Intensive Medical Treatment Research Articles

Surgical versus medical treatment for children with epileptic encephalopathy in infancy and early childhood: Results of an international multicenter cohort study in Far-East Asia (the FACE study)

To compare the seizure and developmental outcomes in infants and young children with epileptic encephalopathy who have undergone surgical and medical treatments. An international, multicenter, observational cohort study was undertaken. A total of 317 children aged <6 years, who had frequent disabling seizures despite intensive medical treatments, were registered. Among the enrolled children, 250 were treated medically (medical group), 31 underwent resective surgery (resective group), and 36 underwent palliative surgery [callosotomy (n=30) or vagal nerve stimulation (n=6); palliative group] on admission. Seizure and developmental outcomes were obtained for 230 children during the 3-year follow-up period. Cox proportional hazard model was used to adjust for clinical backgrounds among treatment groups when comparing the seizure-free survival rates. At the 3-year follow-up, seizure-free survival was 15.7%, 32.1%, and 52.4% in the medical, palliative, and resective groups, respectively. The adjusted hazard ratios for seizure recurrence in the resective and palliative groups versus the medical group were 0.43 (95% CI, 0.21-0.87, P=0.019) and 0.82 (95% CI, 0.46-1.46, P=0.50), respectively; the former was statistically significant. Regarding the developmental outcome, the mean DQs in the resective group increased significantly compared to those in the medical group during the follow-up (P<0.01). As for subgroup analysis, better seizure and development outcomes were demonstrated in the resective group compared to the medical group in children with nonsyndromic epilepsies (those to which no known epilepsy syndromes were applicable). These results suggest that surgical treatments, particularly resective surgeries, are associated with better seizure and developmental outcomes compared with successive medical treatment. The present observations may facilitate the identification of infants and young children with epileptic encephalopathy who could benefit from surgery.

Understanding Acute Liver Failure– A Basic Overview of Definition and Treatment

Acute liver failure is a rare but fatal condition characterized by rapid deterioration of liver function resulting in coagulopathy and altered mentation in patients without known liver disease. The three most common causes of liver failure in Korea are hepatitis B virus, exposure to certain herbs, and hepatitis A virus. Because the cause of liver failure is the most important prognostic factor, the etiology of liver failure should be evaluated as the initial step in the assessment of affected patients. Patients with acute liver failure should be intensively monitored and treated for various secondary conditions that may occur or have already developed, including cerebral edema, seizures, hemodynamic instability, renal failure, infection, bleeding, and metabolic disturbances. Although treatment with N acetylcysteine has shown a survival benefit in patients with mild hepatic encephalopathy, the overall mortality rate associated with acute liver failure is high unless patients undergo liver transplantation, prompting patients and physicians to be prepared for transplantation. Therefore, patients who are suspected to have, or who have been diagnosed with, acute liver failure should be transferred to a transplant facility and be prepared for liver transplantation while they undergo intensive monitoring and medical treatment. Keywords: Liver failure, Acute; Diagnosis; Therapy 중심 단어: 급성 ê°„ë¶€ì „; 진단; 치료

Abstract 19403: Deterioration of Cardiac Performance and Dysfunction of Sympathetic Activity Affects Respiratory Instability in Chronic Heart Failure: Non-invasive and Simple Quantitative Assessment of Respiratory Stability

