Haemodynamic determinants of elevated pulse wave velocity during acute isometric handgrip exercise

Background

Measure ment of pulse wave velocity (PWV) provides a reliable index of vascular stiffness. Despite its widespread application, the physiological inter-relationships between PWV, blood pressure (BP) and in particular, heart rate (HR), have yet to be fully elucidated. Furthermore, little is known about altered arterial compliance during acute exercise.

Aim

To examine the effects of 3-min supine non-dominant isometric handgrip exercise (ISOMEX), performed at 30% of maximum voluntary contraction, on carotid-radial PWV, BP and HR in the dominant arm of 51 healthy subjects.

Results

During exercise, PWV correlated strongly with diastolic BP (r = 0.55, p < 0.01) and mean arterial pressure (r = 0.51, p < 0.01). PWV and HR failed to correlate at rest or during exercise.

Conclusion

ISOMEX invoked an elevated PWV, which is predominantly related to BP or factors determining it, and not HR. The carotid-radial PWV stress test is a simple measurement that may have prognostic potential for use in large-scale population studies.     

Neonatal hearing screening of high-risk infants using automated auditory brainstem response: a retrospective analysis of referral rates

Objective

The past decade has seen the widespread introduction of universal neonatal hearing screening (UNHS) programmes worldwide. Regrettably, such a programme is only now in the process of nationwide implementation in the Republic of Ireland and has been largely restricted to one screening modality for initial testing; namely transient evoked otoacoustic emissions (TEOAE). The aim of this study is to analyse the effects of employing a different screening protocol which utilises an alternative initial test, automated auditory brainstem response (AABR), on referral rates to specialist audiology services.

Methods

A retrospective analysis was performed of all neonatal hearing screening in Letterkenny General Hospital over 5 years, from January 2008 to December 2012, which was confined to infants possessing one or more known risk factors for permanent childhood hearing impairment. 1,163 infants were screened using AABR during this period and subsequent re-test and referral rates to specialist audiology services were examined.

Results

Of the infants screened, 50 (4.3 %) failed the initial AABR. A further 16 of these (32 %) failed the repeat AABR, resulting in an overall referral rate to specialist audiology services of 1.38 %.

Conclusion

Our results demonstrate strikingly low overall referral rates in this cohort, falling well below both the international benchmark and the initial results of the Irish UNHS programme. This provides a convincing argument for examining AABR as a potential alternative to TEOAE in the nationwide UNHS.     

Medical complications and outcomes at an onsite rehabilitation unit for older people

Background

The rehabilitation of older patients in Ireland after an acute medical event occurs at dedicated onsite hospital units or at offsite centres. Information on medical complications and outcomes is inadequate.

Aims

Enumeration of medical complications of patients admitted to a dedicated onsite rehabilitation unit for older people, and the extent of co-morbidity in the population with the effects that this had on the evolution of medical complications.

Methods

A retrospective analysis of patients admitted to a 58-bed onsite unit over a 1-year period was performed. Information collating co-morbidities, medical complications and functional outcomes was recorded.

Results

Medical complications occurred in almost 95 % of patients, where full data were available. Over one-third required intravenous therapy.

Conclusion

Twenty-four hour medical cover is required for older patients managed at onsite rehabilitation units. Further studies on offsite medical rehabilitation facilities for older patients are required.     

Acute haemodynamic effects of cigarette smoking in healthy young subjects

Background

Invasive studies in middle-aged patients suggest an acute adverse haemodynamic effect of smoking.

Aims

To study acute changes in blood pressure (BP), cardiac output, peripheral resistance and aortic compliance following cigarette smoking in healthy young subjects.

Methods

Using a non-invasive photoplethysmographic technique we compared the effects of smoking one cigarette with sham smoking in 12 healthy volunteers (22–25 years). Data was analysed using JMP version 5.0.

Results

In contrast to sham smoking there was a prompt increase in blood pressure with a maximum effect at 15 min (123±7/75±5 to 143±6/86±6 mmHg, mean±SEM, p< 0.01) which is attributed to a rise in cardiac output (p< 0.05) rather than changes in peripheral vascular resistance. There was also a significant (p < 0.05) increase in heart rate and a reduction in aortic compliance.

Conclusion

These results suggest that health or young age do not protect from the adverse effects of smoking.     

Dexmedetomidine and propofol total intravenous anesthesia for airway foreign body removal

Purpose

To detail our experience using dexmedetomidine in combination with propofol for airway foreign body removal in spontaneously breathing patients.

