A woman in her late 70s presented to the acute general surgical take with a 3-day history of worsening right leg pain and swelling. She had undergone right revision total hip arthroplasty 20 months previously and reported chronic postoperative right thigh pain attributed to a femoral deep venous thrombosis for which she had been warfarinised. On examination, Grey Turner's sign (bruising of the flanks indicating retroperitoneal haemorrhage) was present, as well as a large tender mass in the right iliac fossa and pitting oedema throughout the right lower limb. Urgent CT scan with intravenous contrast revealed a right retroperitoneal haematoma secondary to a right acetabular screw protruding into the right external iliac vein. The patient was successfully managed with warfarin reversal and surgical removal of the relevant acetabular screw. At 2-month follow-up, the patient's symptoms continue to resolve.

PURPOSE:

Management of severe pre-eclamptic patients is a challenge for the staff on obstetrical wards. We demonstrate that ultrasound applied to several organs performed at a patient's bedside gave the information required for the patient's management, without the need to transfer her to the radiology department or to call external consultants. CLINICAL FEATURES: A 29-yr-old severely pre-eclamptic patient with HELLP syndrome (hemolysis, cytolysis, thrombopenia) presented, in the post-partum period, with an occult uterine hemorrhage diagnosed with bedside abdominal/pelvic ultrasound. Ultrasound was also used to insert a central venous catheter. After undergoing a hysterectomy to control hemorrhage and receiving activated factor VII, the patient recovered uneventfully. Hemodynamic management was optimized non-invasively using pulmonary and cardiac ultrasound, when the patient developed hemorrhagic shock followed by pulmonary edema. Volume replacement was guided by cardiac ultrasound findings, and we were able to detect incipient interstitial pulmonary edema and follow its course using pulmonary ultrasound.

CONCLUSION:

Practitioners must be aware of the role of whole-body ultrasound in the diagnosis and treatment of complex, multi-organ conditions such as pre-eclampsia. Moreover, ultrasound helps in the management of global hemodynamics. The training of anesthesiologists in a variety of ultrasound techniques should be encouraged.

Because tumor necrosis factor-alpha (TNF-α) induces many of the pathophysiological signs and symptoms observed in sepsis, it is a potential therapeutic target for treatment. The primary objective of this study was to assess the safety, tolerability, pharmacokinetics, and pharmacodynamics of single and multiple intravenous (i.v.) infusions of two doses of AZD9773 in Japanese patients with severe sepsis and/or septic shock. In this Phase II, double-blind, placebo-controlled, dose-escalation study (ClinicalTrials.gov Identifier: NCT01144624), Japanese patients were randomized to two successive treatment cohorts (cohort 1, loading/maintenance doses of 250/50 U/kg or placebo; cohort 2, loading/maintenance doses of 500/100 U/kg or placebo) for a 5-day treatment period, then a follow-up period to day 29. Twenty patients were enrolled (AZD9773 cohort 1, n = 7; AZD9773 cohort 2, n = 7; placebo, n = 6), and all completed the study. Most treatment-emergent adverse events (TEAEs) were mild or moderate and none led to discontinuation. The most common TEAEs in the AZD9773 cohorts were pleural effusion (64.3 %) and peripheral edema (28.6 %). Pharmacokinetic data demonstrated an approximately proportional increase in concentration with increasing dose. Treatment with AZD9773 led to a decrease in TNF-α concentrations, which was more discernible in the AZD9773 cohort 2; TNF-α concentrations generally decreased with time in patients receiving placebo. A similar pattern of response was observed with interleukin-6 (IL-6) and IL-8. AZD9773 was generally well tolerated with dose-proportional pharmacokinetics in Japanese patients with severe sepsis/septic shock.

