Pelvic fractures in blunt trauma patients:A comparative study

BACKGROUND Pelvic fractures(PF)with concomitant injuries are on the rise due to an increase of high-energy trauma.Increase of the elderly population with age related comorbidities further complicates the management.Abdominal organ injuries are kindred with PF due to the proximity to pelvic bones.Presence of contrast blush(CB)on computed tomography in patients with PF is considered a sign of active bleeding,however,its clinical significance and association with outcomes is debatable.AIM To analyze polytrauma patients with PF with a focus on the geriatric population,co-injuries and the value of contrast blush.METHODS This retrospective cohort study included 558 patients with PF admitted to level 1 trauma center(01/2017-01/2023).Analyzed variables included:Age,sex,mechanism of injury(MOI),injury severity score(ISS),Glasgow coma scale(GCS),abbreviated injury scale(AIS),co-injuries,transfusion requirements,pelvic angiography,embolization,laparotomy,orthopedic pelvic surgery,intensive care unit and hospital lengths of stay,discharge disposition and mortality.The study compared geriatric and non-geriatric patients,patients with and without CB and abdominal co-injuries.Propensity score matching was implemented in comparison groups.RESULTS PF comprised 4%of all trauma admissions.89 patients had CB.286(52%)patients had concomitant injuries including 93(17%)patients with abdominal co-injuries.Geriatric patients compared to non-geriatric had more falls as MOI,lower ISS and AIS pelvis,higher GCS,less abdominal co-injuries,similar CB and angio-embolization rates,less orthopedic pelvic surgeries,shorter lengths of stay and higher mortality.After propensity matching,orthopedic pelvic surgery rates remained lower(8%vs 19%,P<0.001),hospital length of stay shorter,and mortality higher(13%vs 4%,P<0.001)in geriatric patients.Out of 89 patients with CB,45(51%)were embolized.After propensity matching,patients with CB compared to without CB had more pelvic angiography(71%vs 12%,P<0.001),higher embolization rates(64%vs 22%,P=0.02)and comparable mortality.CONCLUSION Half of the patients with PF had concomitant co-injuries,including abdominal co-injuries in 17%.Similarly injured geriatric patients had higher mortality.Half of the patients with CB required an embolization.

Major liver resections,perioperative issues and posthepatectomy liver failure:A comprehensive update for the anesthesiologist

Significant advances in surgical techniques and relevant medium-and long-term outcomes over the past two decades have led to a substantial expansion in the indications for major liver resections.To support these outstanding results and to reduce perioperative complications,anesthesiologists must address and master key perioperative issues(preoperative assessment,proactive intraoperative anesthesia strategies,and implementation of the Enhanced Recovery After Surgery approach).Intensive care unit monitoring immediately following liver surgery remains a subject of active and often unresolved debate.Among postoperative complications,posthepatectomy liver failure(PHLF)occurs in different grades of severity(A-C)and frequency(9%-30%),and it is the main cause of 90-d postoperative mortality.PHLF,recently redefined with pragmatic clinical criteria and perioperative scores,can be predicted,prevented,or anticipated.This review highlights:(1)The systemic consequences of surgical manipulations anesthesiologistsmust respond to or prevent,to positively impact PHLF(a proactive approach);and(2)the maximal intensivetreatment of PHLF,including artificial options,mainly based,so far,on Acute Liver Failure treatment(s),to buytime waiting for the recovery of the native liver or,when appropriate and in very selected cases,toward livertransplant.Such a clinical context requires a strong commitment to surgeons,anesthesiologists,and intensivists towork together,for a fruitful collaboration in a mandatory clinical continuum.

Validating a point of care lactate meter in adult patients with sepsis presenting to the emergency department of a tertiary care hospital of a low-to middle-income country

BACKGROUND: Timely identifi cation of high blood lactate levels in septic patients may allow faster detection of those patients requiring immediate resuscitation. Point-of-care(POC) testing is being increasingly utilized in the emergency department(ED). We examined the accuracy and timesaving effect of a handheld POC lactate device for the measurement of fingertip and whole blood lactate as compared with reference laboratory blood testing in septic ED patients.METHODS: A convenience sample of adult ED patients receiving serum lactate testing were enrolled prospectively in the ED of a multidisciplinary tertiary care hospital serving the population of one of the major cities of Pakistan. Participants underwent fi ngertip POC lactate measurement with a portable device and simultaneous whole blood sampling for analysis by both the POC lactate device and standard laboratory method. Lactate measurements were compared by intraclass correlation(ICC) and Bland and Altman plots.RESULTS: Forty-three septic patients were included in the study. The fingertip POC & whole blood POC lactate measurements each correlated tightly with the reference method(ICC=0.93 & ICC=0.92, respectively). Similarly at 6 hours, the fingertip POC & whole blood POC lactate measurements demonstrated satisfactory correlation with the reference method(ICC=0.95 & ICC=0.97, respectively).CONCLUSION: Fingertip POC lactate measurement is an accurate method to determine lactate levels in septic ED patients.KEY WORDS: Sepsis; Point of care; Lactate; Emergency department;

Gastrointestinal stress ulcer prophylaxis in the intensive care unit,where is the data?

