Can We Do Anything Else before Removing a Button Battery from the Esophagus?-Hyaluronic Acid

OBJECTIVE

 This article tests the protective effect of a commercially available mixture of hyaluronic acid, chondroitin sulfate, and poloxamer 407 on the damage caused by the exposure of esophageal mucosa to button batteries in an animal model.

METHODS

 Experimental study. Sixty porcine esophageal samples were distributed in three groups: control (CG), exposure (EG), and exposure-protection (EPG). In EG and EPG, one CR2032 button battery per sample was inserted, both were subdivided into 2-, 4-, 6-, and 24-hour exposure subgroups, with subsequent battery removal. EPG samples were irrigated with the solution 1 hour after battery exposure. Esophageal pH and final voltage of the battery were measured.

RESULTS

 pH in CG remained stable. No significant differences in pH at 1 hour were found between EG and EPG. In EPG, the pH of the mucosa exposed to the anode was lower than in GE at 2 hours (12.44 vs. 11.89, p = 0.203) and 4 hours (13.78 vs. 11.77, p < 0.0001). In the cathode pH was significantly higher in EG at 2 hours (2.5 vs. 4.11, p < 0.0001), 4 hours (2.33 vs. 4.78, p < 0.0001), and 6 hours (2.17 vs. 2.91, p < 0.0001). Significant voltage reduction at 1 hour was found in EG compared to EPG (0.48 vs. 1.08 V, p = 0.004).

CONCLUSION

 Exposure to hyaluronic acid solution buffers the acidification on the side exposed to the cathode and basification on the anode. This effect can be maintained up to 3 to 5 hours, even after stopping its application. Our results suggest that a solution containing hyaluronic acid could be used as an esophageal protector after accidental ingestion of button batteries.

Prehospital Damage Control: The Management of Volume, Temperature… and Bleeding!

Damage control resuscitation should be initiated as soon as possible after a trauma event to avoid metabolic decompensation and high mortality rates. The aim of this article is to assess the position of the Trauma and Emergency Surgery Group (CTE) from Cali, Colombia regarding prehospital care, and to present our experience in the implementation of the “Stop the Bleed” initiative within Latin America. Prehospital care is phase 0 of damage control resuscitation. Prehospital damage control must follow the guidelines proposed by the “Stop the Bleed” initiative. We identified that prehospital personnel have a better perception of hemostatic techniques such as tourniquet use than the hospital providers. The use of tourniquets is recommended as a measure to control bleeding. Fluid management should be initiated using low volume crystalloids, ideally 250 cc boluses, maintaining the principle of permissive hypotension with a systolic blood pressure range between 80- and 90-mm Hg. Hypothermia must be management using warmed blankets or the administration of intravenous fluids warmed prior to infusion. However, these prehospital measures should not delay the transfer time of a patient from the scene to the hospital. To conclude, prehospital damage control measures are the first steps in the control of bleeding and the initiation of hemostatic resuscitation in the traumatically injured patient. Early interventions without increasing the transfer time to a hospital are the keys to increase survival rate of severe trauma patients.

Damage Control Surgery may be a Safe Option for Severe Non-Trauma Peritonitis Management: Proposal of a New Decision-Making Algorithm

BACKGROUND

Damage control surgery (DCS) has emerged as a new option in the management of non-traumatic peritonitis patients to increase survival in critically ill patients. The purpose of this study was to compare DCS with conventional strategy (anastomosis/ostomies in the index laparotomy) for severe non-traumatic peritonitis regarding postoperative complications, ostomy rate, and mortality and to propose a useful algorithm in the clinical practice.

METHODS

Patients who underwent an urgent laparotomy for non-trauma peritonitis at a single level I trauma center in Colombia between January 2003 and December 2018, were retrospectively included. We compared patients who had DCS management versus definitive initial surgical management (DISM) group. We evaluated clinical outcomes and morbidities among groups.

RESULTS

290 patients were included; 81 patients were treated with DCS and 209 patients underwent DISM. Patients treated with DCS had a worse critical status before surgery with higher SOFA score [median, DCS group: 5 (IQR: 3-8) vs. DISM group: 3 (IQR: 1-6), p < 0.001]. The length of hospital stay and overall mortality rate of DCS group were not significant statistical differences with DISM group. Complications rate related to primary anastomosis or primary ostomy was similar. There is not difference in ostomy rate among groups. At multivariate analysis, SOFA > 6 points and APACHE-II > 20 points correlated with a higher probability of DCS.

CONCLUSION

DCS in severe non-trauma peritonitis patients is feasible and safe as surgical strategy management without increasing mortality, length hospital of stay, or complications. DCS principles might be applied in the non-trauma scenarios without increase the stoma rate.

