Trauma Hospital of Brno

El síndrome de intestino corto (SIC) se define anatómicamente como la presencia de menos de 200 cm de intestino delgado residual o menos, aunque algunos sugieren que 150 cm o menos puede ser más apropiado, medido a partir del ángulo duodeno-yeyunal, independientemente de la presencia o ausencia de colon, existiendo tres tipos dentro de los cuales el de mayor morbimortalidad es el SIC tipo I. El presente trabajo tiene como objetivo describir el manejo integral de un paciente con síndrome de intestino corto y yeyunostomía de alto débito, enfocado en la corrección del desequilibrio hidroelectrolítico, el manejo de la dermatitis periostomal, y la optimización de la absorción intestinal a través de intervenciones nutricionales y farmacológicas, así como evaluar los resultados clínicos obtenidos tras un tratamiento hospitalario. El paciente era una masculino de 50 años, con antecedente de un tumor mesentérico diagnosticado hace dos meses, el cual fue manejado quirúrgicamente mediante una resección tumoral que presento como complicacion una necrosis intestinal que termino con una yeyunostomía terminal y complicaciones relacionadas debido a su alto débito. El manejo SIC presenta múltiples desafíos debido a las complicaciones relacionadas con la reducción de la superficie de absorción intestinal, el tránsito acelerado de nutrientes, y la alteración en el equilibrio de líquidos y electrolitos. La gravedad del cuadro clínico depende de la longitud del intestino remanente, la ubicación de la resección y la integridad del intestino restante. Factores como la hipersecreción gástrica, las deficiencias nutricionales y las alteraciones en la microbiota intestinal contribuyen a la complejidad del tratamiento.

Abstract BackgroundReducing antimicrobial resistance is a global priority that become even more important after the COVID-19 pandemic. To date there is a scarce volume of evidence from antimicrobial stewardship programs from less resourced settings where this phenomenon is bigger. Our aim was to improve the quality of antibacterials prescription in intensive care units (ICUs) in a middle-income country.MethodsWe established a quality improvement collaborative (QIC) model involving nine ICUs over an 11-month period, with a 16-week baseline (BP) and 32-week Intervention (IP) periods. Our co-designed intervention package included audits and feedback on antibacterial use, facility-specific treatment guidelines, antibacterial timeouts, pharmacy-based interventions, and education. The intervention was delivered in two learning sessions with three action periods, along with coaching support and basic quality improvement training.ResultsWe enrolled 912 patients, with 357 in baseline period (BP) and 555 in implementation period (IP). The latter had higher APACHE II (17 (12, 21) vs. 15 (11, 20); p=0.036) and SOFA scores (6 (4, 9) vs. 5 (3, 8); p=0.006), sepsis (36.1% vs. 31.6%, p<0.001), and septic shock (40.0% vs. 33.8%, p<0.001). Days of antibacterial therapy were similar between groups (IP 1112.2, BP 1133.4, RR 0.98 (0.95-1.02); p=0.2973) and the antibacterial Daily Define Dose was lower in IP group (IP, 1193.0; BP, 1301.0; RR, 0.92 (0.89, 0.95); p=0.0001). The rate of adequate antibacterial adjustment was higher during the IP (62.0% vs. 45.3%, p<0.001). We observed a lower rate of ventilation-associated pneumonia and catheter-associated urinary tract infections related to multidrug-resistant organisms (MDRO) in the IP. There was a noticeable improvement in the Infection Prevention and Control (IPC) Assessment Framework compared to baseline.ConclusionThe implementation of a post pandemic antimicrobial stewardship program in ICUs via a QIC demonstrated success in improving antibacterials utilization, reducing HAIs related to MDRO while also enhancing IPC measures.What is already known on this topicHealthcare-associated infections represent a global healthcare issue, particularly prevalent in low- and middle-income countries, where their occurrence is nearly three times higher.Approximately 50% of antimicrobial use is deemed unnecessary or inappropriate, necessitating the development of widely accessible stewardship methods.The misuse and overuse of antibacterials adversely affect patients admitted to intensive care units (ICUs).Further research is urgently required to determine the most effective ways to implement ASPs in LMICs.What this study addsBy establishing a quality improvement collaborative (QIC), we showcased an improvement in antibacterial utilization within ICUs in a low- to middle-income country.Additionally, a reduction in healthcare-associated infections is evident.Moreover, the QIC effectively strengthened the capabilities of infection control and prevention in participating ICUs.How this study might affect research, practice, or policyThis study is among the initial endeavors in a middle-income country to evaluate the efficacy and essential strategies for establishing antimicrobial stewardship programs.This study could serve as a foundational reference for upcoming teams aiming to introduce similar programs in the region.

