Daniele Gui

Hypocholesterolemia and risk of death in the critically ill surgical patient

ObjectiveTo evaluate the additional information provided by the determination of cholesterolemia to the Acute Physiology and Chronic Health Evaluation (APACHE) II score.DesignRetrospective evaluation of patients admitted to the intensive care unit (ICU).SettingICUs in a university hospital.Patients638 consecutive critically ill surgical patients.InterventionsSurgical and medical therapy according to clinical status.Measurements and main resultsTwo indices were devised: DELCUPOS and DELCUNEG (cubed absolute value of the difference between measured cholesterol and the value of 190 mg/dl when cholesterolemia was, respectively, over and under 190 mg). The first estimation of cholesterolemia was taken upon admission to the ICU. The APACHE II score was computed from the worst values obtained during the first 24 h of the ICU stay, including the pre-operative period for patients transferred from the operating theatre. Mortality (24.4%) over the whole time of hospitalization has been considered. A stepwise linear logistic regression on APACHE II, DELCUPOS, DELCUNEG, and on interactions among these three factors has been carried out. A U-shaped relationship between cholesterolemia and mortality was demonstrated. The significance of DELCUPOS (p=0.0021) and DELCUNEG (p=0.0002), considered together with the APACHE II score, has demonstrated an additive information content with respect to the APACHE score for the prediction of mortality.ConclusionBoth hyper- and hypocholesterolemia have a highly significant relationship to mortality. Cholesterolemia improves the prognostic power of the APACHE II score. This result could be used to create a more powerful prognostic index.

Effect of botulinum toxin antral injection on gastric emptying and weight reduction in obese patients: a pilot study

Backgroundu2002 A potential approach to the treatment of morbid obesity is reduction of gastric emptying to achieve satiety. Botulinum toxin A (Btx‐A) is a long‐acting inhibitor of acetylcholine‐mediated peristalsis, which is mainly responsible for gastric motility.

Intra-abdominal vacuum-assisted closure (VAC) after necrosectomy for acute necrotising pancreatitis: preliminary experience.

Infection of pancreatic necrosis, although present in less than 10% of acute pancreatitis, carries a high risk of mortality; debridment and drainage of necrosis is the treatment of choice, followed by ‘open’ or ‘close’ abdomen management. We recently introduced the use of intra‐abdominal vacuum sealing after a classic necrosectomy and laparostomy. Two patients admitted to ICU for respiratory insufficiency and a diagnosis of severe acute pancreatitis developed pancreatic necrosis and were treated by necrosectomy, lesser sac marsupialisation and posterior lumbotomic opening. Both of the patients recovered from pancreatitis and a good healing of laparostomic wounds was obtained with the use of the VAC system. Most relevant advantages of this technique seem to be: the prevention of abdominal compartment syndrome, the simplified nursing of patients and the reduction of time to definitive abdominal closure.

Vacuum-assisted wound care (v.a.C.®) for enteric fistula closure: how we do it

Enterocutaneous fistulas (ECFs) are a surgical problem that is difficult to manage and they have a mortality rate between 6 and 33 % [1]. Many fistulas show a natural tendency to heal; however, the main problem in fistula care usually is adequate drainage of secretions from the wound. Vacuum-assisted wound care (V.A.C. , Kinetic Concept, Inc., San Antonio, TX, USA) therapy can be used to treat intestinal fistulas [2–4]. We successfully treated some cases of ECFs and enteroatmospheric fistulas (EAFs; an EAF is an ECF that opens into the base of a largely disrupted wound with exposed bowel) with the device (Table 1). In our experience, the results we obtained with V.A.C. therapy are strictly related to some tricks used with the black sponge and negative pressure.

Simulation of Trauma Incidents

Mathematical modeling and simulation with medical applications has gained much interest in the last few years, mainly due to the widespread availability of low-cost technology and computational power. This paper presents an integrated platform for the in-silico simulation of trauma incidents, based on a suite of interacting mathematical models. The models cover the generation of a scenario for an incident, a model of physiological evolution of the affected individuals, including the possible effect of the treatment, and a model of evolution in time of the required medical resources. The problem of optimal resource allocation is also investigated. Model parameters have been identified according to the expertise of medical doctors and by reviewing some related literature. The models have been implemented and exposed as web services, while some software clients have been built for the purpose of testing. Due to its extendability, our integrated platform highlights the potential of model-based simulation in different health-related fields, such as emergency medicine and personal health systems. Modifications of the models are already being used in the context of two funded projects, aiming at evaluating the response of health systems to major incidents with and without model-based decision support.

Vacuum-Assisted Healing of a Devastating Retroperitoneal Colonic Perforation With a Homemade Device

Retroperitoneal colonic perforation is a very rare condition, usually due to the presence of a nondiagnosed diverticular disease. Most frequently it manifests with the presence of abscesses of the abdominal wall that invariably causes severe systemic complications. Toilette and drainage is the therapy of choice together with the confection of a derivative colostomy. However, often abscess healing takes a long time. The introduction of vacuum-assisted device medication has proven to be helpful in keeping patient discomfort at minimal levels and helping the healing process. Commercial vacuum-assisted device medication is however costly and often not available for immediate use. We recently encountered a case of a retroperitoneal sigmoid diverticular perforation that led to a devastating necrosis of the abdominal wall, flank, and buttock extending to the articulation of the hip in an obese and diabetic patient, which was successfully treated by a homemade vacuumassisted device (HVAD). This strategy was adopted because of the unavailability of the commercial device. A 61-year-old female was admitted to our department with a 15-day history of left lateral abdominal pain diffused to the homolateral lower extremity. Past history was significant for obesity (body mass index 40) and type II diabetes. Physical examination revealed the following: body temperature 39.2°C, blood pressure 100/60 mm Hg, pulse rate 110 beats per minute, and respiratory rate 40 breaths/minute. There was severe cognitive deterioration. Patient was intubated and transferred to the intensive care unit with diagnosis of septic shock and multiple organ failure. Presence of a large fluctuating abscess extending from the left hip to the gluteal region was evident. Blood and laboratory test results were as follows: white blood cell count 14 600/mm, hemoglobin 11.4 g/dL, platelet count 563 000/mm, blood urea nitrogen 106 mg/dL (normal 10-23 mg/dL), creatinine 3.4 mg/dL (normal 0.71.2 mg/dL), bilirubin 5.6 mg/dL (normal 0.3-1.2 mg/dL), and GOT 165 IU/L (normal 7-45 IU/L). A computed tomography scan (Figure 1) showed a muscle fascial thickening of the left abdominal wall with multiple gas bubbles between the muscle fibers. An abscess measuring 8 cm in diameter extended up to the left iliac crest and a thickening and an enhancement of the perinefric and paranefric left fascie were present. Wide spectrum antibiotic therapy was administered (teicoplanin, meropenem, metronidazole) and a timely surgical intervention for complete drainage was performed. A huge abscess involving the left abdominal wall was drained and a retroperitoneal sigmoid diverticular perforation was detected. A wide muscolofascial necrosis extended from the iliac wing up to the homolateral hip joint (Figure 2). During this operation, a derivative colostomy on the transverse colon was performed. At intervention the use of vacuum-assisted device was considered useful because of the enormous extension of the tissue necrosis, the presence of concomitant comorbidities such as diabetes, obesity, and septic shock. A HVAD was then assembled in the following manner. Vacuum-Assisted Healing of a Devastating Retroperitoneal Colonic Perforation With a Homemade Device