Journal articles on the topic 'Near Drowning, therapy'

Near-drowning predisposes one to infection by the fungus Scedosporium apiospermum, and brain abscess is the most common consequence. Vertebral osteomyelitis due to this organism is exceedingly rare. The authors report on a 43-year-old man who developed fungal spondylodiscitis several weeks after a near-drowning event. The rare nature of this infection led to a delay in diagnosis. A combination of surgical debridement, instrumentation, and antifungal therapy resulted in an excellent outcome at 1 year of follow-up.

Francisella philomiragiais a rare and opportunistic pathogen capable of producing invasive infection in patients with compromised neutrophil function and in patients that have survived a near-drowning. A case ofF philomiragiaadenitis and lung nodules, refractory to cephalosporin therapy, is reported in a 10-year-old boy with chronic granulomatous disease following a facial abrasion from a saltwater crab. To the authors' knowledge, this is the first Canadian clinical isolate to be reported. Genus and species identification was confirmed via 16S ribosomal RNA sequence analysis. A literature review revealed three groups at risk ofF philomiragiainfection: young patients with chronic granulomatous disease; adults with hematogenous malignancy; and near-drowning patients. Pneumonia, fever without an apparent source and sepsis are the main clinical presentations. Invasive procedures may be required to isolate this organism and ensure appropriate antimicrobial therapy. Limited awareness ofF philomiragiahas led to delayed identification, patient death and misidentification asFrancisella tularensis- a biosafety level three pathogen and potential bioterrorism agent.

This article applies the integrative spiral model of psychotherapy described by Laub and Weiner (2013) to the case of a patient who suffered a near-drowning experience. An enhancement to the model is put forward based on actor-network theory (Law, 1999, Latour, 2005), giving it a fractal (same pattern at different scales or details level) structure and “centralisation/densification” dynamic. The process of centralisation converges the risk of death from a traumatic event towards a central node within the association network of self-awareness. This central node is then able to develop a reassuring ‘counter-centre', which is gradually densified through the relationship and complicity shared with the therapist during the therapy.

Shewanella putrefaciensis a gram-negative, nonfermentative, oxidase positive, motile bacillus that produces hydrogen sulphide. It is found widely in the nature especially in marine environments. In some very rare casesShewanella putrefacienscan be a human pathogen. It can produce a wide variety of clinical syndromes including bacteremia as well as skin and soft tissue infections. However, pneumonia due toS. putrefaciensis rare; there are a total of 4 reported cases in the literature. We present a case of 63-year-old male who was presented to emergency room status after cardiac arrest, fell into sea water face down. On the second day of hospitalization, he was diagnosed to have pneumonia based on the clinical, radiological, and laboratory findings. Empirical antibiotic treatment with vancomycin and piperacillin/tazobactam combination was initiated. Gram-stained smear of endotracheal aspirate yielded gram-negative bacteria, and the isolate grown from endotracheal aspirate culture was identified asS. putrefaciensby Biomerieux API 20 NE technique. On review of the literature and according to culture and sensitivity results, therapy in our patient was changed to cefepime. Patient’s pneumonia improved with treatment with cefepime. We believe that our patient developed pneumonia evidently caused byS. putrefaciens, after near drowning in sea water. The pneumonia resolved after treatment with cefepime.