Clinical features

Dexmedetomidine and propofol intravenous anesthesia as a primary anesthetic was used for three pediatric patients with severe respiratory impairment due to foreign body aspiration and two elderly patients requiring airway foreign body removal by rigid bronchoscopy. All patients were spontaneously ventilating, and had successful airway foreign body removal without severe hypoxemia. The three pediatric patients maintained stable respiratory and hemodynamic profiles. However, dexmedetomidine caused a significant change in the hemodynamics of the elderly patients.

Conclusion

Dexmedetomidine and propofol intravenous anesthesia provided good anesthesia without causing respiratory depression. However, this technique related to more hemodynamic depression in elderly patients than in pediatrics.     

Does long-term partial sodium channel blockade alter disease progression in MS? Evidence from a retrospective study

Background

There is accumulating evidence that long-term disability and disease progression in multiple sclerosis (MS) are due to prolonged sodium channel opening along demyelinated axons. Despite good evidence in animal models of MS that partial voltage-gated sodium channel (VGSC) blockade reduces disease progression, little is known about its effects in patients, despite widespread use of such agents in the symptomatic management of MS.

Objective

To determine if long-term exposure to the VGSC-blocking drug carbamazepine (CBZ) alters disease progression in MS.

Methods

Using a retrospective chart review of patients diagnosed with MS, we compared progression of disability between patients exposed the VGSC blocker CBZ with those who were not exposed to the drug. Both whole-group and matched case–control analyses were performed after correcting for the influence of age, gender, MS subtype, expanded disability status score at diagnosis, use of disease-modifying therapy, and year of initial therapy. The multiple sclerosis severity scale (MSSS) was used as a measure of disease severity. The primary outcome measure was MSSS score difference between groups.

Results

Four hundred patients were included; 51 received CBZ symptomatic therapy (average duration of therapy 27 months). There was no significant difference in mean MSSS between the two groups in either the whole group comparison (p = 0.63) or the matched analysis (p = 0.12).

Conclusion

Despite preclinical evidence suggesting a neuroprotective role of VGSC blockers in animal models of MS, this retrospective study suggests that long-term exposure to the VGSC-blocking drug CBZ fails to alter long-term disability and disease progression in MS patients.     

Regional variation in prescribing for chronic conditions among an elderly population using a pharmacy claims database

Background

Age, gender and geographical regions are recognised factors in inequalities in prescribing for chronic diseases in the elderly.

Aim

To compare the health board regional distribution of chronic disease among the elderly and to examine variation in quality prescribing across age, gender and regions.

Methods

Population based study of prescribing for chronic disease using a national pharmacy claims database. All individuals aged 70 years and over (n=271,518) were eligible.

Results

Over 60% of the elderly in all regions received cardiovascular related medication. The South Eastern, North Western and Western Health Boards had below average prescribing for many chronic conditions. Logistic regression identified age, gender and regional variations in prescribing of preventative therapies for CVD and diabetes.

Conclusion

There is a high prevalence of prescribing for chronic conditions in the elderly in Ireland, and there is evidence of gender, age and residing health board inequalities in prescribing.     

Guidelines reduce time to consultation for a liaison psychiatry service in an Irish teaching hospital

Background

Timeliness of response from referral to consultation is necessary to provide best standards of care to inpatients in the general hospital setting.

Aims

To measure the length of time from referral to consultation in a liaison psychiatry service, and improve service delivery by introducing guidelines for time to consultation.

Methods

Time to consultation was measured on all patients presenting to a liaison psychiatry consultation service over an initial 6-month period, with subsequent repeat measurement following the introduction of guidelines.

Results

There were significant reductions for time to consultation in the service for the second cycle of the audit (??²?=?43.84, P?Conclusions Introduction of guidelines for time to consultation, may improve response times, leading to improved quality of service for inpatient consultation services.     

CT and MR findings in a neuroforaminal extraskeletal Ewing sarcoma mimicking benign nerve sheath tumor

Introduction

We report the CT and MR findings in a 30-year-old man with extraskeletal Ewing sarcoma (EES) involving the left neural foramen at L5–S1 level.

Materials and methods

The patient was evaluated with preoperative lumbosacral CT and MR imaging and postoperative lumbosacral MR imaging.

Results

The lesion was hyperdense on CT, isointense on T1- and T2-weighted MR images, and enhanced homogeneously after intravenous gadolinium injection. With these CT and MR findings, surgery was performed with a presumptive diagnosis of nerve sheath tumor, but the histopathological examination revealed EES. Chemotherapy and radiotherapy were planned postoperatively.

Conclusion

This case illustrates that even in benign looking lesions in a neuroforamen one can never exclude malignancy, and this is even more true in a population of young adults.     

