- The 77-year old female patient was admitted to the hospital for vomiting blood and abdominal pain. She suffered from multiple comorbidities and underwent several surgeries previously.
- During her 13-day hospital stay, she developed several complications including ileus, sepsis, pneumonia, and small bowel obstruction. Her condition continued to decline despite treatment.
- She passed away after being placed on comfort care measures only. Her complex medical history and multiple postoperative complications ultimately led to her death.
Eosinophilic esophagitis is characterized by eosinophil-predominant inflammation in the esophagus. Potential etiologies include food and aeroallergen sensitization, genetics involving genes like TSLP, and cytokines/chemokines such as IL-5 and eotaxin-3. The pathogenesis involves activation of epithelial inflammatory pathways producing eotaxin-3, impaired barrier function mediated by loss of desmoglein-1, and increased TGF-β. Clinical features commonly include dysphagia, abdominal pain, failure to thrive, and food impactions. Diagnosis is based on symptoms and histological evidence of ≥15 eosinophils per hpf. Treatment
This article provides a state-of-the-art review of eosinophilic gastroenteritis (EG). EG is characterized by eosinophilic infiltration of the gastrointestinal tract and presents with a variety of gastrointestinal symptoms depending on the site and layer affected. While EG can affect any age, it most commonly affects those in their 30s-40s with a slight male predominance. EG is classified into three patterns based on the layer of involvement: predominantly mucosal, predominantly muscular, and predominantly serosal. Corticosteroids are the main treatment and have shown dramatic efficacy, while dietary treatments and avoiding allergens can be initial approaches.
Napa County Public Health is holding a tabletop exercise on 10/28/13 to discuss the response to an e. Coli outbreak. This is in conjunction with the CA Dept of Public Health and anticipation of the upcoming statewide functional exercise. Slides prepared by The Abaris Group
Patient P.V., a 74-year-old male, presented with progressive body weakness that began 15 days prior. He reported weakness starting in his lower extremities and progressing upwards. He was admitted to the hospital with a chief complaint of body weakness and a diagnosis of Guillain-Barré syndrome was considered. Guillain-Barré syndrome is an autoimmune disorder where the body's immune system attacks the peripheral nervous system, causing muscle weakness and possible paralysis. Nursing care involved assessing the patient, administering medications to treat the condition, providing respiratory support if needed, and patient/family education on Guillain-Barré syndrome and its management.
A case of chronic diarrhea secondary to Capillaria philippinensis in Occidental, Mindoro Philippines: a newly-diagnosed endemic area?
https://www.actamedicaphilippina.org/article/7208-a-case-of-chronic-diarrhea-secondary-to-capillaria-philippinensis-in-occidental-mindoro-possibly-a-newly-described-endemic-area
- The 77-year old female patient was admitted to the hospital for vomiting blood and abdominal pain. She suffered from multiple comorbidities and underwent several surgeries previously.
- During her 13-day hospital stay, she developed several complications including ileus, sepsis, pneumonia, and small bowel obstruction. Her condition continued to decline despite treatment.
- She passed away after being placed on comfort care measures only. Her complex medical history and multiple postoperative complications ultimately led to her death.
Eosinophilic esophagitis is characterized by eosinophil-predominant inflammation in the esophagus. Potential etiologies include food and aeroallergen sensitization, genetics involving genes like TSLP, and cytokines/chemokines such as IL-5 and eotaxin-3. The pathogenesis involves activation of epithelial inflammatory pathways producing eotaxin-3, impaired barrier function mediated by loss of desmoglein-1, and increased TGF-β. Clinical features commonly include dysphagia, abdominal pain, failure to thrive, and food impactions. Diagnosis is based on symptoms and histological evidence of ≥15 eosinophils per hpf. Treatment
This article provides a state-of-the-art review of eosinophilic gastroenteritis (EG). EG is characterized by eosinophilic infiltration of the gastrointestinal tract and presents with a variety of gastrointestinal symptoms depending on the site and layer affected. While EG can affect any age, it most commonly affects those in their 30s-40s with a slight male predominance. EG is classified into three patterns based on the layer of involvement: predominantly mucosal, predominantly muscular, and predominantly serosal. Corticosteroids are the main treatment and have shown dramatic efficacy, while dietary treatments and avoiding allergens can be initial approaches.
Napa County Public Health is holding a tabletop exercise on 10/28/13 to discuss the response to an e. Coli outbreak. This is in conjunction with the CA Dept of Public Health and anticipation of the upcoming statewide functional exercise. Slides prepared by The Abaris Group
Patient P.V., a 74-year-old male, presented with progressive body weakness that began 15 days prior. He reported weakness starting in his lower extremities and progressing upwards. He was admitted to the hospital with a chief complaint of body weakness and a diagnosis of Guillain-Barré syndrome was considered. Guillain-Barré syndrome is an autoimmune disorder where the body's immune system attacks the peripheral nervous system, causing muscle weakness and possible paralysis. Nursing care involved assessing the patient, administering medications to treat the condition, providing respiratory support if needed, and patient/family education on Guillain-Barré syndrome and its management.
A case of chronic diarrhea secondary to Capillaria philippinensis in Occidental, Mindoro Philippines: a newly-diagnosed endemic area?
https://www.actamedicaphilippina.org/article/7208-a-case-of-chronic-diarrhea-secondary-to-capillaria-philippinensis-in-occidental-mindoro-possibly-a-newly-described-endemic-area
This document discusses several aspects of managing elderly patients with multiple chronic conditions (multimorbidity). It notes that multimorbidity is highly prevalent in the elderly and impacts physical and cognitive functioning, depression, mortality and hospitalization. It also discusses how multimorbidity affects the management of specific conditions like COPD, diabetes, heart failure, osteoporosis, dementia and hypertension. The document emphasizes that clinical guidelines focused on single diseases do not adequately address the complexity of multimorbid elderly patients.
This document discusses a protocol for a systematic review that aims to synthesize evidence on the relative risk of mortality in type 2 diabetes mellitus (T2DM). It provides background on the prevalence of T2DM and discusses inconsistencies in reported mortality rates. The systematic review will explore all-cause mortality risk in T2DM expressed as hazard ratios, and examine subgroups based on age, gender, socioeconomic factors and causes of death. The review expects to pool data from large cohort studies to accurately summarize the actual mortality risk in T2DM with limited bias and help direct future research.
Diabetes mellitus type 2: One monster eating allApollo Hospitals
Type 2 diabetes mellitus (T2DM) has become one of the most prevalent non-communicable diseases worldwide. If left uncontrolled, T2DM can damage almost every organ system in the body and lead to numerous serious complications. The main complications discussed in the document are cardiovascular disease, diabetic retinopathy (damage to the retina), diabetic nephropathy (kidney damage), pulmonary dysfunction, diabetic neuropathy, and hepatic dysfunction. Uncontrolled hyperglycemia increases the risks of all these complications through mechanisms like increased advanced glycation end products, oxidative stress, and inflammation. Studies have shown T2DM poses a major threat in India as well, with Indians at high risk of related cardiovascular and metabolic issues.
dialogue between immune cells and stem cells in treating Kawasaki diseaseHNatasha1
This document discusses Kawasaki disease, a condition that causes inflammation in blood vessels. It first provides background on Kawasaki disease and stem cells. It then discusses the etiology, pathophysiology, and immunopathogenesis of Kawasaki disease. The document outlines how intravenous immunoglobulin is used to treat Kawasaki disease but is not always effective. It proposes that induced pluripotent stem cells could be used to model Kawasaki disease and investigate treatment approaches, including stem cell transplantation. In conclusion, induced pluripotent stem cells show potential as an alternative treatment for Kawasaki disease.
Dietary iron intake was assessed using a food frequency questionnaire in a cohort of 58,615 Japanese adults with no history of cardiovascular disease or cancer. During follow up, 2,690 deaths from cardiovascular disease occurred. In men, higher dietary iron intake was associated with increased risk of death from total stroke, ischemic stroke, and total cardiovascular disease. Each of these associations showed a dose-response relationship with increasing quintiles of iron intake. Dietary iron intake was not associated with cardiovascular mortality in women. The results provide some support for the hypothesis that iron intake increases cardiovascular risk, at least in Japanese men.
This document provides an overview of chronic spontaneous urticaria (CSU), including its epidemiology, pathophysiology, clinical presentation, investigations, and management. It discusses the diagnosis and classification of urticaria and focuses on the diagnosis and investigation of CSU. Routine diagnostic measures for CSU include CBC, ESR or CRP, and eliminating possible causes such as medications or foods. Extended diagnostic testing may include allergy testing, infections screening, autoantibody testing such as the autologous serum skin test, and screening for underlying conditions. The gold standard treatment for CSU is non-sedating H1 antihistamines as monotherapy or in increased doses. Refractory cases may require the addition
The document describes the case of a 22-year-old woman who presented to the emergency department with diffuse abdominal pain for the past 48 hours. Her medical history included depression, prior appendectomy, cholecystectomy, and hysterectomy. Initial labs and imaging, including a CT scan, were unremarkable. Additional history revealed the patient's father was of Finnish descent and her urine was reddish-brown. A urine test found highly elevated porphobilinogen levels, leading to a diagnosis of acute intermittent porphyria. She was treated with IV dextrose and hemin and discharged after her symptoms resolved. The case highlights the importance of considering rare diseases and gathering additional history clues to reach the correct diagnosis.
Olivieri ignazio malattia di whipple torino gennaio 2011_14° convegno patolo...cmid
This document discusses the musculoskeletal manifestations of Whipple's disease, a rare infectious disease caused by the bacterium Tropheryma whipplei. It details that arthralgia and arthritis are among the most common extra-intestinal symptoms and may precede gastrointestinal complaints by many years. While spondyloarthritis has been reported in some cases of Whipple's disease, it is not considered to be part of the spondyloarthritis complex.
Matthew Howse is a consultant nephrologist at the Royal Liverpool and Broadgreen University Hospitals NHS Trust and an honorary senior lecturer at the University of Liverpool. He received his medical degree from the University of Liverpool in 2005 and has worked in nephrology and general internal medicine since graduating. His clinical work focuses on nephrology, transplantation, pregnancy-related kidney disease, and general medicine. He also has a research focus and teaches medical students.
