Risk factors for posttraumatic empyema in diaphragmatic injuries

Background

Penetrating diaphragmatic injuries are associated with a high incidence of posttraumatic empyema. We analyzed the contribution of trauma severity, specific organ injury, contamination severity, and surgical management to the risk of posttraumatic empyema in patients who underwent surgical repair of diaphragmatic injuries at a level 1 trauma center.

Methods

This is a retrospective review of the patients who survived more than 48 h. Univariate OR calculations were performed to identify potential risk factors. Multiple logistic regression was used to calculate adjusted ORs and identify independent risk factors.

Results

We included 192 patients treated from 2011 to 2020. There were 169 (88.0) males. The mean interquartile range, (IQR) of age, was 27 (22–35) years. Gunshot injuries occurred in 155 subjects (80.7%). Mean (IQR) NISS and ATI were 29 (18–44) and 17 (10–27), respectively. Thoracic AIS was > 3 in 38 patients (19.8%). Hollow viscus was injured in 105 cases (54.7%): stomach in 65 (33.9%), colon in 52 (27.1%), small bowel in 42 (21.9%), and duodenum in 10 (5.2%). Visible contamination was found in 76 patients (39.6%). Potential thoracic contamination was managed with a chest tube in 128 cases (66.7%), with transdiaphragmatic pleural lavage in 42 (21.9%), and with video-assisted thoracoscopy surgery or thoracotomy in 22 (11.5%). Empyema occurred in 11 patients (5.7%). Multiple logistic regression identified thoracic AIS > 3 (OR 6.4, 95% CI 1.77–23. 43), and visible contamination (OR 5.13, 95% IC 1.26–20.90) as independent risk factors. The individual organ injured, or the method used to manage the thoracic contamination did not affect the risk of posttraumatic empyema.

Conclusion

The severity of the thoracic injury and the presence of visible abdominal contamination were identified as independent risk factors for empyema after penetrating diaphragmatic trauma.

A multidisciplinary approach and implementation of a specialized hemorrhage control team improves outcomes for placenta accreta spectrum

INTRODUCTION

The main complication of placenta accreta spectrum (PAS) is massive bleeding. Endoarterial occlusion techniques have been incorporated into the management of this pathology. Our aim was to examine the endovascular practice patterns among PAS patients treated during a 9-year period in a low-middle income country in which an interdisciplinary group's technical skills were improved with the creation of a PAS team.

METHODOLOGY

A retrospective cohort study including all PAS patients treated from December 2011 to November 2020 was performed. We compared the clinical results obtained according to the type of endovascular device used (group 1, internal iliac artery occlusion balloons; group 2, resuscitative endovascular balloons of the aorta; group 3, no arterial balloons due to low risk of bleeding) and according to the year in which they were attended (reflects the PAS team level of experience). A fourth group of comparisons included the woman diagnosed during a cesarean delivery and treated in a nonprotocolized way.

RESULTS

A total of 113 patients were included. The amount of blood loss decreased annually, with a median of 2,500 mL in 2014 (when endovascular occlusion balloons were used in all patients) and 1,394 mL in 2020 (when only 38.5% of the patients required arterial balloons). Group 3 patients (n = 16) had the lowest bleeding volume (1,245 mL) and operative time (173 minutes) of the entire population studied. Group 2 patients (n = 46) had a bleeding volume (mean, 1,700 mL) and transfusions frequency (34.8%) slightly lower than group 1 patients (n = 30) (mean of 2,000 mL and 50%, respectively). They also had lower hysterectomy frequency (63% vs. 76.7% in group 1) and surgical time (205 minutes vs. 275 in group 1) despite a similar frequency of confirmed PAS and S2 compromise.

CONCLUSION

Endovascular techniques used for bleeding control in PAS patients are less necessary as interdisciplinary groups improve their surgical and teamwork skills.

LEVEL OF EVIDENCE

Therapeutic care management, level III.