Through the looking glass; bioactive glass S53P4 (BonAlive®) in the treatment of chronic osteomyelitis

Background

In terms of eradication, osteomyelitis represents one of the most challenging infective conditions in medicine and surgery. In recent years, the use of bioactive glass in conjunction with antimicrobial therapy has emerged as a viable new treatment.

Aim

We present a short study, from a regional orthopaedic unit, demonstrating its successful use in three patients with chronic osteomyelitis.

Methods

Between September 2010 and May 2011, bioactive glass S53P4 was used in conjunction with intravenous and oral antibiotics to treat chronic osteomyelitis in three patients (two male, one female). All patients underwent debridement and sequestrectomy procedures with the insertion of bioactive glass followed by antimicrobial regimens tailored to isolated pathogen sensitivities. Patient age ranged from 28 to 68 years, with a mean age of 44.7 years. The presentation period, from time of initial diagnosis to treatment, varied from 16 months to 16 years and all three patients had underwent multiple previous debridements and antimicrobial regimens to no avail.

Results

A follow-up of 14–21 months has been achieved with a mean follow-up of 17.3 months. We have seen excellent results in all three patients. All haematological and biochemical parameters have returned to normal, pain has ceased and function has returned in the affected limbs. All antibiotics have stopped and there is no radiological evidence of osteomyelitis. The bioactive glass has integrated with the surrounding bone.

Conclusions

Though a relatively recent development, bioactive glass used in concurrence with antibiotic therapy has significant potential in the treatment of chronic osteomyelitis.     

交泰丸通过骨骼肌磷脂酰肌醇(-3)激酶通路提高糖尿病大鼠胰岛素信号强度

Objective: To investigate the effect of Jiaotai Pill (交泰丸, JTP) at different constitutional proportions on insulin signaling through phosphatidylinositol 3-kinase (PI3K) pathway in the skeletal muscle of diabetic rats. Methods: The rat model of type 2 diabetes mellitus (T2DM) was established by intravenous injection of a small dose of streptozotoein plus high fat diet feeding. JTP at the same dosage of cinnamon and the increasing dosage of Coptis chinensis was administered to diabetic rats for nine weeks respectively. Plasma glucose and insulin levels were assayed. The expressions of proteins were determined by Western blot method. Results: All the three formulations of JTP decreased plasma glucose and fasting insulin levels as well as increased the protein expressions of insulin receptor β (InsRβ) subunit, insulin receptor substrate-1 (IRS-1), PI3K p85 subunit and glucose transporter 4 (GLUT4) in skeletal muscle. Meanwhile, JTP increased the tyrosine phosphorylation of InsRβ subunit and IRS-1, and reduced the serine phosphorylation of IRS-1 in skeletal muscle. Interestingly, the effect of JTP on improving insulin sensitivity was not dose-dependent. In contrast, JTP containing the least amount of Coptis chinensis exhibited the best effect. Conclusion: JTP at different constitutional proportions attenuates the development of diabetes in a rat model of T2DM. The mechanism might be associated with enhancing insulin signaling through PI3K pathway in the skeletal muscle.     

Hesperidin promotes cyclobutane pyrimidine dimer repair in UVB-exposed mice epidermis

Purpose

To investigate whether topical application of hesperin affords protection to Balb/C mice epidermis from UVB-induced cyclobutane pyrimidine dimers (CPDs).

Methods

A DNA damage model of UVB irradiation-induced mice epidermis was established. The immunohistochemical staining and southwestern dot blotting were used for CPDs detection; western blotting was used for P53 detection.

Results

Topical application of hesperidin on Balb/C mice skin significantly decreased the amount of epidermal CPDs 24 and 48 h after 180 mJ/cm² of UVB irradiation as compared to untreated mice. UVB-induced p53 expression was more pronounced in hesperidin-treated mice epidermis compared to that of untreated mice.

Conclusion

Taken together, these results suggest that topical hesperidin application promotes DNA photo-damage repair. Hesperidin is therefore a promising protective substance against UVB radiation.     

Observation on short-term effect and follow-up of integrative medicine in treating 198 patients with hepatolenticular degeneration

Objective

To observe the short-term effect and follow-up of integrative medicine in treating patients with hepatolenticular degeneration (HLD). Methods: The 198 patients with HLD were treated by strengthened decopper therapy with sodium dimercaptosulphonate by intravenous dripping combined with oral intake of Gandou tablet and zinc gluconate during their hospitalization period. After discharge, the maintaining therapy given to them was dimercaptosuccinic acid and penicillamine alternatively combined with Gandou Tablet and zinc gluconate orally. Patients were followed-up for 6 months to 24 years.