Does a glucose-based hydrogen and methane breath test detect bacterial overgrowth in the jejunum?

BACKGROUND

Direct diagnosis of small intestinal bacterial overgrowth (SIBO) requires the collection and culture of fluid from the jejunal lumen, with a finding of over 10⁵ viable bacteria per mL. More often, SIBO is diagnosed indirectly, using a non-invasive test of the exhaled hydrogen and methane generated by microbial fermentation when ingested glucose reaches the jejunum. Our objective was to determine how well this breath test detects chronic overgrowth of jejunal bacteria that is unrelated to gastrointestinal surgery.

METHODS

Eighteen patients reporting symptoms consistent with SIBO received a glucose breath test. On a later day, the jejunal lumen was sampled via aspiration during enteroscopy. Jejunal aspirates were cultured on aerobic and anaerobic media. DNA was extracted from the same samples and analyzed by quantitative pan-bacterial PCR amplification of 16S ribosomal rRNA genes, which provided a culture-independent bacterial cell count.

KEY RESULTS

Combined bacterial colony counts ranged from 5.7 x 10³ to 7.9 x 10⁶ CFU/mL. DNA-based yields ranged from 1.5 x 10⁵ to 3.1 x 10⁷ bacterial genomes per mL. Microbial viability ranged from 0.3% to near 100%. We found no significant correlation of glucose breath test results with either the number of bacterial colonies or with the DNA-based bacterial cell counts. Instead, higher signals in the hydrogen-methane breath test were significantly correlated with a lower viability of jejunal bacteria, at a P-value of .014.

CONCLUSIONS & INFERENCES

The glucose-based hydrogen and methane breath test is not sensitive to the overgrowth of jejunal bacteria. However, a positive breath test may indicate altered jejunal function and microbial dysbiosis.

Genetic structure of Triatoma sordida (Hemiptera: Reduviidae) domestic populations from Bolivia: application on control interventions

The genetic population of Triatoma sordida group 1, a secondary vector of Chagas disease in Bolivia, was studied by multi-locus enzyme electrophoresis. A total of 253 nymphal and adult specimens collected from seven neighbouring localities in the Velasco Province, Department of Santa Cruz, were processed. The relatively low genetic variability was confirmed for this species (rate of polymorphism: 0.20). The absence of genetic disequilibrium detected within the seven localities was demonstrated. A geographical structuration appears between localities with distances greater than 20 km apart. Although T. sordida presents a relatively reduced dispersive capacity, its panmictic unit is wider than compared with T. infestans. Genetic distances between T. sordida populations were correlated with geographic distance. Gene flow between geographic populations of T. sordida provides an efficient framework for effective vigilance and control protocols.

Trypanosoma cruzi genotypes associated with domestic Triatoma sordida in Bolivia

Triatoma sordida is the second species of Triatominae considered of epidemiological significance in Bolivia. Associated with Triatoma infestans in various regions, it is as yet the only triatomine species established in human dwellings in localities of Velasco province, Department of Santa Cruz. This domestication is considered as primary. Flagellate parasites were detected in 16.2% of domiciliary T. sordida and the kDNA-PCR confirmed the presence of Trypanosoma cruzi. Frequencies of T. cruzi clonets 20 and 39, common clonets in Bolivian domestic cycle (T. infestans), were established by their direct detection in feces using PCR and hybridization. These clonets present low frequencies in T. sordida and synanthropic mammals. Forty-six stocks were isolated and analysed by multilocus enzyme electrophoresis (MLEE). The MLEE showed a higher clonal diversity than in T. infestans domestic cycle and the genotypes were clustered in the two principal lineages of T. cruzi. Within each lineage, a broad variability was observed. Mixture of genotypes was mostly observed in mammals. The large diversity of T. cruzi in this cycle should be related to its sylvatic origin. Moreover, the current limited sample of stocks suggests a lineage association with specific hosts.

Low probability of transmission of Trypanosoma cruzi to humans by domiciliary Triatoma sordida in Bolivia

The role of Triatoma sordida in the domestic transmission of Trypanosoma cruzi was assessed in 7 rural localities in Velasco Province, Department of Santa Cruz, Bolivia. Tri. sordida, the only triatomine species identified in these localities, was found inside 58.0% of houses but not in large numbers (3.1 bugs per infested house on average). A total of 220 faecal samples from domiciliary bugs was examined microscopically and by the polymerase chain reaction for the presence of trypanosomes: 21.4% were infected. Analysis of blood meals of domiciliary Tri. sordida showed that humans were the commonest host (70.4%), followed by chickens and dogs. Four of 418 persons tested were seropositive for Tryp. cruzi. Only 2 of a second group of 62 persons living in dwellings infested by Tri. sordida were seropositive. Tryp. cruzi infection was demonstrated in dogs and domestic rats. Three other species of small mammals were found to be infected with trypanosomes. In our study area, domestic Tri. sordida are mainly incriminated in the transmission of Tryp. cruzi to synanthropic animals, whereas transmission to humans is very rare. The presence in houses of small populations of Tri. sordida infected with Tryp. cruzi is therefore currently insufficient for this insect to constitute a major epidemiological risk factor.

