Incarcerated Colonoscope in a Left Inguinal Hernia During Diagnostic Colonoscopy.

Colonoscope entrapment in an inguinal hernia is rare and few cases have been described in the literature. We present a 54-year-old patient who underwent a diagnostic colonoscopy which was complicated by incarceration of the colonoscope in a left inguinal hernia. This rare complication occurs more frequently during withdrawal, and our case was unique, given the incarceration of the colonoscope occurred during the insertion phase. Recognizing this scenario is very important to immediately proceed with general anesthesia and surgical consultation for successful nonoperative hernia reduction and colonoscope removal. We recommend reattempting colonoscopy after surgical hernia repair or proceed with computed tomography colonography if appropriate for the indication.

Graft survival of fourth-time renal transplant recipients is similar to third-time recipients: A SRTR database analysis.

BACKGROUND: Candidates for repeat kidney transplant (KT) have increased. While graft and patient survival are inferior to primary KT, second and third KTs improve patient survival over dialysis. Little is known about the outcomes after fourth KTs. METHODS: We retrospectively compared characteristics of third and fourth KTs in the SRTR. Factors associated with graft survival in third vs fourth KT and patient survival of fourth KT vs patients waitlisted for a 4th KT were assessed by Cox regression and multivariable linear regression analysis. RESULTS: There were 3055 third- and fourth-time KTs performed in the United States. Fourth-time graft survival was not significantly different from third-time transplants (HR 1.06, P = .653). Patients who received a fourth KT have a significant survival advantage compared with patients who remained on the waitlist for a fourth KT (HR = 0.53, P = .006). CONCLUSIONS: Graft and patient survival of fourth KTs are comparable to third KTs, but inferior to first and second KTs in terms of graft and patient survival. Recipients of fourth KT have had an increased life expectancy compared with patients waitlisted for a fourth KT.

Multicenter study of crystalloid boluses and transfusion in pediatric trauma-When to go to blood?

BACKGROUND: The 9th edition of Advanced Trauma Life Support recommends up to three crystalloid boluses in pediatric trauma patients with consideration of transfusion after the second bolus; however, this approach is debated. We aimed to determine if requirement of more than one fluid bolus predicts the need for transfusion. METHODS: The 2010 to 2016 highest tier activation patients younger than 15 years from two ACS Level I pediatric trauma centers were identified from prospectively maintained trauma databases. Those with a shock index (heart rate/systolic blood pressure) greater than 0.9 were included. Crystalloid boluses (20 ± 10 mL/kg) and transfusions administered prehospital and within 12 hours of hospital arrival were determined. Univariate and multivariable analyses were conducted to determine association between crystalloid volume and transfusion. RESULTS: Among 208 patients, the mean age was 5 ± 4 years (60% male), 91% sustained blunt injuries, and median (interquartile range) Injury Severity Score was 11 (6,25). Twenty-nine percent received one bolus, 17% received two, and 10% received at least three. Transfusion of any blood product occurred in 50 (24%) patients; mean (range) red blood cells was 23 (0-89) mL/kg, plasma 8 (0-69), and platelets 1 (0-18). The likelihood of transfusion increased logarithmically from 11% to 43% for those requiring 2 or more boluses (Fig. 1). This relationship persisted on multivariable analysis that adjusted for institution, age, and shock index with good discrimination (Area under the Receiver Operating Characteristic, 0.84). Shock index was also strongly associated with transfusion. CONCLUSION: Almost half of pediatric trauma patients with elevated shock index require transfusion following two crystalloid boluses and the odds of requiring a transfusion plateau at this point in resuscitation. This supports consideration of blood with the second bolus in conjunction with shock index though prospective studies are needed to confirm this and its impact on outcomes. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Lack of utility of repeat monitoring of hemoglobin and hematocrit following blunt solid organ injury in children.

BACKGROUND: Current management protocols for children with blunt solid organ injury to the liver and spleen call for serial monitoring of the child's hemoglobin and hematocrit every 6, 12, or 24 hours, depending on the injury grade. We hypothesized that children who require emergent intervention in the form of laparotomy, angioembolization, or packed red blood cell (PRBC) transfusion because of bleeding from a solid organ injury will have changes in their vital signs that alert the clinician to the need for intervention, making scheduled laboratory evaluation unnecessary. METHODS: We performed a retrospective review of all children admitted to either of two pediatric trauma centers following blunt trauma with any grade liver or spleen injury from January 2009 to December 2013. Data evaluated include a need for intervention, indication for intervention, and timing of intervention. RESULTS: A total of 245 children were admitted with blunt liver or spleen injury. Six patients (2.5%) underwent emergent exploratory laparotomy for hypotension a median of 4 hours after injury (range, 2-4 hours), four of who required splenectomy. No child required laparotomy for delayed bleeding from a solid organ injury. One child (0.4%) underwent angioembolization for blunt splenic injury. Forty-one children (16.7%) received a PRBC transfusion during hospitalization, 32 of whom did not undergo laparotomy or angioembolization. Children who underwent an intervention had a lower nadir hematocrit (median, 22.9 vs. 32.8; p < 0.0001), longer time from injury to nadir hematocrit (median, 35.5 vs. 16 hours; p < 0.0001), and more total blood draws for hemoglobin and hematocrit monitoring (median, 20 vs. 5; p < 0.0001). CONCLUSION: Among children with blunt liver or spleen injury, a need for emergent intervention in the form of laparotomy or PRBC transfusion for hemorrhagic shock occurs within the first 24 hours of injury. Ongoing, scheduled monitoring of serum hemoglobin and hematocrit values may not be necessary. LEVEL OF EVIDENCE: Retrospective study with no negative criteria, prognostic study, level III.

Disseminated varicella-zoster virus in an immunocompetent adult.

Varicella-zoster is the virus that causes varicella (chicken pox), herpes zoster (shingles), and rarely, severe disseminated disease including diffuse rash, encephalitis, hepatitis, and pneumonitis. Disseminated disease is most often seen in immunocompromised patients. We describe a case of disseminated zoster in an immunocompentent patient who had previously been immune to VZV. This case is also unusual in that his clinical presentation was most consistent with varicella while his laboratory data was most consistent with herpes zoster. For the purpose of rapid diagnosis and initiation of appropriate therapy, clinicians should be aware of these more atypical presentations of VZV infection.

Vibrio fischeri exhibit the growth advantage in stationary-phase phenotype.

Vibrio fischeri are bioluminescent marine bacteria that can be isolated from their symbiotic animal partners or from ocean water. A V. fischeri population increases exponentially inside the light organ of the Hawaiian bobtail squid (Euprymna scolopes) while the host is quiescent during the day. This bacterial light organ population reaches stationary phase and then remains high during the night, when the squid use bacterial bioluminescence as a counter-predation strategy. At dawn, host squid release 90%-95% of the light organ contents into the ocean water prior to burying in the sand for the day. As the squid sleeps, the cycle of bacterial population growth in the light organ begins again. These V. fischeri cells that are vented into the ocean must persist under typical marine low nutrient conditions until they encounter another opportunity to colonize a host. We hypothesized that because V. fischeri regularly encounter cycles of feast and famine in nature, they would exhibit the growth advantage in stationary phase (GASP) phenotype. We found that older V. fischeri cells exhibit a Class 2 GASP response in which old cells increase dramatically in frequency while the population of young V. fischeri cells remains almost constant during co-incubation.