Stress-induced gastrointestinal ulcers are common among patients admitted to the intensive care unit(ICU).These ulcers impose significant morbidity and mortality,therefore,stress ulcer prophylaxis(SUP) is a common clinical practice among healthcare providers dealing with these critically-ill patients.Several strategies for SUP have been suggested over the past four decades,with acid suppressive therapies being the most commonly used in the ICU.Whether SUP is effective and safe,or not,remains a topic of controversy.The data is still conflicting,and provision of a simple answer is not feasible at the present time.Recently,a large phase IV,multicenter,randomized clinical trial(SUP-ICU),negated the benefits(and harms) of proton pump inhibitors as SUP.This article reviews some of these controversies.

Glucocorticoid and mineralocorticoid receptor expression in critical illness:A narrative review

The glucocorticoid receptor(GCR)and the mineralocorticoid receptor(MR)are members of the steroid receptor superfamily of hormone-dependent transcription factors.The receptors are structurally and functionally related.They are localized in the cytosol and translocate into the nucleus after ligand binding.GCRs and MRs can be co-expressed within the same cell,and it is believed that the balance in GCR and MR expression is crucial for homeostasis and plays a key role in normal adaptation.In critical illness,the hypothalamic-pituitary-adrenal axis is activated,and as a consequence,serum cortisol concentrations are high.However,a number of patients exhibit relatively low cortisol levels for the degree of illness severity.Glucocorticoid(GC)actions are facilitated by GCR,whose dysfunction leads to GC tissue resistance.The MR is unique in this family in that it binds to both aldosterone and cortisol.Endogenous GCs play a critical role in controlling inflammatory responses in critical illness.Intracellular GC concentrations can differ greatly from blood levels due to the action of the two 11β-hydroxysteroid dehydrogenase isozymes,type 1 and type 2.11β-hydroxysteroid dehydrogenases interconvert endogenous active cortisol and intrinsically inert cortisone.The degree of expression of the two isozymes has the potential to dramatically influence local GC availability within cells and tissues.In this review,we will explore the clinical studies that aimed to elucidate the role of MR and GCR expression in the inflammatory response seen in critical illness.

Two surgical pathways for isolated hip fractures:A comparative study

BACKGROUND Hip fractures(HF)are common among the aging population,and surgery within 48 h is recommended.Patients can be hospitalized for surgery through different pathways,either trauma or medicine admitting services.AIM To compare management and outcomes among patients admitted through the trauma pathway(TP)vs medical pathway(MP).METHODS This Institutional Review Board-approved retrospective study included 2094 patients with proximal femur fractures(AO/Orthopedic Trauma Association Type 31)who underwent surgery at a level 1 trauma center between 2016-2021.There were 69 patients admitted through the TP and 2025 admitted through the MP.To ensure comparability between groups,66 of the 2025 MP patients were propensity matched to 66 TP patients by age,sex,HF type,HF surgery,and American Society of Anesthesiology score.The statistical analyses included multivariable analysis,group characteristics,and bivariate correlation comparisons with theχ^(2)test and t-test.RESULTS After propensity matching,the mean age in both groups was 75-years-old,62%of both groups were females,the main HF type was intertrochanteric(TP 52%vs MP 62%),open reduction internal fixation was the most common surgery(TP 68%vs MP 71%),and the mean American Society of Anesthesiology score was 2.8 for TP and 2.7 for MP.The majority of patients in TP and MP(71%vs 74%)were geriatric(≥65-years-old).Falls were the main mechanism of injury in both groups(77%vs 97%,P=0.001).There were no significant differences in pre-surgery anticoagulation use(49%vs 41%),admission day of the week,or insurance status.The incidence of comorbidities was equal(94%for both)with cardiac comorbidities being dominant in both groups(71%vs 73%).The number of preoperative consultations was similar for TP and MP,with the most common consultation being cardiology in both(44%and 36%).HF displacement occurred more among TP patients(76%vs 39%,P=0.000).Time to surgery was not statistically different(23 h in both),but length of surgery was significantly longer for TP(59 min vs 41 min,P=0.000).Intensive care unit and hospital length of stay were not statistically different(5 d vs 8 d and 6 d for both).There were no statistical differences in discharge disposition and mortality(3%vs 0%).CONCLUSION There were no differences in outcomes of surgeries between admission through TP vs MP.The focus should be on the patient’s health condition and on prompt surgical intervention.

