Cashing in on Seafood

Stephen Heard graduated from the University of Rhode Island in 1970 with a degree in business administration. He started his career by signing up as a management trainee at Woolworth’s Department Store in Wellesley, Massachusetts. It didn’t take him long to realize he missed his calling: being by the Rhode Island shoreline and employed in the fishing industry. Nearly 35 years later, Stephen is a self-made multimillionaire, having followed both his passion for entrepreneurship and for living his life on the Atlantic coast

Management of a Patient with an Encapsulated Parapneumonic Empyema Complicated by the Intraoperative Development of an Acute Bronchopleural Fistula and ARDS

We report the use of independent lung ventilation (ILV) in a patient with severe underlying parenchymal disease who developed bronchopleural fistula (BPF) after thoracotomy and decortication of an empyema with subsequent development of acute respiratory distress syndrome (ARDS). While a great majority of patients with either ARDS or BPF can be successfully managed with conventional ventilation strategies, the additional management challenges presented by BPF in the setting of ARDS and sepsis often necessitate the utilization of alternative ventilation strategies such as ILV, high frequency ventilation (HFV), and extracorporeal support

Ecospirituality in Forensic Mental Health: A Preliminary Outcome Study

Background: In this study, the personal experience of spirituality in nature (the concept of ecospirituality) was supported by occupational therapy and spiritual care staff enabling a community-based group for persons affiliated with a forensic mental health system in Ontario, Canada. Spirituality is a key, though debated, tenet in occupational therapy practice. At the same time, immersive participation in nature has been linked to positive health outcomes. Methods: A qualitative method consistent with Interpretative Phenomenological Analysis was employed. Data was collected via the completion of semi-structured interviews (n = 9). Collected data was transcribed verbatim and then coded for themes by multiple coders. Several methods were employed to support trustworthiness. Results: Results identified that participation in the ecospirituality group enabled the participants to feel an enhanced connection with nature and an opportunity for unguarded reflection and relaxation. The participants described a regenerative and restorative experience, including a sense of peace and connection with the personally sacred. Enhanced resiliency and meaningful connection with others also were identified. Conclusion: Recommendations related to outcomes are identified. These include a focus on enhanced access to natural environments for individuals involved in mental health systems. Just as importantly, the opportunity for personal agency and autonomy in those settings appears indicated

Case Report on Morbidly Obese Patient with Cervical Spine Ankylosing Spondylitis Presenting with Acute Spinal Shock and Complex Airway Management

A 67 year old morbidly obese male presented to the ER with weakness in both lower extremities after a fall at home. The patient sustained a T12/ L1 unstable vertebral fractures and cord compression at the thoracolumbar junction with acute traumatic paraplegia. The patient arrived in the PACU on a backboard and with a cervical collar in place directly from the ER. The review of the patient’s chart revealed that he had a history of hypertension, PE / DVT on coumadin, hypothyroidism, NIDDM, bipolar disorder and cervical spine ankylosing spondylitis of his neck. On physical exam the patient was sleepy, but arousable and unable to move his lower extremities, with loss of bladder and bowel control. There was one 20 G IV in place. The airway exam revealed Mallampati Class 4. The patient was hemodynamically unstable with BP ~80/~40 mm HG; HR ~70’s/min; SpO2 ~86-88%. Resuscitation commenced immediately. The patient was started on face mask @ 10 l/m O2. One liter of normal saline was administered with minimal effect. A phenylephrine infusion was started. The blood pressure improved to SBP of 120’s mm Hg. The O2 saturation increased to 95%. A methylprednisone drip (30mg/kg iv bolus) was started for treatment of his spinal cord injury. For additional IV access, another 20G IV was placed. Two units of FFP were given to normalize the INR of 2.4. After multiple attempts, a right radial arterial catheter was successfully placed. A right internal jugular (RIJ) central venous catheter was inserted under ultrasound guidanc

Anti-inflammatory activity of Punica granatum L. (Pomegranate) rind extracts applied topically to ex vivo skin

