St. Clare Hospital

The optimal dosing for enoxaparin venous thromboembolism (VTE) prophylaxis in low-weight trauma patients is unknown. Estimated blood volume (EBV) has shown promise as a dose modifier. To characterize the association of enoxaparin dose per EBV with the prevalence of VTE and bleeding in low-weight trauma patients. This was a retrospective study of trauma patients admitted over a 4-year period. Included patients were adults weighing <60 kg who received a minimum of 3 consecutive doses of enoxaparin. The primary endpoint was a comparison of enoxaparin dose per EBV in patients experiencing bleeding and VTE. Secondary endpoints included comparisons of dose per body mass index (BMI) and total body weight (TBW) and the ability of dose per EBV to predict clinical endpoints. Subgroup analyses for patients weighing <50 kg were performed for all endpoints. A total of 189 patients were included. Statistical comparisons for VTE were not performed because of low prevalence. The dose of enoxaparin per EBV was not statistically different between patients who did and did not bleed in all analyses. Doses per BMI and TBW were also not statistically different between the groups. In patients weighing <50 kg, numerically higher doses per EBV, BMI, and TBW were noted in patients that bled versus those that did not. Enoxaparin dose per EBV was not a statistically significant predictor of bleeding in logistic regression models. No significant associations between enoxaparin dose per EBV, BMI, or TBW and bleeding were noted in the study. Future analyses of EBV and other dose modifiers should consider inclusion of patients weighing <50 kg.

Introduction: Gallstone ileus is an anatomical mechanical obstruction of the small bowel that is induced by a gallstone also known as gallstone ileus. The pathophysiology includes the migration of a gallstone out of the gallbladder, where the pressure of the stone can create a passage, such as a cholecystoenteric fistula, and can therefore result in SBO. Case Description/Methods: A 74-year-old female presented to the emergency department complaints of 3 day history of nausea, vomiting, left lower quadrant pain, bloating & flatus. Patients vomiting was un-relenting despite electrolytes and OTC medications. On presentation she had significant left upper quadrant tenderness and hypoactive bowel sounds. She had a low-grade temperature; with stable vitals. Labs & Imaging: AST 22 U/L, ALT 19 U/L, Total Bilirubin 0.5 mg/dL, ALP 134 U/L, WBC 12.46 10^3/uL. Image: CT of the abdomen/pelvis without contrast showed “mid to distal small bowel obstruction most likely secondary to gallstone ileus”. Management & post-surgery: IVFs, NPO and Anti-emetics. GI consulted and Surgery consulted. Laparoscopic assisted enterotomy and removal of 3.5 cm gallstone with primary repair of small bowel enterotomy lysis of adhesions. The dilation of the bowel significantly improved thereafter, and the patient tolerated the procedure well. Specimen analysis confirmed findings as gallstone. 3 months post-surgery patient has been doing well with no further complications or surgical interventions. Discussion: Less than 1% of intestinal obstruction are derived from this etiology[1]. A review of Gallstone ileus cases across the nation from 2004-2009 indicated that the incidence is only 0.095%[2]. The associated mortality rate is around 15-18%[3]. Cholesterol gallstone created a fistula allowing air to enter the biliary tree, classic presentation of Rigler’s triad: pneumobilia, small bowel obstruction, and a gallstone 5. This is more of an anatomical obstruction rather than an actual ileus. The surgical approach of the obstruction is the mainstay of the treatment: (1) simple enterolithotomy; (2) enterolithotomy, cholecystectomy and fistula closure; and (3) enterolithotomy with cholecystectomy performed later 1. The biggest controversy in the past has been, if a biliary surgery be carried out at the same time or at a later stage. In this patient management with simple enterolithotomy was proven successful.Figure 1:: CT images of Gallstone Ileus and Gross Appearance of Gall stone

Using archaeological and textual evidence, this chapter discusses the nature and prevalence of infectious disease in early Palestine. An analysis of the human bones from Palestinian tombs, in particular the ones relating to the urban sites of Jerusalem and Jericho, demonstrates a high level of subadult deaths especially of infants. Those socially and economically advantaged were equally at risk with those less well off when faced with an aggressive and persistent pathogen, as evidenced by the Akeldama tombs containing the remains of the wealthy. In one tomb, poor maternal health is suggested by the long-bone measurements of new-born infants, which are well below the norm for the period. And in another tomb (Tomb of the Shroud) both leprosy and tuberculosis were identified in a high-class man, possible a priest. Yet another Akeldama tomb revealed the remains of a man severely infected by the hydated tapeworm Echinococcus granulosus. Malaria is described by Josephus with reference to a Hasmonean king in the first century BCE, but there is no evidence that it was a serious problem in the first century, and certainly there is no evidence for the deadly falciparum form.