Management of hypertensive crises in the elderly

高血压的危机比 180/120 mmHg 高是血压的举起。这些能迫切或突现，取决于结束机关损坏的存在。高血压的危机的临床的演讲在老病人是相当可变的，并且临床医生们必须怀疑非特定的症状。在 pathophysiological 的过细的知识在他们改变的老病人需要的设法的高血压的危机，药理学选择，使用的药的 pharmacokinetics，他们的副作用，和他们和另外的药的相互作用。Clevidipine， nicardipine， labetalol， esmolol，和 fenoldopam 在比较喜欢的选择在之中由于他们的功效和 tolerability 老。除非没有可得到的另外的选择， Nitroprusside， hydralazine，和 nifedipine 应该被避免，由于复杂并发症和无法预言的回答的高风险。

Novel pharmacological therapy in type 2 diabetes mellitus with established cardiovascular disease: Current evidence

Cardiovascular diseases(CVDs) remain the leading cause of death in the world and in most developed countries. Patients with type 2 diabetes mellitus(T2DM)suffer from both microvascular and macrovascular diseases and therefore have higher rates of morbidity and mortality compared to those without T2DM. If current trends continue, the Center for Disease Control and Prevention estimates that 1 in 3 Americans will have T2DM by year 2050. As a consequence of the controversy surrounding rosiglitazone and the increasing prevalence of diabetes and CVDs, in 2008 the Food and Drug Administration(FDA) established new expectations for the evaluation of new antidiabetic agents, advising for pre and,in some cases, post-marketing data on major cardiovascular events. As a direct consequence, there has been a paradigm shift in new antidiabetic agents that has given birth to the recently published American Diabetes Association/European Association for the Study of Diabetes consensus statement recommending sodium-glucose cotransporter-2 inhibitors(SGLT2i) and glucagon like peptide-1 receptor agonists(GLP-1RA) in patients with T2DM and established CVD. As a result of over a decade of randomized placebo controlled cardiovascular outcome trials, the aforementioned drugs have received FDA approval for risk reduction of cardiovascular(CV) events in patients with T2DM and established CV disease.SGLT2i have been shown to have a stronger benefit in patients with congestiveheart failure and diabetic kidney disease when compared to their GLP-1RA counterparts. These benefits are not withstanding additional considerations such as cost and the multiple FDA Black Box warnings. This topic is currently an emerging research area and this mini-review paper examines the role of these two novel classes of drugs in patients with T2DM with both confirmed, and at risk for, CVD.

Asymptomatic bacteriuria among hospitalized diabetic patients:Should they be treated?

Diabetes Mellitus is a significant health care challenge in the United States.The Center for Disease Control and Prevention estimates approximately 9.4%of patients in the United States are afflicted by diabetes.The Infectious Disease Society of America asymptomatic bacteriuria in women as two consecutive cleancatch voided urine specimens with isolation of the same bacterial strain in counts≥105 cfu/mL It is understood that diabetic patients tend to be at higher risk for infections than non-diabetics.Urinary tract infections(UTIs)tend to be the most common infection contracted by this population.UTIs are not only a significant cause of morbidity and mortality,they are also a significant financial burden.The data are conflicting,in regard to treating asymptomatic bacteriuria in diabetic patients to avoid hospital complications and ultimately decrease healthcare costs associated with these complications.However,clinicians continue to prescribe antibiotics empirically.Further randomized controlled study looking into the specific population as immunocompromised diabetic patients,patient with diabetic ketoacidosis and patient in intensive care unit needs to be undertaken.

Role of vitamin C in diabetic ketoacidosis:Is it ready for prime time?

Diabetic ketoacidosis(DKA) is life-threatening acute metabolic complication of diabetes mellitus(DM) that is characterized by acidosis, ketosis, and hyperglycemia, currently affecting mostly patients under 30 years of age with diabetes mellitus type 1. In both, DM and DKA, a pro-inflammatory state exists. This clinical entity occurs as a result of hyperglycemia-induced disturbances, resulting in an increased oxidative metabolism. For the latter reason, the use of vitamin C seems promising in DKA due to its antioxidant role in reducing the superoxide radicals that are consequence of the oxidative stress. This can decrease the proinflammatory state and avoids complications. Vitamin C, or also known as ascorbic acid, has been widely used in several illnesses, such as common cold, tissue healing, fertility, atherosclerosis, cancer prevention, immunity restoration, neuro-degenerative disease and also has been suggested to decrease the risk of DM, and this reason is giving place to believe that vitamin C can have an important role in treating diabetic complications such as DKA. In order to counteract these oxidative disturbances in DKA patients, we analyzed the current data regarding vitamin C and evaluate its role in any type treatment of this complication in the near future.