La laparotomía de control de daños en pacientes sin trauma reduce el número de ostomías

Introducción. El objetivo de este estudio fue evaluar si la laparotomía de control de daños con ligadura y reconstrucción intestinal diferida, en pacientes con peritonitis secundaria a compromiso de víscera hueca, reduce el número de ostomías. Métodos. Se incluyeron todos los pacientes menores de 18 años de edad que ingresaron a la clínica con sospecha de peritonitis de origen no traumático y que se sometieron a laparotomía entre enero del 2003 y diciembre del 2018. Se evaluaron las características sociodemográficas, comorbilidades, escalas de gravedad fisiológica, técnicas de reconstrucción intestinal y resultados clínicos. Resultados. Se incluyeron 306 pacientes, distribuidos en tres grupos: 1) 120 (39,2 %) sometidos a resección y anastomosis, 2) 87 (28,4 %) sometidos a ostomía, y 3) 99 (32,3 %) sometidos inicialmente a ligadura intestinal. Los pacientes sometidos a ligadura intestinal presentaron mayor compromiso fisiológico al ingreso a la unidad de cuidado intensivo, con puntuación APACHE II: 14 (rango intercuartílico, RIC=10-18) en el grupo 1, 13 (RIC=11-18) en el grupo 2, y 18 (RIC=14-24) en el grupo 3 (p<0,01). Sin embargo, más de la mitad se reconstruyeron en la siguiente laparotomía: anastomosis mecánica (16/99; 16,1 %), anastomosis manual (49/99; 49,5 %), ostomía (34/99; 34,3 %). Además, estos pacientes sometidos a ligadura intestinal tuvieron un número significativamente mayor de nuevas laparotomías, y de días de asistencia respiratoria mecánica, de estancia en la unidad de cuidado intensivo y de estancia hospitalaria. No hubo diferencias estadísticamente significativas en la mortalidad entre los subgrupos: (grupo 1=19 (15,8 %), grupo 2=16 (18,4 %), grupo 3=19 (19,2 %) (p=0,79). Conclusión. En este estudio, se logró evitar la ostomía como técnica de reconstrucción definitiva en más de la mitad de los pacientes con peritonitis que se sometieron a laparotomía de control de daños con ligadura intestinal.

Stump appendicitis, a case report and a review of the literature. Is it as uncommon as it is thought?

•

The clinical presentation of stump appendicitis is similar as a first episode of appendicitis.

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The risk factors for SA are not clear, but the data available suggest that a primary laparoscopic appendectomy is not related.

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The length of the stump left in the first surgery might be associated with stump appendicitis.

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Incidence of stump appendicitis seems to be higher than previously reported.

Introduction

Acute appendicitis (AA) is the most common cause of acute surgical abdomen. Complications from surgical appendectomy include intraabdominal abscess, bleeding, surgical site infections, ileus, and stump appendicitis (SA). This last one is one of the least common ones with a reported incidence of 1:50.000.

Methods

We present a case and review 132 cases of SA reported in the literature. Demographic and clinical characteristics were evaluated, as well as details of the surgical treatment. Categorical variables are presented as quantities and proportions, and continuous variables with median and interquartile range. Additionally, we calculate an incidence from 3 papers reported in the literature and our own.

Results

We analyzed 132 cases, 60.3 % were male with a median age at SA of 33 years. There was a wide range time interval between the episode of AA and SA from 1 day to 60 years. Initial open appendectomy was reported in 62 cases. From all the patients with SA 51 % reported complications. The median length of the appendiceal stump was 3 cm. The incidence of SA fluctuated between 0.22–1.37 in 1.000 cases of appendectomies.

Discussion

SA is usually underrated, and which are the risk factors for this condition are not clear. The data available suggest that a primary laparoscopic appendectomy is not related to SA, but the length of the stump left in the first surgery might be associated. The incidence of SA seems to be higher than the one reported of 1 in 50.000.

Bench Validation of a Handcrafted Prototype Catheter for Intra-gastric Pressure Monitoring

BACKGROUND

Abdominal compartment syndrome is a sustained intra-abdominal pressure (IAP) >20 mm Hg associated with new organ dysfunction. In order to prevent its development and related complications, IAP monitoring should be performed in patients with risk factors. Although techniques for its monitoring have been developed, they are of high cost and not always available in low- and lower-middle-income countries. Therefore, we aim to develop and validate in a bench model a handcrafted catheter to be used as an alternative method to measure the intra-gastric pressure (IGP) as a surrogate of the IAP.

METHODS

We used an acrylic water container as a model of the abdomen and four handcrafted catheters made of a 16 Fr Levin tube with a globe finger tied with silk in the distal end, inflated with 1 cm of air. They were placed on the bottom of the container where the water pressure was directly measured as a gold standard. The agreement between the two measures was assessed with the Bland-Altman method.