Coadministered pomegranate rind extract (PRE) and zinc (II) produces a potent virucidal activity against Herpes simplex virus (HSV); however, HSV infections are also associated with localised inflammation and pain. Here, the objective was to determine the anti-inflammatory activity and relative depth penetration of PRE, total pomegranate tannins (TPT) and zinc (II) in skin, ex vivo. PRE, TPT and ZnSO4 were dosed onto freshly excised ex vivo porcine skin mounted in Franz diffusion cells and analysed for COX-2, as a marker for modulation of the arachidonic acid inflammation pathway, by Western blotting and immunohistochemistry. Tape stripping was carried out to construct relative depth profiles. Topical application of PRE to ex vivo skin downregulated expression of COX-2, which was significant after just 6 h, and maintained for up to 24 h. This was achieved with intact stratum corneum, proving that punicalagin penetrated skin, further supported by the depth profiling data. When PRE and ZnSO4 were applied together, statistically equal downregulation of COX-2 was observed when compared to the application of PRE alone; no effect followed the application of ZnSO4 alone. TPT downregulated COX-2 less than PRE, indicating that tannins alone may not be entirely responsible for the anti-inflammatory activity of PRE. Punicalagin was found throughout the skin, in particular the lower regions, indicating appendageal delivery as a significant route to the viable epidermis. Topical application of TPT and PRE had significant anti-inflammatory effects in ex vivo skin, confirming that PRE penetrates the skin and modulates COX-2 regulation in the viable epidermis. Pomegranates have potential as a novel approach in ameliorating the inflammation and pain associated with a range of skin conditions, including cold sores and herpetic stromal keratitis

Co-administration of fish oil with signal transduction inhibitors has anti-migration effects in breast cancer cell lines, in vitro

Background: There is an urgent need for new therapies to treat cancer metastasis. Fish oil, with high omega 3 fatty acid content, has shown anticancer activity and signal transduction inhibitors have shown anti-metastatic properties. Objective: To provide preliminary in vitro data on the anti-migration potential of signal transduction inhibitors and co-administered fish oil. Methods: MCF-7, TamR and FasR breast cancer cell lines were used to determine the effects of combinations of PD98059, LY294002 and fish oil in growth assays. Modulations of p-Src and COX-2, both mediators of motility and invasion, were then determined by Western blotting and IHC to ascertain effects on migration potential. Results: Migration rates for the three cell lines examined were ranked: FasR>TamR>MCF-7 (p <0.05). Addition of fish oil reduced the number of TamR cells migrating after 48h (p <0.05), while the addition of PD98059 and LY294002 also decreased migratory potential of TamR cells (p <0.05). Addition of PD98059 and LY294002 to TamR cells did not result in a significant decrease in p-Src levels; as was the case when PD98059, LY294002 and 4-hydroxytamoxifen were added to MCF-7 cells. However, the co-administration of fish oil markedly reduced p-Src and COX-2 expression in both cell lines. Conclusion: Co-administration of a commercial fish oil with signal transduction inhibitors results in decreased cell migration via an unknown co-operative mechanism and could constitute a novel approach for the treatment of breast cancer metastasis

Post-Anesthesia Evaluation: Using a Systems Based Team Approach to Achieve Compliance with CMS Interpretive Guidelines

Introduction: In December of 2009 the Center for Medicare and Medicaid Services (CMS) issued Revised Anesthesia Services Interpretive Guidelines. The revised post-anesthesia evaluation rules require assessment and documentation within 48 hours from the time the patient is moved into the recovery area for patients (includes outpatients prior to discharge as well as all inpatients). It applies to all patients who have had monitored anesthesia services, regional or general anesthesia. It must be performed and documented by a practitioner who is qualified to administer anesthesia and can be completed at any time and location as long as the patient has recovered sufficiently from anesthesia to answer the key questions related to the evaluation. Required key elements include assessment of mental status, pain, nausea and vomiting, temperature, hydration, respiratory and cardiovascular status. We describe the systems based team approach we used to achieve compliance with the 93% or higher post-anesthesia evaluation set by CMS and The Joint Commission. Background: UMass Memorial is a multi-campus medical center (A: Ambulatory Surgery Center (ASC), C: Tertiary University site, B: Memorial).Annually we provide anesthesia coverage for approximately 37,000 patients at 43 anesthetizing locations (44% inpatients and 56% outpatient procedures). The spread of Anesthesiology resources over three sites and the resident work hour restrictions posed a challenge to ensure compliance with CMS requirements for post-anesthesia evaluation and documentation. Methods: With input from the Anesthesiologists at all three sites we designed a template form that captured the required elements of the post-anesthesia evaluation and became part of the patient medical record (figure 1). We also modified the discharge process from the Post Anesthesia Care Unit (PACU). Previously our patients were discharged when the Alderete criteria were met using a standardized post-anesthesia order set. We modified this post-anesthesia order set to add post-anesthesia evaluation and documentation to the discharge criteria (figure 2). The Peri-anesthesia staff (PACU and Surgical Admission unit) was educated about these changes. We implemented a visual clue by the patient stretcher in the PACU when the patient was discharge ready. A member of the Anesthesia team completed the evaluation and documentation prior to patient discharge from the PACU. Patients who were admitted directly to the ICU or were not seen in the PACU were seen the following day by a member of the group. We used a systems based team approach with the help of the Anesthesiology staff and Peri-anesthesia nursing to implement this process across all three campuses. Random monthly chart audits were performed by our Quality department to assess our compliance with these CMS revised guidelines (20 charts at each site per month). Conclusion: We were able to achieve an average compliance rate of 82 to 93% across the medical center (figure 3)

