Exploring the benefits of wild plants in dietary nutrition: investigating perspectives, choices, health impacts and sustainable practices.

BACKGROUND: This ethnobotanical study in Dunyapur, District Lodhran, Pakistan, focuses on traditional medicinal knowledge, exploring 41 plants across 28 families. The research involves 496 informants from diverse backgrounds, including farmers, herbalists, housewives, teachers, and shopkeepers. The prevalence of herbs (68%) aligns with their accessibility and rapid regrowth, shaping the local medicinal landscape. The study investigates socio-demographic features, emphasizing the importance of considering the community's diverse perspectives. METHODS: The research employs quantitative ethnobotanical data analysis, introducing various indices like PPV, FUV, FIV, RFC, UV, and RI. The analysis of plant growth habits underscores the dominance of herbs, and the method of preparation evaluation identifies decoction as the most common (23%). Leaves (27%) are the most utilized plant part, and Resedaceae stands out with the highest FUV (0.38). FIV highlights the ecological and cultural significance of Poaceae, Boraginaceae, Fabaceae, and Solanaceae. RESULTS: The RFC values range from 0.016 to 0.032, with Cucumis melo having the highest value (0.032), indicating its frequent citation and cultural significance. The study reveals specific plants like Melia azedarach, Peganum harmala and Salvadora oleoides with high PR values for skin issues, reflecting their widespread acceptance and effectiveness. Oligomeris linifolia emerges with the highest UV (0.38), emphasizing its greater significance in local traditional practices. Leptadenia pyrotechnica records the highest RI (9.85), underlining its exceptional importance in the community's traditional pharmacopeia. CONCLUSION: The findings offer a holistic understanding of ethnobotanical knowledge in Dunyapur, emphasizing the role of local contexts and ecological factors in shaping traditional plant uses. The study contributes valuable insights into the diverse practices within the community, laying the foundation for sustainable integration of traditional knowledge into broader healthcare frameworks.

Management of Abdominal Aortic Aneurysm With Concomitant Acute Cholecystitis in the Era of Endovascular Surgery.

The incidence of symptomatic acute cholecystitis with large (greater than 5.5 cm) abdominal aortic aneurysm is an uncommon occurrence. Guidelines on concomitant repair in this setting remain elusive, particularly in the era of endovascular repair. We present a case of acute cholecystitis in a 79-year-old female presenting to a local rural emergency room with abdominal pain and known abdominal aortic aneurysm (AAA). Abdominal computed tomography (CT) revealed a 5.5 cm infrarenal abdominal aortic aneurysm, significantly greater in size compared to previous imaging, as well as a distended gallbladder with mild wall thickening and cholelithiasis concerning for acute cholecystitis. The two conditions were found to be unrelated to each other, but concerns were raised on appropriate timing of care. Following diagnosis, the patient underwent concomitant treatment of acute cholecystitis and large abdominal aortic aneurysm with laparoscopic and endovascular techniques, respectively. In this report, we take the opportunity to discuss the treatment of patients with AAA and concomitant symptomatic acute cholecystitis.

Giant Proximal Right Colon Submucosal Hematoma Leading to a Large Bowel Obstruction.

A 41-year-old female with a previous history of chronic obstructive pulmonary disease (COPD) and polycythemia presented to the emergency department with worsening shortness of breath and cough which progressed to respiratory distress requiring mechanical ventilation. During her hospital stay, she developed abdominal distention followed by a fever and a four-point decrease in hemoglobin. A non-contrasted abdominopelvic CT scan was ordered which showed a very large retroperitoneal hematoma adjacent to the right colon with subtle active bleeding. Selective angioembolization of a distal segment of the right colic artery was performed by Interventional Radiology (IR) to achieve hemostasis and hemodynamic stability. Due to the persistent and worsening abdominal distention, a CT scan with contrast was ordered which clearly showed a submucosal hematoma in the region of the right colon extending from the hepatic flexure to the cecum. The hematoma was completely obstructing the proximal and mid ascending colon leading to a large bowel obstruction. Exploration of the abdomen showed severe bowel dilation, and frank ischemia of the hepatic flexure of the colon. Right hemicolectomy with primary ileocolonic anastomosis to evacuate the right retroperitoneal hematoma was subsequently performed. The patient was discharged on post-operative day 16 with no major complications.

