Management of Thoracic and Cardiac Trauma: A Case Series and Literature Review.

Patients with cardiac and thoracic trauma remain one of the most difficult presentations to diagnose and treat in an emergency room setting. Here, we present our series of four cases of cardiac and thoracic trauma with varied presentations, including lung, vascular, and diaphragmatic injuries that were managed successfully. We further review the manifestations of cardiac trauma, including cardiac contusions, cardiac rupture, pericardial injury, and valvular injuries; thoracic trauma, including lung and diaphragmatic injury. The sheer complexity of the anatomical structures within the thorax makes it of the utmost importance to timely and appropriately manage them.

Hyperammonemia in lung transplant patients and its management: a review.

Objective: To synthesize the evidence for incidence, pathophysiology, etiology, and protocol-based management of hyperammonemia in lung transplant patients. Background: Elevated ammonia levels are toxic to the brain, and hyperammonemia results in a potentially fatal complication for lung transplant recipients. The hallmark of this condition is ammonia production being way out of proportion to the degree of liver derangement. While there are many hypotheses, the cause remains obscure. Methods: A retrospective review of patients with hyperammonemia following lung transplantation was done to understand the pathophysiology, various treatment modalities, and its impact on patient mortality and morbidity. Studies in the English literature were identified through an electronic database search from PubMed/MEDLINE, Ovid Embase, Google Scholar, Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, Web of Science, and ClinicalTrials.gov until June 2020. No restriction of dates were used, and the search was up until June 2020. Discussion: Mortality among patients with hyperammonemia following lung transplantation is high. Multi-modal treatment approaches include avoiding nephrotoxic drugs, use of bowel decontamination, nitrogen scavengers, branched-chain amino acids, adjustment of immunosuppression, antibiotics like fluoroquinolones or azithromycin, and renal replacement therapy. However, there remains a scarcity of preoperative screening protocol for patients at risk of hyperammonemia as well evidence-based post-operative management guidelines. Intermittent hemodialysis, compared to continuous venovenous hemodialysis, provides better patient outcomes. Conclusion: Early detection of patients at risk by appropriate screening, along with maintaining a high degree of suspicion for hyperammonemia and multi-modal treatment approach, is the key to successful patient outcomes. Further prospective observational studies would facilitate development of protocol-based treatment of this potentially fatal condition.

Association of pre-admission opioid abuse and/or dependence on major complications in traumatic brain injury (TBI) patients.

SETTING: In the last few decades, an opioid related health crisis has been a challenging problem in many countries around the world, especially the United States. Better understanding of the association of pre-admission opioid abuse and/or dependence (POAD) on specific major complications in traumatic brain injury (TBI) patients can aid the medical team in improving patient care management and outcomes. STUDY OBJECTIVE: Our goal is to assess and quantify the risk of POAD on in-hospital mortality and major complications in TBI patients. DESIGN: We conducted a retrospective study and used the National Inpatient Sample (NIS) database from 2004 to 2015 to investigate the impact of POAD on in-hospital mortality and major complications in TBI patients. We utilized propensity score matching and conditional logistic regression models, adjusted with injury severity score (ISS) and comorbidities, to obtain the adjusted odds ratios (OR). MAIN RESULTS: POAD TBI patients had lower risks of in-hospital mortality (OR 0.58; p < 0.001) and acute myocardial infarction (OR 0.53; p = 0.045), while a higher risk of respiratory (OR 1.59; p < 0.001) and neurologic complications (OR 2.54; p < 0.001), compared to non-POAD TBI patients. Additionally, POAD patients were significantly more likely to have sepsis (OR 2.16, p < 0.001), malnutrition (OR 1.56, p < 0.001), delirium (OR 2.81, p < 0.001), respiratory failure (OR 1.79, p < 0.001), and acute renal failure (OR 1.83, p < 0.001). POAD TBI patients had shorter length of hospital stay compared to non-POAD TBI patients (mean 8.0 vs 9.2 days, p < 0.001). CONCLUSIONS: POAD TBI patients have a lower in-hospital mortality, shorter duration of hospitalization and a lower risk of acute myocardial infarction, while they are more likely to have respiratory failure, delirium, sepsis, malnutrition, and acute renal failure compared to TBI patients without POAD. Prospective study is warranted to further confirm these findings.

Sudden cardiac death: epidemiology, pathogenesis and management.

Sudden cardiac death (SCD) is an unexpected sudden death due to a heart condition, that occurs within one hour of symptoms onset. SCD is a leading cause of death in western countries, and is responsible for the majority of deaths from cardiovascular disease. Moreover, SCD accounts for mortality in approximately half of all coronary heart disease patients. Nevertheless, the recent advancements made in screening, prevention, treatment, and management of the underlying causes has decreased this number. In this article, we sought to review established and new modes of screening patients at risk for SCD, treatment and prevention of SCD, and the role of new technologies in the field. Further, we delineate the current epidemiologic trends and pathogenesis. In particular, we describe the advancement in molecular autopsy and genetic testing, the role of target temperature management, extracorporeal membrane oxygenation (ECMO), cardiopulmonary resuscitation (CPR), and transvenous and subcutaneous implantable cardioverter devices (ICDs).