The document discusses startling statistics about chronic disease in America, despite advances in medicine and healthcare spending. While the U.S. has the most advanced healthcare system, the WHO and AMA said in 1985 that America is experiencing the worst epidemic of chronic disease ever. Two out of three Americans will die from heart disease, cancer, stroke, lung disease or diabetes. Since then, rates of obesity and diabetes have doubled or tripled. Nitric oxide was discovered to play a key role in cardiovascular health, and Dr. Prendergast found that supplementing with L-arginine successfully reduced plaque and reversed disease in his patients.
A 43-year-old Mexican woman presented with 1 week of abdominal pain, fevers, and headache. Over the course of her hospitalization, she was found to have hepatosplenomegaly, elevated liver enzymes, thrombocytopenia, and multiple splenic lesions. A liver biopsy showed granulomatous hepatitis. Blood cultures eventually grew Brucella melitensis, and she reported recent exposure to cows in rural Mexico. The final diagnosis was brucellosis.
Los días 7 y 8 de mayo organizamos en la Fundación Ramón Areces con la Fundación General CSIC el Simposio Internacional 'Microbiología: transmisión'. La "transmisión" en microbiología hace referencia al proceso por el que material genético es transferido de una célula a otra, de una población a otra. Es un proceso clave para entender el origen y la evolución de los seres vivos. El objetivo de esta reunión era conocer mejor la logística de la transmisión para ser capaces de modular o suprimir algunos procesos de transmisión dañinos.
The document presents a case study of a 4-year-old boy diagnosed with Dengue Hemorrhagic Fever grade 3. It describes the patient's family profile, medical history, symptoms, lab results, and treatment over his 7 day hospitalization. Key findings include fever, vomiting, abdominal pain, thrombocytopenia, and signs of plasma leakage. The patient was treated with IV fluids, antibiotics, and supportive care. He recovered well and was discharged once afebrile with improving appetite and stable platelet count above 50,000/mm3.
Strongyloidiasis after corticosteroid therapy: A case reportPavan Lomati
Strongyloides hyperinfection requires prompt diagnosis and initiation of antihelmintic therapy. Even with appropriate therapy, the mortality in disseminated Strongyloidiasis is much higher. In light of this, appropriate screening of high risk individual should be carried out prior to the initiation of therapy that is associated with immunosuppression.
2015 - Gonzalez J et al - Recognition and management of severe malarial infec...Jimmy Gonzalez, Pharm.D.
After being hospitalized for 16 days, patient DS was discharged with prescriptions to treat malaria and HIV. DS, a 53-year-old man returning from Burkina Faso, presented with nausea, vomiting, headache, and diarrhea. He was diagnosed with malaria after Plasmodium falciparum and P. vivax were seen on blood smear. DS developed malaria-associated acute respiratory distress syndrome and required ventilator support for 10 days. He recovered and was discharged on antimalarial and antiretroviral medications.
Glycemic control and excess mortality in type 1 diabetes mellitisDrJawad Butt
This study analyzed mortality rates in 33,915 Swedish patients with type 1 diabetes compared to 169,249 age- and sex-matched controls from the general population. It found that patients with type 1 diabetes and an average HbA1c of 6.9% or lower had twice the risk of death from any cause and cardiovascular causes than controls. Risks increased incrementally with higher HbA1c levels, with risks of death 8-10 times higher in patients with poor control. Excess mortality in type 1 diabetes was mainly due to cardiovascular disease and diabetes-related causes.
The document discusses biblical revelations about nutrition and health based on passages from the Bible. It states that sickness and disease plague mankind due to a lack of knowledge, and that God's words in the Bible contain the truth about health and disease prevention. It provides examples from the Bible of the types of meat, fat, and plants that are healthy to eat according to biblical teachings.
This document discusses the diagnosis, treatment, and long-term management of Kawasaki disease. It begins with an overview of the epidemiology of the disease, including that it predominantly affects children under 5 years old and has the highest incidence in Japan, Korea, and Taiwan. It then covers the pathology and causes of the disease, which involves a systemic vasculitis of medium-sized arteries. Three linked pathological processes are described: necrotizing arteritis in the initial weeks, followed by subacute/chronic vasculitis and luminal myofibroblastic proliferation that can persist for months/years and cause coronary artery aneurysms or stenosis. The document outlines the diagnostic criteria for Kawasaki disease as a high
1) The study surveyed 40 NCAA Division II swimmers about their nutrition knowledge, supplement use, and use of sodium bicarbonate.
2) It found that 85% of swimmers used supplements, with males being more likely to use supplements than females. The majority believed supplements were necessary to perform well but had little actual knowledge about supplements.
3) Regarding sodium bicarbonate specifically, 17% of swimmers reported using it, with most saying it improved performance but one reporting side effects. Knowledge of its side effects was low overall.
This document discusses several aspects of managing elderly patients with multiple chronic conditions (multimorbidity). It notes that multimorbidity is highly prevalent in the elderly and impacts physical and cognitive functioning, depression, mortality and hospitalization. It also discusses how multimorbidity affects the management of specific conditions like COPD, diabetes, heart failure, osteoporosis, dementia and hypertension. The document emphasizes that clinical guidelines focused on single diseases do not adequately address the complexity of multimorbid elderly patients.
This document discusses a protocol for a systematic review that aims to synthesize evidence on the relative risk of mortality in type 2 diabetes mellitus (T2DM). It provides background on the prevalence of T2DM and discusses inconsistencies in reported mortality rates. The systematic review will explore all-cause mortality risk in T2DM expressed as hazard ratios, and examine subgroups based on age, gender, socioeconomic factors and causes of death. The review expects to pool data from large cohort studies to accurately summarize the actual mortality risk in T2DM with limited bias and help direct future research.
Diabetes mellitus type 2: One monster eating allApollo Hospitals
Type 2 diabetes mellitus (T2DM) has become one of the most prevalent non-communicable diseases worldwide. If left uncontrolled, T2DM can damage almost every organ system in the body and lead to numerous serious complications. The main complications discussed in the document are cardiovascular disease, diabetic retinopathy (damage to the retina), diabetic nephropathy (kidney damage), pulmonary dysfunction, diabetic neuropathy, and hepatic dysfunction. Uncontrolled hyperglycemia increases the risks of all these complications through mechanisms like increased advanced glycation end products, oxidative stress, and inflammation. Studies have shown T2DM poses a major threat in India as well, with Indians at high risk of related cardiovascular and metabolic issues.
dialogue between immune cells and stem cells in treating Kawasaki diseaseHNatasha1
This document discusses Kawasaki disease, a condition that causes inflammation in blood vessels. It first provides background on Kawasaki disease and stem cells. It then discusses the etiology, pathophysiology, and immunopathogenesis of Kawasaki disease. The document outlines how intravenous immunoglobulin is used to treat Kawasaki disease but is not always effective. It proposes that induced pluripotent stem cells could be used to model Kawasaki disease and investigate treatment approaches, including stem cell transplantation. In conclusion, induced pluripotent stem cells show potential as an alternative treatment for Kawasaki disease.
Dietary iron intake was assessed using a food frequency questionnaire in a cohort of 58,615 Japanese adults with no history of cardiovascular disease or cancer. During follow up, 2,690 deaths from cardiovascular disease occurred. In men, higher dietary iron intake was associated with increased risk of death from total stroke, ischemic stroke, and total cardiovascular disease. Each of these associations showed a dose-response relationship with increasing quintiles of iron intake. Dietary iron intake was not associated with cardiovascular mortality in women. The results provide some support for the hypothesis that iron intake increases cardiovascular risk, at least in Japanese men.
This document provides an overview of chronic spontaneous urticaria (CSU), including its epidemiology, pathophysiology, clinical presentation, investigations, and management. It discusses the diagnosis and classification of urticaria and focuses on the diagnosis and investigation of CSU. Routine diagnostic measures for CSU include CBC, ESR or CRP, and eliminating possible causes such as medications or foods. Extended diagnostic testing may include allergy testing, infections screening, autoantibody testing such as the autologous serum skin test, and screening for underlying conditions. The gold standard treatment for CSU is non-sedating H1 antihistamines as monotherapy or in increased doses. Refractory cases may require the addition
The document describes the case of a 22-year-old woman who presented to the emergency department with diffuse abdominal pain for the past 48 hours. Her medical history included depression, prior appendectomy, cholecystectomy, and hysterectomy. Initial labs and imaging, including a CT scan, were unremarkable. Additional history revealed the patient's father was of Finnish descent and her urine was reddish-brown. A urine test found highly elevated porphobilinogen levels, leading to a diagnosis of acute intermittent porphyria. She was treated with IV dextrose and hemin and discharged after her symptoms resolved. The case highlights the importance of considering rare diseases and gathering additional history clues to reach the correct diagnosis.
Olivieri ignazio malattia di whipple torino gennaio 2011_14° convegno patolo...cmid
This document discusses the musculoskeletal manifestations of Whipple's disease, a rare infectious disease caused by the bacterium Tropheryma whipplei. It details that arthralgia and arthritis are among the most common extra-intestinal symptoms and may precede gastrointestinal complaints by many years. While spondyloarthritis has been reported in some cases of Whipple's disease, it is not considered to be part of the spondyloarthritis complex.
Matthew Howse is a consultant nephrologist at the Royal Liverpool and Broadgreen University Hospitals NHS Trust and an honorary senior lecturer at the University of Liverpool. He received his medical degree from the University of Liverpool in 2005 and has worked in nephrology and general internal medicine since graduating. His clinical work focuses on nephrology, transplantation, pregnancy-related kidney disease, and general medicine. He also has a research focus and teaches medical students.
The document discusses startling statistics about chronic disease in America, despite advances in medicine and healthcare spending. While the U.S. has the most advanced healthcare system, the WHO and AMA said in 1985 that America is experiencing the worst epidemic of chronic disease ever. Two out of three Americans will die from heart disease, cancer, stroke, lung disease or diabetes. Since then, rates of obesity and diabetes have doubled or tripled. Nitric oxide was discovered to play a key role in cardiovascular health, and Dr. Prendergast found that supplementing with L-arginine successfully reduced plaque and reversed disease in his patients.
A 43-year-old Mexican woman presented with 1 week of abdominal pain, fevers, and headache. Over the course of her hospitalization, she was found to have hepatosplenomegaly, elevated liver enzymes, thrombocytopenia, and multiple splenic lesions. A liver biopsy showed granulomatous hepatitis. Blood cultures eventually grew Brucella melitensis, and she reported recent exposure to cows in rural Mexico. The final diagnosis was brucellosis.
