Rapid Diagnosis of an Ulnar Fracture with Portable Hand-Held Ultrasound

Orthopedic fractures are a common injury in operational activities, injuries that often occur in isolated or hostile environments. Clinical ultrasound devices have become more user friendly and lighter allowing them to be easily transported with forward medical teams. The bone-soft tissue interface has a very large acoustic impedance, with a high reflectance that can be used to visualize breaks in contour including fractures. Herein reported is a case of an ulnar fracture that was quickly visualized in the early phase of a multi-system trauma resuscitation with a hand-held ultrasound device. The implications for operational medicine are discussed

WSES guidelines for management of Clostridium difficile infection in surgical patients

In the last two decades there have been dramatic changes in the epidemiology of Clostridium difficile infection (CDI), with increases in incidence and severity of disease in many countries worldwide. The incidence of CDI has also increased in surgical patients. Optimization of management of C difficile, has therefore become increasingly urgent. An international multidisciplinary panel of experts prepared evidenced-based World Society of Emergency Surgery (WSES) guidelines for management of CDI in surgical patients.Peer reviewe

The effect of perturbations of the glycocalyx on microvascular perfusion in the obese trauma population: an in vitro study

Objectives Patients with morbid obesity have impaired responses to resuscitation following severe injury, which may contribute to adverse outcomes. Obesity is associated with microvascular dysfunction and metabolic changes associated with altered hemorheological profiles. These include decreased red blood cell (RBC) deformity associated with increased aggregation and adhesion. These RBC changes may be impacted by the glycocalyx layer of the endothelial cell (EC) and RBC. Degradation of either or both glycocalyx layers may impair microvascular perfusion. This was studied from blood obtained from patients with obesity and in an in vitro microfluidic device to mimic the microvascular environment.Methods RBCs were obtained from fresh whole blood from normal controls and patients with obesity (body mass index 37.6–60.0). RBC glycocalyx was indexed by fluorescent intensity and shedding of EC glycocalyx components into the serum was determined by measurement of syndecan-1 and hyaluronic acid. In a second set of experiments, human umbilical vein endothelial cell monolayers (HUVEC) were perfused with RBC suspensions from control and patients with obesity using a microfluidic device and RBC adherence under normoxic or shock conditions (hypoxia+epinephrine) was determined using confocal microscopy. HUVEC glycocalyx thickness and shedding were also measured.Results Microfluidic studies demonstrated that RBC obtained from subjects with obesity had increased adhesion to the endothelial layer, which was more profound under shock conditions versus normal subjects. This appeared to be related to increased shedding of the endothelial glycocalyx following shock as well as a diminished RBC glycocalyx layer in the obese population.Conclusion Blood from patients with obesity have decreased RBC glycocalyx thickness accompanied by evidence of increased EC glycocalyx shedding. In vitro adhesion to the endothelium was more pronounced with RBC from patients with obesity and was significantly greater under ‘shock conditions’. Hemorheological properties of RBC from patients with obesity may account for failure of standard resuscitation procedures in the trauma patient.Level of evidenc

Cleavage of SIgA by gram negative respiratory pathogens enhance neutrophil inflammatory potential

Secretory immunoglobulin A (SIgA), the principle immune defense at respiratory and other mucosal sites in the body, is highly dependant on its molecular structure for effective antibody function. Previous studies have demonstrated that gram-negative but not gram-positive isolates from patients with nosocomial pneumonia have IgA protease activity that contributes to the development of infection. We postulate that SIgA cleavage by bacteria would also affect anti-inflammatory properties of IgA and studied this in vitro. Sterile filtrates obtained from Pseudomonas, Acinetobacter, and methicillin resistant Staphylococcus aureus (MRSA) held in culture with SIgA were used to challenge polymorphonuclear neutrophils (PMNs) obtained from healthy volunteers. In a second group of experiments, blood monocytes were incubated with lipopolysaccharide (LPS) or LPS + IgA, and the resulting culture supernatants was used to stimulate PMNs in vitro. LPS-stimulated monocytes increased CD11b expression, O2-generation and elastase release by PMNs. Secretory IgA but not IgG abrogated this response. Cleavage of SIgA by the gram-negative respiratory isolates, Pseudomonas aeruginosa and Acinetobacter baumanii also led to the loss of cellular effector function noted with intact SIgA. Additionally, PMN cytotoxic potential was similar to that noted with PMNs treated with supernatant from LPS-stimulated monocytes. IgA cleavage by gram-negative respiratory isolates may lead to the development of pneumonia and the subsequent severity of the infection as a result of uncontrolled inflammatory responses by the host