The aim of this report is to describe the implementation of the app into the current STEMI workflow in preparation for a pilot project employing the app for inter-hospital STEMI transfer. APPROACH: App deployment involved key leadership stakeholders from all multidisciplinary teams taking care of STEMI patients. The team developed a transition plan addressing all aspects of the health system improvement process including the workflow analysis and redesign, app installation, personnel training including user account access to the app, and development of a quality assurance program for progress evaluation. The pilot will go live in the Emergency Department (ED) of one of the hospitals within the Mount Sinai Hospital System (MSHS) during the daytime weekday hours at the beginning and extending to 24/7 schedule over 4-6 weeks. For the duration of the pilot, ED personnel will combine the STEMIcathAID app activation with previous established STEMI activation processes through the MSHS Clinical Command Center (CCC) to ensure efficient and reliable response to a STEMI alert. More than 250 people were provisioned app accounts including ED Physicians and frontline nurses, and trained on their user-specific roles and responsibilities and scheduled in the app. The team will be provided with a feedback form that is discipline specific to complete after every STEMI case in order to collect information on user experience with the STEMIcathAID app functionality. The form will also provide quantitative metrics for the key time sensitive steps in STEMI care. CONCLUSIONS: We developed a uniform approach for deployment of a mobile application for STEMI activation and transfer in a large urban healthcare system to optimize the clinical workflow in STEMI care. The results of the pilot will demonstrate whether the app has a significant impact on the quality of care for transfer of STEMI patients.

Cuando la ileítis de Crohn no es solo ileítis / When Crohn's ileitis is not just ileitis

RESUMEN En una minoría de pacientes con ileítis de Crohn (EC) de larga evolución, la recrudescencia de los síntomas puede representar una neoplasia ileal, con una clínica indistinguible de la enfermedad basal y por ende poco sospechada. Frecuentemente la patología tumoral se diagnostica en la pieza quirúrgica, tras una intervención por hemorragia u obstrucción intestinal. El objetivo de este trabajo es destacar la importancia de un diagnóstico diferencial ante una ileítis terminal en un paciente con EC con mala respuesta a tratamiento médico.

ABSTRACT In a minority of patients with long-standing Crohn's ileitis, the recrudescence of symptoms may represent a neoplasm involving the ileum that is clinically indistinguishable from the baseline disease and therefore poorly suspected. Tumors are often diagnosed in the surgical specimen, after an intervention due to bleeding or bowel obstruction. The aim of this study is to emphasize the importance of the differential diagnoses of terminal ileitis in a patient with CD with poor response to medical treatment.

Mobile application to optimize care for ST-segment elevation myocardial infarction patients in a large healthcare system, STEMIcathAID: rationale and design.

Aims: Technological advancements have transformed healthcare. System delays in transferring patients with ST-segment elevation myocardial infarction (STEMI) to a primary percutaneous coronary intervention (PCI) centre are associated with worse clinical outcomes. Our aim was to design and develop a secure mobile application, STEMIcathAID, streamlining communication, and coordination between the STEMI care teams to reduce ischaemia time and improve patient outcomes. Methods and results: The app was designed for transfer of patients with STEMI to a cardiac catheterization laboratory (CCL) from an emergency department (ED) of either a PCI capable or a non-PCI capable hospital. When a suspected STEMI arrives to a non-PCI hospital ED, the ED physician uploads the electrocardiogram and relevant patient information. An instant notification is simultaneously sent to the on-call CCL attending and transfer centre. The attending reviews the information, makes a video call and decides to either accept or reject the transfer. If accepted, on-call CCL team members receive an immediate push notification and begin communicating with the ED team via a HIPAA compliant chat. The app provides live GPS tracking of the ambulance and frequent clinical status updates of the patient. In addition, it allows for screening of STEMI patients in cardiogenic shock. Prior to discharge, important data elements have to be entered to close the case. Conclusion: We developed a novel mobile app to optimize care for STEMI patients and facilitate electronic extraction of relevant performance metrics to improve allocation of resources and reduction of costs.