Los días 7 y 8 de mayo organizamos en la Fundación Ramón Areces con la Fundación General CSIC el Simposio Internacional 'Microbiología: transmisión'. La "transmisión" en microbiología hace referencia al proceso por el que material genético es transferido de una célula a otra, de una población a otra. Es un proceso clave para entender el origen y la evolución de los seres vivos. El objetivo de esta reunión era conocer mejor la logística de la transmisión para ser capaces de modular o suprimir algunos procesos de transmisión dañinos.
The document presents a case study of a 4-year-old boy diagnosed with Dengue Hemorrhagic Fever grade 3. It describes the patient's family profile, medical history, symptoms, lab results, and treatment over his 7 day hospitalization. Key findings include fever, vomiting, abdominal pain, thrombocytopenia, and signs of plasma leakage. The patient was treated with IV fluids, antibiotics, and supportive care. He recovered well and was discharged once afebrile with improving appetite and stable platelet count above 50,000/mm3.
Strongyloidiasis after corticosteroid therapy: A case reportPavan Lomati
Strongyloides hyperinfection requires prompt diagnosis and initiation of antihelmintic therapy. Even with appropriate therapy, the mortality in disseminated Strongyloidiasis is much higher. In light of this, appropriate screening of high risk individual should be carried out prior to the initiation of therapy that is associated with immunosuppression.
2015 - Gonzalez J et al - Recognition and management of severe malarial infec...Jimmy Gonzalez, Pharm.D.
After being hospitalized for 16 days, patient DS was discharged with prescriptions to treat malaria and HIV. DS, a 53-year-old man returning from Burkina Faso, presented with nausea, vomiting, headache, and diarrhea. He was diagnosed with malaria after Plasmodium falciparum and P. vivax were seen on blood smear. DS developed malaria-associated acute respiratory distress syndrome and required ventilator support for 10 days. He recovered and was discharged on antimalarial and antiretroviral medications.
Glycemic control and excess mortality in type 1 diabetes mellitisDrJawad Butt
This study analyzed mortality rates in 33,915 Swedish patients with type 1 diabetes compared to 169,249 age- and sex-matched controls from the general population. It found that patients with type 1 diabetes and an average HbA1c of 6.9% or lower had twice the risk of death from any cause and cardiovascular causes than controls. Risks increased incrementally with higher HbA1c levels, with risks of death 8-10 times higher in patients with poor control. Excess mortality in type 1 diabetes was mainly due to cardiovascular disease and diabetes-related causes.
The document discusses biblical revelations about nutrition and health based on passages from the Bible. It states that sickness and disease plague mankind due to a lack of knowledge, and that God's words in the Bible contain the truth about health and disease prevention. It provides examples from the Bible of the types of meat, fat, and plants that are healthy to eat according to biblical teachings.
This document discusses the diagnosis, treatment, and long-term management of Kawasaki disease. It begins with an overview of the epidemiology of the disease, including that it predominantly affects children under 5 years old and has the highest incidence in Japan, Korea, and Taiwan. It then covers the pathology and causes of the disease, which involves a systemic vasculitis of medium-sized arteries. Three linked pathological processes are described: necrotizing arteritis in the initial weeks, followed by subacute/chronic vasculitis and luminal myofibroblastic proliferation that can persist for months/years and cause coronary artery aneurysms or stenosis. The document outlines the diagnostic criteria for Kawasaki disease as a high
1) The study surveyed 40 NCAA Division II swimmers about their nutrition knowledge, supplement use, and use of sodium bicarbonate.
2) It found that 85% of swimmers used supplements, with males being more likely to use supplements than females. The majority believed supplements were necessary to perform well but had little actual knowledge about supplements.
3) Regarding sodium bicarbonate specifically, 17% of swimmers reported using it, with most saying it improved performance but one reporting side effects. Knowledge of its side effects was low overall.
This study investigated the prevalence of anemia and nutrient deficiencies in the first year after laparoscopic gastric bypass surgery in 377 patients. The results found that 25% of patients developed anemia, with 33% having iron deficiency, 15% with folate deficiency, and 50% with vitamin B12 deficiency. Overall, 63% of patients were diagnosed with at least one of these deficiencies. Female patients and those with a prior gastric band had higher rates of deficiencies. The study recommends increased supplementation of iron, folate, and B12 after surgery to prevent deficiencies and anemia.
The authors worked together effectively to provide information about healthy eating and supplement use at a booth at Northeast Baptist Hospital over two days in March. They discussed their topic in February and decided to provide correct information about supplements and the benefits of a balanced diet given media coverage of supplements. Their booth used different materials like posters, handouts, and activities to engage people. A survey of 7 people found that all found the booth helpful and wanted to see more nutrition booths, with most finding the presenters knowledgeable. The booth successfully reached many people to provide truthful information about supplements and healthy diets.
The document discusses a study assessing NCAA swimmers' use of sodium bicarbonate (SB), including their knowledge, beliefs, and perceived benefits. It reviews literature showing many athletes consume supplements without fully understanding them. Studies found swimmers commonly use multivitamins and creatine. SB acts as a buffer against lactic acid buildup, potentially improving short-term, high-intensity performance. However, its effects on swimmers specifically are unclear due to limited research. The purpose of this study is to understand NCAA swimmers' SB use, attitudes, and nutrition knowledge.
This patient is a 28-year-old male who was admitted to the hospital for exertional rhabdomyolysis and acute renal failure after participating in a soccer tournament. He had a history of heat exhaustion from soccer previously. During his hospital stay he was aggressively hydrated and his renal function and creatine kinase levels gradually improved. Nutrition education was provided regarding adequate carbohydrate intake for his high activity levels and future prevention of similar issues.
The document announces a St. Patrick's Day lunch being held on March 14th from 11:30 am to 1:00 pm in the TCID dining room. A traditional Irish menu including Irish salad, colcannon, soda bread, corned beef, and apple crumble will be served at the standard staff price.
This document summarizes two studies that investigated the effects of sodium bicarbonate supplementation on sprint and endurance exercise performance. The first study found that sodium bicarbonate ingestion increased the intensity of repeated sprint exercise in trained male athletes but did not affect lactate or hydrogen ion ratios. The second older study found that sodium bicarbonate ingestion improved average and peak power output during repeated sprint cycling in males and females. It also found benefits for endurance cycling performance in trained male cyclists. Both studies provide evidence that sodium bicarbonate can enhance sprint and endurance sports performance.
This document provides recipes for several dishes:
1) Red Potato Colcannon, a potato and cabbage dish, made by steaming potatoes and sautéing cabbage and onions before mixing together.
2) Fighting Green Irish Salad, a salad with lettuce, asparagus, peas, tomatoes and a lemon vinaigrette dressing.
3) Lucky Apple Crumble, a dessert of baked apples topped with an oat and flour crumble topping.
The document announces a St. Patrick's Day lunch celebration on March 14th from 11:30 am to 1:00 pm in the TCID dining room. The lunch will feature traditional Irish foods like Fighting Irish Green Salad, Fried Potato Colcannon, Soda Bread, Brown Sugar and Mustard Glazed Corned Beef, and Lucky Apple Crumble. A short poem is also included wishing good health, luck, and happiness.
The document contains a survey asking the respondent to rate statements about a meal experience on a scale of agree, disagree, neither agree nor disagree, or not applicable. The statements cover the professionalism of foodservice staff, proper food temperatures, staff politeness, attractiveness of served foods, quality and flavor of ingredients meeting expectations, and wanting to have the meal again. It requests suggestions to improve the meal experience and closes with an Irish blessing.
Allison Kliewer is a registered dietitian living in San Antonio, Texas. She received a master's degree in science from the University of the Incarnate Word in 2012 and a bachelor's degree in science from Henderson State University in 2010. Currently, she works as a clinical dietitian at North Central Baptist Hospital and has previous experience as a dietetic technician at St. Luke's Baptist Hospital. She is an active member of several professional organizations and volunteer activities. Kliewer has received several honors and awards for her academic and athletic achievements.
EnglishLive is an online English language learning school founded by Rosally Daniel, Andre Bodowski, and Nakia Jawara. It provides live and recorded online English classes taught by certified teachers in the US. The document outlines the founders and mission, market opportunity in teaching English globally, business model, financial projections showing profitability within a year, and low capital needs to launch the business.
This document provides a business plan for Sonny Sport Nutrition, a proposed sports nutrition service for athletes at the University of the Incarnate Word. The summary is:
Sonny Sport Nutrition will provide individualized sports nutrition services and education to athletes at the University of the Incarnate Word. The company aims to help athletes enhance performance, speed recovery, and make informed choices about nutrition, supplements, and more. As the only such service in the area, it will offer UIW a unique recruiting advantage as the school transitions to Division I athletics. The business will be operated as a limited liability corporation by its founder, a registered dietitian with experience as an athlete and coach.
Rakesh Sharma was the first Indian citizen to travel to space. In 1984, as a Squadron Leader in the Indian Air Force, he was selected to join the Intercosmos space program, a joint program between India and the Soviet Union. Sharma spent eight days aboard the Salyut 7 space station, becoming the first Indian to travel in space.
Kalpana Chawla was the first Indian-American woman in space. She flew on two space shuttle missions - in 1997 on STS-87 and in 2003 on the ill-fated STS-107 mission, where she and six other crew members died during re-entry when the shuttle disintegrated. Chawla held multiple
A 25-year-old female presented with abdominal pain, repeated fits and profuse vaginal bleeding after delivering a dead baby at home. She was diagnosed with HELLP syndrome based on her symptoms and lab results. She was treated aggressively in the intensive care unit with magnesium sulfate to control seizures, blood transfusions, evacuation of retained placenta, antihypertensives, and hemodialysis. Her condition improved over several days and she was discharged after 10 days on oral medications. The case illustrates the importance of early detection and rapid treatment by a multidisciplinary team for successful management of HELLP syndrome.
The patient is a 45-year-old female presenting with sudden abdominal pain for 3 hours in her epigastric and right upper quadrant areas. She reports one episode of vomiting and a subjective fever. Her vital signs show elevated blood pressure, heart rate, and temperature. Physical exam reveals tenderness in the epigastric and right upper quadrants. Based on her history and exam findings, she is suspected to have acute cholecystitis.
This clinical trial demonstrated persistent graft function and regulated insulin secretion in a patient with type 1 diabetes who received an allogeneic islet transplant using a novel oxygenated chamber system without immunosuppression. The patient showed basal C-peptide production and stimulated insulin response over 10 months. The chamber protected the islets from immune rejection while continuously supplying oxygen. This approach may enable widespread application of islet and other cell-based therapies by overcoming limitations of donor availability and need for immunosuppression.