SUMMARY Scedosporium spp. are increasingly recognized as causes of resistant life-threatening infections in immunocompromised patients. Scedosporium spp. also cause a wide spectrum of conditions, including mycetoma, saprobic involvement and colonization of the airways, sinopulmonary infections, extrapulmonary localized infections, and disseminated infections. Invasive scedosporium infections are also associated with central nervous infection following near-drowning accidents. The most common sites of infection are the lungs, sinuses, bones, joints, eyes, and brain. Scedosporium apiospermum and Scedosporium prolificans are the two principal medically important species of this genus. Pseudallescheria boydii, the teleomorph of S. apiospermum, is recognized by the presence of cleistothecia. Recent advances in molecular taxonomy have advanced the understanding of the genus Scedosporium and have demonstrated a wider range of species than heretofore recognized. Studies of the pathogenesis of and immune response to Scedosporium spp. underscore the importance of innate host defenses in protection against these organisms. Microbiological diagnosis of Scedosporium spp. currently depends upon culture and morphological characterization. Molecular tools for clinical microbiological detection of Scedosporium spp. are currently investigational. Infections caused by S. apiospermum and P. boydii in patients and animals may respond to antifungal triazoles. By comparison, infections caused by S. prolificans seldom respond to medical therapy alone. Surgery and reversal of immunosuppression may be the only effective therapeutic options for infections caused by S. prolificans.

The use of exogenous surfactant and nitric oxide in neonates has reduced the number of infants requiring ECMO. The purpose of this study was to demonstrate whether these two therapeutic options might reduce the number of over 28 days old children with severe ARDS requiring ECMO, without reducing changes of survival and morbidity. Over a 30 month period all non-neonatal ARDS patients transferred to our institution for ECMO evaluation were treated based on a study-algorithm. If they did not fulfill “fast entry criteria” (paO2< 40 for more than 3 hrs.) we first tried different ventilation, vasodilatation, and hemodynamic strategies for max. 4 hrs. (inv. I/E ratio, HFOV, epoprostenol, high doses norepinephrine. If the 01 did not decrease by< 10, 30-280 mg natural surfactant or 1-20 ppm nitric oxide were treatment options depending on the degree of pulmonary hypertension measured by echocardiography and by mixed venous saturation measurements. It was possible to use NO and surfactant sequentially. The patients had different etiologies of ARDS as near drowning, pneumonia, immunosuppression, and sepsis. If their 01 did not decrease by 10 in 8 hrs. ECMO was installed. Nineteen patients were evaluated, 6 improved with conventional therapy, their 01 decreased without a relapse (mean 01 at begin of the study: 38). Six patients improved with surfactant therapy alone (mean 01: 54), 4 patients improved after surfactant and sequential NO-treatment, 3 patients were initially treated with NO, 1 sequentially with surfactant. One patient did not show any benefit from NO or surfactant and was put on ECMO. Three patients died (withdrawal of life support because of severe brain damage caused by the underlying disease). We could not observe any respiratory related failure. No patient had to be discharged on oxygen. A sophisticated treatment algorithm integrating different modern ARDS treatment options can reduce the number of patients requiring ECMO. We speculate however that these options can only be used effectively in centers involved in ARDS treatment quite frequently and that these centers have to provide ECMO as one of their therapeutic tools.

