Pancreatic pseudocysts are a complication of acute or chronic pancreatitis or result from blunt trauma to the pancreas. It is a localized fluid collection around the pancreas surrounded by a wall of fibrous tissue or inflammation. We present a case of a 56-years old male who presented with abdominal pain and sepsis due to spontaneous rupture of the hemorrhagic pancreatic cyst into the peritoneal cavity and spleen. 56-years old male with medical history of gastroesophageal reflux disease presented with epigastric and left upper quadrant intermittent abdominal pain. Patient denied fever, chills, nausea, and vomiting, family history of pancreatic cancer, anticoagulation use, gallstones, alcohol intake and prior history of pancreatitis. On admission, vitals were B.P 137/82, Pulse 102, RR 16, O2 saturation 92% on room air. Physical exam was significant for left upper quadrant and epigastric tenderness. Labs were lipase 230, amylase 112, lactate 0.7, wbc 7.0, hemoglobin of 15.2 and triglyceride levels were 189mg/dl. Computed tomography (CT) abdomen showed acute pancreatitis and a 4.5 x 4.4 x 2.8 cm cystic lesion between the tail of the pancreas and splenic hilum. Ultrasound of the abdomen showed normal gallbladder with no evidence of biliary ductal dilatation. Magnetic resonance cholangiopancreatography (MRCP) abdomen showed 4.3 cm walled off, possibly hemorrhagic fluid collection, between the spleen and the pancreas. Patient had normal CA-19 level. Patient was evaluated by general surgery who recommended conservative management with repeat CT in 6 weeks with possible pancreatectomy and removal of mass if not resolved. Patient was readmitted 3 days after discharge with worsening abdominal pain and sepsis. Physical exam was significant for epigastric and left upper quadrant tenderness without guarding or rebound. Labs showed lactate 3.4, wbc 11.3, hgb 12.1 and lipase 600. Repeat CT scan showed rupture of the hemorrhagic pancreatic cyst with possible extravasation and enlarged spleen with perisplenic and subcapsular blood represent splenic infarcts. Repeat MRCP confirmed CT findings. Patient was planned for splenectomy and distal pancreatectomy. Most pancreatic pseudocysts resolve spontaneously [1]. Bleeding, infection, rupture, pseudoaneurysm, splenic and biliary complications and portal hypertension are some of the complications if left untreated. Hemorrhage into the pancreatic pseudocyst is a rare complication with a reported incidence of 10-30% with a high mortality rate (40%). Bleeding most commonly involves splenic artery (30–50%), followed by the gastroduodenal artery (17%) and pancreaticoduodenal arteries (11%) [2]. Diagnosis is made by ultrasound, CT scan, MRI or ERCP. Treatment involves either percutaneous drainage, or endoscopic or surgical approach. Spontaneous rupture into the peritoneal cavity is a rare life threatening complication requiring immediate surgical intervention. This case highlights the early recognition of complications of ruptured pancreatic pseudocyst to prevent fatal consequences. References: 1: Lerch MM, Stier A, Wahnschaffe U, Mayerle J: Pancreatic Pseudocysts: Observation, Endoscopic Drainage, or Resection. Deutsches Ärzteblatt International 2009, 106:614-621.10.3238/arztebl.2009.0614. 2: Novacic K1, Vidjak V, Suknaic S, Skopljanac A: Embolization of a large pancreatic pseudoaneurysm converted from pseudocyst (hemorrhagic pseudocyst). JOP 2008, 9:317-21. joplink.net/prev/200805/13.html

Postpartum hemorrhage is a leading cause of maternal death, yet many deaths related to hemorrhage might be prevented with early recognition and intervention. The birthing unit of a U.S. community hospital formed an interprofessional task force to plan and implement a postpartum hemorrhage protocol that would provide the obstetric team with the knowledge, skills, and tools needed for early identification and quick action when hemorrhage occurred. Lewin's model of change provided a framework for protocol implementation. The purpose of this doctoral project was to evaluate this quality improvement project. Secondary data internal to the organization were collected and analyzed to answer the practice-focused question, Is there a relationship between implementation of a postpartum hemorrhage protocol and the incidence of postpartum hemorrhage? To determine the incidence of postpartum hemorrhage, the number of hemorrhages with and without blood transfusion was divided by the number of deliveries and recorded monthly. The chi-square test was used to analyze the rates of hemorrhage pre- and post-implementation. A statistically significant decrease in hemorrhage was noted post-implementation, suggesting that there was a relationship between implementation of a protocol and the incidence of postpartum hemorrhage. This project supported the Walden University mission by working towards optimal health outcomes for women. Eliminating preventable harm related to hemorrhage benefits women, families, and communities. Lessons learned from the implementation and evaluation of this quality improvement project are expected to be utilized by nursing leaders to address other challenges identified in the obstetric setting.