Effects of in utero exposure to D-004, a lipid extract from Roystonea regia fruits, in the male rat: a comparison with finasteride.

D-004 is a lipid extract obtained from Cuban royal palm fruits, consisting of a mixture of free fatty acids, that prevents prostate hyperplasia induced with testosterone in rodents. This study investigated the possible alterations due to D-004 of androgen-dependent development after exposure in utero and compared them with those due to finasteride. Rats were randomized into five experimental groups: a control group, three groups treated with D-004 at 500, 750, or 1,000 mg/kg/day, respectively, and a group treated with finasteride (10 mg/kg/day). Male rats were treated 10 weeks before and during mating. Female rats were treated for 15 days prior mating, during mating, during pregnancy, and until lactation (day 21) except for those treated with finasteride, which were only administered the drug on gestational days 12-21. All male offspring were monitored individually until necropsy after postnatal day 90. The results of the present study indicate that D-004 induced no alterations in androgen-dependent development after the exposure in utero. Also, the current study demonstrated a permanent reduction in anogenital distance and retention of nipples in adult male rats exposed to finasteride during late gestation. Significant alterations induced by exposure to finasteride were mainly in tissues dependent on dihydrotestosterone during development.

Oral subchronic toxicity of a lipid extract from Roystonea regia fruits in mice.

D-004 is a lipid extract of royal palm (Rosytonea regia) fruits that prevents prostate hyperplasia induced with testosterone in rodents. Previous studies have shown no D-004-related toxicity in rats, but no study in mice had been reported. D-004 (500, 1000, and 2000 mg/kg) was evaluated in a subchronic (eight weeks) study in NMRI mice. No evidences of treatment-related toxicity were detected. Thus, body-weight gain, clinical observations, food consumption, blood biochemical, hematology, organ-weight ratios, and histopathological findings were similar in control and treated groups. This study supports that D-004 orally administered up to 2000 mg/kg did not induce treatment-related toxicity.

Effects of D-003 on hepatic drug-metabolizing enzyme activities in rats.

D-003 is a mixture of very-long-chain aliphatic acids with cholesterol-lowering and concomitant anti-platelet effects. The microsomal cytochrome P-450 system comprises a superfamily of proteins present in hepatic and extrahepatic tissues that is responsible for the metabolism of many drugs. The present study was undertaken to investigate the effects of D-003 on in vivo drug-metabolizing hepatic enzymes. Two experimental series (n = 6 animals/group) were performed. In the first series rats were randomly distributed in one control and two groups treated with D-003 at 1,000 and 2,000 mg/kg for 14 days. In the second one they were distributed in one control and three groups treated with D-003 (250, 500, and 1,000 mg/kg) for 6 months. All treatments were orally administered by gastric gavage. Control rats were orally treated only with acacia gum/water vehicle. The content of microsomal P-450, b (5) cytochromes, total sulfhydryl groups, nonprotein sulfhydryl groups, and protein-bound sulfhydryl groups as well as the activities of NADPH cytochrome c reductase, aminopyrine demethylase, dimethylnitrosamine N-demethylase, 7-ethoxyresorufin O-deethylation, 7-pentoxyresorufin O-depentylation, and cytosolic glutathione S-transferase were assessed. D-003 administered up to 2,000 mg/kg or 1,000 mg/kg during 14 days or 6 months did not affect the activities of the hepatic drug-metabolizing enzymes investigated. It is concluded that D-003 is not metabolized by the liver cytochrome system and that potential risk derived from drug-to-drug interactions between D-003 and concomitant drugs appears to be low.