Extraperitoneal bladder injury with extensive contrast extravasation - A case report.

Extraperitoneal bladder ruptures account for 70-90% of all bladder injuries. Management of uncomplicated extraperitoneal bladder ruptures may be treated conservatively with catheter drainage via foley or suprapubic tube. The extend of contrast extravasation at the time of cystogram does not typically affect therapy. We presented a case of a 59 -year-old- male who sustained a traumatic extraperitoneal bladder rupture after falling off a horse. The patient had severe contrast extravasation into the extraperitoneal space. Conservative management was the treatment of choice. The patient's bladder injury successfully healed after prolonged management with foley catheter decompression.

Split-thickness skin grafting in the management of cutaneous sequelae of intramuscular pentazocine injections: a novel approach.

INTRODUCTION: Pentazocine, a synthetic opioid with partial agonist and antagonist activity administered by parenteral injection, was used clinically in the 1970s. Dermatologic complications at injection sites were reported soon after its introduction. These complications are thought to be underreported. Many well-documented cases describe the development of fibrosis and calcinosis at the site of parenteral pentazocine injections, but few reports document management or successful treatment of the long-term sequelae of these manifestations. CASE REPORT: The successful use of STSG for the treatment of chronic nonhealing ulcers secondary to pentazocine-induced cutaneous fibrosis in a 78-year-old male is presented. In the early 1970s, he was started on 3-times-daily intramuscular pentazocine injections to treat pain secondary to ulcerative colitis. He injected himself in the proximal thighs and buttocks for a period of approximately 10 years. He gradually developed severe soft tissue calcifications of both buttocks and anterior thighs. In the mid-to-late 1980s, the pentazocine injections were discontinued. The diffuse sclerosis and disfiguring fibrosis remained. CONCLUSIONS: This case underscores the lasting effects of pentazocine-induced cutaneous sclerosis and fibrosis, with cutaneous complications manifesting in this patient even decades after use. It also highlights the novel use of STSG as a treatment strategy for these cutaneous complications.

Kaolin and Jasmonic acid improved cotton productivity under water stress conditions.

Drought is one of the most emerging threat that causes a severe reduction in cotton plant growth and development. Being cotton is a major cash crop has great threat to prevailing drought events in Pakistan. A field experiment was conducted in Kharif season 2018 at Research Area of MNS-University of Agriculture, Multan, Pakistan to assess the role of foliar applied kaolin and jasmonic acid on vegetative growth, gas exchange and reproductive traits of cotton under normal irrigated and artificial water deficit conditions. The experiment was laid -out in a factorial randomized complete block design with split - split plot arrangement. Main plots were allocated for irrigation levels, sub-plots for two -cotton genotypes viz. NIAB - 878 and SLH - 19 while sub - sub plots for treatments of kaolin and Jasmonic acid. Water deficit stress was created by skipping irrigation at flowering for 21 days. Foliar sprays of Kaolin (5%, w/v) and Jasmonic acid (100 µM) were applied alone or in combination at 60 days after planntinon both to normal irrigated and water-stresse skip irrigation while irrigation water alone was sprayed in control plots. Both cotton genotypes responded variably to normal irrigated and skip conditions. Skipping irrigation for up to 21 days at flowering caused a significant decrease in leaf relative water content, SPAD values, net photosynthetic rate and seed cotton yield in both the genotypes. Seed cotton yield showed an overall decline of 24.7% in skip over Normal irrigated crop. The genotype NIAB - 878 produced maximum seed cotton yield of 3.304 Mg ha-1 in normal that dropped to 2.579 Mg ha-1 in skip, thus showing an average decline of 21.9 %. Similarly, SLH - 19 produced 2.537 Mg ha-1 seed cotton under normal that dropped to 1.822 Mg ha-1 in skip, showing an average decline of 28.2%. The Application of Kaolin and JA Jasmonic acid, either applied individually or in combination, improved vegetative and reproductive development of both cotton varieties in normal and skip regimes. However, combined kaolin and Jasmonic Acid application proved to be more beneficial in terms of seed cotton production and other parameters studied.

