Emphysematous gastritis in a patient with neutropenic sepsis: A case report and literature review with comment on management.

Emphysematous gastritis is a severe form of gastritis caused by gas-forming infectious organisms and is most frequently encountered in critically unwell patients. Diagnosis rests on the radiographic appearances of air within the gastric wall, which may extend into the portal venous system. Not previously described in the context of neutropenic sepsis, our case involves a 77-year-old patient with emphysematous gastritis who was admitted to the intensive care unit with a neutrophil count of 0.1 × 109/L and managed successfully with conservative treatment. Presenting complaints usually include abdominal pain, nausea, vomiting and occasionally haematemesis, in the context of systemic upset. Predisposing factors may include diabetes and immunosuppression, ingestion of corrosive substances, alcohol abuse, and abdominal surgery. The historical approach to management which previously involved urgent exploratory laparotomy with gastrectomy, has largely been replaced with conservative therapy, including broad-spectrum antimicrobials, gut rest and parenteral nutrition, with improved outcomes. Previously considered a commonly terminal diagnosis with mortality rates as high as 60%, this recent shift in approach to management has contributed to mortality rates being halved. The role of oesophago-gastro-duodenoscopy has not been established and is unlikely to be indicated in every case. Longterm complications may be of concern and include fibrosis and gastric contractures.

A humanized monoclonal antibody targeting protein a promotes opsonophagocytosis of Staphylococcus aureus in human umbilical cord blood.

Low and very-low-birth-weight (V/LBW) neonates are highly susceptible to bacterial sepsis and meningitis. Bacterial infections caused by Staphylococcus aureus can be particularly dangerous for neonates and can result in high mortality and long-term disabilities.Antibody-based strategies have been attempted to protect V/LBW neonates against staphylococcal disease. However, these efforts have so far been unsuccessful. Failures were attributed to the immaturity of the neonatal immune system but did not account for the anti-opsonic activity of Staphylococcal protein A (SpA). Here we show that monoclonal antibody 3F6, which blocks SpA activity, promotes complement-dependent cell-mediated phagocytosis of S. aureus in human umbilical cord blood. A substitution in the crystallizable fragment (Fc) region of 3F6 that enhances recruitment of complement component C1q further increases the phagocytic activity of cord blood. Our data demonstrate that the neonatal immune system possesses bactericidal activity that can be harnessed by antibodies that circumvent a key innate immune strategy of S. aureus.

Myoglobin-derived iron causes wound enlargement and impaired regeneration in pressure injuries of muscle.

The reasons for poor healing of pressure injuries are poorly understood. Vascular ulcers are worsened by extracellular release of hemoglobin, so we examined the impact of myoglobin (Mb) iron in murine muscle pressure injuries (mPI). Tests used Mb-knockout or treatment with deferoxamine iron chelator (DFO). Unlike acute injuries from cardiotoxin, mPI regenerated poorly with a lack of viable immune cells, persistence of dead tissue (necro-slough), and abnormal deposition of iron. However, Mb-knockout or DFO-treated mPI displayed a reversal of the pathology: decreased tissue death, decreased iron deposition, decrease in markers of oxidative damage, and higher numbers of intact immune cells. Subsequently, DFO treatment improved myofiber regeneration and morphology. We conclude that myoglobin iron contributes to tissue death in mPI. Remarkably, a large fraction of muscle death in untreated mPI occurred later than, and was preventable by, DFO treatment, even though treatment started 12 hr after pressure was removed. This demonstrates an opportunity for post-pressure prevention to salvage tissue viability.

Telehealth in Geriatrics.

Telehealth is commonly used in the care of geriatric patients; however, it requires special considerations for effective implementation. Although available evidence suggests that this model of care is useful and feasible, interventions should be carefully designed with the unique needs of geriatric patients in mind. Further, more research is needed to determine the most effective telehealth interventions in this population, which will assist in determining cost-effectiveness and reimbursement policies.

