Fulminant Nocardia Colitis: A Case Report

Background: Nocardia infection is a rare but well-recognized side effect of immunosuppressive therapy including tumor necrosis factor-α (TNF-α) antagonists. However, Nocardia colitis has only been previously reported once in the English literature. Case Report: We present a 58-y-old female with history of Crohn disease maintained on multiple medications including infliximab (a TNF-α antagonist). The patient presented to the emergency department with hematochezia and abdominal pain. Computed tomography (CT) scan revealed extensive pneumotosis throughout the bowel as well as mesenteric and portal venous gas. She underwent an exploratory laparotomy that revealed bowel edema without ischemia. No bowel was resected and at a planned second-look laparotomy 48?h later, the bowel appeared normal and the abdomen was closed. Post-operatively, the patient tested negative for Clostridium difficile infection. The blood and abdominal fluid cultures were positive for Nocardia farcinica. Conclusion: The patient had a complicated post-operative course and developed multiple hospital-acquired infections. However, she survived and was placed in sub-acute rehabilitation four weeks after the acute surgical intervention.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/140345/1/crsi.2016.0013.pd

Anesthetic Techniques Influence the Induction of Pulmonary Capillary Hemorrhage During Diagnostic Ultrasound Scanning in Rats

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/135630/1/jum2015342289.pd

Sonographic Scoring for Operating Room Triage in Trauma

Objective: The focused assessment with sonography for trauma (FAST) exam is a routine diagnostic adjunct in the initial assessment of blunt trauma victims but lacks the ability to reliably predict which patients require laparotomy. Physiologic data play a major role in decision making regarding the need for emergent laparotomy versus further diagnostic testing or observation. The need for laparotomy often influences the decision to transfer the patient to a trauma center. We set out to derive a simple scoring system using both ultrasound findings and immediately available physiologic data that would predict which patients require laparotomy.Methods: We conducted a prospective observational study of victims of blunt trauma who presented to a Level 1 Trauma Center. We collected FAST findings, physiologic data, and lab values. A previously-developed ultrasound scoring system was applied to the FAST findings. Patients were followed to determine if they underwent laparotomy. We used logistic regression analysis to determine which variables correlated with laparotomy and developed a new scoring system.Results: We enrolled a convenience sample of 1,393 patients. A simple scoring system (range 0-6) was developed that included both FAST findings and vital signs (heart rate and blood pressure). Patients with a score of 0 or 1 had a less than 1% chance of requiring laparotomy.Conclusion: The combination of FAST findings with vital signs in our scoring system predicted which victims of blunt trauma did not undergo laparotomy. Applying this to trauma patients who present to non-trauma centers could help prevent unnecessary patient transfers. This derivation set must be validated prior to use in patient care. [West J Emerg Med. 2010; 11(2):138-143.

Pulmonary Capillary Hemorrhage Induced by Acoustic Radiation Force Impulse Shear Wave Elastography in Ventilated Rats

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/151830/1/jum14950.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/151830/2/jum14950_am.pd

A Propensity Score Analysis of the Impact of Invasive Intracranial Pressure Monitoring on Outcomes after Severe Traumatic Brain Injury

Although a recent clinical trial (BEST TRIP) demonstrated no improvement in outcomes with invasive intracranial pressure (ICP) monitoring (ICPM) following severe traumatic brain injury (TBI), its generalizability has been called into question. In several global settings ICPM is not the standard of care and is used at the discretion of the attending neurosurgeon. Our objective was to determine the impact of ICPM on mortality and 6-month functional outcomes following severe TBI. The setting was a referral trauma center with 36 intensive care unit (ICU) beds and 300?600 TBI admissions per year. During a 2-year period data were prospectively entered into a severe TBI registry. Patients with severe TBI aged >12 years meeting Brain Trauma Foundation (BTF) criteria for ICPM were included in the study. Outcomes of interest were in-hospital mortality and poor 6-month functional outcome defined as Glasgow Outcome Scale (GOS) score of 3 or lower. A propensity score based analysis incorporating known predictors of outcome in TBI was utilized to examine the impact of ICPM on outcomes. Of 1345 patients meeting study criteria 497 (37%) underwent ICPM. In-hospital mortality was 35% (471/1345). Of 454 patients for whom 6-month outcome was available, 161 (35%) suffered a poor functional outcome. Following propensity score analysis ICPM use was associated with an 8% (p?=?0.002) decrease in mortality but no significant effect (p?=?0.2) on functional outcome. The use of ICPM following severe TBI was associated with decreased in-hospital mortality. Further clinical trials of ICPM in TBI may be warranted.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/140170/1/neu.2015.4015.pd

Sonographic Scoring for Operating Room Triage in Trauma

Objective: The focused assessment with sonography for trauma (FAST) exam is a routine diagnostic adjunct in the initial assessment of blunt trauma victims but lacks the ability to reliably predict which patients require laparotomy. Physiologic data play a major role in decision making regarding the need for emergent laparotomy versus further diagnostic testing or observation. The need for laparotomy often influences the decision to transfer the patient to a trauma center. We set out to derive a simple scoring system using both ultrasound findings and immediately available physiologic data that would predict which patients require laparotomy.Methods: We conducted a prospective observational study of victims of blunt trauma who presented to a Level 1 Trauma Center. We collected FAST findings, physiologic data, and lab values. A previously-developed ultrasound scoring system was applied to the FAST findings. Patients were followed to determine if they underwent laparotomy. We used logistic regression analysis to determine which variables correlated with laparotomy and developed a new scoring system.Results: We enrolled a convenience sample of 1,393 patients. A simple scoring system (range 0-6) was developed that included both FAST findings and vital signs (heart rate and blood pressure). Patients with a score of 0 or 1 had a less than 1% chance of requiring laparotomy.Conclusion: The combination of FAST findings with vital signs in our scoring system predicted which victims of blunt trauma did not undergo laparotomy. Applying this to trauma patients who present to non-trauma centers could help prevent unnecessary patient transfers. This derivation set must be validated prior to use in patient care. [West J Emerg Med. 2010; 11(2):138-143.

Acute hemorrhagic cholecystitis with gallbladder rupture and massive intra-abdominal hemorrhage

Acute hemorrhagic cholecystitis is a rare, life-threatening condition that can be further complicated by perforation of the gallbladder. We describe a patient with clinical and radiologic findings of acute cholecystitis with a gallbladder rupture and massive intra-abdominal bleeding. Our patient is a 67-year-old male who presented with an ischemic stroke and was treated with early tissue plasminogen activator. His hospital course was complicated by a fall requiring posterior spinal fusion surgery. He recovered well, but several days later developed subxiphoid and right upper quadrant pain and an episode of hemobilia and melena. A computed tomography scan revealed an inflamed, distended gallbladder with indistinct margins and a large hematoma in the gallbladder fossa extending to the right paracolic gutter. The patient also developed hemodynamic instability concerning for hemorrhagic shock. He underwent an emergent laparoscopic converted to open subtotal fenestrating cholecystectomy with abdominal washout for management of his acute hemorrhagic cholecystitis with massive intra-abdominal hemorrhage. Prompt recognition of this lethal condition in high-risk patients is crucial for optimizing patient care

The Impact of Hemorrhagic Shock on Lung Ultrasound–Induced Pulmonary Capillary Hemorrhage

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/167032/1/jum15463_am.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/167032/2/jum15463.pd