Raymond Kao - Academia.edu (original) (raw)

Papers by Raymond Kao

Research paper thumbnail of Care of victims of suicide bombing

Canadian Journal of Surgery, 2018

Suicide bombers often target crowds. This commentary discusses the additional features required i... more Suicide bombers often target crowds. This commentary discusses the additional features required in a medical response beyond conventional mass casualty care, including forensic documentation, preservation of evidence, suspect tissue identification and viral status, victim counselling and postexposure prophylaxis. We propose a pathway for care of victims of a suicide bomb, adapting elements from protocols for child abuse, sexual assault and needle-stick exposure.

Research paper thumbnail of Enhanced case management can be delivered for patients with EVD in Africa: Experience from a UK military Ebola treatment centre in Sierra Leone

The Journal of infection, 2018

Limited data exist describing supportive care management, laboratory abnormalities and outcomes i... more Limited data exist describing supportive care management, laboratory abnormalities and outcomes in patients with Ebola virus disease (EVD) in West Africa. We report data which constitute the first description of the provision of enhanced EVD case management protocols in a West African setting. Demographic, clinical and laboratory data were collected by retrospective review of clinical and laboratory records of patients with confirmed EVD admitted between 5 November 2014 and 30 June 2015. A total of 44 EVD patients were admitted (median age 37 years (range 17-63), 32/44 healthcare workers), and excluding those evacuated, the case fatality rate was 49% (95% CI 33%-65%). No pregnant women were admitted. At admission 9/44 had stage 1 disease (fever and constitutional symptoms only), 12/44 had stage 2 disease (presence of diarrhoea and/or vomiting) and 23/44 had stage 3 disease (presence of diarrhoea and/or vomiting with organ failure), with case fatality rates of 11% (95% CI 1%-58%), 27...

Research paper thumbnail of Proposed specifications of a mobile operating room for far-forward surgery

Canadian Journal of Surgery

Research paper thumbnail of Introduction: combat damage-control resuscitation/surgery and beyond

Canadian Journal of Surgery

Research paper thumbnail of A retrospective observational study of daytime and nighttime transfers from the intensive care unit: through the lens of critical care response teams

Canadian Journal of Anesthesia/Journal canadien d'anesthésie

Research paper thumbnail of Correction to: To develop a regional ICU mortality prediction model during the first 24 h of ICU admission utilizing MODS and NEMS with six other independent variables from the critical care information system (CCIS) Ontario, Canada

Journal of Intensive Care

Research paper thumbnail of Anti-Ebola therapy for patients with Ebola virus disease: a systematic review

BMC Infectious Diseases

Background: Management of Ebola virus disease (EVD) has historically focused on infection prevent... more Background: Management of Ebola virus disease (EVD) has historically focused on infection prevention, case detection and supportive care. Several specific anti-Ebola therapies have been investigated, including during the 2014-2016 West African outbreak. Our objective was to conduct a systematic review of the effect of anti-Ebola virus therapies on clinical outcomes to guide their potential use and future evaluation. Methods: We searched PubMed, EMBASE, Global Health, Cochrane Library, African Index Medicus, WHOLIS (inception-9 April 2018), and trial registries for observational studies or clinical trials, in any language, that enrolled patients with confirmed EVD who received therapy targeting Ebola virus and reported on mortality, symptom duration, or adverse effects. Results: From 11,257 citations and registered trials, we reviewed 55 full-text citations, of which 35 met eligibility criteria (1 randomized clinical trial (RCT), 8 non-randomized comparative studies, 9 case series and 17 case reports) and collectively examined 21 anti-Ebola virus agents. The 31 studies performed during the West African outbreak reported on 4.8% (1377/28616) of all patients with Ebola. The only RCT enrolled 72 patients (0.25% of all patients with Ebola) and compared the monoclonal antibody ZMapp vs. standard care (mortality, 22% vs. 37%; 95% confidence interval for risk difference, − 36 to 7%). Studies of convalescent plasma, interferon-β-1a, favipiravir, brincidofovir, artesunate-amodiaquine and TKM-130803 were associated with at least moderate risk of bias. Conclusions: Research evaluating anti-Ebola virus agents has reached very few patients with EVD, and inferences are limited by non-randomized study designs. ZMapp has the most promising treatment signal.

Research paper thumbnail of Thoracic Aortic Dissecting Aneurysm Presenting with Stroke, Disseminated Intravascular Coagulopathy (DIC), and Gastrointestinal Hemorrhage

Canadian Journal of General Internal Medicine

Acute ischemic stroke secondary to vessel occlusion from an aneurismal dissection is an uncommon ... more Acute ischemic stroke secondary to vessel occlusion from an aneurismal dissection is an uncommon presentation. Disseminated intravascular coagulation (DIC) can present as a consequence of aortic dissection, although this is also rare. In some cases, the laboratory diagnosis of DIC uncovers a vascular abnormality or bleeding diathesis. This article describes a patient presenting with three sequential complications of a dissecting thoracic aortic aneurysm: ischemic stroke, upper gastrointestinal bleeding, and consumptive coagulopathy.