Background: Cardiac sympathetic activity, in general assessed by 123I-meta-iodobenzylguanidine cardiac scintigraphy (mIBG-s), has been shown to be a critical indicator to predict morbidity and mortality associated with chronic heart failure (HF). We herein hypothesized that nocturnal respiratory stability, which has been suggested to be impaired by autonomic dysfunction, may be correlated with sympathetic nerve activity in advanced HF. To test this hypothesis, we developed respiratory stability index (RSI), which is calculated by computer-based non-invasive measurements. Methods: Fifteen patients with chronic HF under intensive medical treatments including maximized beta-blocker therapy were enrolled. All patients echocardiographically displayed their ejection fraction (EF) less than 35%. Nocturnal respiratory signals were serially collected by the under-pillow sensor to evaluate the respiratory spectrum during asleep. RSI was calculated from average of the reciprocal of the standard deviation of respiratory spectral ranges (Figure). Results: RSI was successfully and reproducibly evaluated in all cohorts with an average value being 44±21. mIBG-s-based values to indicate sympathetic activity, such as heart-to-mediastinum ratio (HMR) or wash-out rate, showed abnormality in all cohorts. Of note, the RSI was strongly correlated with HMR (ρ=0.83, p&lt;0.01) or wash-out rate (ρ=-0.87, p&lt;0.01). In addition, RSI was significantly correlated with standard indicator of HF such as plasma brain natriuretic peptide level (ρ=-0.59, p&lt;0.05), EF (ρ=0.73, p&lt;0.05) or pulmonary capillary wedge pressure assessed by right heart catheter study (ρ=-0.70, p&lt;0.05). Conclusions: RSI showed a significant correlation with degree of autonomic dysfunction assessed by mIBG-s in advanced HF of chronic stage. This non-invasive method might enable serial evaluation to predict cardiac events even in patients on home healthcare, though further validation is required.

Cost trajectories from the final life year reveal intensity of end-of-life care and can help to guide palliative care interventions

ObjectiveExploration of healthcare utilisation patterns in the final life year to assess palliative care potential.MethodsRetrospective cluster analyses (k-means) of anonymised healthcare expenditure (HCE) trajectories, derived from health insurance claims of...

Prospective study of the primary evaluation of 1016 horses with clinical signs of abdominal pain by veterinary practitioners, and the differentiation of critical and non-critical cases.

BackgroundThe majority of research on the evaluation of horses with colic is focused on referral hospital populations. Early identification of critical cases is important to optimise outcome and welfare. The aim of this prospective study was to survey the primary evaluation of horses with clinical signs of abdominal pain by veterinary practitioners, and compare the initial presentation of critical and non-critical cases.ResultsData from 1016 primary evaluations of horses presenting with clinical signs of colic were submitted by 167 veterinary practitioners across the United Kingdom over a 13 month period. The mean age of the study population was 13.5 years (median 12.0, range 0–42). Mean heart rate on primary presentation was 47 beats/min (median 44, range 18–125), mean respiratory rate was 20 breaths/min (median 16, range 6–100), and median gastrointestinal auscultation score (0–12, minimum–maximum) was 5 (range 0–12). Clinical signs assessed using a behavioural severity score (0–17, minimum–maximum), were between 0 and 6 in 70.4 % of cases, and 7–12 for 29.6 % of cases. Rectal examination was performed in 73.8 % of cases. Cases that responded positively to simple medical treatment were categorised retrospectively as ‘non-critical’; cases that required intensive medical treatment, surgical intervention, died or were euthanased were categorised as ‘critical’. Eight-hundred-and-twenty-two cases met these criteria; 76.4 % were ‘non-critical’ and 23.6 % were ‘critical’. Multivariable logistic regression was used to identify features of the clinical presentation associated with critical cases. Five variables were retained in the final multivariable model: combined pain score: (OR 1.19, P < 0.001, 95 % CI 1.09–1.30), heart rate (OR 1.06, P < 0.001, 95 % CI 1.04–1.08), capillary refill time >2.5 s (OR 3.21, P = 0.046, 95 % CI 1.023–10.09), weak pulse character (OR 2.90, P = 0.004, 95 % CI 1.39–5.99) and absence of gut sounds in ≥1 quadrant (OR 3.65, P < 0.001, 95 % CI 2.08–6.41).ConclusionsThis is the first study comparing the primary presentation of critical and non-critical cases of abdominal pain. Pain, heart rate, gastrointestinal borborygmi and simple indicators of hypovolaemia were significant indicators of critical cases, even at the primary veterinary examination, and should be considered essential components of the initial assessment and triage of horses presenting with colic.Electronic supplementary materialThe online version of this article (doi:10.1186/s13028-015-0160-9) contains supplementary material, which is available to authorized users.

Hyponatremia and perioperative complications in patients with head and neck squamous cell carcinoma.