The panniculus carnosus muscle: a missing link in the chronicity of heel pressure ulcers?

Chronic and recurring pressure ulcers (PUs) create an unmet need for predictive biomarkers. In this work, we examine the panniculus carnosus, a thin cutaneous muscle, traditionally considered vestigial in humans, and ask whether the panniculus may play a role in the chronicity and reinjury of heel PUs. To determine whether humans have a panniculus muscle layer at the heel, we dissected eight cadavers. To assess the influence of the panniculus layer on PU, we performed computational simulations of supine weight bearing. Finally, we assessed panniculus regeneration in fluorescent mice. Results show a panniculus layer present in all cadavers examined. Simulations show a thin layer of panniculus muscle causes a dramatic decrease in the volume of soft tissue experiencing high strain and stress, compared to a heel without a panniculus. Importantly, in the mouse model, the panniculus fails to regenerate after PU, even when other cutaneous layers had fully regenerated. Our work shows that the panniculus is able to redistribute load around the heel bone, which might allow it to prevent PUs. Moreover, it is highly susceptible to incomplete regeneration after PU. Poor panniculus regeneration after PU might be a predictive anatomical biomarker for recurrence, and this biomarker should be evaluated prospectively in future clinical trials.

Telemedicine: The art of innovative technology in family medicine.

Technology in medicine has been rapidly evolving over the past decade, greatly improving the quality and types of services providers can offer to patients. Physicians in training are eager to embrace these novel innovations, and medical school and residency educators strive to offer learning experiences of a high standard that are relevant. One example of an emerging healthcare innovation is telemedicine, which permits the provision of medical care to patients away from clinics and hospitals, bringing patient-centered care to the patient. It has proven to be cost-effective, improve health outcomes, and enhance patient satisfaction. This article describes the development and structure of our family medicine residency program's telemedicine curriculum, first created in 2016 in response to the growing demand for this type of healthcare delivery model. There is discussion about the history of telemedicine, and about what contributed to its growth. A timeline of the steps taken to create our new telemedicine residency curriculum is reviewed, along with the key components that contributed to its success. The Lessons Learned section provides other educators insight into the strengths and opportunities revealed during the creation of the curriculum, and guidance on how the curriculum could be further enhanced.

Copper (II) complexes possessing alkyl-substituted polypyridyl ligands: Structural characterization and in vitro antitumor activity.

In an effort to find alternatives to the antitumor drug cisplatin, a series of copper (II) complexes possessing alkyl-substituted polypyridyl ligands have been synthesized. Eight new complexes are reported herein: µ-dichloro-bis{2,9-di-sec-butyl-1,10-phenanthrolinechlorocopper(II)} {[(di-sec-butylphen)ClCu(µ-Cl)2CuCl(di-sec-butylphen)]}(1), 2-sec-butyl-1,10-phenanthrolinedichlorocopper(II) {[mono-sec-butylphen) CuCl2} (2), 2,9-di-n-butyl-1,10-phenanthrolinedichlorocopper(II) {[di-n-butylphen) CuCl2}(3), 2-n-butyl-1,10-phenanthrolinedichlorocopper(II) {[mono-n-butylphen) CuCl2} (4), 2,9-di-methyl-1,10-phenanthrolineaquadichlorocopper(II) {[di-methylphen) Cu(H2O)Cl2}(5), µ-dichloro-bis{6-sec-butyl-2,2'-bipyridinedichlorocopper(II)} {(mono-sec-butylbipy) ClCu(µ-Cl)2CuCl(mono-sec-butylbipy)} (6), 6,6'-di-methyl-2,2'-bipyridinedichlorocopper(II) {6,6'-di-methylbipy) CuCl2} (7), and 4,4'-dimethyl-2,2'-bipyridinedichlorocopper(II) {4,4'-di-methylbipy) CuCl2} (8). These complexes have been characterized via elemental analysis, UV-vis spectroscopy, and mass spectrometry. Single crystal X-ray diffraction experiments revealed the complexes synthesized with the di-sec-butylphen ligand (1) and mono-sec-butylbipy ligand (6) crystallized as dimers in which two copper(II) centers are bridged by two chloride ligands. Conversely, complexes 2, 7, and 8 were isolated as monomeric species possessing distorted tetrahedral geometries, and the [(di-methylphen)Cu(H2O)Cl2] (5) complex was isolated as a distorted square pyramidal monomer possessing a coordinating aqua ligand. Compounds 1-8 were evaluated for their in vitro antitumor efficacy. Compounds 1, 5, and 7 in particular were found to exhibit remarkable activity against human derived lung cancer cells, yet this class of copper(II) compounds had minimal cytotoxic effect on non-cancerous cells. In vitro control experiments indicate the activity of the copper(II) complexes most likely does not arise from the formation of CuCl2 and free polypyridyl ligand, and preliminary solution state studies suggest these compounds are generally stable in biological buffer. The results presented herein suggest further development of this class of copper-based drugs as potential anti-cancer therapies should be pursued.