RESULTS

We performed 120 simultaneous measures. The mean pressure difference was 0.218 (95% CI 0.074 to 0.363).

CONCLUSIONS

The handcrafted prototype catheter and the direct measure were highly correlated. The new catheter is a reliable and reproducible tool for pressure monitoring. However, before it can be used in the clinical setting for IAP monitoring, validation in human models in a real clinical setting needs to be performed.

Ileostomía y lavado colónico anterógrado con Vancomicina en el manejo de infección por Clostridium difficile

La infección por Clostridium difficile es la principal causa de diarrea asociada al cuidado de la salud. Durante los últimos años se ha incrementado la morbilidad y mortalidad por esta infección. Las recientes investigaciones se orientan a la búsqueda de tratamientos alternativos a la colectomía subtotal para los pacientes con infecciones severas por Clostridium difficile, es por esto que el presente artículo tiene como objetivo hacer la revisión del caso clínico de una paciente con colitis severa por Clostridium difficile refractaria al manejo de primera línea, que respondió satisfactoriamente al tratamiento con lavado colónico anterógrado con vancomicina vía ileostomía en asa.

Could resuscitative endovascular balloon occlusion of the aorta improve survival among severely injured patients with post-intubation hypotension?

Current literature shows the association of post-intubation hypotension and increased odds of mortality in critically ill non-trauma and trauma populations. However, there is a lack of research on potential interventions that can prevent or ameliorate the consequences of endotracheal intubation and thus improve the prognosis of trauma patients with post-intubation hypotension. This review paper hypothesizes that the deployment of REBOA among trauma patients with PIH, by its physiologic effects, will reduce the odds of mortality in this population. The objective of this paper is to review the current literature on REBOA and post-intubation hypotension, and, furthermore, to provide a rational hypothesis on the potential role of REBOA in severely injured patients with post-intubation hypotension.

Efficacy of respiratory muscle training in weaning of mechanical ventilation in patients with mechanical ventilation for 48hours or more: A Randomized Controlled Clinical Trial

OBJECTIVE

To evaluate the efficacy of respiratory muscular training in the weaning of mechanical ventilation and respiratory muscle strength in patients on mechanical ventilation of 48hours or more.

DESIGN

Randomized controlled trial of parallel groups, double-blind. Ambit: Intensive Care Unit of a IV level clinic in the city of Cali.

PATIENTS

126 patients in mechanical ventilation for 48hours or more.

INTERVENTIONS

The experimental group received daily a respiratory muscle training program with treshold, adjusted to 50% of maximal inspiratory pressure, additional to standard care, conventional received standard care of respiratory physiotherapy. MAIN INTEREST VARIABLES: weaning of mechanical ventilation. Other variables evaluated: respiratory muscle strength, requirement of non-invasive mechanical ventilation and frequency of reintubation.

ANALYSIS

intention-to-treat analysis was performed with all variables evaluated and analysis stratified by sepsis condition.

RESULTS

There were no statistically significant differences in the median weaning time of the MV between the groups or in the probability of extubation between groups (HR: 0.82 95% CI: 0.55-1.20 P=.29). The maximum inspiratory pressure was increased in the experimental group on average 9.43 (17.48) cmsH20 and in the conventional 5.92 (11.90) cmsH20 (P=.48). The difference between the means of change in maximal inspiratory pressure was 0.46 (P=.83 95%CI -3.85 to -4.78).

CONCLUSIONS

respiratory muscle training did not demonstrate efficacy in the reduction of the weaning period of mechanical ventilation nor in the increase of respiratory muscle strength in the study population. Registered study at ClinicalTrials.gov (NCT02469064).

Variations in the anatomical relationship between the common carotid artery and the internal jugular vein: An ultrasonographic study