Recent studies suggest that hyponatremia is associated with perioperative morbidity and mortality after general surgical procedures, as well as mortality among medical inpatients. We investigated the association of hyponatremia with perioperative complications in patients undergoing surgical resection of head and neck squamous cell carcinoma (HNSCC). All patients with pathologically confirmed HNSCC undergoing either primary or salvage surgical resection from March 1, 2013, until May 31, 2014, at a single tertiary care academic center were included in this retrospective review. The primary outcome was 30-day mortality. Secondary outcomes included postoperative complications (respiratory, cardiac, renal, and wound), hospital and intensive care unit (ICU) length of stay, and need for blood transfusion. Two hundred fourteen surgical patients with HNSCC were identified for analysis. Patient ages ranged from 22 to 100 years (mean, 67 years). One hundred thirty-eight men and 76 women were included. Primary tumor sites were oral cavity (47.7%), oropharynx (18.7%), larynx (12.6%), salivary glands (7.9%), cutaneous (7.5%), sinonasal (2.8%), and hypopharynx (2.3%). Surgical resections were balanced between primary (48.1%) and salvage (51.9%). Thirty-five patients (16.4%) carried a presurgical diagnosis of diabetes. Fifteen patients (7.0%) demonstrated preoperative hyponatremia, and 46 (24.9%) had postoperative hyponatremia. Within the primary outcome measure, no difference in mortality was identified. Complications were noted in 58 patients (27.1%), and were more frequent in hyponatremic patients, both preoperatively and postoperatively (60.0% and 41.3%, respectively). Binomial logistic regression demonstrated risk of complications significantly associated with preoperative hyponatremia (odds ratio [OR] = 4.374; 95% confidence interval [CI] = 1.231-15.545; p = .023), increasing age (OR = 1.385; 95% CI = 1.032-1.857; p = .030), and increasing length of surgery (OR = 1.234; 95% CI = 1.046-1.455; p = .013). Postoperative hyponatremia was associated with increased hospital length of stay (p = .034). Hyponatremia is a frequent electrolyte abnormality in patients with HNSCC. Both preoperative and postoperative hyponatremia are associated with perioperative morbidity, thus meriting intensive postoperative medical monitoring and treatment. Additional investigation is warranted to identify the pathophysiologic mechanisms behind this association. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1370-E1374, 2016.

On the validity of measuring change over time in routine clinical assessment: a close examination of item-level response shifts in psychosomatic inpatients.

Significant life events such as severe health status changes or intensive medical treatment often trigger response shifts in individuals that may hamper the comparison of measurements over time. Drawing from the Oort model, this study aims at detecting response shift at the item level in psychosomatic inpatients and evaluating its impact on the validity of comparing repeated measurements. Complete pretest and posttest data were available from 1188 patients who had filled out the ICD-10 Symptom Rating (ISR) scale at admission and discharge, on average 24days after intake. Reconceptualization, reprioritization, and recalibration response shifts were explored applying tests of measurement invariance. In the item-level approach, all model parameters were constrained to be equal between pretest and posttest. If non-invariance was detected, these were linked to the different types of response shift. When constraining across-occasion model parameters, model fit worsened as indicated by a significant Satorra-Bentler Chi-square difference test suggesting potential presence of response shifts. A close examination revealed presence of two types of response shift, i.e., (non)uniform recalibration and both higher- and lower-level reconceptualization response shifts leading to four model adjustments. Our analyses suggest that psychosomatic inpatients experienced some response shifts during their hospital stay. According to the hierarchy of measurement invariance, however, only one of the detected non-invariances is critical for unbiased mean comparisons over time, which did not have a substantial impact on estimating change. Hence, the use of the ISR can be recommended for outcomes assessment in clinical routine, as change score estimates do not seem hampered by response shift effects.