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Postpartum hemorrhage is the second leading cause of maternal death in the United States. According to American College of Obstetricians and Gynecologists, postpartum hemorrhage is an obstetric emergency. Between 2012 and 2013, a medical facility reported 369 postpartum hemorrhages, a 4.7% increase from previous years. It is important to address this practice issue because postpartum hemorrhage can lead to maternal mortality. The purpose of this project was to increase staff nurses' awareness and knowledge of their role on the management of postpartum hemorrhage. The outcome of the project paper was implementation of an educational module on postpartum hemorrhage at this medical facility. The conceptual model, Academic Center for Evidence-Based Practice, was used to guide this project. The project researcher presented a postpartum hemorrhage module to a staff of 80 postpartum nurses. The module included a pre and post-test developed using Association of Women's Health, Obstetric, and Neonatal Nurses' guidelines and was reviewed by a panel of experts for content validity, content on postpartum hemorrhage, and an evaluation of the project. The panel consisted of the Director of Maternal Child unit and 3 appointed obstetricians. Nurses' knowledge of postpartum hemorrhage was evaluated by comparing mean aggregate pre and post-test scores. Results showed an increase in the staff nurses' knowledge and awareness of postpartum hemorrhage. These findings are important for nurse leaders and healthcare organizations because they demonstrate that providing staff nurses with an educational program on the importance of postpartum hemorrhage can impact the level of knowledge and thereby increase positive patient outcomes.

This is the peer reviewed version of the following article: Tominari, S., Morita, A., Ishibashi, T., Yamazaki, T., Takao, H., Murayama, Y., Sonobe, M., Yonekura, M., Saito, N., Shiokawa, Y., Date, I., Tominaga, T., Nozaki, K., Houkin, K., Miyamoto, S., Kirino, T., Hashi, K., Nakayama, T. and for the Unruptured Cerebral Aneurysm Study Japan Investigators (2015), Prediction model for 3-year rupture risk of unruptured cerebral aneurysms in Japanese patients. Ann Neurol., 77: 1050–1059. doi: 10.1002/ana.24400, which has been published in final form at http://dx.doi.org/10.1002/ana.24400. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Self-Archiving. / 京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第19585号 / 医博第4092号 / 新制||医||1014(附属図書館) / 32621 / 京都大学大学院医学研究科医学専攻 / (主査)教授 古川 壽亮, 教授 小泉 昭夫, 教授 佐藤 俊哉 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

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Several case reports have been filed regarding the latent presentation of hemorrhagic pheochromocytomas in the trauma setting; however, few patients have been found to exhibit these symptoms in the absence of a tumor. In this report, we discuss a patient who sustained blunt abdominal trauma leading to the development of an adrenal hemorrhage and his unexpected sequelae of symptoms. Discovery of the source of the patient's symptoms was delayed secondary to multiple comorbidities in the critical care setting and work-up for other sources such as infection and agitation. Hypertensive urgency was confirmed to be of adrenal etiology with measurement of persistently elevated plasma and urine metanephrines during the hospital course. The patients hypertensive urgency was successfully managed with the use of antisympathomimetics including an esmolol drip, clonidine, and eventually tapered dose of metoprolol. Symptoms improved over time, and repeat CT imaging weeks later showed resolution of the hematoma. Review of literature reveals only one other case of adrenal hemorrhage after blunt force trauma resulting in hemorrhagic psuedotumor. To our knowledge, this is the second such case ever presented. This case is discussed along with the presentation, diagnostic work-up, and treatment of a critically ill patient with an adrenal hemorrhage masked as a pseudotumor.

BACKGROUND: Subarachnoid Hemorrhage (SAH) accounts for 3-5% of total stroke patients annually. Despite its rare incidence, SAH carries a 50% mortality rate. Survivors are often left with varying degrees of disability, many will never return to their previous jobs and require long-term care. One of the leading causes for this high mortality and morbidity rate in SAH is Delay Cerebral Ischemia (DCI). Researchers are now beginning to investigate neuroinflammation as the underlying cause for DCI. Studies have shown the activation of the innate immune system in the central nervous system is initiated by excess hemoglobin in the subarachnoid space. This process is mediated by the Toll-Like Receptor 4 expressed on the tissue-resident macrophages. Activated macrophages release pro-inflammatory cytokines and cause neuronal apoptosis in the surrounding tissue. However, macrophages may also mediate neuroprotection in SAH. A macrophage surface receptor called CD163 is responsible for the recognition and endocytosis of excess hemoglobin. The thesis provides a closer assessment of the neuroprotective role of macrophages in SAH patients. METHODS: Cerebrospinal fluid (CSF) was obtained from twenty three patients diagnosed with SAH (on day 1 and day 7 post-admission) or unruptured aneurysms. Immune cells were separated from CSF and analyzed by flow cytometry. The following antibody panel was used in this study: PE-anti-CD163, PeCy7-anti-CD15, and APC-anti-CD14. Macrophage expression of CD14 and CD163 was quantified using FlowJo. SAH patients were graded by the Hunt and Hess scale for the clinical states upon admission; modified Fisher scale for the size of the hemorrhage; and modified Rankin scale for clinical outcome at the time of discharge. RESULTS: Significant increase in macrophage CD14 and CD163 expression is observed in day 1 SAH patients (p<0.05) as compared to the control group. Male SAH patients have equivocal macrophages CD163 expression on day 1 as compared to the control group (p>0.05), and significantly higher expression on day 7 as compared to day 1(p<0.05). Female SAH patients have significantly higher macrophages CD163 expression on day 1 as compared to control patients (p<0.05), but slightly decreased expression on day 7 as compared to day 1(p>0.05). Lower macrophages CD163 expression is observed in SAH patients with more severe hemorrhage (marked by higher modified Fisher score), but not in patients with more severe clinical states at admission (marked by higher Hunt and Hess score). Furthermore, SAH patients with low day 1 macrophage CD163 expression and low expression on day 7 may be correlated with better clinical outcome (marked by lower modified Rankin score). However, more patients are required before correlation can be established. CONCLUSION: The data further support our previous findings in mouse SAH model that macrophages in the central nervous system may mediate inflammation via the increased expression TLR4, measured by increased expression of its co-receptor CD14. Macrophages also may be neuroprotective, mediated by increased expression of CD163 in SAH patients. The macrophage CD163 expression may be the key in determining clinical outcome in SAH patients, but additional patients are required to establish statistical significance. / 2017-06-16T00:00:00Z