Optical Density Optimization of Malaria Pan Rapid Diagnostic Test Strips for Improved Test Zone Band Intensity.

For the last few decades, the immunochromatographic assay has been used for the rapid detection of biological markers in infectious diseases in humans and animals The assay, also known as lateral flow assay, is utilized for the detection of antigen or antibody in human infectious diseases. There are a series of steps involved in the development of these immuno-chromatographic test kits, from gold nano colloids preparation to nitrocellulose membrane coating (NCM). These tests are mostly used for qualitative assays by a visual interpretation of results. For the interpretation of the results, the color intensity of the test zone is therefore very significant. Herein, the study was performed on a malaria antigen test kit. Several studies have reported the use of gold nanoparticles (AuNPs) with varying diameters and its binding with various concentrations of protein in order to optimize tests. However, none of these studies have reported how to fix (improve) test zone band intensity (color), if different sized AuNPs were synthesized during a reaction and when conjugated equally with same amount of protein. Herein, different AuNPs with average diameter ranging from 10 nm to 50 nm were prepared and conjugated equally with protein concentration of 150 µg/mL with KD = 1.0 × 10-3. Afterwards, the developed kits' test zone band intensity for all different sizes AuNPs was fixed to the same band level (high) by utilization of an ultraviolet-visible spectrophotometer. The study found that the same optical density (OD) has the same test zone band intensity irrespective of AuNP size. This study also illustrates the use of absorption maxima (λ max) techniques to characterize AuNPs and to prevent wastage of protein while developing immunochromatographic test kits.

Retrograde Intussusception after Roux-en-Y Gastric Bypass.

Retrograde intussusception (RI), although relatively uncommon, has been increasingly seen in adults post Roux-en-Y gastric bypass (RYGB) surgery. The exact mechanism for its occurrence remains unknown but several theories have attributed it to bowel persialtic dysmotility. The increase in bariatric surgery over the last decade has resulted in a proportionate increase in the number of cases of intussusception seen globally. We report a case of RI seven years following RYGB done for morbid obesity.

WITHDRAWN: Hyperammonemia Following Lung Transplant Is a Diagnostic and Therapeutic Challenge: A Case Report.

Available online 14 February 2020. This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.

Anxiety during alcohol withdrawal involves 5-HT2C receptors and M-channels in the lateral habenula.

Anxiety disorders often co-occur with alcohol use disorders, but the mechanisms underlying this comorbidity remain elusive. Previously, we reported that rats withdrawn from chronic alcohol consumption (Post-EtOH rats) exhibited robust anxiety-like behaviors (AB), which were accompanied by neuronal hyperexcitability, and the downregulation of M-type potassium channels (M-channels) in the lateral habenula (LHb); and that serotonin (5-HT) stimulated LHb neurons via type 2C receptors (5-HT2CRs). Also, 5-HT2CR activation is known to inhibit M-current in mouse hypothalamic neurons. The present study investigated whether LHb 5-HT2CRs and M-channels contribute to AB in adult male Long-Evans rats. We used the intermittent-access to 20% ethanol two-bottle free-choice drinking paradigm to induce dependence. We measured AB with the elevated plus-maze, open-field, and marble-burying tests at 24 h withdrawal. We found that intra-LHb infusion of SB242084, a selective 5-HT2CR antagonist alleviated AB and reduced the elevated c-Fos expression in the LHb of Post-EtOH rats. By contrast, intra-LHb infusion of the selective 5-HT2CR agonist WAY161503 induced AB and increased c-Fos expression in the LHb in alcohol-naive but not Post-EtOH rats. Also, intra-LHb SB242084 significantly reduced self-administration of alcohol intake in the operant chambers. Furthermore, both 5-HT2CR protein levels and 5-HIAA/5-HT ratio was increased in the LHb of Post-EtOH rats. Finally, intra-LHb SB242084 increased LHb KCNQ2/3 membrane protein expression in Post-EtOH rats. Collectively, these results suggest that enhanced LHb 5-HT2CR signaling that interacted with M-channels triggers AB in Post-EtOH rats and that 5-HT2CRs may be a promising target for treating comorbid anxiety disorders in alcoholics.

Tension Pneumothorax During Rigid Bronchoscopy for Chronic Foreign Body Removal in a Child: A Case Report.

Rigid bronchoscopy for chronic foreign body removal can cause rare but life-threatening complications in the form of tension pneumothorax. A two-year-old child who developed sudden cardiac arrest during the procedure required urgent chest tube insertion. Integrated team effort with effective communication prevented devastating neurological sequelae from hypoxic ischemic encephalopathy.

