Delayed cardiac tamponade secondary to blast injury from gunshot wound.

Penetrating injuries are recognized for the direct tissue damage, which is typically evident on physical examination. Secondary injuries resulting from kinetic energy transfer in the case of gunshot wounds (GSWs), often referred to as "blast injuries", may affect tissues distant to the ballistic trajectory and are often occult. We present a case of delayed cardiac tamponade resulting from secondary blast injury. The patient sustained a thoraco-abdominal GSW with entry adjacent to the cardiac box. An Advanced Trauma Life Support (ATLS)-guided assessment revealed intra-abdominal injuries necessitating operative intervention without evidence of cardiac injury. On post-operative day four, the patient developed chest pain, tachycardia, and shortness of breath. Imaging revealed a large pericardial effusion with cardiac tamponade. Emergent exploration revealed hemopericardium secondary to a bleeding epicardial hematoma without evidence of pericardial violation. Clinicians must maintain a high clinical suspicion for occult, indirect blast injuries which may be life-threatening.

Toxic Clostridioides (formerly Clostridium) difficile colitis: No longer a diarrhea associated infection.

BACKGROUND: Clostridioides difficile infection (CDI) is traditionally taught to be an antibiotic associated diarrheal infection. This diagnosis is based on the presence of clinical symptoms (usually defined as more than 3 watery, loose or unformed stool within 24 h) coupled with a diagnostic test. There is now a new presentation of CDI, including progression to toxic megacolon, in patients without diarrhea. METHODS: We report a case series of 9 surgical patients from a single institution who developed CDI without preceding diarrhea. RESULT: All 9 patients had CDI with positive laboratory testing for C. difficile toxin. They, however, presented with a lack of or minimal bowel movements. Six patients had rapid development of abdominal distention, 1 patient had a single episode of watery stool in 3 days, while the other 2 patients presented with constipation. Seven patients received stool softeners, suppositories and/or enemas for presumed constipation. Four patients had a mild course of infection and were successfully treated medically. The other 5 patients developed toxic megacolon, and eventually required total abdominal colectomy. Out of the 5 patients that required total colectomy, 2 expired. CONCLUSION: CDI must be suspected in patients who rapidly develop abdominal distention, vague abdominal complaints or change in bowel function even in the absence of diarrhea, especially if coupled with multi-system organ failure.

The utility of impedance cardiography in hemodynamic monitoring of patients with sepsis.

BACKGROUND: Commonly used biochemical indicators and hemodynamic and physiologic parameters of sepsis vary with regard to their sensitivity and specificity to the diagnosis. The aim of this preliminary study was to evaluate non-invasive impedance cardiography as a monitoring tool of the hemodynamic status of patients with sepsis throughout their initial volume resuscitation to explore the possibility of identifying additional measurements to be used in the future treatment of sepsis. METHODS: Nine patients who presented to the emergency room and received a surgical consultation during a 3-month period in 2016, meeting the clinical criteria of sepsis defined by systemic inflammatory response syndrome in the 2012 Surviving Sepsis Campaign Guidelines, were included in this study. We applied cardiac impedance monitors to each patient's anterior chest and neck and obtained baseline recordings. Measurements were taken at activation of the sepsis alert and 1 hour after fluid resuscitation with 2 L of intravenous crystalloid solution. RESULTS: Nine patients met the inclusion criteria. The mean age was 60±17 years and two were female; eight were febrile, five were hypotensive, four were tachycardic, seven were treated for infection, and six had positive blood cultures. Hemodynamic parameters at presentation and 1 hour after fluid resuscitation were heart rate (beats per minute) (97±13 and 93±18; p=0.23), mean arterial pressure (mm Hg) (81±13 and 85±14; p=0.55), systemic vascular resistance (dyne-s/cm- 5) (861±162 and 1087±272; p=0.04), afterload measured as systemic vascular resistance index (dyne-s/cm- 5/m2) (1813±278 and 2283±497; p=0.04), and left cardiac work index (kg*m/m2) (3.6±1.4 and 3.3±1.3; p=0.69). DISCUSSION: Through measuring a patient's systemic vascular resistance and systemic vascular resistance index (afterload), statistical significance is achieved after intervention with a 2 L crystalloid bolus. This suggests that, along with clinical presentation and biochemical markers, impedance cardiography may show utility in providing supporting hemodynamic data to trend resuscitative efforts in patients with sepsis. LEVEL OF EVIDENCE: Level IV.

Effect of baicalin on GLUT4 expression and glucose uptake in myotubes of rats.

AIMS: Although baicalin could attenuate obesity-induced insulin resistance, the detailed mechanism of baicalin on glucose uptake has not been sufficiently explored as yet. The aim of this study was to survey if baicalin might facilitate glucose uptake and to explore its signal mechanisms in L6 myotubes. MATERIALS AND METHODS: L6 myotubes were treated with 100, 200, 400 µM baicalin for 6 h, 12 h and 24 h in this study. Then 2-NBDG and insulin signal protein levels in myotubes of L6 cells were examined. KEY FINDINGS: We discovered that administration of baicalin enhanced GLUT4, PGC-1α, pP38MAPK, pAKT and pAS160 contents, as well as GLUT4 mRNA and PGC-1α mRNA levels in L6 myotubes. The beneficial metabolic changes elicited by baicalin were abrogated in myotubes of L6 by P38MAPK or AKT inhibitors. SIGNIFICANCE: These results suggest that baicalin promoted glucose uptake in myotubes by differential regulation on P38MAPK and AKT activity. In conclusion, these data provide insight that baicalin is a powerful and promising agent for the treament of hyperglycemia via AKT/AS160/GLUT4 and P38MAPK/PGC1α/GLUT4 pathway.

NF-κΒ inhibition is ineffective in blocking cytokine-induced IL-8 production but P38 and STAT1 inhibitors are effective.

OBJECTIVE: In vitro but not in vivo evidence indicates that blockade of NF-κB is effective in reducing inflammation and production of IL-8. We hypothesized that the failure of in vitro experiments to predict in vivo outcome was due to the use of short time periods of observation and the use of single cytokines to stimulate NF-κB. METHODS: HEK cells with a NF-κB reporter gene or CaCo-2 cells were stimulated with CM (IL-1-ß; TNF-α, and IFN-γ) or individual cytokines in the presence and absence of NF-κB inhibitors, a STAT1 inhibitor, and/or a p38 MAPK inhibitor for periods up to 24 h. NF-κB activation, IL-8 production, and nitric oxide production were measured. RESULTS: CM-induced IL-8 production in HEK cells was additive to synergistic. CM enhanced production of IL-8 at 24 h but not 4 h was independent of NF-κB. The p38 inhibitor SB203580 and the STAT1 inhibitor EGCG blocked CM-induced IL-8 production at both early and late time periods. The NF-κB inhibitors PDTC and BAY11-7082 were found to increase CM-stimulated IL-8 production in Caco-2 cells at 24 h. CONCLUSIONS: Our data suggest an effective strategy to reduce IL-8 production is to block p38 or STAT1 rather than NF-κB.