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Prone position ventilation (PPV) is one of the few interventions with a proven mortality benefit in the management of acute respiratory distress syndrome (ARDS), yet it is underutilized as demonstrated by multiple large observational studies. Significant barriers to its consistent application have been identified and studied. But the complex interplay of a multidisciplinary team makes its consistent application challenging. We present a framework of multidisciplinary collaboration that identifies the appropriate patients for this intervention and discuss our institutional experience applying a multidisciplinary team to implement prone position (PP) leading up to and through the current COVID-19 pandemic. We also highlight the role of such multidisciplinary teams in the effective implementation of prone positioning in ARDS throughout a large health care system. We emphasize the importance of proper selection of patients and provide guidance on how a protocolized approach can be utilized for proper patient selection.
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COVID-19 , Síndrome do Desconforto Respiratório , Humanos , Decúbito Ventral , Pandemias , Síndrome do Desconforto Respiratório/terapia , Respiração Artificial , Posicionamento do PacienteRESUMO
Nasogastric tube insertion is a routine procedure that is utilized on a daily basis in our hospitals and long-term care facilities. Blind insertion of these tubes is usually performed by nurses, residents and other health care providers. In this report, we present an incident of misplacement of the nasogastric tube into the bronchial tree causing parenchymal injury and pneumothorax. We also highlight the importance of nasogastric tube placement confirmation and possible pitfalls in interpreting confirmation radiographs.
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Intubação Gastrointestinal , Pneumotórax , Hospitais , Humanos , Intubação Gastrointestinal/efeitos adversos , Pneumotórax/diagnóstico por imagem , Pneumotórax/etiologia , RadiografiaRESUMO
Chylothorax is the presence of a chylous effusion in the pleural space. Diagnosing chylothorax requires a high clinical suspicion, awareness of the different appearances of a chylothorax and the performance of tests on the pleural fluid, additional to those typically required to differentiate an exudate from a transudate based on Light's criteria. Chylothorax is a more common diagnosis in the trauma and post-surgical patients, but it is still important for practitioners of other disciplines to be aware of it. In this article we provide a concise summary of chylothorax diagnosis and management.
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Quilotórax , Derrame Pleural , Quilotórax/diagnóstico , Quilotórax/terapia , Exsudatos e Transudatos , HumanosRESUMO
In 1989, an acquired high anion gap metabolic acidosis due to elevated 5-oxoproline (pyroglutamic acid) was first reported. This is related to chronic acetaminophen use in malnourished patients and women with chronic medical conditions, it could happen even using therapeutic or low doses. The mainstay of treatment is cessation of acetaminophen use along with the administration of intravenous fluids. N-acetyl cysteine might accelerate improvement. The best explanation of the disorder is glutathione depletion and activation of a key enzyme in the γ-glutamyl cycle. This review article aims to highlight the mechanism and management of acquired high anion gap metabolic acidosis caused by 5-oxoproline in the adult population.
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Acidose , Analgésicos não Narcóticos , Acetaminofen , Equilíbrio Ácido-Base , Acidose/induzido quimicamente , Adulto , Feminino , Humanos , Ácido Pirrolidonocarboxílico/metabolismoRESUMO
While portal-systemic encephalopathy is a common entity in cirrhotic patients, it is less frequent in non-cirrhotic patients. We are reporting a case of a 68-year-old female who presented with unresponsiveness for the second time in six months. She underwent extensive evaluation for liver disease with ultrasonography and computerized tomography of the abdomen, testing for causes of liver disease including testing for viral hepatitis was negative. A liver biopsy was done clearing any doubt about the presence of significant liver disease or clinically significant portal hypertension. With absence of liver disease hence lower likelihood of portal-systemic encephalopathy (PSE) we evaluated for other causes of encephalopathy with unremarkable neuroimaging including brain MRI and head CT, unremarkable CSF analysis and EEG showing no seizure activity. Given the negative workup and the high ammonia level with the significant clinical response to ammonia lowering therapy we further evaluated the patient for other causes of PSE with Doppler ultrasonography of the liver and eventually angiography of the portal system with the high suspicion for a portosystemic shunt as a cause of her encephalopathy. A shunt from the inferior mesenteric vein to the left renal vein was diagnosed and successfully occluded utilizing coil embolization. The patient recovered normal mentation and was eventually discharged home. This case sheds light on the importance of diagnosing portosystemic shunts leading to encephalopathy, as occlusion of the shunt can correct the encephalopathy and help prevent further episodes.