Results

By the end of therapeutic course in hospital, the clinically cured, markedly improved and improved cases were 22 (11.11%), 15 (7.58%) and 131(66.16%) respectively, the cure rate+ markedly effective rate being 18. 69% and the total effective rate 84.85%. The markedly effective rate and the total effective rate were increased significantly at the 6 months follow-up, while in the over 6 months to 24 years follow-up period the cure + markedly effective rate increased, and ineffective and worsened rate also increased, only improved rate lowered were shown.

Conclusion

Most HLD patients would acquire long-term survival and better quality of life if they insist on long-term decopper therapy. Condition would be deteriorated, even death often occur in those who cannot insist the treatment or in severe cases of advanced stage.     

Bilateral synchronous rupture of the quadriceps tendon

Background

Bilateral simultaneous rupture of the quadriceps tendon is a rare entity. They are often associated with degenerative changes of the tendons and predisposing conditions such as diabetes or excessive steroid use. They most commonly tend to occur in patients of 40 years of age or older.

Materials and methods

We describe a case of a 67-year-old man with simultaneous rupture of both quadriceps tendons.

Conclusion

The diagnosis can be difficult and often delayed or missed in the initial examination. We report bilateral quadriceps tendon rupture in a previously healthy patient with good post-operative functional outcome.     

Contamination of blood pressure cuffs by methicillin-resistant Staphylococcus aureus and preventive measures

Background

Although blood pressure cuffs are commonly used and shared in medical facilities, their routine disinfection is performed infrequently.

Aims

We investigated the contamination of blood pressure cuffs by methicillin-resistant Staphylococcus aureus (MRSA).

Methods

The MRSA level on the inner side (the surface in contact with patients’ skin) of blood pressure cuffs used in the wards and outpatient clinics of a university hospital (733 beds) was determined using the gauze and swab wiping methods.

Results

Using the gauze wiping method (n = 35), the MRSA contamination rate was 31.4 %, and the MRSA contamination level was 1,702.6 ± 9,996.1 (0–58, 320) colony-forming units (cfu)/cuff. No MRSA was detected on blood pressure cuffs after washing (n = 30) or wiping with 80 vol% ethanol (n = 18).

Conclusions

Blood pressure cuffs are frequently contaminated by MRSA.     

Role of central and peripheral opioid receptors in the cardioprotection of intravenous morphine preconditioning

Background

Both central and peripheral opioid receptors activation produce cardioprotection. This study investigates the role of central and peripheral opioid receptors in intravenous morphine preconditioning (MPC) and ischemic preconditioning (IPC).

Methods

Sixty-five anesthetized, open chests, male Sprague?CDawley rats were assigned to one of nine groups after intrathecal catheter placement. IPC was induced by three cycles of intermittent occlusion of left anterior descending artery (5?min occlusion interspersed with 5?min of reperfusion). MPC was induced by three consecutive intravenous infusions of 100???g/kg morphine over five minutes. The opioid receptors antagonist naloxone methiodide (NM), at a dose of 20???g/kg, was intravenously or intrathecally given 10?min before IPC or MPC (IVNM?+?IPC, ITNM?+?IPC, IVNM?+?MPC, ITNM +MPC). Control group (CON) and intravenously or intrathecally administered NM (IVNM, ITNM) were used as negative controls, respectively. All hearts were subjected to 30?min of ischemia follow by 2?h of reperfusion. Infarct size, as a percentage of the area at risk, was determined by 2, 3, 5-triphenyltetrazolium staining. Heart rate and mean arterial blood pressure were monitored.

Results

The infarct size was significantly reduced in the IPC and MPC groups compared with control. The additional of intravenous or intrathecal NM both reversed the cardioprotective effects of MPC. In comparison only intravenous administration of NM before IPC could attenuate the cardioprotection.

Conclusions

MPC could mimic IPC, produce a similar cardioprotective effect. Both central and peripheral opioid receptors mediate in the cardioprotection of MPC, however, only peripheral opioid receptors in IPC.     

Evaluation of the effect of intra-operative intravenous fluid on post-operative pain and pulmonary function: a randomized trial comparing 10 and 30 ml kg−1 of crystalloid

Background

Existing evidence suggests that administration of intravenous fluids has been shown to improve outcomes including pain in gynecological laparoscopic surgery but the optimum fluid dose has not been determined.

Aims

To determine the effect of administration of intravenous fluids on post-operative pain and pulmonary function after gynecological laparoscopy.