-

Background The definition of an aneurysm is a dilation of an artery more than 1.5 to 2 times its normal diameter. Visceral (or splanchnic) artery aneurysms include those concerning the celiac truncus, superior mesenteric artery, inferior mesenteric artery, and their branches. This classification does not include aortic and renal artery aneurysms. It is a rare, but clinically significant pathology because of the high mortality risk. Despite this rarity, cases have been accumulated and this pathology is better understood. Novel techniques for the management of aneurysms have been developed with the advent of interventional radiology. However, our case concerns the emergent surgical repair of a ruptured aneurysm, rather than the elective repair. Case presentation The 61-year-old female patient complains of diffuse, intermittent abdominal pain lasting for almost one week. On the last day the patient suffers from excruciating abdominal pain and is brought to the emergency department. Objective evaluation shows pallor, diaphoresis, low blood pressure, tachycardia and abdominal guarding in all quadrants. An abdominal ultrasound spots the presence of free fluid in all recesses. A diagnostic peritoneal needle aspiration shows pure blood. AB0 and Rhesus blood type is identified and the patient is prepared for the operating theatre. Following a laparotomy, peritoneal lavage, a rupture of gastro-duodenal aneurysm is identified and the artery is ligated in its origin. The patient tolerated the procedure well and was discharged in good health. Discussion Rare case reports in literature have reported Gastro-duodenal artery aneurysms. Because of this rarity in incidence there is no clear protocol on how to diagnose and manage it. Possible risk factors and associated conditions include: chronic pancreatitis, liver cirrhosis, vascular abnormalities as fibromuscular dysplasia and polyarteritis nodosa. Other events and diseases such as trauma, septic emboli, hypertension and atherosclerosis are also mentioned. The main symptoms of visceral artery aneurysms, with or without rupture are abdominal pain, hypotension, gastric emptying delay and other non-specific manifestations such as vomiting, diarrhoea, jaundice, upper gastro-intestinal tract haemorrhage (which occurs in about 50% of the cases with gastro-duodenal artery aneurysms) and retro and intra-peritoneal bleeding. Conclusion The rupture of gastro-duodenal artery is a serious fatal presentation of a rare condition. It requires high alertness and decisive action, as warning signs and symptoms may be dull or absent. Quick diagnosis before rupture can change the course of this disease and prevent lethal complications. As this disorder is so uncommon, there are no specific screening or follow-up recommendations. Treatment and diagnostic options should be decided on a case basis. Keywords: General Surgery, Visceral Artery Aneurysm, VAA, Splanchnic Aneurysm, Aneurysm Rupture. DOI: 10.7176/JEP/14-8-02 Publication date: March 31 st 2023