Research paper thumbnail of Experimental diabetes mellitus exacerbates ischemia/reperfusion-induced myocardial injury by promoting mitochondrial fission: Role of down-regulation of myocardial Sirt1 and subsequent Akt/Drp1 interaction

The International Journal of Biochemistry & Cell Biology

Research paper thumbnail of Bilateral blindness secondary to optic nerve ischemia from severe amlodipine overdose: a case report

Journal of medical case reports, Jan 3, 2017

Calcium channel blockers are commonly prescribed medications; calcium channel blocker overdose is... more Calcium channel blockers are commonly prescribed medications; calcium channel blocker overdose is becoming increasingly prevalent. The typical presentation of a calcium channel blocker overdose is hypotension and decreased level of consciousness. We describe a case of a calcium channel blocker overdose that led to bilateral cortical blindness, a presentation that has not previously been reported. A 49-year-old white woman with known bilateral early optic atrophy presented to our hospital with hypotension and obtundation following a known ingestion of 150 mg of amlodipine. She was transferred to our intensive care unit where she was intubated, mechanically ventilated, and required maximal vasopressor support (norepinephrine 40 mcg/minute, epinephrine 40 mcg/minute, and vasopressin 2.4 units/hour) along with intravenously administered crystalloid boluses. Despite these measures, she continued to deteriorate with persistent hypotension and tachycardia, as well as anuria. Intralipid emu...

Research paper thumbnail of C-peptide attenuates acute lung inflammation in a murine model of hemorrhagic shock and resuscitation by reducing gut injury

The journal of trauma and acute care surgery, Jan 27, 2017

The study aims to evaluate whether C-peptide can reduce gut injury during hemorrhagic shock and r... more The study aims to evaluate whether C-peptide can reduce gut injury during hemorrhagic shock and resuscitation (HS/R) therefore attenuate shock-induced inflammation and subsequent acute lung injury. Twelve-week-old male mice (C57/BL6) were hemorrhaged (mean arterial blood pressure maintained at 35 mmHg for 60 minutes) and then resuscitated with Ringer's lactate, followed by red blood cell transfusion with (HS/R) or without C-peptide (HS/R+C-peptide). Mouse gut permeability, bacterial translocation into the circulatory system and intestinal pathology, circulating HMGB1, and acute lung injury were assessed at different times after resuscitation. The mice in the control group underwent sham procedures without hemorrhagic shock. Compared to the sham group, the mice in the HS/R group showed increased gut permeability (6.07±3.41 μg of FD4/mL) and bacterial translocation into the circulatory system [10.05±4.92, lipopolysaccharide (LPS) of pg/mL), and increased gut damage; conversely, mi...

Research paper thumbnail of Hepato-bronchial fistula secondary to perforated sigmoid diverticulitis: a case report

Journal of medical case reports, Jan 13, 2017

Patients with diverticulitis are predisposed to hepatic abscesses via seeding through the portal ... more Patients with diverticulitis are predisposed to hepatic abscesses via seeding through the portal circulation. Hepatic abscesses are well-documented sequelae of diverticulitis, however instances of progression to hepato-bronchial fistulization are rare. We present a case of diverticulitis associated with hepatic abscess leading to hepato-bronchial fistulization, which represents a novel disease course not yet reported in the literature. A 61-year-old Caucasian man presented with a history of unintentional weight loss and dyspnea both at rest and with exertion. He had a significant tobacco and alcohol misuse history. A massive right-sided pleural effusion was found on chest X-ray, which responded partially to chest tube insertion. A computed tomography scan of his thorax confirmed the presence of innumerable lung abscesses as well as a complex pleural effusion. An indeterminate tiny air pocket at the dome of the liver was also noted. A follow-up computed tomography scan of his abdomen...

Research paper thumbnail of Carbon monoxide releasing molecule-3 improves myocardial function in mice with sepsis by inhibiting NLRP3 inflammasome activation in cardiac fibroblasts

Basic research in cardiology, Mar 1, 2017

The NLRP3 inflammasome is an intracellular multiple-protein complex that controls the maturation ... more The NLRP3 inflammasome is an intracellular multiple-protein complex that controls the maturation and release of interleukin (IL)-1β and IL-18. Endogenous carbon monoxide (CO) is anti-inflammatory. The aim of this study was to assess the effects/mechanisms of CO-releasing molecule-3 (CORM-3)-dependent modulation of the NLRP3 inflammasome in cardiac fibroblasts (CF) and its effect on myocardial function in sepsis. CF were treated with CORM-3 or inactive CORM-3 (iCORM-3) before NLRP3 inflammasome priming with lipopolysaccharides (LPS) or following activation with adenosine triphosphate (ATP). In parallel, cardiomyocytes (CM) were challenged with supernatants of LPS/ATP-stimulated CF or a cytokine mixture (Cyto-mix) containing IL-1β, IL-18, and HMGB1. In vivo, mice were treated with CORM-3 before or after LPS to induce sepsis (endotoxemia). Pretreatment of CF with CORM-3 prevented an LPS-induced increase in NLRP3 and pro-IL-1β expression. Treatment of CF with CORM-3 before ATP prevented...