Risk of Stroke and Cardiac Events in Medically Treated Asymptomatic Carotid Stenosis

The risk of stroke in patients with 50% or more asymptomatic carotid stenosis (ACS) on intensive medical treatment is low. Hence, the optimal treatment of ACS remains controversial at this point of time. We assessed the risk of stroke/transient ischemic attack (TIA) and cardiac events in patients with 50% or more ACS on intensive medical treatment. All patients with TIA/minor stroke (National Institutes of Health Stroke Scale score ≤5) who had undergone vessel imaging as part of their evaluation and patients with coronary artery disease who had undergone vessel imaging before cardiac intervention were screened for the presence of asymptomatic carotid stenosis. The risk of TIA/stroke, cardiac events, and vascular deaths were evaluated. Of 1,800 patients, 92 patients (.05%) had ACS having 50% to 99% stenosis; 63 had TIA/minor stroke, and 29 had coronary artery disease, of whom 7 patients had bilateral ACS, thus constituting 99 study units of ACS. The mean follow-up was 34.7 months (range 3-120 months). Two patients developed ischemic events on the side ipsilateral to the ACS and 9 patients developed cardiac events during the follow-up. The average annual event rate for cerebral ischemic events was .93% (95% confidence interval [CI], .11-3.37), 4.21% (95% CI, 1.92-7.98) for cardiac events, and 3.27% (95% CI, 1.31-6.74) for death. Although the risk of stroke in patients with ACS is low, acute coronary events and vascular deaths were significant. This highlights the importance of intensive risk factor modification to reduce adverse cardiovascular events in ACS rather than revascularization of the carotid stenosis.

Obesity and Insulin Resistance Are the Central Issues in Prevention of and Care for Comorbidities.

For a long time the assumption has been that, although weight reduction was necessary and desirable, comorbidities were far more important and needed treatment even if weight loss was not a treatment goal, preferably with medication. This controversy leads to postponement of treatment, and later on causes very intensive medical treatment, thus, raising the health care costs to unacceptable levels, leading to the medicalization of individuals, and a declining of the responsibility of patients for their health, leaving the question of when to regard their own weight as a problem that should be dealt with up to individuals. The central problem is insulin resistance, which leads to a cascade of health problems. This condition should be diagnosed in primary practice and obesity clinics to ensure a better, tailor-made treatment for patients. Treatment should start at the earliest stage possible, when comorbidities are still reversible and includes a personalized dietary advice and counseling, preferably by a dietitian, to tackle insulin resistance. An exercise program is part of the treatment.

Left Ventricular Non-compaction Cardiomyopathy - A Case Report

Abstract Background: Left non-compaction cardiomyopathy (LVNC) or “spongy myocardium” is a relatively rare primary genetic cardiomyopathy, characterized by prominent wall trabeculations and intertrabecular recesses which communicate with the ventricular cavity. It appears in isolated form or coexists with other congenital heart diseases and/or systemic abnormalities. Material and method: A 28-year-old woman was admitted with exertional dyspnoea, palpitations, non-specific chest pain and progressive fatigue on exertion. In her family history sudden cardiac-related deaths at young age are present. Cardiovascular system examination revealed tachycardia, intermittent extrabeats. The rest EKG showed sinusal tachycardia (105 bpm), negative T-waves in DII, DIII, aVF, V4-V6. Consecutive 24 hours Holter EKG monitoring revealed nonsustained ventricular tachycardia, paroxysmal atrial fibrillation, isolated ventricular extrasystoles. Echocardiography showed left ventricular systolic dysfunction (LVEF:30-35%), slight LV enlargement, normal right ventricle and small left ventricle (LV) trabeculae in the apical area. Cardiac MRI demonstrated dilated LV and the presence of the trabeculations of LV walls suggestive for non-compaction cardiomyopathy. A combined treatment for heart failure and cardiac arrhythmias was initiated with good clinical results. Patient was scheduled for an implantable cardioverter defibrillator “life-saving”. Conclusions: The symptoms of heart failure and cardiac arrhythmias should be considered important in apparently healthy young patients. Besides intensive medical treatment is indicated the implantation of an ICD “life-saving” and in advanced cases heart transplantation. Even if the electrocardiographic findings are non specific for noncompaction, a complete diagnostic evaluation is important, including sophisticated imaging techniques, a screening of first-degree relatives, and an extensive clinical, and genetic appreciation by a multidisciplinary team.

Haematuria increases progression of advanced proteinuric kidney disease.