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Encefalopatias , Encefalopatia Hepática , Hipertensão Portal , Derivação Portossistêmica Cirúrgica , Idoso , Feminino , Encefalopatia Hepática/etiologia , Humanos , Derivação Portossistêmica Cirúrgica/efeitos adversosRESUMO
Pulmonary hypertension (PH) is defined as mean pulmonary artery pressure (mPAP) 25 mmHg or greater at rest; this measurement is obtained during right heart catheterization. The exact prevalence of PH in the U.S. is unknown. Advances in hemodynamic studies of the right heart side and pulmonary circulations has helped improve our understanding of this condition. This better understanding aids the development of treatment agents aimed at improving quality of life, morbidity and mortality. Awareness of this condition and understanding the classification of PH and the available treatment modalities is crucial hence we aim to briefly review the classification, diagnosis and treatment of PH in this article.
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Hipertensão Pulmonar , Qualidade de Vida , Cateterismo Cardíaco , Hemodinâmica , Humanos , Hipertensão Pulmonar/diagnóstico , Hipertensão Pulmonar/epidemiologia , Hipertensão Pulmonar/terapia , PrevalênciaRESUMO
The number of people older than 65 will double by 2060, and with it, the number of people suffering from heart failure will also surge. In the United States, it is estimated that there are close to 250,000-500,000 endstage/ advanced heart failure cases. Mechanical circulatory support (MCS) is an evolving advanced therapy for end-stage heart failure. MCS can be an interim measure along with acute mechanical circulatory support measures including but not limited to the intra-aortic balloon pump, extracorporeal membrane oxygenation, or temporary ventricular assist devices such as Impella, or MCS can be a more prolonged and ambulatory measure in conjunction with an implantable, durable left ventricular assist device (LVAD). As the technology of LVADs advances, the complication rate is decreasing, and the living LVAD patient population is expanding. This indicates that the probability of a non-heart failure specialist encountering these patients is also on the rise. In this article, we aim to expand the familiarity and basic knowledge of non-heart failure specialists by detailing the concepts and complications of LVADs, enabling them to more comfortably manage these patients.
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Oxigenação por Membrana Extracorpórea , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/terapia , Coração Auxiliar , Idoso , Transição Epidemiológica , Insuficiência Cardíaca/epidemiologia , Coração Auxiliar/tendências , Humanos , Estados Unidos/epidemiologiaRESUMO
An elderly female presented to the emergency department with a two-month history of dyspnea on exertion and productive cough. Imaging revealed miliary nodular pattern involving both lungs. She underwent extensive work up evaluating different possible pathological processes. The condition was ultimately lethal. In this educational case report, we review the common - and not-so-common - etiologies that might present with this constellation of signs and symptoms, along with the diagnostic strategies and thought processes used to identify the final diagnosis.
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Tosse , Dispneia , Idoso , Tosse/diagnóstico , Dispneia/diagnóstico , Serviço Hospitalar de Emergência , Feminino , HumanosAssuntos
Alanina Transaminase/sangue , Aspartato Aminotransferases/sangue , Atorvastatina/efeitos adversos , Inibidores de Hidroximetilglutaril-CoA Redutases/efeitos adversos , Doenças Musculares/induzido quimicamente , Feminino , Humanos , Hiperlipidemias/tratamento farmacológico , Testes de Função Hepática , Pessoa de Meia-Idade , Índice de Gravidade de DoençaRESUMO
BACKGROUND: Cardiogenic shock (CS) remains a major cause of morbidity and mortality, particularly in developing countries where there are limited resources and a lack of data on CS outcomes. This study aimed to investigate 30-day all-cause mortality in Egyptian patients with CS at tertiary referral centers. RESULTS: This prospective, observational multicenter registry analyzed 16,681 patients from six cardiac centers, to evaluate the incidence, causes and predictors of CS-related mortality. Among the 529 diagnosed CS patients, 68.2% had an ischemic etiology. No discernable variations were observed in clinical or laboratory features, as well as mortality rates, between ischemic and non-ischemic CS patients. Within 30 days, 210 deaths (39.7%) occurred. Non-survivors with ischemic CS had a higher prevalence of diabetes, worsening renal function, and were more likely to receive multiple inotropes. Mortality did not significantly differ between acute coronary syndrome patients with ST elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) (42.7% vs. 43.7%, p < 0.887). However, anterior STEMI patients had significantly higher mortality than those with inferior STEMI (49.5% vs. 21.6%, p < 0.003). Multivariate regression analysis identified predictors of mortality in CS, including the median hospital stay duration, leucocyte count, alanine transaminase levels, highest creatinine levels, resuscitated cardiac arrest, and use of norepinephrine, epinephrine, and dopamine. CONCLUSION: In an Egyptian cohort, CS incidence was 3.17%, with no mortality difference based on the underlying etiology. Independent predictors of 30-day all-cause mortality included worsening renal function, leucocyte count, resuscitated cardiac arrest, and use of multiple inotropes/vasopressors.