Research paper thumbnail of Polymicrobial Bacteremia With Actinomyces odontolyticus, Fusobacterium and Atopobium parvulum Secondary to Septic Thrombophlebitis in an Immunocompetent Patient

Journal of Medical Cases, 2016

A 25-year-old immunocompetent man was found to have polymicrobial bacteremia secondary to a right... more A 25-year-old immunocompetent man was found to have polymicrobial bacteremia secondary to a right arm septic thrombus. His blood cultures grew Actinomyces odontolyticus, Fusobacterium and Atopobium parvulum. Co-infections with these three bacteria are rarely documented and this is the first known reported case of thrombophlebitis associated with these bacteria.

Research paper thumbnail of A Health Care Worker with Ebola Virus Disease and Adverse Prognostic Factors Treated in Sierra Leone

The American journal of tropical medicine and hygiene, Jan 22, 2016

We describe the management of a Sierra Leonean health care worker with severe Ebola virus disease... more We describe the management of a Sierra Leonean health care worker with severe Ebola virus disease complicated by diarrhea, significant electrolyte disturbances, and falciparum malaria coinfection. With additional resources and staffing, high quality care can be provided to patients with Ebola infection and adverse prognostic factors in west Africa.

Research paper thumbnail of Acute Refractory Hypotension 24 Hours Post-Inferior Vena Cave Filter Insertion Complicated by Early Phlegmasia Cerulea Dolens

Journal of Medical Cases, 2015

We present a case of a 67-year-old man with T4aN3bM0 gastric adenocarcinoma who developed refract... more We present a case of a 67-year-old man with T4aN3bM0 gastric adenocarcinoma who developed refractory hypotension 24 hours postinferior vena cave filter (IVCF) insertion for a new finding of pulmonary embolism (PE) and ongoing melena stool. After 18 hours of aggressive 20 L intravenous fluid resuscitation in the ICU followed by vasopressors and intravenous antibiotics, a point-of-care echocardiography did not reveal right ventricular strain and a non-contrast CT scan of the abdominal and pelvis was reported as not remarkable. But his lower limbs became progressively edematous and swollen while his upper limb maintained its normal circumference. At 24 hours post-ICU admission, his lower limbs had worsened with severe pain and pallor. The compartmental pressure measurements were in the high normal ranges. At morning rounds, the complete occlusion of the IVCF causing severe hypovolemic shock was considered and re-review of the non-contrast CT abdomen and pelvis showed complete collapsed IVC above the IVCF. The IVC below the IVCF was distended, as were the common and external iliac veins bilaterally concerning for extensive venous thrombosis and early phlegmasia cerulea dolens (PCD). The patient was treated with local catheterdirected thrombolysis with thrombus maceration and aspiration followed by localized direct tissue plasminogen activator (tPA) infusion and systemic heparin infusion. The patient's refractory hypotension resolved quickly and had surgery to remove his gastric tumor 8 days post-IVCF insertion. The placement of IVCF in a patient with known malignancy can greatly increase the risk for additional thrombus formation. But in our patient the speed is unprecedented, in which complete vena cava thrombosis (VCT) occurred at the site of the IVCF and below and its mechanism of causing refractory hypotension is rare. The consideration of PCD in a patient with refractory hypovolemic shock post-IVCF insertion followed by aggressive fluid resuscitation and worsening lower limb pain and discoloration remains a rare but important differential diagnosis.

Research paper thumbnail of Diagnosis of Febrile Illnesses Other Than Ebola Virus Disease at an Ebola Treatment Unit in Sierra Leone

Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, Jan 19, 2015

Patients with febrile illnesses presenting to an Ebola treatment unit in Sierra Leone had a wide ... more Patients with febrile illnesses presenting to an Ebola treatment unit in Sierra Leone had a wide range of diagnoses other than Ebola virus disease. Rapid diagnostic tests were useful in confirming these diagnoses, reducing the length of patient stay with valuable consequences. These alternative diagnoses should assist in future planning.