Introduction: The internal jugular vein locates anterior or anterolateral to the common carotid artery in two-thirds of the subjects studied by ultrasound when the head is in a rotated position. Aim: To identify variables associated with the anterior location of the internal jugular vein. Methods: Ultrasound examinations were performed with the patients in the supine position, with the head rotated to the opposite side. The proximal third of the neck was visualized transversely with a 7.5-mHz transducer. The relationship between the vessels was described in accordance with the proportion of the artery overlapped by the vein. Univariate comparisons and a multivariate analysis of potential variables that may affect the anatomic relationships were performed. Results: Seventy-eight patients were included, 44 of whom were men. The patients' ages ranged from 17 to 90 years (median 64.0, interquartile range 41-73). The right and left sides were studied 75 and 73 times, respectively. The vein was located lateral to the artery in 24.3% (95%CI= 17.4-32.2) of the studies, anterolateral in 33.8% (95%CI= 26.2-41.4) and anterior in 41.9% (95%CI= 33.9-49.8). The multivariate analysis identified age group (OR= 3.7, 95% CI 2.1-6.4) and, less significantly, the left side (OR= 1.7, 95%CI= 0.8-3.5) and male gender (OR= 1.2, 95%CI= 0.6-2.7) as variables associated with the anterior position of the vein. Conclusión: The anterior position of the internal jugular vein relative to the common carotid artery increases gradually with age. Additionally, left-sided localization and male sex further increased the probability of an anterior position.

Evaluation of indigenous bacterial strains for biocontrol of the frogeye leaf spot of soya bean caused by Cercospora sojina

AIMS

Assessment of biological control of Cercospora sojina, causal agent of frogeye leaf spot (FLS) of soya bean, using three indigenous bacterial strains, BNM297 (Pseudomonas fluorescens), BNM340 and BNM122 (Bacillus amyloliquefaciens).

METHODS AND RESULTS

From cultures of each bacterial strain, cell suspensions and cell-free supernatants were obtained and assayed to determine their antifungal activity against C. sojina. Both mycelial growth and spore germination in vitro were more strongly inhibited by bacterial cell suspensions than by cell-free supernatants. The Bacillus strains BNM122 and BNM340 inhibited the fungal growth to a similar degree (I ≈ 52-53%), while cells from P. fluorescens BNM297 caused a lesser reduction (I ≈ 32-34%) in the fungus colony diameter. The foliar application of the two Bacillus strains on soya bean seedlings, under greenhouse conditions, significantly reduced the disease severity with respect to control soya bean seedlings and those sprayed with BNM297. This last bacterial strain was not effective in controlling FLS in vivo.

CONCLUSIONS

Our data demonstrate that the application of antagonistic bacteria may be a promising and environmentally friendly alternative to control the FLS of soya bean.

SIGNIFICANCE AND IMPACT OF THE STUDY

  To our knowledge, this is the first report of biological control of C. sojina by using native Bacillus strains.

Assessment of the role of chemotaxis and biofilm formation as requirements for colonization of roots and seeds of soybean plants by Bacillus amyloliquefaciens BNM339

This article correlates colonization with parameters, such as chemotaxis, biofilm formation, and bacterial growth, that are believed to be connected. We show here, by using two varieties of soybean plants that seeds axenically produced exudates, induced a chemotactic response in Bacillus amyloliquefaciens, whereas root exudates did not, even when the exudates, also collected under axenic conditions, were concentrated up to 200-fold. Root exudates did not support bacterial cell division, whereas seed exudates contain compounds that support active cell division and high cell biomass at stationary phase. Seed exudates of the two soybean varieties also induced biofilm formation. B. amyloliquefaciens colonized both seeds and roots, and plant variety significantly affected bacterial root colonization, whereas it did not affect seed colonization. Colonization of roots in B. amyloliquefaciens occurred despite the lack of chemotaxis and growth stimulation by root exudates. The data presented in this article suggest that soybean seed colonization, but not root colonization, by B. amyloliquefaciens is influenced by chemotaxis, growth, and biofilm formation and that this may be caused by qualitative changes of the composition of root exudates.

Oxygen and light effects on the expression of the photosynthetic apparatus in Bradyrhizobium sp. C7T1 strain

Photosynthetic bradyrhizobia are nitrogen-fixing symbionts colonizing the stem and roots of some leguminous plants like Aeschynomene. The effect of oxygen and light on the formation of the photosynthetic apparatus of Bradyrhizobium sp. C7T1 strain is described here. Oxygen is required for growth, but at high concentration inhibits the synthesis of bacteriochlorophyll (BChl) and of the photosynthetic apparatus. However, we show that in vitro, aerobic photosynthetic electron transport occurred leading to ADP photophosphorylation. The expression of the photosynthetic apparatus was regulated by oxygen in a manner which did not agree with earlier results in other photosynthetic bradyrhizobia since BChl accumulation was the highest under microaerobic conditions. This strain produces photosynthetic pigments when grown under cyclic illumination or darkness. However, under continuous white light illumination, a Northern blot analysis of the puf operon showed that, the expression of the photosynthetic genes of the antenna was considerable. Under latter conditions BChl accumulation in the cells was dependent on the oxygen concentration. It was not detectable at high oxygen tensions but became accumulated under low oxygen (microaerobiosis). It is known that in photosynthetic bradyrhizobia bacteriophytochrome photoreceptor (BphP) partially controls the synthesis of the photosystem in response to light. In C7T1 strain far-red light illumination did not stimulate the synthesis of the photosynthetic apparatus suggesting the presence of a non-functional BphP-mediated light regulatory mechanism.