Cystic fibrosis-related diabetes:The unmet need

Cystic fibrosis(CF)is a common autosomal recessive disease.Life expectancy of patients with CF continues to improve mainly driven by the evolving therapies for CF-related organ dysfunction.The prevalence of CF-related diabetes(CFRD)increases exponentially as patients’age.Clinical care guidelines for CFRD from 2010,recommend insulin as the mainstay of treatment.Many patients with CFRD may not require exogenous insulin due to the heterogeneity of this clinical entity.Maintenance of euglycemia by enhancing endogenous insulin production,secretion and degradation with novel pharmacological therapies like glucagonlike peptide-1 agonist is an option that remains to be fully explored.As such,the scope of this article will focus on our perspective of glucagon-like peptide-1 receptor agonist in the context of CFRD.Other potential options such as sodiumglucose cotransporter-2 and dipeptidyl peptidase 4 inhibitors and their impact on this patient population is limited and further studies are required.

Donor preoperative oxygen delivery and post-extubation hypoxia impact donation after circulatory death hypoxic cholangiopathy

AIM: To evaluate donation after circulatory death(DCD) orthotopic liver transplant outcomes [hypoxic cholangiopathy(HC) and patient/graft survival] and donor risk-conditions.METHODS: From 2003-2013, 45 DCD donor transplants were performed. Predonation physiologic data from UNOS Donor Net included preoperative systolic and diastolic blood pressure, heart rate, p H, SpO_2, PaO_2, FiO_2, and hemoglobin. Mean arterial bloodpressure was computed from the systolic and diastolic blood pressures. Donor preoperative arterial O_2 content was computed as [hemoglobin(gm/d L) × 1.37(m L O_2/gm) × SpO_2%) +(0.003 × PaO_2)]. The amount of preoperative donor red blood cell transfusions given and vasopressor use during the intensive care unit stay were documented. Donors who were transfused ≥ 1 unit of red-cells or received ≥ 2 vasopressors in the preoperative period were categorized as the red-cell/multi-pressor group. Following withdrawal of life support, donor ischemia time was computed as the number-of-minutes from onset of diastolic blood pressure < 60 mm Hg until aortic cross clamping. Donor hypoxemia time was the number-of-minutes from onset of pulse oximetry < 80% until clamping. Donor hypoxia score was(ischemia time + hypoxemia time) ÷ donor preoperative hemoglobin.RESULTS: The 1, 3, and 5 year graft and patient survival rates were 83%, 77%, 60%; and 92%, 84%, and 72%, respectively. HC occurred in 49% with 16% requiring retransplant. HC occurred in donors with increased age(33.0 ± 10.6 years vs 25.6 ± 8.4 years, P = 0.014), less preoperative multiple vasopressors or red-cell transfusion(9.5% vs 54.6%, P = 0.002), lower preoperative hemoglobin(10.7 ± 2.2 gm/d L vs 12.3 ± 2.1 gm/d L, P = 0.017), lower preoperative arterial oxygen content(14.8 ± 2.8 m L O_2/100 m L blood vs 16.8 ± 3.3 m L O_2/100 m L blood, P = 0.049), greater hypoxia score >2.0(69.6% vs 25.0%, P = 0.006), and increased preoperative mean arterial pressure(92.7 ± 16.2 mm Hg vs 83.8 ± 18.5 mm Hg, P = 0.10). HC was independently associated with age, multi-pressor/redcell transfusion status, arterial oxygen content, hypoxia score, and mean arterial pressure(r^2 = 0.6197). The transplantation rate was greater for the later period with more liberal donor selection [era 2(7.1/year)], compared to our early experience [era 1(2.5/year)]. HC occurred in 63.0% during era 2 and in 29.4% during era 1(P = 0.03). Era 2 donors had longer times for extubation-to-asystole(14.4 ± 4.7 m vs 9.3 ± 4.5 m, P = 0.001), ischemia(13.9 ± 5.9 m vs 9.7 ± 5.6 m, P = 0.03), and hypoxemia(16.0 ± 5.1 m vs 11.1 ± 6.7 m, P = 0.013) and a higher hypoxia score > 2.0 rate(73.1% vs 28.6%, P = 0.006).CONCLUSION: Easily measured donor indices, including a hypoxia score, provide an objective measure of DCD liver transplantation risk for recipient HC. Donor selection criteria influence HC rates.

Community emergency medicine:Benefits and challenges of screening for elder abuse in the emergency department of a developing country

As people live longer and fewer babies are born,the elderly became the fastest and largest growing population of the world,expected to increase further from 86 million in 2005 to 394 million in 2050 worldwide.Older patients represent a large bulk of the population arriving in emergency departments(EDs)all over the world.^([1])They use hospitals more frequently than younger patients。