BackgroundHaematuria has been traditionally considered as a benign hallmark of some glomerular diseases; however new studies show that haematuria may decrease renal function.ObjectiveTo determine the influence of haematuria on the rate of chronic kidney disease (CKD) progression in 71 proteinuric patients with advanced CKD (baseline eGFR <30 mL/min) during 12 months of follow-up.ResultsThe mean rate of decline in eGFR was higher in patients with both haematuria and proteinuria (haemoproteinuria, HP, n=31) than in patients with proteinuria alone (P patients, n=40) (-3.8±8.9 vs 0.9±9.5 mL/min/1.73m2/year, p<0.05, respectively). The deleterious effect of haematuria on rate of decline in eGFR was observed in patients <65 years (-6.8±9.9 (HP) vs. 0.1±11.7 (P) mL/min/1.73m2/year, p<0.05), but not in patients >65 years (-1.2±6.8 (HP) vs. 1.5±7.7 (P) mL/min/1.73m2/year). Furthermore, the harmful effect of haematuria on eGFR slope was found patients with proteinuria >0.5 g/24 h (-5.8±6.4 (HP) vs. -1.37± 7.9 (P) mL/min/1.73m2/year, p<0.05), whereas no significant differences were found in patients with proteinuria < 0.5 g/24 h (-0.62±7.4 (HP) vs. 3.4±11.1 (P) mL/min/1.73m2/year). Multivariate analysis reported that presence of haematuria was significantly and independently associated with eGFR deterioration after adjusting for traditional risk factors, including age, serum phosphate, mean proteinuria and mean serum PTH (β=-4.316, p=0.025).ConclusionsThe presence of haematuria is closely associated with a faster decrease in renal function in advanced proteinuric CKD patients, especially in younger CKD patients with high proteinuria levels; therefore this high risk subgroup of patients would benefit of intensive medical surveillance and treatment.

Long-Term Clinical Outcomes and Cardiovascular Events after Carotid Endarterectomy

Long-term atherosclerotic adverse events are anticipated in patients undergoing carotid endarterectomy (CEA); however, their incidence and risk predictors remain unknown. A consecutive cohort of CEAs between 1/1/2000-12/31/2007 was analyzed. End points were any stroke, coronary event (myocardial infarction, coronary bypass, or stenting), vascular interventions for critical limb ischemia, aortic aneurysm or carotid disease, and death. Survival analysis and Cox regression models were used to identify clinical predictors. A total of 1,136 CEAs (bilateral, 89; mean age, 71.2 ± 9.2 years; 56.5% male; 36.3% symptomatic, and 3.9% combined with coronary bypass) were performed during the study period with a mean clinical follow-up of 60 months (0-155 months). The postoperative combined stroke and/or death rate was 2.7% and 1.9% for asymptomatic and 4.1% for symptomatic patients. Five and 10-year risks of the end points were 7.2% and 16.1% for stroke, 18.4% and 31.5% for coronary interventions, 20.6% and 28.5% for major vascular interventions, and 25.8% and 50.1% for death. Statins conferred a significant protective effect for stroke (hazard ratio [HR], 0.53; P = 0.016) and death (HR, 0.66; P < 0.0001). Baseline vascular disease predicted future vascular interventions: aortic aneurysm (HR, 1.90; P = 0.003), peripheral arterial disease (HR, 2.03; P < 0.0001), and contralateral internal carotid artery (ICA) stenosis ≥50% (HR, 4.61; P < 0.0001). Renal insufficiency predicted worse outcomes for all other end points (HR, 2.21; P = 0.023 for stroke; HR, 1.62; P = 0.008 for coronary events; HR, 2.38; P < 0.0001 for death). Patients undergoing CEA continue to derive long-term low stroke rate benefit but still sustain major coronary events and require vascular interventions, indicating a need for more intensive medical treatment and rigorous follow-up.

Current Status of the Treatment of Fulminant Colitis

Fulminant colitis is not a well-defined entity that constitutes a severe complication. It usually occurs in the course of ulcerative colitis and Clostridium difficile colitis. A multidisciplinary management combining a gastroenterologist and surgeons is crucial with intensive medical treatment and early surgery in non-responders. It is important to distinguish if we are facing a flare of IBD or, on the contrary, it is an infectious colitis, due to the fact that although general therapeutic measures to adopt will be the same, they will demand opposed specific measures.