Background Intrahepatic cholangiocarcinoma is an aggressive primary cancer of the liver with limited systemic therapeutic options. Surgical resection may be the only feasible option. It has an overall low incidence among gastrointestinal tumours (3%), and is the second most common cancer of the liver after hepatocellular type. Most patients diagnosed are asymptomatic, however the most common complaint is abdominal pain and other less common non-specific symptoms such as weight loss. Case presentation Our patient is a 72 years old male with the following medical history and presentation: 5 years prior he is diagnosed with adenocarcinoma of the stomach, antro-pyloric region. A 4/5 gastric resection and gastro-entero anastomosis, Braun anastomosis with D2 lymphatic curage without splenectomy was performed. Examinations show a hepatic lesion of segments II – III. A fibrogastroscopy and colonoscopy result normal. By means of puncture-biopsy a diagnosis of cholangiocarcinoma is established. The patient undergoes a left hepatectomy (Réglée) after he receives a chemotherapy course. His post-operative course was uneventful and was discharged in good health. Discussion This specific case posed a diagnostic challenge, knowing his past history for adenocarcinoma of the stomach 5 years prior. Abdominal pain and weight loss lead to a cross sectional imaging detection of a hypovascular lesion of liver segments II – III. Careful evaluation with gastroscopy and colonoscopy, along with puncture biopsy was needed to determine whether it was a metastasis or a primary tumour. In contrast to other intrahepatic tumors like hepatocellular carcinoma, therapeutic methods for intrahepatic cholangiocarcinoma are still being developed due to its rarity. Hepatic resection does, however, have a most important place in the treatment of patients. Conclusion Intra-hepatic cholangiocarcinoma remains a difficult condition in terms of diagnosis, surgical decision-making and survivability. However multiple studies confirm the role of surgical resection R0 with lymphadenectomy. Lymphatic permeation, vascular invasion, and intrahepatic satellite lesions were acknowledged as predictors of poor survival. Other treatment options such as chemotherapy and tumor ablation or embolization are still controversial with respect to their survival benefit, but can provide a role in select cases. Keywords: General Surgery, Hepatobiliary Surgery, Cholangiocarcinoma, Adenocarcinoma, Hepatectomy. DOI: 10.7176/JEP/14-5-04 Publication date: February 28 th 2023

Předkládaná kazuistika prezentuje případ pacientky s chronickým průběhem schizofrenní poruchy, odkázané na invalidní důchod, silněizolované od společnosti. Díky placenému programu pracovní rehabilitace se u pacientky podařilo natolik zrekonstruovat pracovní návyky,že bylo možné ji následně na částečný úvazek zaměstnat na otevřeném trhu práce. Na začátku a konci programu pracovní rehabilitace bylysledovány psychopatologické symptomy poruchy a byla hodnocena subjektivně prožívaná kvalita života.

Patients with Gaucher type 1 (GD1) throughout Argentina were enrolled in the Argentine bone project to evaluate bone disease and its determinants. We focused on presence and predictors of bone lesions (BL) and their relationship to therapeutic goals (TG) with timing and dose of enzyme replacement therapy (ERT). A total of 124 patients on ERT were enrolled in a multi-center study. All six TG were achieved by 82% of patients: 70.1% for bone pain and 91.1% for bone crisis. However, despite the fact that bone TGs were achieved, residual bone disease was present in 108 patients on ERT (87%) at time 0. 16% of patients showed new irreversible BL (bone infarcts and avascular osteonecrosis) despite ERT, suggesting that they appeared during ERT or were not detected at the moment of diagnosis. We observed 5 prognostic factors that predicted a higher probability of being free of bone disease: optimal ERT compliance; early diagnosis; timely initiation of therapy; ERT initiation dose ≥45 UI/kg/EOW; and the absence of history of splenectomy. Skeletal involvement was classified into 4 major phenotypic groups according to BL: group 1 (12.9%) without BL; group 2 (28.2%) with reversible BL; group 3 (41.9%) with reversible BL and irreversible chronic BL; and group 4 (16.9%) with acute irreversible BL. Our study identifies prognostic factors for achieving best therapeutic outcomes, introduces new risk stratification for patients and suggests the need for a redefinition of bone TG. Am. J. Hematol. 91:E448-E453, 2016. © 2016 Wiley Periodicals, Inc.