Perioperative Transfusion Associated With Increased Morbidity and Mortality in Geriatric Patients Undergoing Hip Fracture Surgery.

INTRODUCTION: Both conservative and liberal transfusion thresholds, in regard to hematocrit and hemoglobin levels, have been widely studied with varying outcomes. The aim of this study was to evaluate if transfusion administered peri- (anytime during the admission), pre-, intra-, or postoperatively an its association with morbidity and mortality in the geriatric population undergoing hip surgery. METHODS: This study was an institutional review board approved retrospective analysis of data collected from 841 patients at a single urban institution who underwent surgical repairs for hip fractures from 2008 to 2010. RESULTS: Our analysis included data from 841 surgical patients. Mean patient age was 83, 74% were female, 48% received spinal anesthesia while 52% underwent general anesthesia. Out of 841 patients, 425 were transfused during the perioperative period. Most transfusions occurred postoperatively. Perioperative, intraoperative and postoperative transfusion was associated with an increase in post-operative AKI. Intraoperative blood transfusion was associated with an increase in morbidity (11.6% increased to 22.2%) by 1.9 fold, AKI (3.9% increased to 11.1%) by 2.8 fold, as well as an increase in mortality (5.2 increased to 15.6%) within 60 days by 3 fold. CONCLUSIONS: This may suggest that patients transfused prior to surgery, despite having met a specific trigger hemoglobin level earlier, may have been treated before deteriorating to a point that would cause future systemic implications.

Rectal foreign body of a shattered glass bottle; Case report of unexpected late post-operative hemorrhage managed transanally.

INTRODUCTION: Retained rectal foreign bodies are commonly implicated in patients engaging in erotic behavior. The foreign bodies vary widely, however, penetrating rectal wounds are uncommon and often complicate the retrieval of the object. The rich vascular bed of the rectal mucosa provides additional bleeding complications. PRESENTATION OF CASE: A 55-year-old male presented with active bleeding after intentional insertion of a glass bottle into the rectum which shattered. Partial retrieval via proctoscopy was followed by an exploratory laparotomy with a diverting colostomy, mucous fistula, and presacral drainage. Postoperative course was complicated by severe hematochezia. Colonoscopy was performed in the operating room found actively bleeding ulcers at sites of previously lacerated mucosa; one pulsating, protruding, vessel was visible. Clips were placed over the vessel with cessation of bleeding. Barium enema at three months follow revealed no leaks allowing for reversal of the colostomy. DISCUSSION: This case of operative retrieval of a rectal foreign body is unique because it displays deviation from commonly used algorithms are periodically needed to optimize patient recover. CONCLUSION: The utilization of minimally-invasive colonoscopy prior to additional surgical intervention in post-operative rectal bleeding following a rectal foreign body retrieval may improvie patient recovery time, functionality, and long-term outcomes.

Azithromycin decreases Chlamydia pneumoniae-mediated Interleukin-4 responses but not Immunoglobulin E responses.

BACKGROUND: Chlamydia pneumoniae is an obligate intracellular bacterium that causes respiratory infection. There may exist an association between C. pneumoniae, asthma, and production of immunoglobulin (Ig) E responses in vitro. Interleukin (IL-4) is required for IgE production. OBJECTIVE: We previously demonstrated that doxycycline suppresses C. pneumoniae-induced production of IgE and IL-4 responses in peripheral blood mononuclear cells (PBMC) from asthmatic subjects. Whereas macrolides have anti-chlamydial activity, their effect on in vitro anti-inflammatory (IgE) and IL-4 responses to C. pneumoniae have not been studied. METHODS: PBMC from IgE- adult atopic subjects (N = 5) were infected +/- C. pneumoniae BAL69, +/- azithromycin (0.1, 1.0 ug/mL) for 10 days. IL-4 and IgE levels were determined in supernatants by ELISA. IL-4 and IgE were detected in supernatants of PBMC (day 10). RESULTS: When azithromycin (0.1, 1.0 ug/ml) was added, IL-4 levels decreased. At low dose, IgE levels increased and at high dose, IgE levels decreased. When PBMC were infected with C. pneumoniae, both IL-4 and IgE levels decreased. Addition of azithromycin (0.1, 1.0 ug/mL) decreased IL-4 levels and had no effect on IgE levels. CONCLUSIONS: These findings indicate that azithromycin decreases IL-4 responses but has a bimodal effect on IgE responses in PBMC from atopic patients in vitro.

Chlamydia pneumoniae immunoglobulin E antibody levels in patients with asthma compared with non-asthma.

Chlamydia pneumoniae is an obligate intracellular bacterium that causes respiratory infection in adults and children. There is evidence for an association between atypical bacterial pathogens and asthma pathogenesis. We sought to determine whether past C. pneumoniae infection triggers C. pneumoniae- IgE antibodies (Abs) in asthmatics and non-asthmatics, who had detectable IgG titers. C. pneumoniae IgE Abs were quantified using enzyme immunoassay (EIA). C. pneumoniae IgE Ab levels were higher in asthmatics compared with non-asthmatics. There was no correlation found between total serum IgE levels and specific C. pneumoniae IgE Ab levels. C. pneumoniae infection may trigger IgE-specific responses in asthmatics.

A Case of Late Diagnosis of Acute Aortic Dissection Involving the Carotid Arteries in a Patient Presenting with Signs of Acute Ischemic Stroke.

BACKGROUND Acute aortic dissection (AAD) is a rare but life-threatening condition with high mortality. The Stanford classification of aortic dissection includes type A, which originates in the ascending aorta, and type B, which originates in the descending aorta. The diagnosis may be missed due to its ability to mimic other more common cardiovascular conditions. A case is presented of late diagnosis of AAD involving the right carotid arteries in a 55-year-old man who presented with acute ischemic stroke. CASE REPORT A 55-year-old man presented with sudden onset of left-sided facial weakness and aphasia. He was diagnosed with acute ischemic stroke and treated with tissue plasminogen activator. Further imaging showed an AAD involving the entire length of the aorta. Treatment with tissue plasminogen activator was discontinued, and the patient underwent surgical repair of the aorta. His hospital stay was complicated by acute kidney injury (AKI), pneumonia, and sepsis, and he died three weeks later from renal failure. CONCLUSIONS This case demonstrated that AAD can be challenging to diagnose, and may present atypically with ischemic stroke when it involves the carotid arteries. In such cases, imaging studies of the chest, abdomen, and head and neck may identify AAD and prevent inappropriate treatment with anticoagulants.

Female Genital Mutilation: Health Consequences and Complications-A Short Literature Review.

Female genital mutilation (FGM) is a procedure performed on women in developing countries and is underreported; it involves cutting or altering the female genitalia. The health consequences of FGM include bacterial and viral infections, obstetrical complications, and psychological problems. In this study, we report FGM societal importance, ramifications, classifications, cultural significance, prevalence, complications, implications, and treatment. Although efforts have been made to eradicate FGM, the dynamics that perpetuate the practice have societal roots. Intervention methods to promote change from within the community are necessary for successful eradication of the practice. For prevention, further studies are needed to develop programs that raise awareness.