Early clinical outcomes of two regimens of prophylactic antibiotics in cardiac surgical patients with delayed sternal closure

BACKGROUND Delayed sternal closure(DSC)can be a lifesaving approach for certain patients who have undergone cardiac surgery.The value of the type of prophylactic antibiotics in DSC is still debatable.AIM To investigate clinical outcomes of different prophylactic antibiotic regimens in patients who had DSC after cardiac surgery.METHODS This was a retrospective observational single-center study.Fifty-three consecutive patients who underwent cardiac surgery and had an indication for DSC were included.Patients were subjected to two regimens of antibiotics:Narrow-spectrum and broad-spectrum regimens.RESULTS The main outcome measures were length of hospital and intensive care unit(ICU)stay,duration of mechanical ventilation,and mortality.Of the 53 patients,12(22.6%)received narrow-spectrum antibiotics,and 41(77.4%)received broad-spectrum antibiotics.The mean age was 59.0±12.1 years,without significant differences between the groups.The mean duration of antibiotic use was significantly longer in the broad-spectrum than the narrowspectrum group(11.9±8.7 vs 3.4±2.0 d,P<0.001).The median duration of open chest was 3.0(2.0-5.0)d for all patients,with no difference between groups(P=0.146).The median duration of mechanical ventilation was significantly longer in the broad-spectrum group[60.0(Δinterquartile range(IQR)170.0)h vs 50.0(ΔIQR 113.0)h,P=0.047].Similarly,the median length of stay for both ICU and hospital were significantly longer in the broadspectrum group[7.5(ΔIQR 10.0)d vs 5.0(ΔIQR 5.0)d,P=0.008]and[27.0(ΔIQR 30.0)d vs 19.0(ΔIQR 21.0)d,P=0.031].Five(9.8%)patients were readmitted to the ICU and 18(34.6%)patients died without a difference between groups.CONCLUSION Prophylactic broad-spectrum antibiotics did not improve clinical outcomes in patients with DSC post-cardiac surgery but was associated with longer ventilation duration,length of ICU and hospital stays vs narrow-spectrum antibiotics.

Gastrointestinal Behcet's disease:A review

Beh?et's disease(BD) is an idiopathic, chronic, relapsing, multi-systemic vasculitis characterized by recurrent oral and genital aphthous ulcers, ocular disease and skin lesions. Prevalence of BD is highest in countries along the ancient silk road from the Mediterranean basin to East Asia. By comparison, the prevalence in North American and Northern European countries is low. Gastrointestinal manifestations of Beh?et's disease are of particular importance as they are associated with significant morbidity and mortality. Although ileocecal involvement is most commonly described, BD may involve any segment of the intestinal tract as well as the various organs within the gastrointestinal system. Diagnosis is based on clinical criteria- there are no pathognomonic laboratory tests. Methods for monitoring disease activity on therapy are available but imperfect. Evidence-based treatment strategies are lacking. Different classes of medications have been successfully used for the treatment of intestinal BD which include 5-aminosalicylic acid, corticosteroids, immunomodulators, and anti-tumor necrosis factor alpha monoclonal antibody therapy. Like inflammatory bowel disease, surgery is reserved for those who are resistant to medical therapy. A subset of patients have a poor disease course. Accurate methods to detect these patients and the optimal strategy for their treatment are not known at this time.

Microalbuminuria in hepatitis C-genotype 4:Effect of pegylated interferon and ribavirin