Intraoperative Catastrophe during Benign Mediastinal Tumor Mass Excision: A Case Report.

Mature teratoma of the mediastinum poses a significant surgical challenge due to close vicinity to vital structures causing respiratory insufficiency or hemodynamic compromise. While the malignant variety of germ cell tumors (GCT) generally present with florid symptoms, benign teratomas are detected incidentally on imaging. Large teratomas presenting as mediastinal mass syndrome have additional difficulty in airway access. Herein, we report a case of a 40-year-old-female with no significant comorbidities presenting with rapidly progressing symptoms of chest pain, dyspnea, and superior vena cava (SVC) compression. Computed tomography (CT) scan of the neck and chest confirmed a large cystic lesion with marked compression of the great veins in the neck, arch of aorta, trachea, and proximal bronchial divisions. Airway access intraoperatively was done by awake fiberoptic bronchoscopy. However, sudden hypoxia and hemodynamic deterioration warranted emergency sternotomy. Adequate preoperative preparation, as well as standby extracorporeal circulatory support, led to successful and complete excision of the tumor. The patient had an uneventful recovery and extubated in the intensive care unit (ICU) the next day. Histopathology of the mass confirmed to be mature benign cystic teratoma. At six-month follow-up, the patient was completely asymptomatic without any complications. The impact of intraoperative catastrophe on the healthcare team can be immense. Inability to achieve a secure airway and the resultant hypoxia can result in permanent neurological damage. A multidisciplinary approach leading to adequate preoperative assessment, intraoperative preparedness for an emergency sternotomy with standby extracorporeal circulatory support due to the risk of mediastinal mass syndrome, were key features in the successful management of the patient.

Alcohol withdrawal drives depressive behaviors by activating neurons in the rostromedial tegmental nucleus.

Rostromedial tegmental nucleus (RMTg) GABA neurons exert a primary inhibitory drive onto midbrain dopamine neurons and are excited by a variety of aversive stimuli. There is, however, little evidence that the RMTg-ventral tegmental area (VTA)-nucleus accumbens shell (Acb) circuit plays a role in the aversive consequences of alcohol withdrawal. This study was performed in adult male Long-Evans rats at 48-h withdrawal from chronic alcohol drinking in the intermittent schedule. These rats displayed clear anhedonia and depression-like behaviors, as measured with the sucrose preference, and forced swimming tests. These aberrant behaviors were accompanied by a substantial increase in cFos expression in the VTA-projecting RMTg neurons, identified by a combination of immunohistochemistry and retrograde-tracing techniques. Pharmacological or chemogenetic inhibition of RMTg neurons mitigated the anhedonia and depression-like behaviors. Ex vivo electrophysiological data showed that chemogenetic inactivation of RMTg neurons reduced GABA release and accelerated spontaneous firings of VTA dopamine neurons. Finally, using a functional hemispheric disconnection procedure, we demonstrated that inhibition of unilateral RMTg, when combined with activation of D1 and D2 dopamine receptors in the contralateral (but not ipsilateral) Acb, mitigated the anhedonia and depression-like behaviors in alcohol-withdrawal rats. These data show that the integrity in the RMTg-VTA-Acb pathway in a single hemisphere is sufficient to elicit depression-like behavior during ethanol-withdrawal. Overall, the present results reveal that the RMTg-VTA-Acb pathway plays a crucial role in the depression-like behavior in animals undergoing alcohol withdrawal, further advocating the RMTg as a potential therapeutic target for alcoholism.

Neurobiology of Propofol Addiction and Supportive Evidence: What Is the New Development?

Propofol is a short-acting intravenous anesthetic agent suitable for induction and maintenance of general anesthesia as well as for procedural and intensive care unit sedation. As such it has become an unparalleled anesthetic agent of choice in many institutional and office practices. However, in addition to its idealistic properties as an anesthetic agent, there is accumulating evidence suggesting its potential for abuse. Clinical and experimental evidence has revealed that not only does propofol have the potential to be abused, but also that addiction to propofol shows a high mortality rate. Based on this evidence, different researchers have shown interest in determining the probability of propofol to be an addictive agent by comparing it with other drugs of abuse and depicting a functional similitude that involves the mesocorticolimbic pathway of addiction. In light of this, the Drug Enforcement Agency and the American Society of Anesthesiologists have put forth certain safety recommendations for the use of propofol. Despite this, the abuse potential of propofol has been challenged at different levels and therefore the preeminent focus will be to further validate the linkage from medicinal and occasional use of propofol to its addiction, as well as to explore the cellular and molecular targets involved in establishing this linkage, so as to curb the harm arising out of it. This review incorporates the clinical and biomolecular evidence supporting the abuse potential of propofol and brings forth the promising targets and the foreseeable mechanism causing the propofol addiction phenotypes, which can be called upon for future developments in this field.