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Lattice structures are a type of lightweight structure that is more commonly being applied to engineering systems as a way to reduce mass and enhance mechanical properties. The cantilever beam case is one of the primary modes of loading in many engineering applications, where light-weighting is also crucial. However, lightweight lattice structured cantilever beams have not been investigated considerably due to design and manufacturing limitations. Therefore, the aim of this study was to investigate the response of four different lattice structured cantilever beams comprising of unit cells made from Schwarz-P, Schwarz-D, Gyroid, and Octet-truss structures fabricated using Multi Jet Fusion additive manufacturing technology. An investigation into the cross-sections of these structures leads to a conclusion that the beams made from such structures are non-prismatic in nature as a result of variation in cross-sections. This led to the development of equations for the moment of inertia of these structures, which helped in calculating symmetric and un-symmetric bending. These beams were subjected to cantilever loading until failure, which provided insights into flexural properties such as flexural stress, stiffness, and strain energy. Experimental results indicate that the surface-based structures, due to better surface-area-to-volume ratio, have better ability in transferring loads and hence perform better than the beam-based Octet-truss beam. The Schwarz-D beam had performed the best among all the beams, which is further supported in literature due to its stretch-dominated topology that results in higher values of modulus. The finite element analysis (FEA) findings also validate these findings in which the distribution of stresses can be seen to be better transmitted than the other structures. The FEA validation shows that the distribution of Von-Mises stress and their position in experimental tests and failure of these structures is also very close, which provides validation to the experimental setup and the testing of beams.
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The antiproliferative activities of 2',3,4',5,5'-pentahydroxy-cis-stilbene 1, resveratrol 2, oxyresveratrol 3, norartocarpetin 4, kuwanon C 5, morusin 6, cudraflavone A7, kuwanon G 8, albafuran C 9, mulberrofuran G 10, 3-acetyl-O-α-amyrin 11, 3-acetyl-O-ß-amyrin 12, ursolic acid-3-O-acetate 13 and uvaol 14, previously identified from the barks of Morus nigra L., were investigated against HepG2 and MCF-7 cell lines. In addition, a series of methylated stilbenes 15-19 were prepared using compounds 1-3 and their antiproliferative effects were similarly investigated. The structure of a new 2',3,4'-trimethoxy-5-hydroxy-trans-stilbene 19 was elucidated using spectroscopic techniques. It showed remarkable activity against MCF-7 cells with IC50 12.5 µM. However, kuwanon C (5) showed the highest antiproliferative activity with IC50 3.92 and 9.54 µM against MCF-7 and HepG2, respectively.
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Antineoplásicos Fitogênicos/farmacologia , Morus/química , Estilbenos/química , Estilbenos/farmacologia , Antineoplásicos Fitogênicos/química , Benzofuranos/análise , Benzofuranos/farmacologia , Proliferação de Células/efeitos dos fármacos , Ensaios de Seleção de Medicamentos Antitumorais , Flavonoides/análise , Flavonoides/farmacologia , Células Hep G2 , Humanos , Células MCF-7 , Casca de Planta/química , Resveratrol/análise , Resveratrol/farmacologia , Estilbenos/análise , Terpenos/análise , Terpenos/farmacologiaRESUMO
We present a very rare case of concurrent empyema and liver abscess caused by Fusobacterium. Our patient presented with 3-month history of subtle abdominal discomfort and cough leading to eventually presenting with marked chest pain, dyspnoea and septic shock. CT revealed a liver abscess and large right-sided pleural effusion. Drainage of the pleural effusion yielded gross pus with the growth of Fusobacterium varium, while drainage of the liver abscess yielded Fusobacterium nucleatum The patient responded to drainage and antibiotic therapy with resolution of symptoms and decrease in the size of empyema and abscess on follow-up imaging. We also include a review if literature of related fusobacterial infections.