1. The document provides background information on pneumonia including its causes, risk factors, signs and symptoms, and treatment. It discusses pneumonia as a leading cause of death from infectious disease.
2. It then outlines the general and specific objectives of studying the case of a 47-year-old female patient admitted for difficulty breathing later diagnosed with pneumonia.
3. The theoretical framework draws upon Florence Nightingale's environmental theory, noting how the patient's living conditions relating to air, water, sanitation and space likely contributed to her illness.
Diabetic Ketoacidosis is a disease secondary to Uncontrolled hyperglycemia. It can occur in Type I as well as advancement of Type II DM (Diabetes Mellitus). Biochemistry case presentation from harper's biochemistry case 6 - diabetic ketoacidosis.
1. Suzanne Jones, 76-year-old patient with COPD is admitted to the.docxjeremylockett77
1. Suzanne Jones, 76-year-old patient with COPD is admitted to the ICU. Mrs. Jones is placed on mechanical ventilation to assist with her breathing. After 2 days on the ventilator, Mrs. Jones is extubated and then transferred to a medical-surgical unit. The medication regimen is adjusted during the hospitalization. Mrs. Jones is discharged home after 6 days. She and her family are pleased with the care she receive in the hospital. (Learning Objectives 3 and 6)
a. Describe the quality performance tools that may be used to demonstrate that the care and treatment rendered are both cost-efficient and of high quality.
b. Describe the quality performance tools that may be used to demonstrate that the nursing care utilized is evidence-based care and high quality, resulting in patient satisfaction and good patient outcomes.
2. The registered nurse working in the cardiac care clinic is tasked with implementing quality improvement measures. To educate the clinic staff, the nurse plans an in-service program to introduce concepts of quality improvement and evidence-based practice. Additionally, the role of the case manager will be included in the presentation. The nurse plans on using care of the patient with Congestive Heart Failure as a template, and prepares sample clinical pathways, care maps, and multidisciplinary action plans. (Learning Objective 3)
a. Describe how clinical pathways are used to coordinate care of caseloads of patients.
b. What is the role of the case manager in evaluating a patient’s progress?
c. What are examples of evidence-based practice tools used for planning patient care?
. Mr. Jones, who is 74 years of age, is being discharged home after having a right knee replacement. The discharge orders from the orthopedic surgeon include: continuous passive motion (CPM) at the current setting of 0-degrees extension worn when walking with crutches (nonweight-bearing postdischarge day 1, and may begin weight-bearing postdischarge day 2); and home nurse visits, as needed. Physical therapy should begin the day after discharge at an orthopedic center. The orders will be faxed to the center. The following medications with prescriptions attached include: Lovenox (enoxaparin) 70 mg subcutaneously once daily for 7 days, Vicodin (hydrocodone bitartrate) 10 mg every 4 hours PRN, and Colace (docusate sodium) 100 mg every day. The patient is to follow up with the orthopedic surgeon in 3 weeks. His daughter plans to stay with him for several weeks to assist him with meals and household chores, and take him to physical therapy and the orthopedic surgeon for follow-up. Mr. Jones has three other children who live in other states. He is a widower and attends a local church. (Learning Objective 4)
a. What preparations should the nurse make in advance before attaining necessary community resources and referrals before the patient is discharged?
1. What necessary community resources and referrals will the patient need?
2. Mrs. Johnson, a 67-year-old ...
Acute Leukemia Initial Presentation as Acute Appendicitis - Case Reportasclepiuspdfs
Appendicitis represents a real, everyday working problem for the primary physician and those who care for children. Acute appendicitis can be initial manifestation of leukemia or relapse. However, such cases have only been reported in adults. Very few cases are reported in pediatric population. Here, we report a 5-year-old girl who presented with clinical features suggestive of acute appendicitis. The clinical findings were supported with radiological findings. On further investigations, found to have acute leukemia. Acute appendicitis was treated conservatively. The parents were reluctant to accept the clinical diagnosis. The parents were keen to get more and more second opinion in this regard before accepting final diagnosis.
1. Malnutrition is common in head and neck cancer patients due to mechanical obstruction, sensory impairment, pain with swallowing, and the effects of cancer treatments like surgery, radiation and chemotherapy.
2. Factors contributing to malnutrition include reduced oral intake, anorexia, nausea, inadequate chewing and swallowing difficulties. Cancer cachexia, where the body breaks down muscle and fat stores, further worsens malnutrition.
3. Malnutrition is associated with increased complications, longer hospital stays, decreased survival, and poorer outcomes for head and neck cancer patients. Early nutritional intervention is important.
This summary provides an overview of a clinical case study presentation about a 68-year old female patient with a history of smoking, obesity, multiple gastric surgeries, achalasia, chronic malnutrition, and recurrent aspiration pneumonia. The presentation traces the progression of the patient's diseases and treatments, highlights the nutrition care process and interventions, and explores the connections between the patient's achalasia and history of bulimia. The patient was recently admitted for acute respiratory failure from aspiration pneumonia and declined further interventions, passing away after 9 days in the hospital.
Principal Diagnosis- list- describe- and code Secondary diagnosis- lis.docxchahuckfiru
Principal Diagnosis: list, describe, and code
Secondary diagnosis: list describe and code
Explain why you are choosing a particular diagnosis as the principal diagnosis and also why you are sequencing the codes in a particular fashion.
Module 5 cases : please code cases 4 and 5.
Please do not code any procedures.
4. Inpatient admission: The patient, witharterio sclerotic coconary heart disease and type 2 diabetes metlitus, eemme to the hospital with sympioms that were believed to represent sepois. She was placed on antibioties; and the sy mipious . improved. ST- and T-wave changes patient's glocose showed marked on an EKG. The patienis to becondary to the sepsis: The blond sugars were brought under control The with an adjustment of her insalin therapy and an appropriate diet. Discharge diagnosess. (1) Arterioselerotic : Uncontooled el abeles may cefer to kisod nugars being Nowatiod coconary heart disesse, ( 2 ) uncontrolled type 2 diabetes mellitus, (3) questionable sepsis. Etros Tyee 2 dinceter metica watho 2704 bong formicutinte used aisuin Comments: The admission was recesstated by signs and Byt ceoms of sopsis, which was nevar ruled cut and, thecolere. is: Fo princlpal dagnoils iCDig-.CM coong gudolnes stane biat Iter at a agnosis of eeasis, the aspropriate codo for the undirying. Systerici infese on is assigned, Code Acs.9 is aseigned if the : (hyperpycemiay oi 40 low (tippoglysemis), in this case, tho : paient's glucose thowed mained eleration, For by diabeles : codo, refer to the man uem 0 sbelet, in the Aphabotio index. The subterm funcontrelid meaning Zyperglyeemis, adisos tha usor to 'seo. Dlibotes, by type, with typenelyeerria.". No eode is assigned ter ses ST.and T. Wave changes on the. EkG becauso they represint abonomal fodings that wore not treased or furtior avalussed. Codo 2794 is assigned for the patunts long-term insuifin therapy. 5. Dutpatient clinic visit: The HIV-infecred patient was. Suffering from an acute lymphadenitis due to his HIV infection. The glands in the nock area were most affected. Antibiotics were preseribed. but the patient refused antiretrosiral treatment. at this time. He was of the opinion that bis 8xy) Runan ititunodethenc vies it M ditebset religion would eventally make antiretroviral medication unnecessiry Another consideration Was his nareotic dependency. He was encounaged to costinue participation in support groups for people with narcotic addiction and HIV. F1120 Cplad depundense, uncorgiculid Diagnoses: (1) Mcute lymphadeniris secosdary to HIV infection. (2) narcotic dependence, (3) refusal of medication due to religious reasons. Comments: Code 820 is assigned for al Hiv lotections and is C. Cosignssed as the cealon fec encounter whan the pabent wat sean for Hiv inlection or a re atod consition, Code L0t A. Acule bimphadenitis of tise, heod and neck ehould not be assigesd : achg w in code Ba0 beceuse of the torcludest note as camegery Lo4 exeluding Hil di soaso resuling in gkoalaled lymphade. no.
1) A 32-year-old woman presented with a 10-year history of severe recurrent abdominal pain.
2) Extensive prior testing and evaluations did not identify a cause, though she was diagnosed with conversion disorder during one hospitalization.
3) During her most recent hospitalization for abdominal pain, she developed hyponatremia that was initially thought to be due to poor oral intake but worsened despite IV fluids.
4) Further testing revealed findings consistent with SIADH and elevated urine porphyrin levels, leading to a diagnosis of acute intermittent porphyria, a rare genetic disorder causing episodic severe abdominal pain and other symptoms.
This case study describes a 46-year-old male who presented to the emergency room with abdominal pain that had worsened over three days. A CT scan revealed evidence of acute appendicitis with inflammation and dilation of the appendix. The patient was admitted with a diagnosis of acute appendicitis and scheduled for an appendectomy. Physical exam findings and diagnostic test results are provided to support the diagnosis.
Risk of pulmonary aspiration with the outpatient electroconvulsive therapy: C...Ahmed Elaghoury
A case study presented at the 2nd International Brain Stimulation in Barcelona.
Cite as: Gad, M., & Elaghoury, A. (2017). Risk of pulmonary aspiration with the outpatient electroconvulsive therapy: Case report. Brain Stimulation: Basic, Translational, and Clinical Research in Neuromodulation, 10(2), 419.
http://dx.doi.org/10.1016/j.brs.2017.01.244
The first document describes two emergency cases seen at the hospital on October 6th, 2022. The first case involves a 37-year-old man brought to the emergency department for worsening lethargy and abdominal pain. On examination, he appears weak with low blood pressure and pale conjunctiva. The second case involves a 3-year-old girl brought to the emergency department for intermittent abdominal pain and vomiting blood. On examination, she appears weak with a palpable mass in her right lower abdomen. The tutor leads a discussion on identifying and discussing the problems in these cases chronologically while considering all possible diagnoses. References are also provided for some laboratory results.