A Rare Outcome From a Self-Inflicted Gunshot Wound to the Neck.

The incidence of self-inflicted gunshot wounds has increased significantly in the civilian population. In this case, we present a 25-year-old male with a self-inflicted gunshot wound to the neck exiting to the left shoulder. Penetrating injuries to the neck carry a high likelihood of severe injury and death. Exsanguination due to damage to the carotid or vertebral arteries is the most common cause of immediate death. Traumas caused by gunshot wounds can be complicated by an unusual path and can be devastating, depending on the extent of the injury. Our patient presents with a unique singular outcome of a spinal cord injury from anterior penetrating neck trauma. The aim of this case report is to raise awareness of a unique outcome from a self-inflicted gunshot wound, as it is vital to be aware of all possible outcomes because these injuries become more prevalent in our communities.

Developing an interplay among the psychological barriers for the adoption of industry 4.0 phenomenon.

This research aims to identify, rank, and create an interplay among the psychological barriers to adopting Industry 4.0 technologies in the manufacturing sector. A comprehensive literature review tracked by a discussion with industry and academic experts recognized 20 barriers. Based on three widely acclaimed statistical techniques, hybrid AHP-TOPSIS (Analytical Hierarchy Process-Technique for Order Performance by Similarity to Ideal Solution) and ISM (Interpretative Structural Modeling), critical psychological barriers have been investigated. A group of 8 experts from industry and academia with at least 10 years of experience was consulted for AHP and ISM techniques. Whereas TOPSIS was conducted by 443 operational-level users, including managers and supervisors of different functional areas of the manufacturing industry located in Pakistan. The findings reveal that 'Fear of job losses', 'Fear of data loss/Risk of security breaches, 'Lack of advanced & continued education of employees' and 'Lack of standards and reference architecture', with highest importance weights, emerged as the most prominent psychological barriers in developing economies. Then the interrelations among these barriers resulted in a four-layered structural model. The driver barriers identified in the final model advocate that development in 'advanced & continued education of employees', 'standards & reference architecture' and 'minimization of fear of job & data loss' can expedite the adoption of industry 4.0 (i4.0) technologies. The study uniquely develops hierarchical relationships among the psychological barriers for adopting i4.0 in the manufacturing context using AHP-TOPSIS and ISM techniques. The study would be valuable for practitioners, decision-makers and companies that wish to focus their efforts and resources on removing the most critical barriers and challenges for the seamless implementation of Industry 4.0.

Acute Cholecystitis-like Presentation in an Adult Patient with Gallbladder Agenesis: Case Report and Literature Review.

INTRODUCTION: Gallbladder agenesis (GA) is a rare congenital malformation, and majority are asymptomatic; however, symptomatic patients present with a clinical picture similar to biliary colic. Work up usually shows contracted gallbladder (GB) on ultrasound (US), and HIDA scan shows nonvisualization. Magnetic resonance cholangiopancreatography (MRCP) can be helpful in the diagnosis; however, the diagnosis without the latter can only be established intraoperatively. Management should be conservative treatment with antispasmodic drugs. Case Report. A 35-year-old female presented to the emergency department with nausea, vomiting, and worsening right upper quadrant (RUQ) abdominal pain. Vitals and laboratory values were unremarkable except for mild leukocytosis, and RUQ US reported "contracted GB, cholelithiasis, 4.2 mm wall thickness, and no ductal dilation." Surgical consultation was prompted by the diagnosis of acute cholecystitis. The patient was transferred to the operating room for laparoscopic cholecystectomy; however, no GB was found, which was confirmed by intraoperative indocyanine green cholangiography. The procedure was aborted. Postoperatively, CT scan showed absent GB. A HIDA scan showed nonvisualization of the GB after 4 hours. Gastroenterology consultation was suggested to assess for peptic ulcer disease, stricture, or other etiology for her presenting symptoms, and the upper endoscopy showed gastritis. Upper GI with small bowel follow-through study showed mild delayed gastric emptying and contrast in the colon in 45 minutes. CONCLUSION: When US imaging findings are equivocal for nonvisualization of GB in a patient with no known history of prior cholecystectomy, additional imaging is required considering the diagnosis of gallbladder agenesis. MRCP is the test of choice. Management is usually conservative with smooth muscle relaxants without the need for surgical operation.