Quantification of experimental venous thrombus resolution by longitudinal nanogold-enhanced micro-computed tomography.

INTRODUCTION: The assessment of thrombus size following treatments directed at preventing thrombosis or enhancing its resolution has generally relied on physical or histological methods. This cross-sectional design imposes the need for increased numbers of animals for experiments. Micro-computed tomography (microCT) has been used to detect the presence of venous thrombus in experimental models but has yet to be used in a quantitative manner. In this study, we investigate the use of contrast-enhanced microCT for the longitudinal assessment of experimental venous thrombus resolution. MATERIALS AND METHODS: Thrombi induced by stenosis of the inferior vena cava in mice were imaged by contrast-enhanced microCT at 1, 7 and 14 days post-induction (n=18). Thrombus volumes were determined longitudinally by segmentation and 3D volume reconstruction of microCT scans and by standard end-point histological analysis at day 14. An additional group of thrombi were analysed solely by histology at 1, 7 and 14 days post-induction (n=15). RESULTS: IVC resident thrombus was readily detectable by contrast-enhanced microCT. MicroCT-derived measurements of thrombus volume correlated well with time-matched histological analyses (ICC=0.75, P<0.01). Thrombus volumes measured by microCT were significantly greater than those derived from histological analysis (P<0.001). Intra- and inter-observer analyses were highly correlated (ICC=0.99 and 0.91 respectively, P<0.0001). Further histological analysis revealed noticeable levels of contrast agent extravasation into the thrombus that was associated with the presence of neovascular channels, macrophages and intracellular iron deposits. CONCLUSION: Contrast-enhanced microCT represents a reliable and reproducible method for the longitudinal assessment of venous thrombus resolution providing powerful paired data.

Synthesis, characterization, and antitumor activity of unusual pseudo five coordinate gold(III) complexes: distinct cytotoxic mechanism or expensive ligand delivery systems?

Gold(III) complexes bearing bidentate ligands based on the 1,10-phenanthroline and 2,2'-bipyridine scaffolds have shown promising anticancer activity against a variety of tumor cell lines. In particular, our laboratory has previously found that a pseudo five coordinate gold(III) complex possessing the 2,9-di-sec-butyl-1,10-phenanthroline ligand {[((di-sec-butyl)phen)AuCl3]} exhibits antitumor activity against a panel of five different lung and head-neck tumor cell lines. However, the [((di-sec-butyl)phen)AuCl3] complex was determined to be less active than the free 2,9-di-sec-butyl-1,10-phenanthroline ligand. In order to determine if this class of gold(III) complexes has a distinct mechanism of initiating tumor cell death or if these gold complexes simply release the polypyridyl ligand in the intracellular environment, structural analogues of the [((di-sec-butyl)phen)AuCl3] complex have been synthesized and structurally characterized. These structural congeners were prepared by using mono-alkyl and di-phenyl substituted 1,10-phenanthroline ligands, di-alkyl and di-phenyl substituted 4-methyl-1,10-phenanthroline ligands, and mono-alkyl 2,2'-bipyridine ligands. The redox stability of this library of distorted square pyramidal gold(III) complexes has been studied and the in vitro antitumor activity of gold(III) complexes and corresponding polypyridyl ligands has been determined. The [((di-n-butyl)phen)AuCl3] and [((mono-n-butyl)phen)AuCl3] complexes have been found to be significantly more potent at inhibiting the growth of A549 lung tumor cells than the clinically used drug cisplatin. More importantly, these two gold(III) complexes are significantly more active than their respective free ligands, providing evidence that this class of pseudo five coordinate gold(III) complexes has a mechanism of initiating tumor cell death that is independent of the free ligand.