1[Shortened Title up to 50 Characters]2Week 9 Assignment.docxhallettfaustina
1
[Shortened Title up to 50 Characters] 2Week 9 Assignment
Bethel U. Godwins
Walden University
NURS 6551, Section 8, Primary Care of Women
July 31, 2016
Abnormal Uterine Bleeding
Society for Reproductive Endocrinology and Infertility (SREI, 2012) described abnormal uterine bleeding as bleeding that differs in quality and quantity from normal menstrual bleeding, such as women spotting or bleeding between the women’s menstrual periods; bleeding after sex; bleeding heavier or last more days than normal; and bleeding post menopause. According to SREI (2012), factors that can cause abnormal bleeding include structural abnormalities of the reproductive system, such as uterine polyps, fibroids, and adenomyosis. Furthermore, SREI (2012) explained that vaginal, uterine or cervical lesions, miscarriage, ectopic pregnancy, endometritis, adhesions in the endometrium, and use of an intrauterine device (IUD) can also cause abnormal bleeding. Johns Hopkins Medicine (2016) specified that early recognition of abnormal bleeding, and seeing a health care provider immediately for appropriate diagnosis and treatment increase the chance of successful treatment. Therefore, the author will focus on a single patient comprehensive evaluation, which includes the patient’s personal/health history; physical examination; laboratory/diagnostic tests; diagnosis; treatment/management plan; education strategies; and follow-up care. Comment by DeAllen B Millender: Good introduction.
General Patient Information
Age: 41-year-old
Race/Ethnicity: Hispanic American
Partner Status: Married Comment by DeAllen B Millender: This information is not in APA format.
Current Health Status
Chief Complaint: “I have heavy, prolonged menstrual bleeding with severe cramping for the past one year”.
History of Present Illness (HPI): RG is a 41-year-old Hispanic American female who presented to the clinic with complaint of heavy prolonged menstrual bleeding with severe cramping for the past one year. Patient reported sharp pelvic pain during menstruation, bleeding between periods, pain with intercourse, blood clots during periods. Abdominal pain/pressure and bloating. Patient suggested that these symptoms started after her second caesarean section surgery one year ago. Patient also reported that she takes over-the counter medication, such as ibuprofen to relieve the pain. she also suggested that she uses heating pad on her abdomen/pelvic for pain relief, and she stated that she soaks in a warm sitz bath to ease pelvic pain and cramping. Patient also reported fatigue and weakness. Patient further stated that she decided to see an obstetrician and gynecologist (OB/GYN) because the heavy prolonged bleeding with severe menstrual cramp interfere with her regular activities. Patient denied nausea, vomiting, diarrhea, fever, and chills.
Timing/Onset: Patient said one year ago.
Location: The location of the problem as stated by the patient is pelvic/uterus/vaginal.
Duration: 5 to7 days du ...
1[Shortened Title up to 50 Characters]16Week 9 Assignment.docxhallettfaustina
1
[Shortened Title up to 50 Characters] 16Week 9 Assignment
Bethel U. Godwins
Walden University
NURS 6551, Section 8, Primary Care of Women
July 31, 2016
Abnormal Uterine Bleeding
Society for Reproductive Endocrinology and Infertility (SREI, 2012) described abnormal uterine bleeding as bleeding that differs in quality and quantity from normal menstrual bleeding, such as women spotting or bleeding between the women’s menstrual periods; bleeding after sex; bleeding heavier or last more days than normal; and bleeding post menopause. According to SREI (2012), factors that can cause abnormal bleeding include structural abnormalities of the reproductive system, such as uterine polyps, fibroids, and adenomyosis. Furthermore, SREI (2012) explained that vaginal, uterine or cervical lesions, miscarriage, ectopic pregnancy, endometritis, adhesions in the endometrium, and use of an intrauterine device (IUD) can also cause abnormal bleeding. Johns Hopkins Medicine (2016) specified that early recognition of abnormal bleeding, and seeing a health care provider immediately for appropriate diagnosis and treatment increase the chance of successful treatment. Therefore, the author will focus on a single patient comprehensive evaluation, which includes the patient’s personal/health history; physical examination; laboratory/diagnostic tests; diagnosis; treatment/management plan; education strategies; and follow-up care. Comment by DeAllen B Millender: Good introduction.
General Patient Information
Age: 41-year-old
Race/Ethnicity: Hispanic American
Partner Status: Married Comment by DeAllen B Millender: This information is not in APA format.
Current Health Status
Chief Complaint: “I have heavy, prolonged menstrual bleeding with severe cramping for the past one year”.
History of Present Illness (HPI): RG is a 41-year-old Hispanic American female who presented to the clinic with complaint of heavy prolonged menstrual bleeding with severe cramping for the past one year. Patient reported sharp pelvic pain during menstruation, bleeding between periods, pain with intercourse, blood clots during periods. Abdominal pain/pressure and bloating. Patient suggested that these symptoms started after her second caesarean section surgery one year ago. Patient also reported that she takes over-the counter medication, such as ibuprofen to relieve the pain. she also suggested that she uses heating pad on her abdomen/pelvic for pain relief, and she stated that she soaks in a warm sitz bath to ease pelvic pain and cramping. Patient also reported fatigue and weakness. Patient further stated that she decided to see an obstetrician and gynecologist (OB/GYN) because the heavy prolonged bleeding with severe menstrual cramp interfere with her regular activities. Patient denied nausea, vomiting, diarrhea, fever, and chills.
Timing/Onset: Patient said one year ago.
Location: The location of the problem as stated by the patient is pelvic/uterus/vaginal.
Duration: 5 to7 days d ...
The patient is a 64-year-old male admitted with aspiration pneumonia. He has a history of stroke which caused swallowing dysfunction and reduced mobility. Laboratory findings show anemia and elevated white blood cell count indicating infection. The patient requires full assistance with activities of daily living and nutrition is provided through a feeding tube. Nursing care involves treatment of the infection, prevention of further aspiration, and rehabilitation to improve swallowing and function.
A fatal case of complicated HELLP Syndrome and Antepartum Eclamptic Fit with ...Apollo Hospitals
Subcapsular hematoma and hepatic rupture are very unusual catastrophic complication of preeclampsia/eclampsia and HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome. The reported incidence of this condition varies from 1 in 40,000 to 1 in 2,50,000 deliveries.There is no agreement on the best approach to treat this severe complication of pregnancy and optimal management is still evolving.
This document describes a case of exertional rhabdomyolysis in a 28-year-old male soccer player after participating in a 3-day, 7-game soccer tournament. He experienced cramping and was diagnosed with rhabdomyolysis. He was treated with IV fluids and supportive care and discharged after 10 days. Rhabdomyolysis results from skeletal muscle breakdown causing the release of intracellular contents into circulation. Causes discussed include exertion, dehydration, electrolyte imbalances, heat illness, trauma, and drugs. The pathophysiology involves disruption of sodium-potassium pumps in muscle cells leading to calcium overload, activation of proteases, and muscle cell breakdown.
This document summarizes research on the use of sodium bicarbonate as an ergogenic aid among collegiate athletes, particularly swimmers. It finds that sodium bicarbonate can benefit performance in high-intensity, short-duration exercise by acting as a buffer and reducing muscle acidosis. However, its effects on performance are moderate. While some studies show it can improve swimming performance, more research is needed, especially on collegiate swimmers and their motivations for using sodium bicarbonate. In general, many athletes lack nutrition knowledge and are influenced by coaches and peers to use supplements like sodium bicarbonate without fully understanding their effects.
The document summarizes a St. Patrick's Day themed meal served at a long-term care facility for tuberculosis patients. Key details include:
- The menu included corned beef, potato colcannon, Irish salad, soda bread, and apple crumble.
- 46 meals were served, slightly under the target of 50. Most foods were well-received though salad ran out early.
- A consumer survey found most patients agreed the meal was professionally served, at proper temperature, and met expectations for quality and flavor.
The document outlines a 3-day menu designed by a dietetic intern to meet the nutritional needs of patients at the Texas Center for Infectious Disease, a long-term care facility. The menu was created to follow guidelines for a cardiac, 200g carbohydrate, renal, and mechanical soft diet based on the facility's population which includes patients with tuberculosis, substance abuse issues, and malnutrition from various countries. Nutritional analysis of the menu shows it meets standards for heart healthy eating while controlling carbohydrates and restricting nutrients for renal and dental diets.
This study examined the prevalence of anemia and nutrient deficiencies in the first year after laparoscopic gastric bypass surgery in 377 patients. Key results included:
- 66% of patients developed new anemia within the first post-op year
- 33% were iron deficient at one year
- 15% were folic acid deficient
- 50% were vitamin B12 deficient
- Overall, 63% of patients were deficient in iron, folic acid, or B12 by the end of the first post-op year. Risk was higher in females.
This document describes a case of exertional rhabdomyolysis in a 28-year-old male soccer player after participating in a 3-day, 7-game soccer tournament. He experienced cramping and was diagnosed with rhabdomyolysis. He was treated with IV fluids and supportive care and discharged after 10 days. Rhabdomyolysis results from skeletal muscle breakdown causing the release of intracellular contents into circulation. Causes discussed include exertion, dehydration, electrolyte imbalances, heat illness, trauma, and drugs. The pathophysiology involves disruption of sodium-potassium pumps in muscle cells leading to calcium overload, activation of proteases, and muscle cell breakdown.
This document outlines the case of a 77-year-old female patient who was admitted to the hospital with an upper gastrointestinal bleed and developed ileus. It provides background information on ileus, including causes, pathophysiology, and risks. It then details the progression of the patient's disease and complications in the intensive care unit, including pneumonia, sepsis, and small bowel obstruction. The document discusses evidence for using trophic or full-energy enteral nutrition in critically ill patients and describes the nutrition care process implemented for this patient, including total parenteral nutrition supplemented with trophic enteral feeds.
This document provides guidelines and recommendations for physical activity and hydration. It recommends that children get at least 60 minutes of physical activity per day, and adults aim for 150 minutes of moderate activity or 75 minutes of vigorous activity per week. It also stresses the importance of staying hydrated during exercise, with recommendations to drink water before, during, and after physical activity and not rely solely on thirst. The hot and humid weather in San Antonio increases the risk of dehydration.
This patient is a 28-year-old male who was admitted to the hospital for exertional rhabdomyolysis after playing in a soccer tournament. Rhabdomyolysis is a condition where skeletal muscle breaks down and releases intracellular contents into circulation. If untreated, it can lead to kidney failure. The patient was initially diagnosed with heat exhaustion but later diagnosed with rhabdomyolysis and acute renal failure. He had a 10-day hospital stay and lacked understanding of his condition upon discharge.
Allison Kliewer is a recent graduate of the University of the Incarnate Word with a Masters of Science degree in Dietetics. She completed her dietetic internship at Baptist Health System and holds a Bachelors of Science degree from Henderson State University. Her relevant work experience includes serving as a Dietetic Technician at St. Luke's Baptist Hospital and as a Graduate Assistant for the UIW swim team. She has received numerous honors and awards for her academic and athletic achievements.