The effectiveness of intensive medical treatment in patients initially diagnosed with refractory angina

The effectiveness of intensive medical treatment in patients initially diagnosed with refractory angina

Management of Children with Status Epilepticus

Status epilepticus is defined as generalised convulsions lasting 30 minutes or longer, which are either continuous, or where there is failure regain consciousness between seizures. The longer the time taken to gain control of seizures the worse the neurological outcome for the child and the harder it is to terminate the seizures. The outcome is further influenced by the underlying aetiology. Treatment of status epilepticus consists of four stages - pre-hospital treatment, emergency department, in-hospital treatment (ward or high care) and anaesthesia (ICU). There are numerous protocols available world-wide. Most are based on the available facilities and the anecdotal preferences of the units involved. Beyond the first level of intervention there are no large evidence based guidelines which identify the optimal intervention. Newer agents are increasingly being used, but studies to assess the true efficacy of these are not available. Further, protocols differ between resource poor countries compared to equipped countries where the capacity to provide intensive care support and expensive medical interventions is limited. There are two targets in the management of status epilepticus namely the rapid identification of the underlying aetiology as this affects treatment and prognosis and the early initiation towards terminating status epilepticus which decreases morbidity and mortality.

Therapeutic approach to Candida bezoar in children

Candida bezoar (CB) is a rare finding in neonates and infants with candiduria, presenting as necrotic debris with proliferating mycelia in the collecting system of the kidney. If initial antifungal medical treatment does not result in clearance of candiduria and disappearance of CB on ultrasound in dilated kidneys, invasive interventions like insertion of nephrostomy tubes (NT) or surgical interventions to drain the kidney are sometimes advocated(.). However, NT placement can be a technical challenge, especially in pre- and dysmature neonates, and NT displacement or obstruction by the CB can lead to suboptimal treatment. Identification of those children who will benefit from invasive renal drainage is important. This study evaluates the management of patients with CB in three tertiary referral hospitals to determine criteria for intervention. A retrospective multicenter chart analysis was conducted of children with candiduria and ultrasonographic demonstration of CB (diagnosed between March 1995 and August 2012). The indication for invasive renal drainage (if performed) and subsequent clinical outcome, serum creatinine levels and ultrasound findings were assessed. A total of 12 children were included, two of which were premature neonates. Eight children had congenital urogenital anomalies. One older child with acute myeloid leukemia had CB during chemotherapy and one ex-premature developed CB following cerebral candidiasis. All children received systemic antifungal medication; in seven children invasive treatment was added. Indications for invasive treatment were clinical deterioration, progressive renal dilation, pyonephrosis, rising creatinine levels and persistence of CB. Two underwent a Y-cutaneous ureterostomy and nephrostomy tubes were inserted in five children. Percutaneous renal drainage by nephrostomy led to complications in 3 of 6 procedures. In all patients, irrespective of therapeutic modality, follow-up ultrasound demonstrated no de novo changes. No additional parenchymal defects or deterioration of split renal function were seen on DMSA or MAG-3 scan. In the literature renal drainage is suggested in case of complete obstruction. However dilatation is a frequent finding in children as part of the congenital renal anomaly and does not necessarily mean that there is obstruction of the urinary tract. Even in children without candida infections the diagnosis of obstruction is not straightforward, while the results of a MAG 3 scan can be obscured by compromised kidney function, parenchymal bacterial infiltration and neonatal immaturity of the kidney. If candiduria and CB persist despite intensive medical treatment, intensive consultation is required before renal drainage, because NT insertion might be a surgical challenge. Complications such as displacement of the NT, urinoma development, or NT obstruction can occur and was seen in three of six procedures. Premature neonates seem to be more prone to complications due to their small anatomical proportions, requiring medical equipment with small diameters prone to displacement and obstruction. Some studies describe successful pharmaceutical management in the majority of patients with CB. Other studies describe unilateral surgical intervention in children with bilateral CB where unilateral drainage did not influence overall renal outcome. This is in line with our results. A limitation of the present study is its retrospective design. In this population, the motivation for invasive renal drainage or conservative management was not well documented in all cases, and was mainly based on clinical and diagnostic parameters like creatinine levels and radiographic findings. Renal drainage should be considered in selected cases after failure of systemic antifungal treatment. Inserting and maintaining a nephrostomy tube in young children is associated with a high rate of complications; conservative treatment is likely to be sufficient in the majority of patients with candiduria and CB.