Genetic and functional characterization of a Bacillus sp. strain excreting surfactin and antifungal metabolites partially identified as iturin-like compounds

AIMS

A bacterial strain producing antifungal compounds active against the plant pathogenic fungi Fusarium, Rhizoctonia and Sclerotinia has been characterized and shown to control Rhizoctonia root rot of soya bean.

METHODS AND RESULTS

The metabolites excreted by Bacillus BNM 122 remained active after autoclaving, were resistant over a wide pH range and to hydrolytic enzymes. By (1)H-NMR and thin-layer chromatography analyses surfactin and iturin-like compounds were partially identified. Moreover, soya bean seeds bacterization with BNM 122 in a compost-based formulation was as effective controlling Rhizoctonia solani as pentachloronitrobenzene. According to its 16S rDNA sequence BNM 122 was closely related to Bacillus amyloliquefaciens and Bacillus subtilis. PCR analysis of the 16S-23S rRNA intergenic spacer region and repetitive sequence-based PCR (rep-PCR) genomic fingerprinting revealed a close genetic relationship to B. amyloliquefaciens. However, by physiological characterization using API tests, this strain resembled more B. subtilis.

CONCLUSIONS

This is the first report describing the co-production of surfactin and iturin-like compounds by a putative strain of B. amyloliquefaciens. The synergistic effect of both lipopetides is a remarkable trait for a candidate biocontrol agent.

SIGNIFICANCE AND IMPACT OF THE STUDY

This kind of research has relevance in order to minimize the use of synthetic fungicides and surfactants, contributing to the preservation of the environment.

The LHIalpha and LHIIalpha complexes in association with phospholipids are able to be inserted in heavy membranes of Rhodobacter capsulatus B10

We show in this paper that a complex constituted by phospholipids and LHI and LHII alpha polypeptides was inserted in a heavy membrane fraction in a nonextractable form, indicating a transmembrane localization. The best accepting membranes originated from aerobically grown cells. Addition of ATP during the insertion inhibited this reaction 25 to 30% in heavy membranes isolated from aerobically grown cells (HMaer) and a higher inhibition (60 to 65%) was detected when using heavy membranes isolated from photosynthetically grown cells (HMpho). Purification by gel filtration of a crude Na2CO3 extract yielded three phosphate-labeled fractions. Two of them contained protein and phospholipids in a stable association. However, only fractions containing phosphatidylethanolamine were shown to be reconstituted. The third radioactive fraction contained labeled ATP and protein, but no phospholipids and could not be reassociated to the heavy membranes of any origin. A model for the insertion of the LH polypeptides is presented in which the recently synthesized polypeptides are phosphorylated and become associated to anionic phospholipids. The interaction of this complex to the membrane spontaneously leads to stable insertion.

Isolation and purification of reaction center from Rhodopseudomonas viridis NHTC 133 by means of LDAO

Two different procedures are described to isolate and purify the reaction center complex from Rhodopseudomonas viridis NHTC 133 by means of the non-ionic detergent dodecyldimethylamine oxide. Both reaction center particles thus obtained were active, as shown by a photobleaching centered at 975 nm. The reaction center also contained, in addition to bacteriochlorophyll, bacteriopheophytin. Other components were also found in this particle: cytochromes C553 and C558 and a menaquinone-like substance. The SDS gel electrophoresis of reaction centers is shown. The molecular weights of the subunits forming the reaction center in 0.5% sodium dodecyl sulfate and 1% mercaptoethanol were calculated as being: 45 +/- 1.5 and 37 +/- 1.5 kdalton, 29 +/- 1.5 and 23 +/- 1.5 kdalton. The molecular weight of the complex determined by means of gel filtration (Sepharose 6-B and Bio-Gel P-300) gives a value of approximately 240 kdalton. The minimum molecular weight of the complex calculated by disc gel electrophoresis was 231 kdalton.