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Empiema Pleural/microbiologia , Fusobacterium , Abscesso Hepático Piogênico/microbiologia , Infecções por Fusobacterium , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
We present a case of right sided chylothorax in the setting of cirrhosis believed to be secondary to extensive venous thromboembolism of the left upper extremity and exacerbated by chylous ascites. Our patient responded to conservative management with anticoagulation and a repeat thoracentesis revealed transformation of the fluid back to straw coloured transudate. We also include a brief discussion of the diagnosis and management of chylothorax.
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Quilotórax/diagnóstico , Tromboembolia Venosa/diagnóstico , Anticoagulantes/uso terapêutico , Braço/irrigação sanguínea , Quilotórax/complicações , Quilotórax/diagnóstico por imagem , Quilotórax/tratamento farmacológico , Diagnóstico Diferencial , Dispneia/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Paracentese , Tomografia Computadorizada por Raios X , Tromboembolia Venosa/complicações , Tromboembolia Venosa/tratamento farmacológico , Varfarina/administração & dosagem , Varfarina/uso terapêuticoRESUMO
Aim: To examine the impact of CYP2C19 genotype on selective serotonin reuptake inhibitor (SSRI) prescribing patterns. Patients & methods: Observational cohort containing 507 unique individuals receiving an SSRI prescription with CYP2C19 genotype already in their electronic medical record. Genotype was distributed as follows: n = 360 (71%) had no loss of function alleles, 136 (26.8%) had one loss of function allele and 11 (2.2%) had two loss of function alleles. Results & conclusion: For poor metabolizers exposed to sertraline, citalopram or escitalopram, providers changed prescribing patterns in response to alerts in the electronic medical record by either changing the drug, changing the dose or monitoring serial EKGs longitudinally. For intermediate metabolizers exposed to sertraline, citalopram or escitalopram, no alert was needed (mean QTc = 440.338 ms [SD = 31.1273] for CYP2C19*1/*1, mean QTc = 440.371 ms [SD = 29.2706] for CYP2C19*1/*2; p = 0.995).
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Citocromo P-450 CYP2C19/genética , Síndrome do QT Longo/induzido quimicamente , Síndrome do QT Longo/genética , Inibidores Seletivos de Recaptação de Serotonina/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Antidepressivos de Segunda Geração/efeitos adversos , Antidepressivos de Segunda Geração/metabolismo , Antidepressivos de Segunda Geração/uso terapêutico , Estudos de Coortes , Citocromo P-450 CYP2C19/metabolismo , Feminino , Genótipo , Humanos , Síndrome do QT Longo/metabolismo , Masculino , Pessoa de Meia-Idade , Testes Farmacogenômicos , Padrões de Prática Médica , Inibidores Seletivos de Recaptação de Serotonina/metabolismo , Inibidores Seletivos de Recaptação de Serotonina/uso terapêuticoRESUMO
8-beta-Hydroxypimar-15-en-19-oic acid (1), taxodione (2), 6,7-dehydro-8-hydrotaxodone (3), quercetin-3-O-beta-D-glucopyranoside (4), and shikimic acid (5) were isolated from the leaves of Taxodium distichum L. (Rich.) for the first time. Previously reported compounds [beta-sitosterol (6), isorhamnetin (7), quercetin (8), isorhamnetin-3-O-alpha-arabinofuranoside (9), quercetin-3-O-a-arabinofuranoside (10)] have also been isolated. The activity of taxodione as an inhibitor for hepatic stellate cells was determined. The antitumour activity of 2, 3, and 5 using a DNA affinity probe was examined.