Research paper thumbnail of Recombinant Human Erythropoietin Improves Gut Barrier Function in a Hemorrhagic Shock and Resuscitation Rat Model

The Journal of Trauma: Injury, Infection, and Critical Care, 2011

Gut injury and bacterial translocation develop and persist after limited periods of hemorrhagic s... more Gut injury and bacterial translocation develop and persist after limited periods of hemorrhagic shock. Erythropoietin (EPO) can exert hemodynamic, anti-inflammatory, and tissue protective effects. We tested the hypothesis that EPO given at the time of resuscitation with saline will reduce functional ileal injury 24 hours after shock. Sprague-Dawley rats (n = 6 per group) were randomized to sham surgery or hemorrhagic shock maintained at mean arterial pressure 40 mm Hg for 60 minutes and then treated with either saline resuscitation (three times the volume of shed blood) or saline + recombinant human EPO (rHuEPO) resuscitation. Intravenous rHuEPO (1,000 U/kg) was given at the start of saline resuscitation, and at 24 hours ileal function was evaluated using quantitative cultures of mesenteric lymph nodes to assess for bacterial translocation (colony-forming units per gram of tissue [CFU/g]), determination of portal vein plasma endotoxin levels and histopathological evaluation using semi-thin plastic sections of the distal ileum. In a second series of animals, fluorescein isothiocyanate-dextran 4000 (FD-4) was used to assess mucosal permeability of the distal ileum to macromolecules. At 24 hours, the saline group had morphologic evidence of intestinal injury when compared with the sham group, and the degree of mucosal injury was less in the saline + rHuEPO when compared with the saline group, which demonstrated significantly reduced bacterial translocation to the mesenteric lymph nodes (383 CFU/g ± 111 CFU/g vs. 1130 CFU/g ± 297 CFU/g; p < 0.05) and decreased terminal ileum permeability to FD-4 (3.08 μg/mL ± 0.31 μg/mL vs. 5.14 μg/mL ± 0.88 μg/mL; p < 0.05). No significant difference was found in the portal vein endotoxin levels between the two groups. Histopathological evaluation demonstrated a trend for decreased enterocyte disarray or disruption and vacuolization in the saline + rHuEPO versus saline group. Using rHuEPO at time of saline resuscitation resulted in decreased bacterial translocation and permeability to macromolecules 24 hours after shock. These observations suggest that rHuEPO can mediate a protective effect on intestinal mucosal barrier function during ischemic injury.

Research paper thumbnail of Effects of trauma-related cues on pain processing in posttraumatic stress disorder: an fMRI investigation

Journal of Psychiatry & Neuroscience, 2011

Background: Imaging studies of pain processing in primary psychiatric disorders are just emerging... more Background: Imaging studies of pain processing in primary psychiatric disorders are just emerging. This study explored the neural correlates of stress-induced analgesia in individuals with posttraumatic stress disorder (PTSD). It combined functional magnetic resonance imaging (fMRI) and the traumatic script-driven imagery symptom provocation paradigm to examine the effects of trauma-related cues on pain perception in individuals with PTSD. Methods: The study included 17 patients with PTSD and 26 healthy, trauma-exposed controls. Participants received warm (nonpainful) or hot (painful) thermal stimuli after listening to a neutral or a traumatic script while they were undergoing an fMRI scan at a 4.0 T field strength. Results: Between-group analyses revealed that after exposure to the traumatic scripts, the blood oxygen level-dependent (BOLD) signal during pain perception was greater in the PTSD group than the control group in the head of the caudate. In the PTSD group, strong positive correlations resulted between BOLD signal and symptom severity in a number of brain regions previously implicated in stress-induced analgesia, such as the thalamus and the head of the caudate nucleus. Trait dissociation as measured by the Dissociative Experiences Scale correlated negatively with the right amygdala and the left putamen. Limitations: This study included heterogeneous traumatic experiences, a different proportion of military trauma in the PTSD versus the control group and medicated patients with PTSD. Conclusion: These data indicate that in patients with PTSD trauma recall will lead in a state-dependent manner to greater activation in brain regions implicated in stress-induced analgesia. Correlational analyses lend support to cortical hyperinhibition of the amygdala as a function of dissociation.

Research paper thumbnail of Hydrophobia Associated with Severe Hypernatremia, Acute Kidney Injury, and Rhabdomyolysis

Canadian Journal of General Internal Medicine

A 33-year-old male was brought to the emergency department (ED) by his family with a 10-day histo... more A 33-year-old male was brought to the emergency department (ED) by his family with a 10-day history of decreased to no oral intake and a progressive unsteady gait. He had a known history of major depressive disorder, agoraphobia, acrophobia, and hydrophobia, which had not been treated with any medications; he had been followed up by outpatient psychiatry.On arrival at the ED, he was noted to be drowsy, with a Glasgow Coma Score (GCS) of 14/15 (E4, V4, M6), blood pressure of 85/40 mm Hg, heart rate of 140 beats/minute, temperature of 38.5ºC, respiratory rate of 38 breaths/minute, and oxygen saturation at 95% on room air. He was noted to be severely dehydrated with dry mucous membranes, a flat jugular venous pressure, mottled skin, and anuria. He was resuscitated in the ED with 4 L of intravenous normal saline over 4 hours and started on empiric intravenous antibiotics, piperacillintazobactam 4.5 g IV q6h, for presumptive septic shock.

