The management of patients after cardiothoracic surgery can be very complex. Variabilities exist in hemodynamic status after cardiac surgery and the use of cardiopulmonary bypass – all of which can have a significant impact on myocardial Frank–Starling curves. Typically, invasive monitoring with pulmonary artery catheters is used to assess the complex physiology that these patients experience in the perioperative setting. However, the use of invasive monitoring is not without risk, and the broader benefits are poorly defined. Furthermore, there is growing evidence to support the use of hemodynamic early goal-directed therapy to optimize outcomes in critically ill patients. The purpose of this editorial statement is the review of some of the current literature with regards to the utility of goal-directed therapy as applied to the postoperative cardiac surgical patient.

The purpose of this systematic review was to identify the antecedent factors of workplace injuries in small- and medium-sized enterprises (SMEs). A customized systematic review protocol included the research question, literature search, quality appraisal, data management and extraction, and evidence synthesis. The evidence was evaluated using the Critical Appraisal Skills Programme checklists and the Cochrane Collaboration “Risk of Bias” assessment tools. A total of 1355 articles were identified before duplicate removal. Ten articles were relevant to the study objective. Of these, two articles examined antecedents related to physical injuries, three examined those related to psychological injuries, and four focused on a combination. Antecedent factors included older workers, unsafe acts, unsafe working conditions, accident type and type of work performed, trips and falls, loss in productivity, social isolation, financial stress, and lack of employer support during the return to the workplace. The findings of this systematic review support the need for increased research to identify antecedent factors associated with injury in SMEs. Research should focus on interventions to mitigate injury rates that associate employees with employers, thus promoting collaboration in augmenting health and safety in SMEs.

Background: High-pressure injection (HPI) injury is an unusual type of injury in hand trauma, which could lead to a serious morbidity. We aimed to assess the clinical presentation, management, and outcome with HPI injury of the hand. Methods: A retrospective study was conducted between 2001 and 2015 for patients with HPI injuries who were admitted to a Level 1 trauma center. We reviewed the medical records, imaging files, and demographic data including gender, age, mechanism of injury, and site of hand injury. The kind of injected materials, time to first treatment procedure, clinical management, and complications were also described. Results: A total of 32 cases of HPI injuries were included in the study. The average age of the patients was 32.7 ± standard deviation 8.3 years, and all the patients were right handed. The most common material involved was grease (53%), followed by paints (25.0%), chemicals (9.4%), and air (6.3%). The most commonly affected part of the hand was the palm (31.3%), followed by index finger (25.0%). The average delay in the presentation was 12 h (range 3–96 h), and the mean hospital stay was 5.8 days. Management included debridement (90.6%) or conservative treatment (9.4%). Complications included chronic pain (9.4%), followed by amputation (3.1%). Conclusions: HPI injury is not uncommon, usually underestimated, and needs more community awareness, particularly laborers. Delay of treatment could increase the risk of amputation. Therefore, it is important to inform the risk groups about the seriousness of such injuries and to take preventive measures.

Objective: To evaluate the renoprotective effects of berberine and/or pentoxifylline in reduction of diclofenac-induced acute kidney injury (AKI) in rats. Material and Methods: Fifty male Sprague-Dawley rats were allocated into five groups, Group 1: Rats treated with distilled water plus normal saline for 12 days. Group 2: Rats treated with distilled water plus diclofenac for 12 days. Group 3: Rats treated with berberine plus diclofenac for 12 days. Group 4: Rats treated with pentoxifylline plus diclofenac for 12 days. Group 5: Rats treated with berberine + pentoxifylline plus diclofenac 15 mg/kg for 12 days. Blood urea, creatinine, neutrophil gelatinase-associated lipocalin (NGAL), kidney injury molecules (KIM-1), and cystatin-c were used to measure the severity of AKI. Results: Diclofenac led to significant AKI by significant elevation of blood urea, serum creatinine, KIM-1, and NGAL. Treatment with berberine showed no significant effect on all biomarkers level compared to diclofenac group except on serum KIM-1 level which also seen in the pentoxifylline group whereas combination of berberine and pentoxifylline led to more significant effect in the reduction of all renal biomarkers. Conclusion: Combination of berberine with pentoxifylline illustrated a synergistic effect in attenuation of diclofenac-induced AKI.

Purpose: We aimed to assess the pattern and impact of sternal injury with rib fracture in a Level 1 trauma center. Patients and Methods: We conducted a retrospective review of trauma registry data to identify patients who presented with sternal fracture between 2010 and 2017. Data were analyzed and compared in patients with and without rib fracture. Results: We identified 212 patients with traumatic sternal injury, of them 119 (56%) had associated rib fractures. In comparison to those who had no rib fracture,patients with rib fractures were older (40.1 ± 13.6 vs. 37.8 ± 14.5), were frequently involved in traffic accidents (75% vs. 71%), had higher chest abbreviated injury scale (AIS 2.8 ± 0.6 vs. 2.2 ± 0.5) and Injury Severity Score (ISS 17.5 ± 8.6 vs. 13.3 ± 9.6), were more likely to be intubated (33% vs. 19%), required chest tube insertion (13.4% vs. 4.3%), and received blood transfusion (29% vs. 17%). Rates of spine fracture, head injury, and solid organ injury were comparable in the two groups. Manubrium, clavicular and scapular fractures, lung contusion, hemothorax, and pneumothorax were significantly more evident in those who had rib fractures. Hospital length of stay was prolonged in patients with rib fractures (P = 0.008). The overall mortality was higher but not statistically significant in patients with rib fractures (5.0% vs. 3.2%). Conclusions: Sternal fractures are rare, and detection of associated injuries requires a high index of suspicion. Combined sternal and rib fractures are more evident in relatively older patients after chest trauma. This combination has certain clinical implications that necessitate further prospective studies.