The present study developed a combined ball milling-aqueous swelling (CBMAS) pretreatment to accelerate the hydrolysis of corncob. The enzymatic hydrolysis of microcrystalline cellulose carried out in the plates and flasks indicated that the response of enzymatic hydrolysis to CBMAS was quite evident. The fermentable reducing sugars of hydrolysates from CBMAS-pretreated corncob was 59.8g/L, which was 1.3 and 1.7 folds higher than those from diluted acid and alkaline pretreated corncob hydrolysates, respectively. Simultaneous CBMAS pretreatment and enzymatic hydrolysis was also conducted, reducing the processing time from 66h to 28h. The enzymatic hydrolysates from CBMAS-pretreated corncob could be directly utilized as the substrate for butanol fermentation without detoxication. Under the optimal conditions, fermentable sugars in the corncob hydrolysate were completely consumed to generate 9.52g/L butanol.

STRUCTURED

ABSTRACT:

: Study Design. Case report.

Objective.

To present a case of primary hydatid cyst in the lombar subcutaneous tissue affecting posterior paravertebral muscle and mimicking disc herniation.Summary of Background Data. Cystic Hydatid Disease is a rare but significant parasitic disease in endemic areas. Musculoskeletal or soft tissue hydatidosis accounts for about 0,5-5% of all echinococcal infections in endemic areas and is almost secondary to the hepatic or pulmonary disease. Primary lomber subcutaneous hydatid cyst affecting paravertebral muscle and extending to neural foramina is a very rare condition even in endemic areas.Methods. A 25 year-old female patient was admitted with swelling and pain in the right lumbar region for three months. The pain was reflecting in the right gluteal region and the right leg. Lumbar extension and right lateral flexion was painful and straight leg raising test was positive at right side. There was a mild hypoesthesia at L5 dermatome. According to the magnetic resonance imaging which the clinician requested for initial diagnosis of lumbar disc herniation we find multi-cystic masses located at the right paravertebral muscle at the level of L3-5 and extends to L4-5 neural foramina and at subcutaneous tissue at the riht gluteal region.

Results.

The patient was operated for the purpose of removal of cysts. Postoperatively, diagnosis of hydatid cyst was confirmed by histopathology.

Conclusion.

By this case, we emphasize that cystic hydatid disease should be taken into consideration in the differential diagnosis of low back pain and could mimic disc herniation.

The aim of this study was to prepare electrospun chitosan-based nanofiber mats and to incorporate the fruit hull of Garcinia mangostana (GM) extracts into the mats. Chitosan-ethylenediaminetetraacetic acid/polyvinyl alcohol (CS-EDTA/PVA) was selected as the polymers. The GM extracts with 1, 2 and 3% wt α-mangostin were incorporated into the CS-EDTA/PVA solution and electrospun to obtain nanofibers. The morphology and diameters of the mats were analyzed using scanning electron microscopy (SEM). The mechanical and swelling properties were investigated. The amount of GM extracts was determined using high-performance liquid chromatography (HPLC). The antioxidative activity, antibacterial activity, extract release and stability of the mats were evaluated. In vivo wound healing tests were also performed in Wistar rats. The results indicated that the diameters of the fibers were on the nanoscale and that no crystals of the extract were observed in the mats at any concentration. The mats provided suitable tensile strength and swelling properties. All of the mats exhibited antioxidant and antibacterial activity. During the wound healing test, the mats accelerated the rate of healing when compared to the control (gauze-covered). The mats maintained 90% of their content of α-mangostin for 3 months. In conclusion, the chitosan-based nanofiber mats loaded with GM extracts were successfully prepared using the electrospinning method. These nanofiber mats loaded with GM extracts may provide a good alternative for accelerating wound healing.