Research paper thumbnail of Care of victims of suicide bombing

Canadian Journal of Surgery, 2018

Suicide bombers often target crowds. This commentary discusses the additional features required i... more Suicide bombers often target crowds. This commentary discusses the additional features required in a medical response beyond conventional mass casualty care, including forensic documentation, preservation of evidence, suspect tissue identification and viral status, victim counselling and postexposure prophylaxis. We propose a pathway for care of victims of a suicide bomb, adapting elements from protocols for child abuse, sexual assault and needle-stick exposure.

Research paper thumbnail of Enhanced case management can be delivered for patients with EVD in Africa: Experience from a UK military Ebola treatment centre in Sierra Leone

The Journal of infection, 2018

Limited data exist describing supportive care management, laboratory abnormalities and outcomes i... more Limited data exist describing supportive care management, laboratory abnormalities and outcomes in patients with Ebola virus disease (EVD) in West Africa. We report data which constitute the first description of the provision of enhanced EVD case management protocols in a West African setting. Demographic, clinical and laboratory data were collected by retrospective review of clinical and laboratory records of patients with confirmed EVD admitted between 5 November 2014 and 30 June 2015. A total of 44 EVD patients were admitted (median age 37 years (range 17-63), 32/44 healthcare workers), and excluding those evacuated, the case fatality rate was 49% (95% CI 33%-65%). No pregnant women were admitted. At admission 9/44 had stage 1 disease (fever and constitutional symptoms only), 12/44 had stage 2 disease (presence of diarrhoea and/or vomiting) and 23/44 had stage 3 disease (presence of diarrhoea and/or vomiting with organ failure), with case fatality rates of 11% (95% CI 1%-58%), 27...

Research paper thumbnail of Proposed specifications of a mobile operating room for far-forward surgery

Canadian Journal of Surgery

Research paper thumbnail of Introduction: combat damage-control resuscitation/surgery and beyond

Canadian Journal of Surgery

Research paper thumbnail of A retrospective observational study of daytime and nighttime transfers from the intensive care unit: through the lens of critical care response teams

Canadian Journal of Anesthesia/Journal canadien d'anesthésie

Research paper thumbnail of Correction to: To develop a regional ICU mortality prediction model during the first 24 h of ICU admission utilizing MODS and NEMS with six other independent variables from the critical care information system (CCIS) Ontario, Canada

Journal of Intensive Care

Research paper thumbnail of Anti-Ebola therapy for patients with Ebola virus disease: a systematic review

BMC Infectious Diseases

Background: Management of Ebola virus disease (EVD) has historically focused on infection prevent... more Background: Management of Ebola virus disease (EVD) has historically focused on infection prevention, case detection and supportive care. Several specific anti-Ebola therapies have been investigated, including during the 2014-2016 West African outbreak. Our objective was to conduct a systematic review of the effect of anti-Ebola virus therapies on clinical outcomes to guide their potential use and future evaluation. Methods: We searched PubMed, EMBASE, Global Health, Cochrane Library, African Index Medicus, WHOLIS (inception-9 April 2018), and trial registries for observational studies or clinical trials, in any language, that enrolled patients with confirmed EVD who received therapy targeting Ebola virus and reported on mortality, symptom duration, or adverse effects. Results: From 11,257 citations and registered trials, we reviewed 55 full-text citations, of which 35 met eligibility criteria (1 randomized clinical trial (RCT), 8 non-randomized comparative studies, 9 case series and 17 case reports) and collectively examined 21 anti-Ebola virus agents. The 31 studies performed during the West African outbreak reported on 4.8% (1377/28616) of all patients with Ebola. The only RCT enrolled 72 patients (0.25% of all patients with Ebola) and compared the monoclonal antibody ZMapp vs. standard care (mortality, 22% vs. 37%; 95% confidence interval for risk difference, − 36 to 7%). Studies of convalescent plasma, interferon-β-1a, favipiravir, brincidofovir, artesunate-amodiaquine and TKM-130803 were associated with at least moderate risk of bias. Conclusions: Research evaluating anti-Ebola virus agents has reached very few patients with EVD, and inferences are limited by non-randomized study designs. ZMapp has the most promising treatment signal.

Research paper thumbnail of Thoracic Aortic Dissecting Aneurysm Presenting with Stroke, Disseminated Intravascular Coagulopathy (DIC), and Gastrointestinal Hemorrhage

Canadian Journal of General Internal Medicine

Acute ischemic stroke secondary to vessel occlusion from an aneurismal dissection is an uncommon ... more Acute ischemic stroke secondary to vessel occlusion from an aneurismal dissection is an uncommon presentation. Disseminated intravascular coagulation (DIC) can present as a consequence of aortic dissection, although this is also rare. In some cases, the laboratory diagnosis of DIC uncovers a vascular abnormality or bleeding diathesis. This article describes a patient presenting with three sequential complications of a dissecting thoracic aortic aneurysm: ischemic stroke, upper gastrointestinal bleeding, and consumptive coagulopathy.