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Diterpenos/isolamento & purificação , Folhas de Planta/química , Taxodium/química , Animais , Sítios de Ligação , DNA/metabolismo , Diterpenos/farmacologia , Flavonóis/isolamento & purificação , Flavonóis/farmacologia , Glicosídeos/isolamento & purificação , Glicosídeos/farmacologia , Fígado/citologia , Fígado/efeitos dos fármacos , Quercetina , Ratos , SolventesRESUMO
INTRODUCTION: Virus-induced diseases of the central nervous system (CNS) represent a significant burden to human health worldwide. They are common causes of morbidities and mortality. There are no previous epidiomologic studies about viral CNS infections done in Qatar or in the Gulf region. We conducted this study to determine the etiology, clinical and epidimiological characteristics, and outcome of viral central nerveous system infection in patients across a larger national healthcare system. METHODOLOGY: We retrospectively evaluated all cerebrospinal fluid findings from January 2011 - March 2015 at any of the 7 hospitals in the Hamad Medical Corporation healthcare system. We included those with an abnormal CSF finding in our study. We excluded those with missing medical records, those with no clinical evidence of CNS infection or proven bacterial CNS infection. Based on pre-defined clinical and CSF (lab, culture, PCR) criteria, persons with abnormal CSF and CNS clinical findings were classified as having meningitis, meningoencephalitis, encephalitis or myelitis. We reviewed the laboratory results to determine the proportion of persons with confirmed viral etiology. RESULTS: Among 7690 patients with available CSF results, 550 cases met the case definition criteria for viral CNS infection (meningitis 75%; meningoencephalitis 16%; encephalitis 9%; myelitis 0.4%). Two-thirds (65%) were male and 50% were between 16-60 years old. Persons from Southeast Asia (India, Pakistan, Bangladesh, Nepal, and Sri Lanka) accounted for 39.6 of all infections. A definitive virologic etiologic agent was found in 38%, among whom enterovirus was the most common (44.3%) followed by Epstein-Barr virus (31%) and varicella zoster virus (12.4%). The clinical outcome was overall good, only 2 cases died and the rest discharged to home. Ninety-eight per cent were admitted to medical ward (mean stay 7.8±6.4 days) and 2 % to an intensive care unit. (mean stay 2.7±5.4 days). Among those with confirmed viral etiology, 83.8% received ceftriaxone, 38% received vancomycin and 38% received at least one other antibiotic. CONCLUSION: Viral etiology is not uncommon among those evaluated for CNS infection in Qatar, and is most commonly seen in Southeast Asian immigrants. Clinical outcomes are generally excellent in this group of patients. Antibiotics are overly used even when a viral etiology is confirmed. There is a need for clinician education regarding etiology and treatment of CNS infections.
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BACKGROUND: Central nervous system (CNS) viral infections are an important cause of morbidity and mortality. No data are available regarding their epidemiology in Qatar. DESIGN: We retrospectively evaluated all cerebrospinal fluid findings from January 2011-March 2015 at Hamad Medical Corporation. Those with abnormal CSF finding were included in our study. We excluded those with missing medical records, no clinical evidence of viral CNS infection, or proven bacterial, fungal or tuberculosis CNS infection. CNS clinical findings were classified as meningitis, encephalitis or myelitis. RESULTS: Among 7690 patients with available CSF results, 550 cases met the inclusion criteria (meningitis 74.7%; encephalitis 25%; myelitis 0.4%). Two-thirds (65%) were male and 50% were between 16-60 years old. Viral etiology was confirmed in 38% (enterovirus, 44.3%; Epstein-Barr virus, 31%; varicella zoster virus, 12.4%). The estimated incidence was 6.4 per 100,000 population. Two persons died and the rest were discharged to home. Among those with confirmed viral etiology, 83.8% received ceftriaxone (mean duration 7.3±5.2 days), 38% received vancomycin (mean duration 2.7±5.4 days) and 38% received at least one other antibiotic. Intravenous acyclovir was continued for more than 48h in patients with confirmed negative viral etiology (mean duration 5±5.6 days). CONCLUSION: Viral etiology is not uncommon among those evaluated for CNS infection in Qatar. Clinical outcomes are excellent in this group of patients. Antibiotics and acyclovir are overly used even when a viral etiology is confirmed. There is a need for clinician education regarding etiology and treatment of viral CNS infections.
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Viroses do Sistema Nervoso Central/epidemiologia , Aciclovir/uso terapêutico , Adolescente , Adulto , Viroses do Sistema Nervoso Central/tratamento farmacológico , Viroses do Sistema Nervoso Central/etiologia , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Catar/epidemiologia , Estudos Retrospectivos , Adulto JovemRESUMO
Phytochemical investigation of Gomphocarpus fruticosus (L.) Ait. of Egyptian origin afforded the new pregnane glycoside lineolon-3-O-[ß-D-oleandropyranosyl-(1-4)-ß-D-cymaropyranosyl-(1-4)-ß-D-cymaropyranoside], along with six known compounds. The structures of the isolated compounds were elucidated on the basis of extensive spectroscopic evidences derived from 1D, 2D NMR experiments, mass spectrometry and by comparing their physical and spectroscopic data to literature. These included the triterpenoids 3ß-taraxerol, 3ß-taraxerol acetate and betulinic acid, which are identified for the first time in G. fruticosus and the cardenolides uzarigenin, gomphoside and calotropin.