Treating infections caused by carbapenemase-producing Enterobacterales (CPE): a pragmatic approach to antimicrobial stewardship on behalf of the UKCPA Pharmacy Infection Network (PIN)

open access articleThe emergence of carbapenemase-producing Enterobacterales (CPE) as a major cause of invasive infection both within the UK and internationally poses a very real concern for all providers of healthcare. The burden of morbidity and mortality associated with CPE infections is well described. The need for early, targeted, effective and safe antimicrobial therapy remains key for the management of these infected patients yet reliable antimicrobial treatment options remain scarce. In the absence of a universal treatment for these CPE invasive infections, individual treatment options tailored to susceptibilities and severity of infection are required. This working group from within the UK Clinical Pharmacy Association (UKCPA) Pharmacy Infection Network has developed evidence-based treatment recommendations to support infection specialists in managing these complex infections. A systematic review of peer-reviewed research was performed and analysed. We report consensus recommendations for the management of CPE-associated infections. The national expert panel makes therapeutic recommendations regarding the pharmacokinetic and pharmacodynamic properties of the drugs and pharmacokinetic targets, dosing, dosage adjustment and monitoring of parameters for novel and established antimicrobial therapies with CPE activity. This manuscript provides the infection specialist with pragmatic and evidence-based options for the management of CPE infections

Case reports describing treatments in the emergency medicine literature: missing and misleading information

Abstract Background Although randomized trials and systematic reviews provide the "best evidence" for guiding medical practice, many emergency medicine journals still publish case reports (CRs). The quality of the reporting in these publications has not been assessed. Objectives In this study we sought to determine the proportion of treatment-related case reports that adequately reported information about the patient, disease, interventions, co-interventions, outcomes and other critical information. Methods We identified CRs published in 4 emergency medicine journals in 2000–2005 and categorized them according to their purpose (disease description, overdose or adverse drug reactioin, diagnostic test or treatment effect). Treatment-related CRs were reviewed for the presence or absence of 11 reporting elements. Results All told, 1,316 CRs were identified; of these, 85 (6.5%; 95CI = 66, 84) were about medical or surgical treatments. Most contained adequate descriptions of the patient (99%; 95CI = 95, 100), the stage and severity of the patient's disease (88%; 95CI = 79, 93), the intervention (80%; 95CI = 70, 87) and the outcomes of treatment (90%; 95CI = 82, 95). Fewer CRs reported the patient's co-morbidities (45%; 95CI = 35, 56), concurrent medications (30%; 95CI = 21, 40) or co-interventions (57%; 95CI = 46, 67) or mentioned any possible treatment side-effects (33%; 95CI = 24, 44). Only 37% (95CI = 19, 38) discussed alternative explanations for favorable outcomes. Generalizability of treatment effects to other patients was mentioned in only 29% (95CI = 20, 39). Just 2 CRs (2.3%; 95CI = 1, 8) reported a 'denominator" (number of patients subjected to the same intervention, whether or not successful. Conclusion Treatment-related CRs in emergency medicine journals often omit critical details about treatments, co-interventions, outcomes, generalizability, causality and denominators. As a result, the information may be misleading to providers, and the clinical applications may be detrimental to patient care.</p

Delayed Emergence from General Anesthesia

The incidence of perioperative morbidity associated with varying degrees of untreated thyroid disease is unknown, however major complications have been reported including severe hypotension or cardiac arrest, extreme sensitivity to opioids and anesthetics with prolonged unconsciousness, and myxedema coma. Myxedema coma is a rare and life-threatening illness the outcome of which has not been robustly studied in large numbers, partly due to its low incidence. This case illustrates the differential diagnosis of delayed emergence from general anesthesia and the value of a complete history and physical exam. Although delayed emergence from general anesthesia is not uncommon, recognizing the cause and instituting timely treatment is imperative in conditions where delayed therapy can increase morbidity and mortality