Hyperbaric oxygen (HBO) therapy is reported to attenuate pain in both clinical pain conditions and animal pain models, but the underlying mechanism remains to be investigated. Here, we show that 7 daily 60-minute HBO (100% oxygen, 2 atmosphere absolute) treatments effectively and persistently inhibited heat hyperalgesia, mechanical allodynia, and paw edema induced by peripheral injection of complete Freund's adjuvant (CFA). Five daily 60-minute HBO treatments also produced a prolonged reversal effect of the ongoing inflammatory pain. Furthermore, such an HBO treatment reduced CFA-induced activation of glial cells, phosphorylation of mitogen-activated protein kinases, and production of a variety of proinflammatory cytokines (tumor necrosis factor alpha [TNF-α], interleukin-1 beta [IL-1β], and interleukin-6 [IL-6]) and chemokines (monocyte chemoattractant protein-1 [MCP-1], keratinocyte-derived chemokine [KC], and IFN-gamma-inducible protein 10 [IP-10]) in the spinal cord. HBO treatment also decreased lipopolysaccharide-induced mRNA expression of these cytokines and chemokines in primary cultures of astrocytes and microglia. In addition, the mRNA expressions of IL-1β, IL-6, MCP-1, KC, and IP-10 in the inflamed paw skin were decreased by HBO. Taken together, these data suggest that HBO treatment is an effective therapy for inflammatory pain in animals. The inhibition of the neuroinflammation that is mediated by glial cells and inflammatory mediators may, at least in part, contribute to the antinociceptive effect of HBO therapy. PERSPECTIVE: Our results suggest that repetitive HBO treatment attenuates CFA-induced pain and reduces glial activation and inflammatory mediators' production. These findings provide the evidence of the antinociception effect of HBO on inflammatory pain and characterize some of the underlying mechanisms.

The aim of our study was to develop a model of high altitude cerebral edema (HACE) using an acute, hypobaric hypoxia environment combined with exhaustive exercise. Forty healthy male Sprague-Dawley rats were randomly divided into a plains control group (PC group) and a plateau altitude hypoxia group (AH group). After 2 days of treadmill adaptation under normoxic conditions, the AH group was housed in hypobaric conditions (simulating 4000m above sea level) for 2 days while performing exhaustive exercise. The simulated altitude was then increased to 8000m for 3 days of simple hypobaric hypoxia exposure. Compared with the PC group, the AH group showed significantly greater (P<0.01) water content and Evans blue staining in their brain tissue. Furthermore, the hippocampal formation was seriously damaged, and the number of pyramidal cells decreased. In addition, the brain structure was altered into a loose state with notable edema, which was demonstrated by the leakage of lanthanum nitrate particles from brain microvessels into the surrounding tissue through widened tight junctions. Some neurons and glial cell organelles were swollen and some nerve fibers were demyelinated as well. We have shown that acute hypobaric hypoxia exposure with exhaustive exercise increases the permeability of the blood-brain barrier and leads to cerebral edema, making this a valid animal model of HACE.

The recent outbreak of hantavirus in Yosemite National Park has attracted national attention, with 10 confirmed cases of hantavirus cardiopulmonary syndrome and thousands of more people exposed. This article will review the epidemiology, presentation, workup, and treatment for this rare but potentially lethal illness. The possibility of infection with hantavirus deserves consideration in patients with severe respiratory symptoms with rodent exposure or rural/wilderness travel. Accurate diagnosis requires a high index of suspicion. Hantavirus cardiopulmonary syndrome presents as a vague prodrome of fever, cough, myalgias, chills, and nausea followed by a rapidly worsening respiratory phase. Presumptive diagnosis can be made based on pulmonary interstitial edema on chest radiographs in association with leukocytosis, thrombocytopenia, and hemoconcentration. Suspected cases should be confirmed with a reference laboratory and reported to the appropriate public health authorities. Although treatment is primarily supportive, aggressive fluid administration should be avoided due to the risk of pulmonary edema. The cardiopulmonary phase of the disease can progress rapidly with catastrophic decompensation in as little as a few hours. Patients require rapid intensive care unit admission for monitoring, mechanical ventilation, vasoactive agents, and possibly extracorporeal mechanical ventilation. Emergency physicians should be aware of outbreaks and vigilant for hantavirus exposures, especially during the summer and early fall months.