Research paper thumbnail of Experimental diabetes mellitus exacerbates ischemia/reperfusion-induced myocardial injury by promoting mitochondrial fission: Role of down-regulation of myocardial Sirt1 and subsequent Akt/Drp1 interaction

The International Journal of Biochemistry & Cell Biology

Research paper thumbnail of Bilateral blindness secondary to optic nerve ischemia from severe amlodipine overdose: a case report

Journal of medical case reports, Jan 3, 2017

Calcium channel blockers are commonly prescribed medications; calcium channel blocker overdose is... more Calcium channel blockers are commonly prescribed medications; calcium channel blocker overdose is becoming increasingly prevalent. The typical presentation of a calcium channel blocker overdose is hypotension and decreased level of consciousness. We describe a case of a calcium channel blocker overdose that led to bilateral cortical blindness, a presentation that has not previously been reported. A 49-year-old white woman with known bilateral early optic atrophy presented to our hospital with hypotension and obtundation following a known ingestion of 150 mg of amlodipine. She was transferred to our intensive care unit where she was intubated, mechanically ventilated, and required maximal vasopressor support (norepinephrine 40 mcg/minute, epinephrine 40 mcg/minute, and vasopressin 2.4 units/hour) along with intravenously administered crystalloid boluses. Despite these measures, she continued to deteriorate with persistent hypotension and tachycardia, as well as anuria. Intralipid emu...

Research paper thumbnail of C-peptide attenuates acute lung inflammation in a murine model of hemorrhagic shock and resuscitation by reducing gut injury

The journal of trauma and acute care surgery, Jan 27, 2017

The study aims to evaluate whether C-peptide can reduce gut injury during hemorrhagic shock and r... more The study aims to evaluate whether C-peptide can reduce gut injury during hemorrhagic shock and resuscitation (HS/R) therefore attenuate shock-induced inflammation and subsequent acute lung injury. Twelve-week-old male mice (C57/BL6) were hemorrhaged (mean arterial blood pressure maintained at 35 mmHg for 60 minutes) and then resuscitated with Ringer's lactate, followed by red blood cell transfusion with (HS/R) or without C-peptide (HS/R+C-peptide). Mouse gut permeability, bacterial translocation into the circulatory system and intestinal pathology, circulating HMGB1, and acute lung injury were assessed at different times after resuscitation. The mice in the control group underwent sham procedures without hemorrhagic shock. Compared to the sham group, the mice in the HS/R group showed increased gut permeability (6.07±3.41 μg of FD4/mL) and bacterial translocation into the circulatory system [10.05±4.92, lipopolysaccharide (LPS) of pg/mL), and increased gut damage; conversely, mi...

Research paper thumbnail of Hepato-bronchial fistula secondary to perforated sigmoid diverticulitis: a case report

Journal of medical case reports, Jan 13, 2017

Patients with diverticulitis are predisposed to hepatic abscesses via seeding through the portal ... more Patients with diverticulitis are predisposed to hepatic abscesses via seeding through the portal circulation. Hepatic abscesses are well-documented sequelae of diverticulitis, however instances of progression to hepato-bronchial fistulization are rare. We present a case of diverticulitis associated with hepatic abscess leading to hepato-bronchial fistulization, which represents a novel disease course not yet reported in the literature. A 61-year-old Caucasian man presented with a history of unintentional weight loss and dyspnea both at rest and with exertion. He had a significant tobacco and alcohol misuse history. A massive right-sided pleural effusion was found on chest X-ray, which responded partially to chest tube insertion. A computed tomography scan of his thorax confirmed the presence of innumerable lung abscesses as well as a complex pleural effusion. An indeterminate tiny air pocket at the dome of the liver was also noted. A follow-up computed tomography scan of his abdomen...

Research paper thumbnail of Carbon monoxide releasing molecule-3 improves myocardial function in mice with sepsis by inhibiting NLRP3 inflammasome activation in cardiac fibroblasts

Basic research in cardiology, Mar 1, 2017

The NLRP3 inflammasome is an intracellular multiple-protein complex that controls the maturation ... more The NLRP3 inflammasome is an intracellular multiple-protein complex that controls the maturation and release of interleukin (IL)-1β and IL-18. Endogenous carbon monoxide (CO) is anti-inflammatory. The aim of this study was to assess the effects/mechanisms of CO-releasing molecule-3 (CORM-3)-dependent modulation of the NLRP3 inflammasome in cardiac fibroblasts (CF) and its effect on myocardial function in sepsis. CF were treated with CORM-3 or inactive CORM-3 (iCORM-3) before NLRP3 inflammasome priming with lipopolysaccharides (LPS) or following activation with adenosine triphosphate (ATP). In parallel, cardiomyocytes (CM) were challenged with supernatants of LPS/ATP-stimulated CF or a cytokine mixture (Cyto-mix) containing IL-1β, IL-18, and HMGB1. In vivo, mice were treated with CORM-3 before or after LPS to induce sepsis (endotoxemia). Pretreatment of CF with CORM-3 prevented an LPS-induced increase in NLRP3 and pro-IL-1β expression. Treatment of CF with CORM-3 before ATP prevented...