Sevoflurane-Induced Thrombocytopenia in Post-Robotic-Assisted Paraesophageal Hernia Repair.

BACKGROUND: Transient transaminitis is an expected outcome from liver retraction after foregut surgeries. However, severe thrombocytopenia is usually not a sequela of that. We present a case in which sevoflurane is suspected of inducing thrombocytopenia as it was the only newly introduced medication to the patient during the hospital course. Thrombocytopenia may present in a variety of settings in hospitalized patients. However, managing this occurrence requires deep exploration of pathophysiology that can cause decreased platelets, which may be a challenging task in certain circumstances. The liver plays an important role in thrombopoiesis by releasing megakaryocyte growth factors. Therefore, liver dysfunction can present as thrombocytopenia or other platelet dysfunctions. OBJECTIVE: To describe a presentation of thrombocytopenia possibly associated with anesthesia-induced transaminitis after a robotic paraesophageal hernia repair with mesh and fundoplasty with intraoperative esophagogastroduodenoscopy (EGD). METHODS: A 55-year-old presented to the ED with abdominal pain and was found to have a large type IV paraesophageal hernia that was surgically treated with a robotic paraesophageal hernia repair with mesh. However, on the first postoperative day (POD) (#1), the patient developed new onset thrombocytopenia with transaminitis. Workup for thrombocytopenia failed to determine an etiology. With platelet transfusion, platelet count showed an upward trend. The patient was then evaluated and cleared for discharge by POD#5. RESULTS: The patient's POD#1 daily labs showed elevated values for liver function tests and a low platelet count of 10,000 platelets per microliter with an international normalized value (INR) of 1.3. She had received two doses of intravenous acetaminophen just prior to surgery. Her platelet count responded to two units of platelets but decreased again immediately after. She continued to have transaminitis with down-trending liver enzymes. Peripheral smear on review showed no evidence of schistocytes. A heparin-induced thrombocytopenia (HIT) screening was negative. The patient was regularly evaluated, and the platelets stabilized and slowly started to trend up. The patient recovered by the morning of her POD#5 and was cleared for discharge. CONCLUSION: We are reporting on a case of acute postoperative thrombocytopenia that was associated with transaminitis and elevated liver enzymes. We are linking the role of the liver dysfunction in noncirrhotic patients with surgical abdominal procedures. Although liver retraction transaminitis possibly played a role in the laboratory findings in the patient, the acute drop in her platelet count could be closely related to the use of sevoflurane anesthetic considering its potential hepatotoxic side effects. We also cannot rule out the sevoflurane directly affecting the platelet count.

Structural colouration in the Himalayan monal, hydrophobicity and refractive index modulated sensing.

The Himalayan monal is a bird in the pheasant family, and it is the national bird of Nepal. The bird possesses spectacular iridescent plumage with a range of different metallic colours. Here, we have studied the internal structure of its feathers from different parts of the bird's body and showed that its beautiful colours and iridescence are due to photonic structures present in the internal structure of the feathers. Sharp changes in the reflected brilliance were observed from the feathers upon changing the illumination conditions, such as horizontal and azimuthal angles. The feathers exhibited interesting hydrophobic properties, with the dull-coloured proximal end showing lower hydrophobicity with a contact angle between 90° and 110° compared with the iridescent distal end of a feather exhibiting a contact angle between 115° and 120°, attributed to the change in the internal structure and/or density of the feathers. A quick reversible change in colours of these feathers was observed when they were soaked in water and other liquids, which reversed upon drying. The shift in colour was suggested to be due to the swelling of the keratin layer of barbules that absorbed liquids and as a result modified the refractive index and periodicity of the internal photonic structures. The colour shift response of feathers was different in the case of alcohols and other water-based solutions, suggesting different swelling behaviour of keratin against different liquids; the water-based solution had the more pronounced effect. Such photonic modulation can be utilized in colour selective filters and sensing devices.