Adhd Medication Shortage Uk - trinexpharmacy.comreignlana06
The UK is currently facing a Adhd Medication Shortage Uk, which has left many patients and their families grappling with uncertainty and frustration. ADHD, or Attention Deficit Hyperactivity Disorder, is a chronic condition that requires consistent medication to manage effectively. This shortage has highlighted the critical role these medications play in the daily lives of those affected by ADHD. Contact : +1 (747) 209 – 3649 E-mail : sales@trinexpharmacy.com
Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
share - Lions, tigers, AI and health misinformation, oh my!.pptxTina Purnat
• Pitfalls and pivots needed to use AI effectively in public health
• Evidence-based strategies to address health misinformation effectively
• Building trust with communities online and offline
• Equipping health professionals to address questions, concerns and health misinformation
• Assessing risk and mitigating harm from adverse health narratives in communities, health workforce and health system
TEST BANK For Community Health Nursing A Canadian Perspective, 5th Edition by...Donc Test
TEST BANK For Community Health Nursing A Canadian Perspective, 5th Edition by Stamler, Verified Chapters 1 - 33, Complete Newest Version Community Health Nursing A Canadian Perspective, 5th Edition by Stamler, Verified Chapters 1 - 33, Complete Newest Version Community Health Nursing A Canadian Perspective, 5th Edition by Stamler Community Health Nursing A Canadian Perspective, 5th Edition TEST BANK by Stamler Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Pdf Chapters Download Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Pdf Download Stuvia Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Study Guide Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Ebook Download Stuvia Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Questions and Answers Quizlet Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Studocu Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Quizlet Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Pdf Chapters Download Community Health Nursing A Canadian Perspective, 5th Edition Pdf Download Course Hero Community Health Nursing A Canadian Perspective, 5th Edition Answers Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Ebook Download Course hero Community Health Nursing A Canadian Perspective, 5th Edition Questions and Answers Community Health Nursing A Canadian Perspective, 5th Edition Studocu Community Health Nursing A Canadian Perspective, 5th Edition Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Pdf Chapters Download Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Pdf Download Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Study Guide Questions and Answers Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Ebook Download Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Questions Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Studocu Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Stuvia
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
1. Case Ileus 1
Case Ileus
Allison Kliewer
Baptist Health System Dietetic Internship
March 28, 2013
2. Case Ileus 2
Case Ileus
Life expectancy in developed countries has almost doubled within the last 100 years and
now ranges from 76-80 years (Hiranyakas, 2011). The population aged over 65 years is
predicted to increase from 40 million in 2010, to 55 million in 2020 which is a 38 percent
increase since 2000 (Hiranyakas, 2011). This increase in the elder population will by necessity,
increase the number of surgical procedures and number of hospital stays. Elderly patients have
a higher complication of disease and have an increased need for more complicated and invasive
procedures which increase length of stay at the hospital and increase cost (Kuy, 2011). It is
important that these patients are properly cared for and given the best healthcare in order to
reduce hospital length of stay, costs to the patient, and related morbidity and mortality. The
following reading will discuss current literature and the clinical care of an elderly woman who
presented with ileus and associated complications.
Patient Profile
The 77 year old female was admit to North East Baptist Hospital on the twenty-fifth of
January, 2013. The patient stayed in the hospital for 13 days and was pronounced dead on the
sixth of February, 2013. She was brought to the hospital by her friend for vomiting blood. The
patient had been vomiting all night and felt weak. She complained of mid-epigastric abdominal
pain and generalized weakness. The patient had a remarkable past medical history of
cerebrovascular accident, sacral fracture, hypertension, dyslipidemia, coronary artery disease,
osteoporosis, and deconditioning. The patient had a past surgical history of hernia repair,
hysterectomy, diskectomy, exploratory surgery and pyloroplasty from duodenal ulcer in 2007, a
3. Case Ileus 3
cholecystectomy in 2007, and a recent sacroplasty in October of 2012. Family history includes
mother deceased at age 86 from a massive myocardial infarction, and father deceased from
metastatic prostate cancer. The patient experiences hallucinations when taking hydrocodone,
but is able to tolerate Tylenol with codeine, so it is not a true allergy, per se. Patient denies
history of melena, syncopal episodes, easy bruising or bleeding, chest pain, shortness of breath,
and history of bright red blood per rectum or hemorrhoids. The patient takes Ecotrin daily at
325 mg for her heart condition, codeine for body aches, and is a chronic aspirin user. She lives
in independent living and does not drink, smoke, or use drugs. She has two daughters and a
friend. The patient was underweight upon admittance with a body mass index of 16.8, at a
height of 66 in and 47.3 kg. Her ideal body weight (IBW) was 59 kg and she was at 80 percent of
IBW.
Course of Treatment
On day one of admission the impression of the patient’s condition was that of an acute
upper gastrointestinal tract bleed with associated hematemesis coffee ground in nature. The
bleed was considered to possibly be related to aspirin use. The patient was put on a nil by
mouth (NPO) status with IV fluids, proton pump inhibitors, and Protonix twice daily. The aspirin
regimen was discontinued, as well as, the Fosomax which the patient was taking for
osteoporosis. Fosomax was discontinued because it can cause additional gastrointestinal upset.
Other medications were continued for urinary retention, Baclofen, Claritin, and Codeine for
pain. Within the next two days of stay the patient had an endoscopy and she was found to have
an upper gastrointestinal bleed secondary to erosive induced gastritis and esophagitis. The
4. Case Ileus 4
patient tolerated the procedure well but continued with nausea and vomiting while feeling
weak and dizzy. The patient was tolerating a clear liquid diet but did not have an appetite. The
patient developed fever and following fever workup was found to have left lobe pneumonia
and was started on Levequin. On the fourth day of stay the patient was advanced to a full liquid
diet while still experiencing nausea and vomiting.
The patient continued on the fifth day with loss of appetite and was evaluated for a
skilled nursing facility (SNF), but the patient refused to go to a SNF. It is important to note that
the patient had previously refused SNF placement following a cholestectomy. Kuy and colleges,
(2011) found that following a cholecystectomy, a large portion of elderly patients required
home health care support, institutional short-term rehabilitation, and nursing home care
following discharge, which may increase the risk of post-discharge mortality. On the sixth day of
stay the patient was noted to need full assisted living and nutritional supplements. The patient
was not able to tolerate an oral diet.
A dietary consult was received on the seventh day of the patients stay for nutritional
supplements. The patient continued with feculent vomiting and was nauseated. She was put on
Zofran for nausea and vomiting and Megace to increase her appetite. The patient had been
receiving medication for nausea but the medication was not working, therefore, Zofran was
added to the medication list. The patient was given an enema for constipation.
Early in the morning on the eighth day of stay the patient developed respiratory distress
and was transferred to the intensive care unit (ICU) and put on BIPAP. She had been
experiencing an increased occurrence of vomiting. After assessment in the ICU the patient was
5. Case Ileus 5
diagnosed with erosive esophagitis and gastritis, aspiration pneumonia, ileus, sepsis secondary
to pneumonia, hypoxia, hypokalemia, hypophosphatemia, hypomagnesaemia, and leukopenia.
Her antibiotics were broadened to include Zosyn and Levaquin and the patient was also started
on pressors for hypertension. Sepsis was treated along with fluid replacement as hypertension
was likely related to volume depletion given the high amount of vomit. For hypoxia, the plan
was to begin her on a high flow system as opposed to BIPAP which she would possibly tolerate
better. The ileus is considered to be multifactorial and related to decreased mobility and low
electrolytes. The patient was given a PICC line and speech therapy was consulted for a swallow
evaluation.
The patient was seen by a gastrointestinal doctor when in the ICU, and dietary received
a consult for total parenteral nutrition (TPN). The patient’s primary diagnosis was ileus, rule out
obstruction, and the patient met the ASPEN guidelines for TPN with the following: patient does
not have functioning bowel, and patient has a nonfunctional gastrointestinal tract with
expected need for parenteral nutrition for at least seven days.
On the eighth day of stay, the patient passed her swallow evaluation and was given a
regular diet with thin liquids. Although the swallow function was working properly, the patient
was still unable to tolerate oral feeds and was put on TPN. At this point the patient began to
experience altered blood glucose, and insulin was added to her medications. Over the next four
days the patient was increased from level I sliding scale insulin to level III and insulin was
increased in her TPN as well. Significant lab values can be viewed in Table I. The patient’s
respiratory failure continued along with sepsis, ileus, and a new diagnosis of small bowel
6. Case Ileus 6
obstruction. On the eleventh day of stay the patient was intubated and sedated due to her
decreasing respiratory status.
The twelfth day of stay was remarkable to the beginning of trophic feeds while
continuing on TPN. On the final day of life the patient failed another trial to extibate on BIPAP,
and possibly developed acute respiratory failure. After discussion with the family, the patient
was put on supportive comfort care and declared do not resuscitate (DNR). The patient
deceased at 15:37 on February sixth, 2013.
Sepsis
The term sepsis is used when a patient has an infection and an identifiable organism
(Wilker and Malone, 2008). Sepsis leads to the release of cytokines, proteolytic enzymes, or
toxic oxygen species and activate the inflammatory cascade (Wilker and Malone, 2008). Sepsis
further complicates ileus by worsening gut dysfunction. The alterations in the intestinal gut
barrier function in association with malnutrition are thought to occur through weight loss and
villous atrophy (Wilker and Malone, 2008).
Intensive Care Unit
Patients enter the ICU due to cardiopulomonary diagnosis, intraoperative or
postoperative complication, multiple traumas, burn injury, or sepsis (Wilker and Malone, 2008).