Research paper thumbnail of Polymicrobial Bacteremia With Actinomyces odontolyticus, Fusobacterium and Atopobium parvulum Secondary to Septic Thrombophlebitis in an Immunocompetent Patient

Journal of Medical Cases, 2016

A 25-year-old immunocompetent man was found to have polymicrobial bacteremia secondary to a right... more A 25-year-old immunocompetent man was found to have polymicrobial bacteremia secondary to a right arm septic thrombus. His blood cultures grew Actinomyces odontolyticus, Fusobacterium and Atopobium parvulum. Co-infections with these three bacteria are rarely documented and this is the first known reported case of thrombophlebitis associated with these bacteria.

Research paper thumbnail of A Health Care Worker with Ebola Virus Disease and Adverse Prognostic Factors Treated in Sierra Leone

The American journal of tropical medicine and hygiene, Jan 22, 2016

We describe the management of a Sierra Leonean health care worker with severe Ebola virus disease... more We describe the management of a Sierra Leonean health care worker with severe Ebola virus disease complicated by diarrhea, significant electrolyte disturbances, and falciparum malaria coinfection. With additional resources and staffing, high quality care can be provided to patients with Ebola infection and adverse prognostic factors in west Africa.

Research paper thumbnail of Acute Refractory Hypotension 24 Hours Post-Inferior Vena Cave Filter Insertion Complicated by Early Phlegmasia Cerulea Dolens

Journal of Medical Cases, 2015

We present a case of a 67-year-old man with T4aN3bM0 gastric adenocarcinoma who developed refract... more We present a case of a 67-year-old man with T4aN3bM0 gastric adenocarcinoma who developed refractory hypotension 24 hours postinferior vena cave filter (IVCF) insertion for a new finding of pulmonary embolism (PE) and ongoing melena stool. After 18 hours of aggressive 20 L intravenous fluid resuscitation in the ICU followed by vasopressors and intravenous antibiotics, a point-of-care echocardiography did not reveal right ventricular strain and a non-contrast CT scan of the abdominal and pelvis was reported as not remarkable. But his lower limbs became progressively edematous and swollen while his upper limb maintained its normal circumference. At 24 hours post-ICU admission, his lower limbs had worsened with severe pain and pallor. The compartmental pressure measurements were in the high normal ranges. At morning rounds, the complete occlusion of the IVCF causing severe hypovolemic shock was considered and re-review of the non-contrast CT abdomen and pelvis showed complete collapsed IVC above the IVCF. The IVC below the IVCF was distended, as were the common and external iliac veins bilaterally concerning for extensive venous thrombosis and early phlegmasia cerulea dolens (PCD). The patient was treated with local catheterdirected thrombolysis with thrombus maceration and aspiration followed by localized direct tissue plasminogen activator (tPA) infusion and systemic heparin infusion. The patient's refractory hypotension resolved quickly and had surgery to remove his gastric tumor 8 days post-IVCF insertion. The placement of IVCF in a patient with known malignancy can greatly increase the risk for additional thrombus formation. But in our patient the speed is unprecedented, in which complete vena cava thrombosis (VCT) occurred at the site of the IVCF and below and its mechanism of causing refractory hypotension is rare. The consideration of PCD in a patient with refractory hypovolemic shock post-IVCF insertion followed by aggressive fluid resuscitation and worsening lower limb pain and discoloration remains a rare but important differential diagnosis.

Research paper thumbnail of Diagnosis of Febrile Illnesses Other Than Ebola Virus Disease at an Ebola Treatment Unit in Sierra Leone

Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, Jan 19, 2015

Patients with febrile illnesses presenting to an Ebola treatment unit in Sierra Leone had a wide ... more Patients with febrile illnesses presenting to an Ebola treatment unit in Sierra Leone had a wide range of diagnoses other than Ebola virus disease. Rapid diagnostic tests were useful in confirming these diagnoses, reducing the length of patient stay with valuable consequences. These alternative diagnoses should assist in future planning.