An unusual recovery from traumatic brain injury in a young man.

Traumatic brain injury (TBI), a complex neurological traumatic incident where brain function is disrupted due to physical trauma, can be categorized in multiple ways and is commonly scored using the Glasgow Coma Scale. Severe closed head injury is a form of TBI with a Glasgow Coma Scale less than 8. The outcomes and prognosis are not uniform in the population but mortality is estimated at 30-50 percent. In this case of severe closed head injury, the patient was able to make a near full recovery after several neurosurgery and medical treatments and intercessory prayer to Saint Luigi Guanella. A 21-year-old male patient received a severe closed head TBI and bilateral hemotympanum while rollerblading without a helmet. After imaging, a left frontal craniotomy and evacuation of epidural and subdural hematomas and resection of a left frontal contusion were performed. Intracranial pressure increased and the patient experienced a transtentorial herniation. He underwent a right frontotemporal and subtemporal craniectomy and evacuation of a frontotemporal subdural hematoma. The patient had intraventricular hemorrhage to which a ventriculostomy was performed and later converted to a ventriculo-peritoneal shunt for recurrent hydrocephalus. The patient was not expected to regain consciousness, but made a recovery after 24 days in the hospital and 10 days in rehabilitation. The patient followed up 6 months after injury for a cranioplasty and soon after returned to near baseline. In this extraordinary case, the severe closed head injury the patient sustained required intensive neurosurgical and medical treatment and the prognosis for recovery of consciousness was very poor; however, with treatment and rehabilitation and intercessory prayer to Saint Luigi Guanella, this patient was able to recover close to baseline from a Glasgow Coma Scale of 7. Head injuries vary in severity and traumatic brain injuries can be extremely serious leading to bleeding, loss of consciousness, and can affect verbal responses, muscles movement in motor responses, and responses with eye movement. Traumatic brain injuries require medical care to assess the severity and treat the injury. In this case report, we discuss a patient's very severe closed head injury while rollerblading without a helmet from which he was not expected to make a full recovery, but did so following intensive medical treatment, rehabilitation, and intercessory prayer to Saint Don Guanella to combat the initial injury and subsequent issues.

Estado actual del tratamiento de la colitis fulminante

Fulminant colitis is not a well-defined entity, that constitutes a severe complication. It usually occurs in the course of úlcerative colitis and Clostridium difficile colitis. A multidisciplinary management combining gastroenterologist and surgeons is crucial with intensive medical treatment and early surgery in non-responders. It is important to distinguish if we are facing a flare of IBD or, on the contrary, it is an infectious colitis, due to the fact that although general therapeutic measures to adopt will be the same, they will demand opposed specific measures.

Clinical Efficacy of a Medically Supervised Low-Calorie Diet Program versus a Conventional Carbohydrate-Restricted Diet