Baker's cyst is a distention or enlargement of the gastrocnemius-semimembranosus bursa toward the popliteal fossa which is usually associated with intra-articular pathologies. Rupture or dissection of the Baker's cyst results in extravasation of the cyst content into the calf within intermuscular space under the fascia. This clinical entity, also called pseudothrombophlebitis, is a self-limited condition that usually resolves with supportive treatment. However, in patients using anticoagulants, excessive hemorrhage may cause compartment syndrome in case of cyst rupture. Early diagnosis of compartment syndrome is the most important step in preventing permanent disability. Therefore, compartment syndrome should be kept in mind and ruled out in a patient with pseudothrombophlebitis syndrome under anticoagulation therapy.

Gallbladder volvulus is a rare condition that most commonly occurs in elderly women and often mimics acute cholecystitis in its presentation. This condition is a surgical emergency requiring cholecystectomy as it can lead to gallbladder perforation and bilious peritonitis with high morbidity to the patient. An 85-year-old woman with chronic lymphocytic leukemia presented with acute-onset right upper-quadrant abdominal pain and associated nausea with emesis. After admission to the surgical service and initiation of intravenous antibiotics, the patient was taken to the operating room for surgical management due to the persistence of symptoms. Intraoperative findings included a necrotic appearing gallbladder that was twisted on the cystic duct. Laparoscopic cholecystectomy was performed, which was complicated by bile leak requiring endoscopic retrograde cholangiopancreatography with bile duct stenting followed by operative washout. Gallbladder volvulus can be challenging to diagnose. This condition should be suspected in elderly women with acute-onset abdominal pain and imaging concerning for acute cholecystitis. Emergent cholecystectomy is the treatment of choice for gallbladder volvulus.

A 47-year-old patient presented to the emergency room with an attack of acute severe asthma. In spite of all primary measures, the patient was deteriorating. Arterial blood gases showed hypercarbia and acidemia. The patient was shifted to the intensive care unit connected to noninvasive ventilation for 3 h, without any obvious improvement. Decision was taken to intubate, ventilate, and keep her deeply sedated. On the 4^th day of ventilation, the patient developed sudden tension pneumothorax and she was near to arrest. Management for tension pneumothorax was immediate and successful. After that, chest X-ray and computerized tomography scan showed hemopneumothorax, for which a chest tube was inserted in both chest sides and blood transfusion was initiated immediately. After this incidence, the patient's parameters improved dramatically. Four days later, the patient was extubated and kept in intensive care unit till the chest tubes were removed and then shifted to the ward and discharged on day 15 from admission.

In the Himalayan region, there is a prevalence of unknown bites (not much data except media) including snakes with high range of mortality among victims because hilly terrain leads to delay in transportation and delayed initiation of proper treatment due to lack of developed tertiary care centers. These bites can present from local hypersensitivity reactions to neurological, cardiological, respiratory, hematological, musculoskeletal, and renal manifestations. We highlight two cases that presented with delayed and varied manifestations, recovered but delayed with dedicated supportive care. A 25-year-old female presented 3 days after bite from an unknown snake, possibly krait, developed cardiotoxicity, neuroxotoxicity, rhabdomyolysis, and hemolytic features and was managed with antivenom and anticholinesterase therapy along with medroxyprogesterone to facilitate recovery from bite-associated neurotoxicity. A 75-year-old male subjected to an unknown bite possibly a scorpion developed shock which was most likely cardiogenic in nature secondary to toxin and was managed initially using inotropic support. Prazosin was started, and he recovered completely though at a later time. Hence, apart from krait bite presenting as multisystem involvement, anticholinesterase and medroxyprogesterone acetate are vital for survival. Similarly, prazosin has a vital role in the recovery of scorpion bite-induced cardiotoxicity. Many such unknown venomous bites go unreported. Further case studies and case reports are necessary to help redefine the epidemiology of such bites in the Himalayan region that poses a diagnostic and therapeutic challenge.

Bladder necrosis and perforation is a rare and life-threatening medical emergency. Risk factors include trauma, malignancy, previous surgery and/or radiation therapy and diabetes mellitus. Signs, symptoms, and imaging findings are often obscure making the diagnosis difficult. Urinary tract infection is common in end-stage renal disease (ESRD) patients who have residual urine production and associated with increased complication and mortality rates. We describe the case of a 57-year-old female with a medical history of recurrent cystitis, type 2 diabetes mellitus and ESRD on hemodialysis that was admitted for septic shock and presumed ischemic colitis. Urine and blood microbiology studies were notable for Escherichia coli. By the second day of hospital admission, her clinical condition significantly deteriorated and was later found to have bladder necrosis and rupture during laparotomy for suspected peritonitis. It is important that clinicians recognize bladder rupture as a potential complication of recurrent bacterial cystitis in ESRD patients on dialysis.