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Explosions cause the majority of injuries in the current conflicts, accounting for 79% of combat related injuries (Ramasamy et al. 2008). Blast overpressure from explosions can cause barotrauma to the lungs and the brain. Blast-induced mild traumatic brain injury has been labeled the "signature wound" of current military conflicts in Iraq and Afghanistan (Snell and Halter 2010). In addition to elevated number of blast-induced traumatic brain injuries due to increased military conflicts overseas and the usage of improvised explosive devices, the incidence of blast-induced polytrauma has risen due to the prevalence of terrorist events around the world (Arnold et al. 2004, Rodoplu et al. 2004). Blast-induced polytrauma is a major concern as lung injury can cause immediate mortality and brain injury causes long-lasting neurocognitive impairment. There is a critical lack of understanding the pathology of blast-induced polytrauma since the needs are multifaceted and therefore few options for treatment. Thus, the research presented in this dissertation required the development of a military-relevant blast polytrauma model to examine injury pathology and subsequently study the effects of hemostatic nanoparticle therapy after blast-induced polytrauma. The pre-clinical model was characterized and static overpressure thresholds were determined for lethality risk. It was confirmed to have many of the classic hallmarks of primary blast lung injury (PBLI), as well as blast-induced neurotrauma (BINT) (Clemedson 1950). Global hemorrhaging was found in the lungs and well as reduced oxygen saturation. Markers of astrogliosis and blood-brain barrier disruption were examined in the amygdala after blast. The novel nanoparticle configuration (hemostatic dexamethasone-loaded nanoparticles (hDNP) functionalized with a peptide that binds with activated platelets) was investigated and hypothesized to increase survival, reduce cellular injury and reduce anxiety-like disorders after blast polytrauma. After investigating hDNP, it was found that the hDNP treatment benefited survival percentage after injury as well as reduced percent hemorrhage in the lungs and improved physiology. Elevated anxiety parameters found in the controls were lower as compared to the hDNP group. Glial fibrillary acidic protein (GFAP) and cleaved caspase-3 were significantly elevated in the controls compared to the hDNP group in the amygdala. SMI-71 was also significantly elevated with the hDNP and hemostatic nanoparticle (hNP) treatments, similar to sham. In addition to the nanoparticles offering immediate life-saving qualities, administration of hemostatic nanoparticles improved amygdala pathology attributed to secondary mechanisms of blast injury, including blood-brain barrier disruption. This model of polytrauma can serve as a foundation for detailed pathological studies as well as testing therapeutics for injury modalities. References (Abstract) Arnold, J. L., P. Halpern, M. C. Tsai and H. Smithline (2004). "Mass casualty terrorist bombings: a comparison of outcomes by bombing type." Ann Emerg Med 43(2): 263-273. Clemedson, C. J., Granstom, S.A. (1950). "Studies on the genesis of "rib markings" in lung blast injury." Acta Physiol Scand. 21: 131-144. Ramasamy, A., S. E. Harrisson, J. C. Clasper and M. P. Stewart (2008). "Injuries from roadside improvised explosive devices." J Trauma 65(4): 910-914. Rodoplu, U., Arnold, J. L., Tokyay, R., Ersoy, G., Cetiner, S., Yucel, T. (2004) "Mass-casualty terrorist bombings in Istanbul, Turkey, November 2003: reports of the events and the prehospital emergency response." Prehosp Disaster Med 19(2):133-145. Snell, F. I. and M. J. Halter (2010). "A signature wound of war: mild traumatic brain injury." J Psychosoc Nurs Ment Health Serv 48(2): 22-28. / Ph. D.