AIM:To study the relation between hepatitis C virus (HCV) genotype 4 and microalbuminuria and renal impairment in relation to hepatic histology, and viremia in the absence of cryoglobulinemia, and to examine the effect of treatment on microalbuminuria.METHODS: Three hundred subjects, including 233 HCV genotype-4 infected patients, were tested for cryoglobulinemia, microalbuminuria, albumin creatinine ratio (ACR), urea, creatinine, and estimated glomerular filtration rate (eGFR). The parameters were measured again in the HCV patients after 48 wk of treatment with pegylated interferon and ribavirin.RESULTS: Significantly higher levels of microalbumin- uria were detected in HCV-positive patients compared to HCV-negative controls (median 9.5 vs 5.9, respectively, Kruskal-Wallis P=0.017). Log microalbuminuria was significantly correlated with hepatic inflammation (r=0.13, P=0.036) and f ibrosis (r=0.12, P=0.061), but not with viral load (r=-0.03, P=0.610), or alanine transaminase (r=-0.03, P=0.617). Diabetes mellitus neither significantly moderated (χ2=0.13, P=0.720), nor mediated (Sobel test P=0.49) the HCV effect. HCV status was signifi cantly associated with log microalbu-minuria (χ2=4.97, P=0.026), adjusting for age, gender, diabetes, cryoglobulinemia, urea and creatinine. A positive HCV status was not significantly associated with low eGFR (<60 mL/min every 1.73 m2) [odds ratio (OR): 0.5, 95% confidence interval (CI):0.2-1.4], nor with high ACR (OR: 1.7, 95% CI:0.7-4.1). End-of-treatment response (ETR) was achieved in 51.9% of patients. Individuals with ETR had significantly lower microalbuminuria post-treatment (χ2=8.19, P=0.004).CONCLUSION: HCV affected the development of microalbuminuria independent of diabetes or cryoglobulinemia. Combination therapy of pegylated interferon-ribavirin had a positive effect in reducing microalbuminuria.

Temporal Epilepsy Causing Recurrent Abdominal Pain in Adults

Abdominal epilepsy is often unrecognised as an epilepsy condition, particularly in adults. We present a rare adult patient who suffers daily episodes of abdominal pinching pain described lasting for 30 seconds, often evolving to loss of consciousness. Scalp EEG-video monitoring showed interictal left temporal slowing and frequent left temporal epileptiform discharges. Three stereotypical complex partial seizures consistent with her habitual attacks were recorded. Two seizures showed a left temporal onset and whereas the third one appeared to start on the right temporal lobe. In patients with paroxysms of abdominal pain, nausea or vomiting, abdominal epilepsy should be considered after exclusion of the most common aetiologies for gastrointestinal conditions.

Medical Management of Gestational Diabetes

Gestational diabetes (GDM) is defined as carbohydrate intolerance that begins or is first recognized during pregnancy. The prevalence of GDM is on the rise due to increasing trends of obesity in females of child bearing age as well as due to increasing maternal age. Women at higher risk should be routinely screened of the condition and offered appropriate management in order to avoid fetal and maternal complications. GDM is associated with higher incidence of maternal and fetal complications during pregnancy and labour. There is a significant relationship between GDM and prediabetic states as well as high risk of developing type 2 diabetes mellitus. The aim of management is to keep glycaemic levels within specific targets to avoid adverse outcomes. Improved health related quality of life has been linked with treatment of gestational diabetes with active lifestyle, glucose monitoring and use of insulin. Historically, non pharmacological intervention and insulin have been the main approaches in management of GDM, though recently there is an emerging evidence of use of oral hypoglycemic agents. In this article we have reviewed the existing evidence and recommendations in management of GDM.

Low dose corticosteroids in COVID-19 with refractory shock:We are not sure?

Low dose corticosteroids to adult patients with coronavirus disease 2019(COVID-19)and refractory shock was given some evidence,the evidence was of low quality given particularly for shock-reversal.Evidence.However bacterial sepsis may not provide a similar evidence like in a viral related one.We think that suggesting steroids for COVID-19 may not be adequate in the current time and future data analysis should be directed to find possible evidence in a matched population.

Intensive care outcome of left main stem disease surgery: A single center three years’ experience