Efficacy of doramectin in the protection of neonatal calves and post-parturient cows against field strikes of Cochliomyia hominivorax

Two studies were conducted in Latin America, one in Venezuela and one in Argentina, using a common protocol to investigate the efficacy of a single s.c. injection of doramectin in the prevention and control of field infestations of Cochliomyia hominivorax in newborn calves and post-parturient cows. In both experiments, pregnant cows were paired on the basis of their calving time. The first cow that calved was assigned to a medicated group, and both cow and calf were treated with doramectin. The cow received a dose of 200 micrograms kg-1 and the calf 1 ml of a 1% doramectin solution. The second cow and calf were assigned to a saline-treated group, and the cow received saline at 1 ml per 50 kg and the calf 1 ml. The procedure was repeated until all animals were allocated to the two treatments. Animals were examined on the treatment day and at 2, 4, 6 and 12 days post-treatment. At each observation day, the navel of newborn calves and external genitalia of the cows were inspected and the presence of C. hominivorax infestations was recorded. Doramectin was 100% effective in the prevention and control of screwworm strikes in newborn calves and in post-parturient cows exposed to continuous field challenge of C. hominivorax. Over the 12 day duration of the studies, 48% and 57% of the saline-treated calves had screwworm navel strikes in the studies in Venezuela and Argentina, respectively. Infested animals required repeated therapeutic treatment, whereas none of the doramectin-treated calves were affected (P < 0.005).(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation of erythropoietin in endurance runners

To evaluate the role of erythropoietin (Epo) in the erythroid abnormalities often found in athletes, Epo was evaluated by radioimmunoassay in endurance runners (ER). In a first study, 46 experienced ER, 11 with iron deficiency (ID group), were studied during a training period. In ID and non-ID runners, serum Epo (SEpo) levels were similar to sedentary controls (ID = 19.1 +/- 4.9 U/L, non-ID = 19.7 +/- 5.5 U/L and controls 19.7 +/- 9.2 U/L). In a second study, serum and urine erythropoietin (UEpo) levels were evaluated in 17 ER during a 6-hour race. Samples were taken before the race (pre-race), immediately following (6-hour) and 4 days after (post-race). No differences were observed in SEpo levels (pre-race = 19.8 +/- 4.1 U/L, 6-hour = 21.2 +/- 4.9 U/L and post-race = 21 +/- 4 U/L), but UEpo increased following the race (pre-race = 15.4 +/- 9.6 U/L, 6-hour = 26.1 +/- 6.2 U/L and post-race = 14.1 +/- 6.5 U/L) (p < 0.0001) and this UEpo increase was related to urine creatinine changes (rs = 0.79, p < 0.00001). In conclusion, SEpo in ER does not differ from sedentary values and does not vary with competition; however, UEpo increases during a long-distance race. These data may be important for a correct evaluation of Epo abusers and sports anemia.

Transient alterations in cardiac performance after a six-hour race

Ten long distance runners were enrolled in a 6-hour competitive race. Immediately after the race technetium-99m-albumin gated blood pool scans were performed and indium-111 antimyosin was injected. Forty-eight hours later antimyosin scans were obtained and control gated blood pool scans were performed. Left ventricular ejection fraction was higher after the race (65 +/- 5 vs 60 +/- 7%, p less than 0.01) due to a decrease in end-systolic counts. Right ventricular ejection fraction was lower after the race (42 +/- 7 vs 54 +/- 12%, p = 0.03) due to an increase in both end-diastolic and end-systolic counts. A longer systolic period was observed after the race (53 +/- 5% of the RR interval vs 39 +/- 3%, p = 0.005). No significant differences were observed in peak filling or peak emptying rates after the race. An increase in pulmonary blood volume (116% of control) was observed after the race. Antimyosin scans were normal in 7 athletes and minimal antimyosin myocardial uptake was seen in 3. Transient alterations in biventricular performance present after the race correspond to function adaptation to strenuous exercise and are not due to irreversible myocyte damage.