Critical illness is associated with catabolic stress state most commonly demonstrated with
systemic inflammatory response and complicated with infectious morbidity, multi-organ
dysfunction, prolonged hospitalization, and disproportionate mortality (McClave, 2009). The
7. Case Ileus 7
Table I
Significant Lab Values
25-Jan 26-Jan 27-Jan 28-Jan 29-Jan 30-Jan 31-Jan 1-Feb 2-Feb 3-Feb 4-Feb 5-Feb 6-Feb
Glucose 140 H 141 H 173 H 261 H 357 H 177 H 133 H 122 H
WBC 13.47 H 22.89 H 28.60 H 15.33 H 16.01 H
Lipase 16 L
Potassium 3.3 L 3.0 L 3.2 L 3.1 L 2.8 L 2.9 L 5.2 H 3.1 L
Red Blood Cells 3.73 L 3.48 L 2.82 L 2.87 L 2.50 L 3.33 L
Hemoglobin 11.2 L 10.5 L 8.5 L 8.6 L 10.4 L 9.8 L
Hematocrit 33.1 L 26.1 L 26.8 L 31.4 L 29.9 L
Chloride 111 H 112 H 114 H
Carbon Dioxide 23 L 19 L 21 L 22 L 19 L 32 H
Calcium 7.3 L 7.6 L 7.7 L 7.0 L 7.0 L 8.3 L 7.8 L
Albumin 2.5 L 2.6 L 2.5 L 1.9 L 1.7 L 1.4 L 1.5 L 1.3 L 1.5 L
Phosphorus 1.3 L 1.9 L 2.1 L 1.1 L 7.5 H 4.6 H
Blood Urea Nitrogen 8 L 7 L 34 H 42 H
Magnesium 1.7 L 1.5 L
Creatine 0.46 L
Note: Values are displayed as the actual value with an H for high values and L for low values. All cells
that are blank indicate values within normal limits or absent lab values.
8. Case Ileus 8
ICU patients often have numerous catheters for intravenous fluids and invasive hemodynamic
monitoring, as well as, tubes for drainage of body fluids (Wilker and Malone, 2008). Nutritional
assessments in the ICU do not follow traditional methods and require more time and attention,
mostly due to the patient’s condition and inability to provide dietary history. Weight values may
be erroneous after fluid resuscitation, and anthropometric measurements are not easily
attainable, nor are they sensitive to acute changes (Wilker and Malone, 2008). Serum albumin
may be altered as a result from the effects malnutrition and the severity of illness or the
underlying disease and other plasma proteins can be altered due to the inflammatory response
and shifts in body fluid (Wilker and Malone, 2008). The difficulty in conducting a nutrition
assessment requires clinical judgment when deciding on nutrition support. The ICU nutrition
assessment focuses on the preadmission, preoperative, or preinjury nutrition status, the
presence of any organ dysfunction, the need for early nutrition support, and options for enteral
or parenteral access (Wilker and Malone, 2008). Laboratory data is used in the critically ill
patient to design the nutrition prescription, rather than define or determine nutrition status
(Wilker and Malone, 2008).
Practice in ICU patients worldwide shows a significant underfeeding with hospital
nutrition protocol despite observational research that shows the amount of energy and protein
received during the early stages of ICU admission impacts patient mortality (Heyland et al,
2010). The goals for nutrition support in the ICU is to minimize starvation, prevent or correct
specific nutrient deficiencies, provide adequate calories to meet energy needs while minimizing
metabolic complications, and manage fluid and electrolytes for adequate urine output and
homeostasis (Wilker and Malone, 2008). Nutrition support should begin as soon as the patient
9. Case Ileus 9
is hemodynamically stable, which includes; stabilized vital functions, balanced fluid,
electrolytes, and acid-base, and adequate tissue perfusion to allow transport of oxygen and fuel
(Wilker and Malone, 2008).
Small Bowel Obstruction
Scarring from GI surgeries may partially or completely obstruct the GI tract of result in
dysfunctional segments (Beyer, 2008). When sections of the GI tract are partially obstructed or
are not moving appropriately, obstructions from food may occur causing prolonged bloating,
abdominal distention, pain, nausea and vomiting (Beyer, 2008). Some intestinal obstruction
may require clear liquids or total restriction of food and parenteral nutrition with fluid may be
needed (Beyer, 2008).
Coffee Ground Emesis
In the United States there are over 300,000 cases of hospital admissions for upper
gastrointestinal bleeds (Bou-Abdallah, 2012). Blood loss from the GI tract is manifested as
hematemesis or bloody coffee grounds (Bou-Abdallah, 2012). The treatment and initial
management of acute upper GI bleed is identical regardless of the mode of presentation and
usually involves stabilization of hemodynamic status (Bou-Abdallah, 2012). A recent case report
by Bou-Abdallah and colleagues (2012) found six patients admit for coffee ground emesis led to
other more severe complications including new-onset atrial fibrillation, ICU admits, pulmonary
emboli, ileus, and small bowel obstruction. The study showed that diagnosis and management
of the other complications were delayed due to the standard management given to patients
diagnosed with acute upper GI bleed (2012). Despite early endoscopy that has shown to have
10. Case Ileus 10
an impact on hospital admission, length of hospital stay, and transfusion requirements, in
patients presenting with coffee ground emesis, endoscopy does not predict further
complications (Bou-Abdallah, 2012).
Ileus
Ileus refers to the partial or complete blockage of the small and/or large
intestine due to impaired peristalsis or because of a mechanical obstruction (Madl and Druml,
2003). There is no standardized definition of ileus for diagnosis and is often difficult to
distinguish between a small-bowel obstruction (SBO) radiologically (Allen et al, 2012).
Diagnostic imaging studies and abdominal X-rays are most commonly used to diagnose and
help differentiate ileus from bowel obstruction (Allen et al, 2012). Symptoms caused by altered
bowel function are characterized by lack of bowel sounds, abdominal distention, accumulation
of gas and fluids in the bowel, decreased or absent defecation, nausea, vomiting, decreased GI
passage, and discomfort (Allen et al, 2012; Madl and Druml, 2003). Ileus is multifactorial in
origin and causative factors include neurogenic, inflammatory, hormonal, and pharmacologic
influences (Senagore, 2010). The neurogenic component relates to pain induced neural reflexes
which result in sympathetic hyperactivity and inhibition of gastrointestinal activity (Sengagore,
2010). Surgical manipulation can cause ileus by activating a number of inflammatory cascades,
which further exacerbate the effects of exogenous opiod analgesics given for analgesia, and
inhibit bowel function (Sengagore, 2010). Hormonal influence on ileus is mediated as a
response to trauma and pain medication may further impair GI motility (Sengagore, 2010).
11. Case Ileus 11
Ileus itself is not life-threatening but can lead to other complications, increased hospital
length of stay and healthcare resource utilization cost (Sengagore, 2010). Treatment usually
includes nasogastric decompression, diet reversal for symptom relief, hydration, antiemetics,
and restoring electrolyte balance (Allen et al, 2012). The abdominal distention increases the risk
of hernia formation and wound dehiscence, and nausea and vomiting impacts the possibility of
feeds and increases the risk for malnutrition and impaired wound healing (Sengagore, 2010).
Prolonged venous access and the need for nasogastric decompression inhibit ambulation and
can increase rates of pulmonary complications and thromboembolus (Sengagore, 2010).
Increased length of stay at hospitals also places a burden economically and raises issues with
hospitals of limited beds and high inpatient demand (Sengagore, 2010).
Gastric motility impaired by ileus can last over five days, and may required total
parenteral nutrition or TPN (Wilker and Malone, 2008). However, because of the demonstrated
benefits of enteral nutrition (EN), tube feeds can often be administered simultaneously with
TPN at low rates to maintain gut intergrity and preserve intestinal mucosa while providing
adequate nutrition (Wilker and Malone, 2008).
Pathophysiology
Ileus has been described as a chaotic activity of individual cells with a loss of
synchronization and impaired peristalsis (Madl and Druml, 2003). The associated increased in
luminal pressure can lead to gut wall ischemia and cause increased intra-abdominal pressure
(Madl and Druml, 2003). Intra-abdominal hypertension has been found in up to 20 percent of
critically ill patients and may lead to multiple complications including cardiovascular, hepatic,
12. Case Ileus 12
pulmonary, renal, and neurological dysfunction (Madl and Druml, 2003). Gastrointestinal
dysmotility may result in increased luminal pressure with intestinal dilatation, releasing nitric
oxide which is a known inhibitor of smooth-muscle tone (Madl and Druml, 2003). During
inflammation neutrophils invades the muscle layer of the gut wall and damages the muscle by
releasing proteolytic enzymes and cytokines (Madl and Druml, 2003). The inflammatory
response leads to the release of nitric oxide in the intestinal muscle layer, paralyzing the muscle
cells and aggravation the intestinal dilatation (Madl and Druml, 2003). The amount and activity
of nitric oxide synthase directly correlates to the severity of intestinal dilatation, and
consequently the severity of gut ischemia (Madl and Druml, 2003). Gut ischemia leads to an
uptake of cytokines and other inflammatory mediators which contribute to the systemic
symptoms of ileus and correlate with the severity of ileus (Madl and Druml, 2003).
Etiology
There is not one known cause of ileus and it can be due to a blockage in the small or
large intestine, as well as, a mechanical or paralytic bowel obstruction (Madl and Druml, 2003).
Disorders associated with a mechanical bowel obstruction can be located outside the gut wall,
within the gut wall, or intraluminal (Madl and Druml, 2003). A paralytic ileus may affect all parts
of the GI tract and is one of the most common complications in critically ill patients (Madl and
Druml, 2003). The cause of a paralytic ileus may be an adverse consequence of a surgical
procedure, use of opiods or catecholaminces, intraperitoneal of retroperitoneal infection,
edema or ascites secondary to massive fluid resuscitation during septic shock, or toxic shock
with capillary leakage, acute bacterial or parasitic intestinal infection, toxic megacolon, arterial
13. Case Ileus 13
or venous injury, intra-abdominal hematomas, or metabolic disturbances (Madl and Druml,
2003). In the critically ill, the degree of impairment of intestinal motility is tightly correlated to
the severity of illness and mortality (Madl and Druml, 2003).
Systemic Consequences
Aspiration
Impaired motility of intestinal contents promotes reflux of intestinal juice of the small
intestine back into the stomach and increases gastric residuals (Madl and Druml, 2003). This
allows for colonization of intestinal bacteria and ascension of microorganisms into the
esophagus, pharynx, and tracheobronchial tree (Madl and Druml, 2003). This along with
vomiting and aspiration increases the risk of evolution of pneumonia (Madl and Druml, 2003).
Hypovolemia
Distention, increased intraluminal pressure, and increased intra-abdominal pressure
impair microcirculation and ultimately result in fluid sequestration into the intestinal wall and
intestinal lumen (Madl and Druml, 2003). The fluid sequestration into the third space can result
in hypovolemia and circulatory impairment and can further aggravate various systemic
consequences of ileus (Madl and Druml, 2003).