Research paper thumbnail of Recombinant Human Erythropoietin Improves Gut Barrier Function in a Hemorrhagic Shock and Resuscitation Rat Model

The Journal of Trauma: Injury, Infection, and Critical Care, 2011

Gut injury and bacterial translocation develop and persist after limited periods of hemorrhagic s... more Gut injury and bacterial translocation develop and persist after limited periods of hemorrhagic shock. Erythropoietin (EPO) can exert hemodynamic, anti-inflammatory, and tissue protective effects. We tested the hypothesis that EPO given at the time of resuscitation with saline will reduce functional ileal injury 24 hours after shock. Sprague-Dawley rats (n = 6 per group) were randomized to sham surgery or hemorrhagic shock maintained at mean arterial pressure 40 mm Hg for 60 minutes and then treated with either saline resuscitation (three times the volume of shed blood) or saline + recombinant human EPO (rHuEPO) resuscitation. Intravenous rHuEPO (1,000 U/kg) was given at the start of saline resuscitation, and at 24 hours ileal function was evaluated using quantitative cultures of mesenteric lymph nodes to assess for bacterial translocation (colony-forming units per gram of tissue [CFU/g]), determination of portal vein plasma endotoxin levels and histopathological evaluation using semi-thin plastic sections of the distal ileum. In a second series of animals, fluorescein isothiocyanate-dextran 4000 (FD-4) was used to assess mucosal permeability of the distal ileum to macromolecules. At 24 hours, the saline group had morphologic evidence of intestinal injury when compared with the sham group, and the degree of mucosal injury was less in the saline + rHuEPO when compared with the saline group, which demonstrated significantly reduced bacterial translocation to the mesenteric lymph nodes (383 CFU/g ± 111 CFU/g vs. 1130 CFU/g ± 297 CFU/g; p < 0.05) and decreased terminal ileum permeability to FD-4 (3.08 μg/mL ± 0.31 μg/mL vs. 5.14 μg/mL ± 0.88 μg/mL; p < 0.05). No significant difference was found in the portal vein endotoxin levels between the two groups. Histopathological evaluation demonstrated a trend for decreased enterocyte disarray or disruption and vacuolization in the saline + rHuEPO versus saline group. Using rHuEPO at time of saline resuscitation resulted in decreased bacterial translocation and permeability to macromolecules 24 hours after shock. These observations suggest that rHuEPO can mediate a protective effect on intestinal mucosal barrier function during ischemic injury.

Research paper thumbnail of Effects of trauma-related cues on pain processing in posttraumatic stress disorder: an fMRI investigation

Journal of Psychiatry & Neuroscience, 2011

Background: Imaging studies of pain processing in primary psychiatric disorders are just emerging... more Background: Imaging studies of pain processing in primary psychiatric disorders are just emerging. This study explored the neural correlates of stress-induced analgesia in individuals with posttraumatic stress disorder (PTSD). It combined functional magnetic resonance imaging (fMRI) and the traumatic script-driven imagery symptom provocation paradigm to examine the effects of trauma-related cues on pain perception in individuals with PTSD. Methods: The study included 17 patients with PTSD and 26 healthy, trauma-exposed controls. Participants received warm (nonpainful) or hot (painful) thermal stimuli after listening to a neutral or a traumatic script while they were undergoing an fMRI scan at a 4.0 T field strength. Results: Between-group analyses revealed that after exposure to the traumatic scripts, the blood oxygen level-dependent (BOLD) signal during pain perception was greater in the PTSD group than the control group in the head of the caudate. In the PTSD group, strong positive correlations resulted between BOLD signal and symptom severity in a number of brain regions previously implicated in stress-induced analgesia, such as the thalamus and the head of the caudate nucleus. Trait dissociation as measured by the Dissociative Experiences Scale correlated negatively with the right amygdala and the left putamen. Limitations: This study included heterogeneous traumatic experiences, a different proportion of military trauma in the PTSD versus the control group and medicated patients with PTSD. Conclusion: These data indicate that in patients with PTSD trauma recall will lead in a state-dependent manner to greater activation in brain regions implicated in stress-induced analgesia. Correlational analyses lend support to cortical hyperinhibition of the amygdala as a function of dissociation.

Research paper thumbnail of Hydrophobia Associated with Severe Hypernatremia, Acute Kidney Injury, and Rhabdomyolysis

Canadian Journal of General Internal Medicine

A 33-year-old male was brought to the emergency department (ED) by his family with a 10-day histo... more A 33-year-old male was brought to the emergency department (ED) by his family with a 10-day history of decreased to no oral intake and a progressive unsteady gait. He had a known history of major depressive disorder, agoraphobia, acrophobia, and hydrophobia, which had not been treated with any medications; he had been followed up by outpatient psychiatry.On arrival at the ED, he was noted to be drowsy, with a Glasgow Coma Score (GCS) of 14/15 (E4, V4, M6), blood pressure of 85/40 mm Hg, heart rate of 140 beats/minute, temperature of 38.5ºC, respiratory rate of 38 breaths/minute, and oxygen saturation at 95% on room air. He was noted to be severely dehydrated with dry mucous membranes, a flat jugular venous pressure, mottled skin, and anuria. He was resuscitated in the ED with 4 L of intravenous normal saline over 4 hours and started on empiric intravenous antibiotics, piperacillintazobactam 4.5 g IV q6h, for presumptive septic shock.