Objective: To determine the effectiveness of a 6 month intensive medical intervention (IMI) with caloric restriction and high-protein meal replacements versus a conventional carbohydrate-restricted (CCR) diet. Methods: This is an observational study designed to determine weight outcomes at 6, 12, 18 and 24 months after completing the IMI or CCR treatment. Patients were also required to participate in at least 5 miles of walking and 240 minutes of overall exercise per week. The primary outcome was percent body weight loss (BWL). Results: A total of 604 patients with obesity or overweight were studied. Sixty-seven percent were in the IMI group, versus 33% in the CCR group. Initial BMI was similar in both groups (36.4 kg/m2 (SD=7.7) vs. 36.0 kg/m2 (SD=7.8), p=0.608). At 6 months, the IMI group had superior body weight loss (11.9% (SD=7.4) vs. 6.0% (SD=6.1), p<0.0001). However, the IMI group had greater weight regain than the CCR group, resulting in similar weight loss at two years (7.1% (SD=10.2) vs. 8.1% (SD=6.3), p=0.735). An adjusted analysis of outcomes averaged across 2 years demonstrated 2.8% greater BWL among the IMI group. Blood pressure significantly improved in both groups (p<0.001). Males (OR=1.77, 95% CI=(1.10,2.84), p=0.019) and patients with BMI ≥ 35 kg/m2 (OR=3.32, 95% CI=(1.95, 5.65), p<0.0001) were more likely to achieve weight loss success with the IMI. Conclusion: An Intensive Medical Intervention (IMI) characterized by high-protein meal replacements and caloric restriction can be highly effective in reducing body weight, even at two years post-intervention. This type of intervention should be strongly considered among obese patients who do not qualify for bariatric surgery, those with contraindications to weight loss medications, or those in need of weight loss prior to a medical procedure.

Gram Negative Bacteremia Diagnosed on Peripheral Blood Smear Examination

Septicemia is a severe clinical syndrome characterized by systemic signs of infection, shock and systemic organ failure. Hence a rapid and definitive diagnosis is mandatory for proper management. Diagnosis of sepsis is routinely confirmed by presence of organisms in blood or at the site of infection which is usually done through culture which is a time consuming method and hence does not play much role in the initial treatment decision. In such scenario microscopic examination of peripheral blood can be of great help to hasten the confirmation of septicaemia, thereby enabling doctors to immediately select a more specific therapy [1-3]. Although several species of bacteria have been described on examination of peripheral blood smears but bacteremia due to gram negative rods has rarely been reported [1, 4-6]. We describe an interesting case of a 28-year-old female who presented with high grade fever which was associated with chills, vomiting, and loss of appetite and generalized weakness. Hematological examination revealed presence of anemia (hemoglobin 9.0 g/dL), leucocytosis (total leucocyte count 26.7 × 103/μL) and thrombocytopenia (62 × 103/μL). Peripheral blood smear (PBS) examination showed neutrophilia (absolute neutrophil count of 21.89 × 103/μL) and presence of shift leucocytes. Apart from these features, toxic vacuolizations were seen in the neutrophils along with frequent presence of intracellular structures which were uniform and rod shaped, suggestive of phagocytised bacilli. Similar bacilli were also seen lying extracellular in small and large clusters (Fig. 1). Gram stain of peripheral blood affirmed the presence of gram negative bacteremia. Later the blood culture confirmed the blood smear findings and revealed presence of Pseudomonas aureginosa. The patient’s condition kept on deteriorating and 2 days after admission, the female developed multi-organ failure and succumbed to her disease in spite of intensive medical treatment. PBS has never been a popular diagnostic tool for septicemia due to certain limitations. Firstly, it is less sensitive technique as detection of microorganism requires a concentration of 105 CFU/mL or greater which is unusual [7, 8]. And secondly, it is the inability to identify the species of microorganism. For these reasons, this method is mainly limited for identification of parasitic organisms in diseases like malaria and filaria. Nevertheless this limitation can be overcome to certain extent. Sensitivity could be increased by using buffy coat along with increasing experience and sufficient training of laboratory observers [9]. Also typical gram reaction, morphologies and arrangements of the observed organisms may help in presumptive identification of certain etiological bacteria [10]. During PBS examination for bacteria certain points should be kept in mind. The organism should be intracellular and the cells containing them must be leucocytes. Associated finding like toxic granules, vacuoles and Dhole inclusion bodies in neutrophils are also very predictive of systemic infection. Presence of only extracellular microorganism should be reported with special care as it may represent contamination [11]. Thus to conclude, simple, inexpensive and safe PBS examination should be more widely used especially when overwhelming bacteremia is suspected in conditions like hyposplenism, AIDS neonatal sepsis, etc. In such scenario, it can prove to be an important tool to provide rapid preliminary diagnosis, thereby allowing clinicians to strengthen the empirical anti-microbial regimen.