Fibrin-targeted magnetic resonance imaging allows in vivo quantification of thrombus fibrin content and identifies thrombi amenable for thrombolysis.

OBJECTIVE: Deep venous thrombosis is a major health problem. Thrombolytic therapies are effective in recanalizing the veins and preventing post-thrombotic complications, but there is no consensus on selection criteria. The aim of this study was to investigate a fibrin-specific MRI contrast agent (EP-2104R) for the accurate quantification of thrombus' fibrin content in vivo and for the identification of thrombus suitable for thrombolysis. APPROACH AND RESULTS: Venous thrombosis was induced in the inferior vena cava of 8- to 10-week-old male BALB/C mice and MRI performed 2, 4, 7, 10, 14, and 21 days later. Eighteen mice were scanned at each time point pre and 2 hours post injection of EP-2104R (8.0 µmol/kg) with 12 mice at each time point used to correlate fibrin contrast uptake with thrombus' histological stage and fibrin content. Six mice at each time point were immediately subjected to intravascular thrombolytic therapy (10 mg/kg of tissue-type plasminogen activator). Mice were imaged to assess response to lytic therapy 24 hours after thrombolytic treatment. Two mice at each time point were scanned post injection of 0.2 mmol/kg of Gd-DTPA (gadolinium with diethylenetriaminepentacetate, Magnevist, Schering AG, Berlin, Germany) for control purpose. Contrast uptake was correlated positively with the fibrin content of the thrombus measured by Western blotting (R(2)=0.889; P<0.001). Thrombus relaxation rate (R1) post contrast and the change in visualized thrombus size on late gadolinium enhancement inversion recovery MRI pre-EP-2104R and post-EP-2104R injection were the best predictors for successful thrombolysis (area under the curve, 0.989 [95% confidence interval, 0.97-1.00] and 0.994 [95% confidence interval, 0.98-1.00] respectively). CONCLUSIONS: MRI with a fibrin-specific contrast agent accurately estimates thrombus fibrin content in vivo and identifies thrombi that are amenable for thrombolysis.

Use of airway pressure release ventilation in a child with refractory hepatopulmonary syndrome after liver transplantation.

HPS is a life-threatening condition in patients with end-stage liver disease, in which intrapulmonary vascular dilatations result in intrapulmonary shunts and hypoxemia. The only successful treatment is liver transplantation. Hypoxemia may be severe prior to transplantation; however, it can worsen or become refractory after liver transplantation and result in increased post-operative mortality. Here, we present the case of a 10-month-old female infant with progressive end-stage liver disease and severe HPS, who developed refractory hypoxemia after a successful liver transplantation. After 19 days of unsuccessful attempts to reverse the hypoxemia using conventional mechanical ventilation and HFOV, the patient responded dramatically to APRV, with rapid improvement in her PaO2 and sharp decline in her OI. She was able to begin weaning from APRV two days later and was extubated within seven days. APRV was successful in treating refractory hypoxemia in this patient with severe HPS after liver transplantation, possibly by modifying distribution of pulmonary blood flow. Although we cannot rule out coincidental natural resolution of the HPS, APRV could be a useful rescue therapy in patients with HPS and refractory hypoxemia.