BACKGROUND Left main coronary artery(LMCA)supplies more than 80%of the left ventricle,and significant disease of this artery carries a high mortality unless intervened surgically.However,the influence of coronary artery bypass grafting(CABG)surgery on patients with LMCA disease on morbidity intensive care unit(ICU)outcomes needs to be explored.However,the impact of CABG surgery on the morbidity of the ICU population with LMCA disease is worth exploring.AIM To determine whether LMCA disease is a definitive risk factor of prolonged ICU stay as a primary outcome and early morbidity within the ICU stay as secondary outcome.METHODS Retrospective descriptive study with purposive sampling analyzing 399 patients who underwent isolated urgent or elective CABG.Patients were divided into 2 groups;those with LMCA disease as group 1(75 patients)and those without LMCA disease as group 2(324 patients).We correlated ICU outcome parameters including ICU length of stay,post-operative atrial fibrillation,acute kidney injury,re-exploration,perioperative myocardial infarction,post-operative bleeding in both groups.RESULTS Patients with LMCA disease had a significantly higher prevalence of diabetes(43.3%vs 29%,P=0.001).However,we did not find a statistically significant difference with regards to ICU stay,or other morbidity and mortality outcome measures.CONCLUSION Post-operative performance of Patients with LMCA disease who underwent CABG were comparable to those without LMCA involvement.Diabetes was more prevalent in patients with LMCA disease.These findings may help in guiding decision making for future practice and stratifying the patients’care.

传统阿拉伯与伊斯兰医药:卡塔尔概念模型的验证和经验评估

目的:探讨传统阿拉伯与伊斯兰医药(TAIM)模型的构建,并分析其适用性。方法:从人种学角度,招募了84名卡塔尔居民(43名女性和41名男性)为志愿者,均会使用卡塔尔四种常见语言阿拉伯语、英语、印地语和乌尔都语中的一种。通过深入访谈,确认模型的组成部分,即健康实践、信念和哲学、诊断和预防疾病、保持健康及对抗疗法。结果:传统阿拉伯与伊斯兰医药模型中主要元素包括了草药、精神疗法、饮食干预、身心疗法和人工技巧等,可单独使用或结合使用。结论:证实了传统阿拉伯与伊斯兰医药模型的实证基础,常见的3种为精神疗法、草药和饮食疗法。

Idiopathic cystic artery aneurysm complicated with hemobilia and acute pancreatitis

BACKGROUND:Aneurysm of the cystic artery is no common,and it is a rare cause of hemobilia.Most o reported cases are pseudoaneurysms resulting from eithe an inflammatory process in the abdomen or abdomina trauma. METHOD:We report a healthy individual who developed hemobilia and acute pancreatitis associated with cysti artery aneurysm. RESULT:The patient was managed with angio-embolization with an uneventful post-embolization course. CONCLUSIONS:Visceral artery aneurysms are rare and can rupture with potentially grave outcome due to excessive bleeding.Angiographic embolization as a common method of treatment for visceral artery aneurysms was used in ou patient with good outcome.

Endotracheal tube exchange and pneumothorax: A case report

Endotracheal intubation and extubation in intensive care unit (ICU) patients are difficult. Extubation will be more worrisome if patient has difficult intubation, sleep apnea, surgical procedure involving airway or surrounding structures. In such extubation airway exchange catheters (AEC) are used, as they are simple to use and able to provide oxygen to the patient. Rarely AEC use can cause potential life threatening complications. We report a case of pneumothorax following use of AEC in post-thyroidectomy patient. Case: A 32 years old male patient was admitted to our ICU, with difficult intubation after thyroidectomy. He was a known case of obtructive sleep apnea, hypertension and large goiter. In ICU for proper visualization of vocal cords and resecuring the airway, AEC was used, but patient had hypoxia with bradycardia. He was recovered with Ambu bag ventilation and required brief cardiopulmonary resuscitation. Post resuscitation he had left impending tension pneumothorax and lung laceration requiring chest drain, which was removed after tracheostomy and weaned from the ventilator. After 9 days supra glottic edema subsided and vocal cords were moving;His trachea was decanulated and he was discharged home. Conclusion: Rarely AEC use can cause life threatening injuries. Pneumothorax following the use of AEC is not always due to tracheobronchial injury;it can also occur as a result of alveolar injury.

Staying psychologically safe as a doctor during the COVID-19 pandemic

INTRODUCTION As we face the ongoing global pandemic of COVID-19,doctors,nurses,ambulance officers,paramedics and many other health workers answer the call to serve in time-pressured,unfamiliar,chaotic and often-traumatic environments.1 We know how to look after ourselves in an infectious physical environment,but it is equally important to look after ourselves psychologically at this time.