Skeletal metastasis in renal cell carcinoma: A review.

BACKGROUND: Renal cell carcinoma account for 3% of all cancers, with peak incidence between 60 and 70 years of age predominantly affecting male population. Renal carcinoma is the most common malignancy of kidney constitutes for 80-90% of renal neoplasm with an overall 45% five years survival rate. Majority are diagnosed incidentally during investigation for other disease process of abdomen. Classical triad of gross hematuria, pain and palpable mass in abdomen is rare accounting to only 6-10%. Treatment of early stages of disease i.e. localized disease is partial or radical nephrectomy. Most common metastasis in RCC occurs to lung, followed by bone involvement in 20-35%, lymph nodes, liver, adrenal gland and brain. In metastatic disease median survival rate of patient is about eight months with 50% mortality rate within first year of life, five years survival rate is 10%. Skeletal metastasis are very destructive in patients with renal cell carcinoma compromising bone integrity leading to skeletal related events including pains, impending fractures, nerve compressions, hypercalcemia and even pathological fractures which may require surgical interventions and other therapy. In addition to skeletal complications, presence of bone metastases in RCC has negative impact on progression free survival and overall survival of patients treated with systemic therapies. OBJECTIVE: In this review we discuss pathophysiology of tumor metastasis, diagnosis, management and Case examples of metastatic renal cell carcinoma. CONCLUSION: Incidence of metastatic renal carcinoma is increasing. Overall prognosis of patient with advanced RCC is poor, emphasizing the importance of early detection and prompt treatment of primary lesion in its early stage. Advancement in targeted therapy in recent decades had made some improvement in treatment of SREs and has helped in improving patent's quality of life but still we are in need of further improvement in treatment modalities to cure disease thereby decreasing morbidity and mortality.

Intravitreal Bevacizumab: Indications And Complications.

BACKGROUND: Bevacizmab is still an unlicensed drug for intraocular use in spite of the fact that it has shown comparable efficacy to other anti-vascular endothelial growth factors (anti-VEGF) medications in some large sample randomized control trails. Although repackaged bevacizumab has got safety concerns but its use is growing because of easy availability and low cost. Our study focuses on the diverse and growing indications of intravitreal bevacizumab (IVB) and its ocular complications in our geographical setting. METHODS: This interventional case series was carried out at my private practice in Said Anwar Medical Complex, Dabgari, Peshawar, from January 2008 to July 2015. Total of 6107 injections were given to 4352 eyes. Intravitreal bevacizumab was injected in proper operating room setting. Bevacizumab injections were prepared from same vial by multiple withdrawals taking care of aseptic precautions. Follow up was done at 1 week and 20 days and adverse effects were noted. RESULTS: Diabetic macular oedema (36%), central retinal vein occlusion (17.6%) and branched retinal vein occlusion (11%) were the top three indications of IVB. Other common indications were proliferative diabetic retinopathy (9.6%), neo-vascular glaucoma (5.9%), proliferative diabetic retinopathy with vitreous bleed (4.4%), proliferative diabetic retinopathy with tractional retinal detachment (3.7%), neo-vascular age related macular degeneration (2.9%), central serous retinopathy (1.48%) and Eale's disease (1.48%). Endohthalmitis occurred in 3 eyes (0.069%) while retinal detachment was found in only 2 eyes (0.046%). CONCLUSIONS: Common indications of bevacizumab are diabetic macular oedema, central retinal vein occlusion and branched retinal vein occlusion. Complications like endophthalmitis and retinal detachment are rare.

Atypical gunshot wound: Bullet trajectory analyzed by computed tomography.