Efecto de la dopamina inhalada en la presión arterial de pacientes con insuficencia renal: cronica en hemodiálisis / Effect of the dopamine inhaled in the presion arterial of patients with insuficience renal: chronic in hemodialisis

La vía común de administración de la Dopamina es la intravenosa a infusión continua con efectos sistémicos que requieren de monitorización cardiovascular. En trabajos anteriores hemos utilizado la dopamina inhalada en pacientes con crisis de asma bronquial y hemos demostrado un efecto broncodilatador. En este estudio prospectivo, evaluamos los efectos de Dopamina inhalada a dosis de 3 µg/kg/min en 21 pacientes con insuficiencia renal crónica en hemodiálisis de los cuales 16 eran hipertensos, 5 normotensos y 11 pacientes normotensos sanos como control. Los resultados nos permiten concluir: 1. La Dopamina inhalada redujo significativamente la presión arterial del grupo control con una presión sistólica de 1162 ± 3,22 mmHg a 100 ± 3,22 mmHg (p<0,002) y el valor de presión diastólica de 72 ± 2,38 mmHg a 65 ± 2,36 mmHg (p<0,05), pero no redujo la presión arterial de los pacientes con Insuficiencia Renal Crónica. 2. Los mecanismos de control de presión arterial en ambos grupos son diferentes, esto condiciona una respuesta cardiovascular distinta a la Dopamina.

Six-month toxicity study of oral administration of D-003 in Sprague Dawley rats.

BACKGROUND: D-003 is a mixture of high molecular weight aliphatic primary acids purified from sugarcane wax (Saccharum officinarum) having cholesterol-lowering and antiplatelet effects. AIM: This study was undertaken to investigate the toxicity induced by long-term oral administration of D-003 for 6 months to Sprague Dawley rats of both sexes. METHODS: Rats were randomly divided into four groups (20 rats of each sex/group): a control group. which received the vehicle, and three treatment groups, which received oral D-003 at doses of 250, 500 and 1000 mg/kg/day, respectively. Daily clinical observations and control of bodyweight and food consumption were conducted throughout the study period. On completion of active treatment, animals were sacrificed. Pharmacological effects associated with D-003 such as inhibition of platelet aggregation and increase in bleeding time were assessed in two satellite groups (14 animals of each sex/group): a control group and a group treated with the highest dose of D-003. Assessments of platelet aggregation to collagen were performed at baseline and at 6 months, and assessments of bleeding time were done at baseline, after 3 and 6 months of treatment, and after 30 days' washout. RESULTS: As expected, D-003 significantly inhibited platelet aggregation. Bleeding time was increased after 3 months of treatment with D-003; this increase was maintained at 6 months, and was reversible after washout. Coagulation factors such as prothrombin time and kaolin-activated thromboplastin-time, which were determined in eight male animals from each group, were unaffected by D-003. Data analyses of bodyweight gain, food consumption, clinical observations, blood biochemistry, haematology, organ weight ratios and histopathological findings did not show trends related to D-003 dose or significant differences between control and treated groups. CONCLUSION: It was concluded that the highest studied dose of D-003 (1,000 mg/kg/day) represented a non-toxic dose level in the present chronic toxicity study in rats.

A 6-Month Study on the Toxicity of High Doses of Policosanol Orally Administered to Sprague-Dawley Rats.

Policosanol is a cholesterol-lowering drug purified from sugar cane. Previous toxicological studies have not demonstrated any policosanol-related toxicity, even with long-term oral administration at 500 mg/kg, a dose 1,724 times larger than the maximal therapeutic dose (20 mg/day) recommended to date. The present study was undertaken to investigate the oral toxicity of policosanol administered for 6 months in doses up to 5,000 mg/kg to Sprague-Dawley rats. Animals were randomly distributed in five groups (15 animals per dose per sex): a control and four groups given oral policosanol (50, 500, 2,500, or 5,000 mg/kg). Eight treated rats (6 males, 2 females) died during the study, five of them (4 males, 1 female) from among those receiving the highest dose (5,000 mg/kg). According to necropsy, all deaths were related to gavage manipulation of higher doses. Although the differences were not significant, body weight gain and food consumption in the groups receiving 2,500 or 5,000 mg/kg tended to be lower than in the control group. Nevertheless, no drug-related toxicity symptoms were detected. Analysis of blood biochemistry, hematology, organ weight ratios, and histopathological findings did not show significant differences compared with controls, nor any tendency with the dose. Therefore, the present study did not show any new evidence of oral toxicity of policosanol, and the findings observed were a consequence of long-term administration by gastric gavage of the highly concentrated suspensions needed to reach the higher doses. It is concluded that policosanol chronically administered by the oral route is safe and that no drug-related toxicity was demonstrated.