Methods

In a prospective randomized double-blinded study 100 ASA 1 and 2 elective patients undergoing gynecological laparoscopy were randomized to receive intravenous compound sodium lactate 10 ml kg^?1 (CSL10-restrictive) or 30 ml kg^?1 (CSL30-liberal) administered intra-operatively. The primary outcome measure was the post-operative pain score at 24, 48 and 72 h, assessed by 0–10 verbal rating scale (VRS). Pulmonary function (FEV1, FVC, PEFR) and oxygen saturation were also measured.

Results

Patients who received CSL 30 had lower post-operative pain scores than CSL 10 (ANCOVA—mean difference = 0.47, 95 % CI 0.11–0.83, P = 0.01). Post-operative pain VRS was lower in CSL30 than CSL10 at 48 h (mean difference 0.56, 95 % CI 0.04–1.09, P = 0.036). Patients in CSL30 reported shoulder tip pain less frequently than those in CSL10 (30.4 vs. 43.9 % of assessments, P = 0.03, OR 0.58) but reported wound pain more frequently 39.0 vs. 24.2 %, P = 0.01, OR 2.0). Indices of pulmonary function did not differ between groups at any time.

Conclusions

Liberal compared to restrictive administration of i.v. crystalloid is associated with a clinical modest reduction in pain. Pulmonary dysfunction was not increased with liberal fluid administration.     

Dexamethasone for preventing postoperative sore throat: a meta-analysis of randomized controlled trials

Background

Postoperative sore throat (POST) is a common complication following tracheal intubation. The effectiveness of prophylactic dexamethasone on POST needs further elucidation.

Aims

To evaluate the effectiveness and safety of intravenous dexamethasone for the prevention of POST in patients undergoing endotracheal intubation.

Methods

Studies were identified by literature searches of PubMed, Embase, and the Cochrane database. Systematic review was performed by two independent investigators.

Results

We summarized 7 RCTs including 727 participants. Intravenous dexamethasone significantly reduced the risk of POST at 24 h [pooled risk ratio (RR) = 0.676; 95 % confidence interval (CI) 0.494–0.925; P = 0.014; heterogeneity test, I ² = 45.8 %], as well as alleviating its severity [standardized mean difference (SMD) = ?1.15; 95 % CI ?1.86 to ?0.45; P = 0.002; heterogeneity test, I ² = 91.7 %]. Further sub-group analysis indicated a significant relationship between dexamethasone and reduced risk of POST when its dose was over 0.1 mg/kg. No severe adverse effects were reported.

Conclusions

Our results suggest that intravenous dexamethasone reduces the risk and severity of POST from intubation at 24 h. The effective dosage of dexamethasone for preventing the risk of POST appeared to be over 0.1 mg/kg.     

Management of recalcitrant urethral strictures with self-dilatation balloon catheter

Introduction

Urethral strictures constitute a significant clinical problem that often requires long-term management.

Objective

To report the long-term outcomes of adjuvant home self-urethral dilatation of recurrent urethral strictures using a balloon catheter.

Materials and methods

Male patients (N = 11), performing self-dilatation with a balloon catheter (minimum 24 months) were assessed by patient-reported outcome measures (PROMs) health questionnaire specific for post treatment assessment of men with urethral stricture disease.

Results

Median duration of balloon catheter use is 46.5 months, IQR (24–150). Patients performed self-balloon dilatation on average 1.4 times a week, median 1, IQR (1–2) to maintain the patency of their urethra. The mean PROMs LUTS score of the patients was 2.45, median 2, IQR (1–4). The median and mean Peeling score was 2 IQR (1–2). 100 % patient reported that they either very satisfied or satisfied with the overall outcome and QoL.

Conclusions

Our initial experience of outpatient self-dilatation with a balloon dilatation is encouraging and is an acceptable inexpensive and simple treatment for patient maintains urethral patency and potentially decreases stricture recurrence.     

In a time of cholera

Introduction

Dr. Nathaniel Alcock in his book A treatise on cholera described 22 cases of cholera that he treated in 1832. Blood-letting, either by leeches or venesection, was an essential part of the treatment.

Rationale

The belief was that reducing the blood volume would relieve stress on the heart and lungs allowing for better function. The receipts of the Townsend Street Cholera Hospital where Dr. Alcock worked show how extensive the practice was. Outside Dublin, local Boards of Health dealt with the cholera epidemic. Various public measures such as street cleaning and removal of patients to temporary hospitals were undertaken and various cures were tried.

Outcome

The overall mortality rate from cholera in Ireland during the epidemic was 38 %, but in some areas much higher.

Conclusion

Even as cholera was spreading in the 1830s, a number of doctors were showing that intravenous fluids could dramatically alter the course of the disease. Unfortunately, their work was ignored and blood-letting continued to be a major component of the treatment of cholera for another 55 years.