Bacterial Overgrowth and Translocation
Ileus is associated with alterations in intestinal flora with an overgrowth of bacteria
(Madl and Druml, 2003). The impaired protective mucosal layer may allow microorganisms
and/or endotoxins/exotoxins to invade the mucosa, cause mucosal inflammation, and increase
14. Case Ileus 14
mucosal perfusion and hypersecretion (Madl and Druml, 2003). Medication has an impact on
bacterium and can promote bacterial selection and overgrowth resulting in antibiotic-induced
diarrhea or colitis, and can promote bacterial translocation (Madl and Druml, 2003).
Bacterial translocation refers to the permeation of viable microorganisms, fragments of
microorganisms, or macromolecules through an intact or injured intestinal wall into the
lymphatic system and/or intestinal venous circulation, such as the liver, spleen, kidney and
bloodstream (Madl and Druml, 2003). Intestinal bacteria is important to mature the immune
system and prompt the proper inflammatory responses but can become compromised when
there is an overgrowth of abnormal bacteria and/or the barrier function of the intestinal wall is
impaired (Madl and Druml, 2003). Bacterial overgrowth, increased permeability in the
intestinal mucosal barrier, and deficiencies in host immune defenses synergistically promote
the spread of indigenous translocation bacteria to cause lethal sepsis (Madl and Druml, 2003).
When the mucosal epithelium is damaged, indigenous bacteria translocate intercellularly
between the epithelial cells to directly access the blood. Sepsis can result with a spillover of
microorganisms into the lymphatic system via the vena cava superior into the circulation and
the lung, and/or spillover into the portal circulation promoting evolution of systemic infections
and septicemia (Madl and Druml, 2003).
Bacterial overgrowth, inflammation and impairment of barrier function of the intestinal
wall, and impairment of systemic immunocompetence are the three determinants of
translocation involved with ileus (Madl and Druml, 2003). Mucosal functions are further
compromised with a reduced mesenteric blood flow and increased intra-abdominal pressure
15. Case Ileus 15
(Madl and Druml, 2003). Therefore, treatment should be aimed particularly at preserving
intestinal functions in intensive care patients (Madl and Druml, 2003).
Pulmonary
Raised intra-abdominal pressure results in increased intrathoracic pressure and affects a
broad pattern of respiratory functions (Madl and Druml, 2003). Increased intra-abdominal
pressure can drop pulmonary residual capacity and may affect lung mechanics and decrease
lung compliance which promotes development of atelectasis and increased intrapulmonary
shunt (Madl and Druml, 2003). Increased pressure can negatively affect breathing and
significantly increased alveolar pressure and influence gas exchange (Madl and Druml, 2003).
Nutrition Therapy
Adequate hydration status is important to support cardiovascular function with ileus
(Madl and Druml, 2003). Maintenance of intestinal motility is a goal for a critically ill patient
with ileus and can be managed by prophylactic measures, motility medications, and early EN
(Madl and Druml, 2003). Early EN, even low in low or minimal amounts has been shown to
maintain intestinal functions, perfusions, motility, and barrier functions (Madl and Druml,
2003). Enteral diets containing dietary fiber can promote motlility, formation of short-chain
fatty acids through fermentation by bacteria, and reduce translocation (Madl and Druml, 2003).
Enteral diets including prebiotics has been shown to support intestinal barrier functions, to
reduce mucosal inflammation by inhibiting the adherence of pathological microorganisms to
the mucosal surface, and to prevent antibiotic-induced intestinal complications (Madl and
Druml, 2003).
16. Case Ileus 16
Feedings
After being NPO for a period of time, many patients do not have an appetite, suffer
from dry mouth, experience taste alterations, are too tired or weak to eat, are in an
uncomfortable position in bed, are in pain, and may require EN to meet their nutritional needs
(Klos). Psychological factors may influence a patient’s willingness to eat, such as stress caused
by being in a hospital and the fear of returned intestinal pain that might occur after the
reintroduction of oral food (Klos). Medications are also the cause of additional nausea,
diarrhea, constipation, dry mouth, and altered appetite that can influence a patients will to eat
(Klos).
Enteral nutrition is the preferred route of nutrition support, with PN reserved for
patients whom adequate EN is not possible (Sriram, 2009). Enteral nutrition has been shown to
decrease infectious complications and is more cost effective when compared to PN (Sriram,
2009). Parenteral nutrition should be used only when the GI tract is not anatomically adequate
or not functional, the GI tract cannot be accessed, or when nutritional requirements cannot be
completely met with EN (Sriram, 2009).
When a patient receives parenteral nutrition (PN), the ultimate goal is to transition back
to enteral nutrition (EN) or oral feeds (Klos). Parenteral nutrition is used when the
gastrointestinal tract is nonfunctional or cannot be accessed, such as small bowel resection,
radiation enteritis, high output enterocutaneous fistula, and paralytic ileus (Klos). Mucosal mass
and function of the ileum and jejunum significantly decrease, as well as, intestinal digestive
enzyme activity and exocrine pancreatic function during total PN (Klos). After a period of time
17. Case Ileus 17
on NPO, the return of the GI function is slow and requires time and effort to resume tolerance
to a normal diet (Klos).
Enteral nutrition has been shown to support intestinal structure and function, prevent
increased permeability, bacterial translocation, and systemic inflammation (Rice et al, 2011).
Enteral nutrition has also been shown to attenuate hypermetabolism of critical illness, decrease
infectious complications, and shorten ICU stays compared to PN, and reduce mortality (Rice et
al, 2011). Overall, EN stimulates epithelial cell growth and proliferation, maintains mucosal
mass and microvilli height, preserves tight junctions between epithelial cells, and promotes
blood flow; all of which are absent with ileus (Rice et al, 2011).
Trpohic feeds refers to small volume enteral feeds in order to stimulate the GI tract by
improving gastrointestinal enzyme activity, hormone release, blood flow, motility, and
microbial flora (Mishra et al, 2007).
Literature
Rice and colleagues (2011) conducted a randomized, open-label study to test the hypothesis
that initial trophic feeds would decrease episodes of gastrointestinal intolerance/complications
and improve outcomes as compared to initial full-energy EN in patients with acute respiratory
failure. The study included 200 patients with acute respiratory failure expected to require
mechanical ventilation for at least 72 hours who randomly received either trophic feeds at 10
ml an hour, or full energy EN for the initial six days of ventilation. Primary outcome measures
included; ventilator-free days to day 28, ICU-free days, mortality, episodes of diarrhea, and
episodes of elevated gastric residual volumes. Rice found that initial trophic EN resulted in
18. Case Ileus 18
similar clinical outcomes in mechanically ventilated patients with acute respiratory failure as
early full-energy EN but with significantly fewer episodes of gastrointestinal intolerance (2011).
The National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome
Clinical Trials Network (2012) conducted a very similar randomized open-label design study
with 1000 adults across 44 hospitals that within 48 hours of developing acute lung injury
required mechanical ventilation. The purpose was to determine if initial trophic feedings would
increase ventilator-free days and decrease gastrointestinal intolerances compared with initial
full EN. Outcomes measures included; ventilator-free days to day 28, 60-day mortality,
infectious complications, vomiting, gastric residual volumes, constipation, plasma glucose
values and insulin administration. It was concluded that trophic feeds did not improve
ventilator-free days, 60-day mortality, or infectious complications but was associated with less
gastrointestinal intolerance (2012).
There is a lack of conclusive evidence regarding the caloric dose required for the critically ill.
The two studies show that more research is needed to determine the role of trophic feeds in
ventilated patients and possibly challenge hospital nutritional standards for the critically ill
patient.
Nutrition Care Process
The patient was consulted on January 31,2013 after a referral from a nurse because the
patient was not eating. The patient was found with limited appetite because she could not keep
her food down. At that time the patient only had an appetite for a milkshake. That day the
patient was given different medications for nausea and vomiting because the other medications
19. Case Ileus 19
seemed to be ineffective. The patient was at 80 percent IBW had a BMI of 16.8, and met
guidelines to be clinically underweight. The patient was receiving adequate fluids with normal
saline at 75 ml per hour. She was assessed for weight gain and her calculated needs were 1420
to 1655 calories per day at 30 to 35 calories per kilogram actual body weight, and 56-71 grams
protein per day at 1.2 to 1.5 gram per kilogram actual body weight. Her nutrition status was
severely compromised with inadequate oral food intake related to her current condition as
evidence by intake record, BMI, and albumin lab values. Dietary intervention was to send
meals, snacks and supplements, and Mighty Shake was recommended twice daily to
supplement oral intake. The outcome set for the patient was to meet over 95 percent of
estimated nutritional needs (ENN), maintain lean body mass, protein profile to trend towards
normal, and to maintain skin integrity.
On the first of February the patient was referred from a physician for TPN assessment.
The patient met ASPEN criteria for TPN with a nonfunctional GI tract (ileus). It was
recommended the patient begin feeds at 85 grams protein, 275 grams dextrose, and 40 grams
of lipids to provide a total of 1675 calories, 85 grams of protein with a 2.3 glucose infusion rate
(GIR). The GI doctor was to write daily TPN orders.
The final nutrition assessment was made on the fifth of February for a follow up
evaluation. The patient had been receiving TPN of 100 grams protein, 300 grams dextrose, and
40 grams of lipids. As discussed previously with the GI doctor on the case, the patient was to
begin trophic feeds. The doctor ordered Pulmocare at 20 ml an hour in addition to the TPN
feeds and would hold for nasogastric residuals over 200 ml. Calculated needs were adjusted
20. Case Ileus 20
and needs were set at 1298 to 1593 calories at 22 to 27 calories per kilogram IBW and 88 to 118
grams protein at 1.5 to 2.0 grams per kilogram IBW. The nutrition status of the patient
remained severe due to an altered GI function related to ileus as evidence by PN and EN. The
nutrition intervention was requesting prealbumin and recommending trophic feeds with Vital
AF 1.2 at 20 ml an hour to help manage inflammation and promote GI tolerance. Outcomes
were that all forms of nutrition will meet over 95 percent of ENN, and that the patient would
tolerate EN feeds.
Reflection
As the patient was ultimately ventilated, it was appropriate in her case to begin trophic
feeds in hope to improve gut integrity, and to improve ileus status. Despite an unfortunate
outcome, the patient’s case provided means for an edifying research of the literature and
prevalent research questions. Effective nutritional support for critically ill patients represents a
difficult aspect of care with the complexity of the clinical status. With new research published
daily, there is a need to challenge commonly used nutritional support practices and to
individualize patient care with an evidence-based approach to achieve optimal nutrition
therapy.
21. Case Ileus 21
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