Point-of-care (POC) glucometers are commonly used in intensive care units (ICUs). The Centers for Medicare & Medicaid Services have called into question the accuracy of POC glucometers in critically ill patients. This study sought to identify specific characteristics within our facility's ICU patients that were associated with inaccuracies in POC glucose measurements. We conducted a prospective cohort study that compared POC capillary blood glucose samples with venous samples collected in our ICU. All nonpregnant patients >18 years old admitted to the ICU with orders for daily laboratory testing that included blood glucose were eligible for inclusion. A total of 46 patients were enrolled and 85 samples were collected. The mean difference between venous and POC samples was 5.23 mg/dL (95% CI, 3.16-7.3 mg/dL). Measurement inaccuracies would have altered treatment in 7/85 instances (8.2%). The only clinically significant inaccuracy found was the omission of 2 units of insulin in 1 hyperglycemic patient. Measurement inconsistencies generally underestimated low blood glucose values (2/2 instances) and overestimated high blood glucose values (4/5 instances). In our study, the mean difference between venous and POC glucose samples was small. Similarly, measurement inaccuracies that would have altered treatment were rare and only one instance was deemed clinically significant. We conclude that POC capillary glucose testing within our cohort and in similar critically ill patients is likely safe and effective.

Perilunate dislocations are uncommon high-energy injuries which are missed in approximately 25% of cases on initial presentation.1 We present the X-rays of a 25-year-old man who fell from a height of approximately 2 metres onto an extended wrist. Plain radiographs (figure 1) show classical signs of a trans-scaphoid perilunate fracture dislocation. Pre-reduction, he had median nerve symptoms which settled with reduction and elevation. Reduction was performed in the emergency department with analgesia/sedation. Figure 1 Posteroanterior and lateral pre-reduction radiographs of the wrist. The sequence of events in this injury is well described: (1) the …

ABSTRACTQualitative metasynthesis (QM) is a research methodology that permits the meaningful integration and interpretation of qualitative research. This study applies a QM approach combined with constructivist grounded theory methods, bolstered by several features of research credibility, to examine the state of consultee-centered consultation (CCC) and related relational, process-oriented school consultation research. A systematic search and retrieval process including two rounds of appraisal resulted in a final sample of 38 relevant studies from 1995 to 2014. Data analyses included two stages of coding/theme development. Integrated themes suggest a number of considerations regarding consultation implementation including: system-level factors; consultation structure; consultee voice, social-emotional support, and learning; ecological orientation and cultural responsiveness; and consultation training. Future research priorities stemming from these themes are identified and elaborated upon, as are future applications for QM in educational research.

More than 5.2 million American Indian and Alaska Native (AI/AN) people live in the United States today (1). Spread mostly throughout the western United States and Alaska, many live mainly on or near reservations and rural communities. The AI/AN population is incredibly diverse, representing 566 federally recognized tribes (2). AI/AN people are disproportionately affected by diabetes. According to the U.S. Department of Health and Human Services Office of Minority Health, AI/AN adults are more than twice as likely as white adults to be diagnosed with diabetes, and AI/AN women are 2.3 times more likely than non-Hispanic whites to die from diabetes (3). At nearly 16%, the age-adjusted prevalence of diabetes in the AI/AN population is the highest of all U.S. racial and ethnic groups (4). In some communities, >50% of AI/AN adults have type 2 diabetes (5). In addition, this population has long experienced lower health status than other Americans, including a lower life expectancy and disproportionate disease burden, which may be attributed to inadequate education, disproportionate poverty, discrimination in the delivery of health services, and cultural differences rooted in economic adversity and …

Repair of interstrand crosslinks (ICLs) requires the coordinate action of the intra-S phase checkpoint and the Fanconi Anemia (FA) pathway, which promote ICL incision, translesion synthesis, and homologous recombination (reviewed in 1,2). Previous studies have implicated the 3′-5′ superfamily 2 helicase HELQ/Hel308 in ICL repair in D. melanogaster (known as Mus301 or Spn-C3) and C. elegans (known as Helq-1 or Hel-3084). While in vitro analysis suggests that HELQ preferentially unwinds synthetic replication fork substrates with 3′ ssDNA overhangs and also disrupts protein/DNA interactions while translocating along DNA5,6, little is known regarding its functions in mammalian organisms. Here we report that HELQ helicase-deficient mice exhibit subfertility, germ cell attrition, ICL sensitivity and tumour predisposition, with HelQ heterozygous mice exhibiting a similar, albeit less severe, phenotype than the null, indicative of haploinsufficiency. We establish that HELQ interacts directly with the RAD51 paralog complex, BCDX2, and functions in parallel to the FA pathway to promote efficient HR at damaged replication forks. Thus, our results reveal a critical role for HELQ in replication-coupled DNA repair, germ cell maintenance and tumour suppression in mammals.

Financing cathedral building in the Middle Ages. The generosity of the faithful. By Wim Vroom (translated by Elizabeth Manton). Pp. 734 incl. 93 ills and 14 graphs. Amsterdam: Amsterdam University Press, 2010. £65. 978 90 8964 035 2 - Volume 62 Issue 4