INTRODUCTION: Gunshot injuries are a result of a bullet or projectile fired from a weapon that penetrates the body. Homicide, suicide, and occasionally, accidental events are a significant cause of firearm-related injuries. In rare cases, the damage from the gunshot injury can be masked due to an atypical bullet trajectory. PRESENTATION OF CASE: A 63-year-old male was found with a gunshot wound to the anterior left knee. Computed tomography (CT) scans revealed a bullet track extending from the anterior aspect of the left knee that traveled cephalad subcutaneously and entered into the peritoneal cavity, perforating the distal descending colon. The bullet was found to be at rest adjacent to the spleen and posterior chest wall, with no injury to the lungs, kidneys or the spleen. The patient required a sigmoid colectomy with descending colostomy and was subsequently discharged home without any complications. DISCUSSION: Intra-abdominal organ damage from a gunshot wound to the distal limb is a rare occurrence. Atypical gun shot wounds, such as this case, have the potential for multiple issues including: delayed diagnostic tests, inaccurate radiological readings, and inappropriate medical management. CONCLUSION: If an abnormal trajectory is maintained, it is possible for a bullet to traverse half the length of the body without the patient realizing it. Accurate CT analysis and quick decisions in surgical and medical management are critical takeaways to provide quality care to patients with these injuries.

Epidemiological characteristics, hospital course and outcome of snakebite victims in West Texas.

INTRODUCTION: Numerous snakebites are reported every spring and summer in the United States especially in the Southwestern part of the country. This is usually associated with significant morbidity but fatalities are rare. Most victims are male and the majority of bites are on the extremities. METHODS: A search for all cases coded with a discharge diagnosis of snakebite injury revealed 90 patients admitted to Northwest Texas Hospital, the trauma center in Amarillo, Texas, between January 2002 and December 2012. These charts were retrospectively reviewed and data extracted including patient demographics, severity of snakebite, treatment given, and ultimate outcome. RESULTS: Ninety patients were admitted to the hospital due to snakebite. It was a rattlesnake in 83 cases. The mean age of the victims was 29.7 years and 74 of them were male. Fifty-one bites were on the upper extremities, thirty-eight bites were on the lower extremities and one bite was on the abdominal wall. About 95% of the lower extremity bites were moderate or severe compared to 74.5% of the upper extremity bites, Cramer's coefficient 0.3, p=0.02. Thirty-one patients had complications and twenty patients required surgical intervention. Eighty-eight patients received a median of 10 vials of antivenin that was well tolerated. Median hospital length of stay was 3 days. None of the patients died. CONCLUSION: Rattlesnake bites cause significant morbidity although mortality is rare. Early administration of antivenin and appropriate supportive measures and monitoring for complications with surgical intervention when needed leads to improved patient outcomes.

A comparative study of spray keratinocytes and autologous meshed split-thickness skin graft in the treatment of acute burn injuries.

BACKGROUND: ReCell (Avita Medical, Northridge, CA) is an autologous cell harvesting (ACH) device that enables a thin split-thickness skin biopsy to be processed to produce a cell population that includes a mixed population of keratinocytes, melanocytes, Langerhans cells, and papillary dermal fibroblasts for immediate delivery via a spray applicator onto a prepared skin surface. MATERIALS AND METHODS: In this Institutional Review Board-approved US Food and Drug Administration phase 2 study, the authors prospectively evaluated the treatment of partial-thickness burns in patients with two 320 cm2 areas, 1 area treated with the ACH device and the other with a meshed split-thickness skin graft (MSTSG) as a control. The authors compared the treatment areas for graft take, pigmentation, and color match to surrounding healthy tissue, scarring, and pain. RESULTS: In this preliminary study, 10 patients were treated with this protocol. Eight patients had 100% take to both treatment areas and 2 patients had significant non-take and graft loss attributable to underexcised wound beds and difficulty with the spray applicator. Pigmentation and color match ratings were identical at week 52 and the Modified Vancouver Scar Scale scores were comparable. One subject rated the autologous cell harvesting site as having a better appearance, while the remaining subjects rated their ACH and MSTSG sites' appearances as being comparable. In early follow-up visits, pain ratings were slightly elevated in the ACH group due to graft healing; however, in visits following week 2, pain ratings at the ACH and MSTSG sites were rated similarly by all patients. CONCLUSION: This preliminary report describes an early experience with the ACH device and the treatment of partial-thickness burn injuries. In this 10-patient series, patients benefitted from having a decreased donor site size and comparable outcomes with MSTSG treatment. While this preliminary underpowered study has provided positive results, there is a learning curve with choosing the proper wound for treatment with the ACH device, as well as with using the device.