From its beginning, mankind suffered injuries through falling, fire, drowning and human aggression [1]. Although the frequency and the kinetics modifiy over millennia, trauma continues to represent an important cause of morbidity and mortality even in the modern society [1]. Significant progresses in the trauma surgery were due to military conflicts, which next to social sufferance came with important steps in injuries’ management, further applied in civilian hospitals. The foundation of modern trauma systems was started by Dominique Jean Larrey (1766-1842) during the Napoleonic Rin military campaign from 1792. The wounded who remained on the battlefield till the end of the battle to receive medical care, usually more than 24 hours, from that moment were transported during the conflict with flying ambulances to mobile hospitals. Starting with the First World War, through the usage of antiseptics, blood transfusions, and fracture management, the mortality decreased from 39% in the Crimean War (1853–1856) to 10%. One of the most preeminent figures of the Second World War was Michael DeBakey, who created the Mobile Army Surgical Hospitals (MASH), concept very similar to the Larrey’s unit. In 1941, in England, Birmingham Accident Hospital was opened, specially designed for injured people, this being the first trauma center worldwide. During the Golf War (1990–1991) the MASH were used for the last time, being replaced by Forward Surgical Teams, very mobile units satisfying the necessities of the nowadays infantry [1]. Nowadays, trauma meets the pandemic criteria, everyday 16,000 people worldwide are dying, injuries representing one of the first five causes of mortality for all the age groups below 60 [2]. A recent 12-month analysis of trauma pattern in the Emergency Hospital of Bucharest revealed 141 patients, 72.3% males, with a mean age of 43.52 ± 19 years, and a mean New Injury Severity Score (NISS) of 27.58 ± 11.32 [3]. The etiology was traffic related in 101 (71.6%), falls in 28 (19.9%) and crushing in 7 (5%) cases. The overall mortality was as high as 30%, for patients with a mean NISS of 37.63 [3]. At the scene, early recognition of severe injuries and a high index of suspicion according to trauma kinetics may allow a correct triage of patients [4]. A functional trauma system should continuously evaluate the rate of over- and under-triage [5]. The over-triage represents the transfer to a very severe patient to a center without necessary resources, while under-triage means a low injured patient referred to a highly specialized center. If under-triage generates preventable deaths, the over-triage comes with a high financial and personal burden for the already overloaded tertiary centers [5]. To maximize the chance for survival, the major trauma patients should be transported as rapid as possible to a trauma center [6]. The initial resuscitation of trauma patients was divided into two time intervals: ten platinum minutes and golden hour [6]. During the ten platinum minutes the airways should be managed, the exsanguinating bleeding should be stopped, and the critical patients should be transported from the scene. During the golden hour all the life-threatening lesions should be addressed, but unfortunately many patients spend this time in the prehospital setting [6]. These time intervals came from Trunkey’s concept of trimodal distribution of mortality secondary to trauma, proposed in 1983 [7]. This trimodal distribution of mortality remains a milestone in the trauma education and research, and is still actual for development but inconsistent for efficient trauma systems [8]. The concept of patients’ management in the prehospital setting covered a continuous interval, with two extremities: stay and play/treat then transfer or scoop and run/ load and go. Stay and play, usually used in Europe, implies airways securing and endotracheal intubation, pleurostomy tube insertion, and intravenous lines with volemic replacement therapy. During scoop and run, used in the Unites States, the patient is immediately transported to a trauma center, addressing the immediate life-threating injuries during transportation. In the emergency department of the corresponding trauma center, the resuscitation of the injured patients should be done by a trauma team, after an orchestrated protocol based on Advanced Trauma Life Support (ATLS). The modern trauma teams include five to ten specialists: general surgeons trained in trauma care, emergency medicine physicians, intensive care physicians, orthopedic surgeons, neurosurgeons, radiologists, interventional radiologists, and nurses. In the specially designed trauma centers, the leader of the trauma team should be the general surgeon, while in the lower level centers this role may be taken over by the emergency physicians. The implementation of a trauma system is a very difficult task, and should be tailored to the needs of the local population. For example, in Europe the majority of injuries are by blunt trauma, while in the United States or South Africa they are secondary to penetrating injuries. In an effort to analyse at a national level the performance of trauma care, we have proposed a national registry of major trauma patients [9]. For this registry we have defined major trauma as a New Injury Severity Score higher than 15. The maintenance of such registry requires significant human and financial resources, while only a permanent audit may decrease the rate of preventable deaths in the Romanian trauma care (Figure 1) [10]. Figure 1 - The website of Romanian