In Vivo Genotoxic Evaluation of D-003, a Mixture of Very Long Chain Aliphatic Acids.

D-003 is a mixture of very long chain aliphatic acids purified from sugar cane wax with cholesterol-lowering effects. The present study was undertaken to investigate the in vivo cytotoxic and genotoxic potential of D-003 using three established assays: bone marrow micronucleus, sperm morphology, and single cell gel electrophoresis (Comet) assay. In a first experimental series, CEN/NMRI mice (6-8 animals per sex per group) were administered D-003 by gastric gavage at 5, 50, or 500 mg/kg for 90 days, then sacrificed 24 hours after the last administration. The effects on bone marrow micronucleus were evaluated only in female mice. D-003 (5-500 mg/kg) did not increase the frequency of micronucleated polychromatic erythrocytes, nor the ratio of polychromatic to normochromatic erythrocytes, compared with the controls. The assessment of the effects on sperm morphology showed that D-003 did not change the sperm count or the frequency of all types of abnormal head shapes, compared with the controls. In a second series, the micronucleus assay was performed in mice of both sexes given 2,000 mg/kg for 6 days. Likewise, in this series, neither cytotoxic nor genotoxic effects were found. Finally, five male Sprague-Dawley rats were treated with D-003 (1,250 mg/kg) by oral gavage for 90 days, and Comet assay on liver cells was performed. No single-strand breaks or alkali-labile site induction on DNA was observed. These results indicate that D-003 does not show evidence of cytotoxic or genotoxic activity on either somatic or germ cells in rodents.

Efectos cardiovasculares de la dopamina inhalada en sujetos normotensos con insuficiencia renal crónica en hemodiálisis / Effects cardiovasculary of the dopamiane inhaled in subjects normotensos with insufficiency renal chronic in hemodialysis

Los efectos sistemáticos de la dopamina reportados en la literatura mundial son principalmente por vía intravenosa y dependen de la dosis utilizada. En pacientes con insuficiencia renal crónica se utiliza dopamina con el propósito de mantener la presión arterial durante las lesiones de hemodiálisis. En este estudio prospectivo, evaluamos los efectos cardiovasculares de la dopamina inhalada a dosis de 3 µgr/kg/min en 11 sujetos normotensos sanos y 5 sujetos normotensos con insuficiencia renal crónica en hemodiálisisy los resultados obtenidos nos permiten sugerir, quelos mecanismos de control de la presión arterial en ambos grupos son diferentes y que la dopamina inhalada es una vía alterna de administración con efectos colaterales mínimos: irritación faríngea y sabor amargo

Prospective study about the incidence of B lactamase producing bacteriae in otitis media in the population of the emergency room of the University Pediatric Hospital

The purpose of the study is to determine the incidence of beta-lactamase producing pathogens causing otitis media (O.M.) in the Emergency Room population of the University Pediatric Hospital. In our first four months of study, 22 patients, between the ages of 6 months to 13 y/o have been evaluated. Middle ear secretion cultures were obtained by tympanocenthesis. The organisms recovered from cultures were S. epidermidis 3(14%), S. pneumoniae 2(9%) H. influenzae 1(5%), mix flora 1(5%) and 13(59%) with no growth. None of these organisms were beta-lactamase producers. Up to 65% of the patients had history of 2 to 5 OM episodes during the last six months. Interesting is the association of bronchial asthma, sinusitis and allergy history with OM. Final study results will be presented in a near future