The effect of a nurse-led multidisciplinary team on ventilator-associated pneumonia rates.

Background. Ventilator-associated pneumonia (VAP) is a worrisome, yet potentially preventable threat in critically ill patients. Evidence-based clinical practices targeting the prevention of VAP have proven effective, but the most optimal methods to ensure consistent implementation and compliance remain unknown. Methods. A retrospective study of the trend in VAP rates in a community-hospital's open medical intensive care unit (MICU) after the enactment of a nurse-led VAP prevention team. The period of the study was between April 1, 2009, and September 30, 2012. The team rounded on mechanically ventilated patients every Tuesday and Thursday. They ensured adherence to the evidence-based VAP prevention. A separate and independent infection control team monitored VAP rates. Results. Across the study period, mean VAP rate was 3.20/1000 ventilator days ±5.71 SD. Throughout the study time frame, there was an average monthly reduction in VAP rate of 0.27/1000 ventilator days, P < 0.001 (CI: -0.40--0.13). Conclusion. A nurse-led interdisciplinary team dedicated to VAP prevention rounding twice a week to ensure adherence with a VAP prevention bundle lowered VAP rates in a community-hospital open MICU. The team had interdepartmental and administrative support and addressed any deficiencies in the VAP prevention bundle components actively.

Bacteremic skin and soft tissue infection caused by Prevotella loescheii.

BACKGROUND: Anaerobes are a major component of gut flora. They play an important role in the pathogenesis of infections resulting from breaches in mucus membranes. Because of the difficulties in cultivating and identifying it, their role continues to be undermined. The purpose of this paper is to report a case of Prevotella loescheii bacteremic skin and soft tissue infection and review the literature. CASE PRESENTATION: A 42-year-old Caucasian man was admitted for an elective bariatric surgery. A lengthy intensive care unit stay and buttocks decubitus ulcers complicated his post-operative course. After being transferred to a long-term care facility, the decubitus ulcer became secondarily infected with multiple bacteria including P. loescheii; an anaerobe that grew in blood and wound cultures. The patient was treated successfully with aggressive surgical debridement, antibiotics and subsequent wound care. CONCLUSION: P. loescheii colonizes the gut and plays an important role in periodontal infections. In rare occasions and under suitable circumstances, it can infect skin and soft tissues as well as joints. Given the difficulties in isolating anaerobes in the microbiology lab, considering this bacterium alongside other anaerobes in infections of devitalized tissue is indicated even if cultures were reported negative.

Traumatic lumbar visceral herniation in a young woman.

INTRODUCTION: Lumbar herniation is uncommon, with traumatic etiology being rare. Traumatic lumbar hernias are usually caused by seatbelt injury in motor vehicle accidents. It is exceedingly uncommon to see lumbar hernias in an unrestrained passenger of a motor vehicle accident. PRESENTATION OF CASE: We present a case of a traumatic inferior lumbar hernia in a young woman who was an unrestrained driver of a vehicle involved in a high-speed collision, with multiple rollover and ejection. CT scans of the abdomen and pelvis suggested soft tissue injury involving muscles in the left lower posterior flank with traumatic herniation of the colon and small bowel. Emergent midline abdominal laparotomy confirmed herniation in the left lower quadrant. After abdominal closure, in the prone position, an extensive laceration over the left flank also confirmed herniation. Due to its dirty nature, the wound was irrigated, lavaged and covered with wound vacuum-assisted closure placement. The decision was made in favor of delayed elective hernia repair. DISCUSSION: Lumbar hernias are usually caused by sudden force to the abdomen, leading to increased intra-abdominal pressure. This pressure combined with areas of weakness in the superior and/or inferior triangle lead to herniation. Uncommonly, the contents of lumbar hernias can strangulate or incarcerate leading to bowel obstruction. This can often be prevented by detection with CT and laparotomy. CONCLUSION: Lumbar herniation of traumatic etiology is rare. Early detection with CT and/or exploratory laparotomy is important to avoid increases in size of the defect and bowel strangulation and incarceration.