Major Trauma Registry (http://www.registrutraume.ro). USA - In the United States of America there are 203 level I centers, 265 level II centers, 205 level III or II centers and only 32 level I or II pediatric centers, according to the 2014 report of National Trauma Databank [11]. USA were the first which recognized trauma as a public health problem, and proceeded to a national strategy for injury prevention, emergency medical care and trauma research. In 1966, the US National Academy of Sciences and the National Research Council noted that ‘’public apathy to the mounting toll from accidents must be transformed into an action program under strong leadership’’ [12]. Considerable national efforts were made in 1970s, when standards of trauma care were released and in 1990s when ‘’The model trauma care system plan’’[13] was generated. The American College of Surgeons introduced the concept of a national trauma registry in 1989. The National Trauma Databank became functional seven years later, in 2006 being registered over 1 million patients from 600 trauma centers [14]. Mortality from unintentional injury in the United States decreased from 55 to 37.7 per 100,000 population, in 1965 and 2004, respectively [15]. Due to this national efforts, 84.1% of all Americans have access within one hour from injury to a dedicated trauma care [16]. Canada - A survey from 2010 revealed that 32 trauma centers across Canada, 16 Level I and 16 Level II, provide definitive trauma care [18]. All these centers have provincial designation, and funding to serve as definitive or referral hospital. Only 18 (56%) centers were accredited by an external agency, such as the Trauma Association of Canada. The three busiest centers in Canada had between 798–1103 admissions with an Injury Severity Score over 12 in 2008 [18]. Australia - Australia is an island continent, the fifth largest country in the world, with over 23 million people distributed on this large area, a little less than the United States. With the majority of these citizens concentrated in large urban areas, access to the medical care for the minority of inhabitants distributed through the territory is quite difficult. The widespread citizens cannot be reached by helicopter, restricted to near-urban regions, but with the fixed wing aircraft of the Royal Flying Doctor Service, within two hours [13]. In urban centers, the trauma care is similar to the most developed countries, while for people sparse on large territories the trauma care is far from being managed in the ‘’golden hour’’, often extending to the ‘’Golden day’’ [19]. Germany - One of the most efficient European trauma system is in Germany. Created in 1975 on the basis of the Austrian trauma care, this system allowed an over 50% decreasing of mortality, despite the increased number of injuries. According to the 2014 annual report of the Trauma Register of German Trauma Society (DGU), there are 614 hospitals submitting data, with 34.878 patients registered in 2013 [20]. The total number of cases documented in the Trauma Register DGU is now 159.449, of which 93% were collected since 2002. In the 2014 report, from 26.444 patients with a mean age of 49.5% and a mean ISS of 16.9, the observed mortality was 10% [20]. The United Kingdom - In 1988, a report of the Royal College of Surgeons of England, analyzing major injuries concluded that one third of deaths were preventable [21]. In 2000, a joint report from the Royal College of Surgeons of England and of the British Orthopedic Association was very suggestive entitled "Better Care for the Severely Injured" [22]. Nowadays the Trauma Audit Research network (TARN) is an independent monitor of trauma care in England and Wales [23]. TARN collects data from hospitals for all major trauma patients, defined as those with a hospital stay longer than 72 hours, those who require intensive care, or in-hospital death. A recent analysis of TARN data, looking at the cost of major trauma patients revealed that the total cost of initial hospital inpatient care was £19.770 per patient, of which 62% was attributable to ventilation, intensive care and wards stays, 16% to surgery, and 12% to blood transfusions [24]. Global health care models Countries where is applied Functioning concept Total healthcare costs from GDP Bismarck model Germany Privatized insurance companies (approx. 180 nonprofit sickness funds). Half of the national trauma beds are publicly funded trauma centers; the remaining are non-profit and for-profit private centers. 11.1% Beveridge model United Kingdom Insurance companies are non-existent. All hospitals are nationalized. 9.3% National health insurance Canada, Australia, Taiwan Fusion of Bismarck and Beveridge models. Hospitals are privatized, but the insurance program is single and government-run. 11.2% for Canada The out-of-pocket model India, Pakistan, Cambodia The poorest countries, with undeveloped health care payment systems. Patients are paying for more than 75% of medical costs. 3.9% for India GDP – gross domestic product Table 1 - Global health care models with major consequences on trauma care [17]. Traumas continue to be a major healthcare problem, and no less important than cancer and cardiovascular diseases, and access to dedicated and timely intervention maximizes the patients’ chance for survival and minimizes the long-term morbidities. We should remember that one size does not fit in all trauma care. The Romanian National Trauma Program should tailor its resources to the matched demands of the specific Romanian urban and rural areas.