The abused female oral and maxillofacial surgery patient: treatment approaches for identification and management

Violence and abuse affect one in four women during their lifetime. Specifically, a woman seeking treatment of a facial injury has a one in three chance of being a victim of violence and abuse. Many dental professionals, however, are uncomfortable discussing these issues with potential victims. The oral and maxillofacial surgeon is in a unique position to approach the topic of violence and abuse. This article discusses violence and abuse as it pertains to the female patient and family members. Suggestions for screening and evaluation of patients are discussed. The overall importance of timely identification for stopping this cycle of violence and abuse and the obligations of health care providers are also addressed.     

Headache associated with miller fisher syndrome

Miller Fisher syndrome, a variant of Guillain-Barre syndrome, is composed of the clinical triad of ophthalmoplegia, ataxia, and areflexia. A variety of other symptoms and signs have been reported in this syndrome, but headache is not a commonly reported symptom. We report a 35-year-old man with anti-GQ(1b) antibody-confirmed Miller Fisher syndrome presenting with severe and persistent headache, and we propose that the headache is caused by antibody-mediated effects on the trigeminovascular pain pathway.     

Novel nerve-agent antidote design based on crystallographic and mass spectrometric analyses of tabun-conjugated acetylcholinesterase in complex with antidotes

Organophosphorus compound-based nerve agents inhibit the essential enzyme acetylcholinesterase (AChE) causing acute toxicity and death. Clinical treatment of nerve-agent poisoning is to use oxime-based antidotes to reactivate the inhibited AChE. However, the nerve agent tabun is resistant to oximes. To design improved oximes, crystal structures of a tabun-conjugated AChE in complex with different oximes are needed to guide the structural modifications of known antidotes. However, this type of structure is extremely challenging to obtain because both deamidation of the tabun conjugate and reactivation of AChE occur during crystallographic experiments. Here we report, for the first time, the crystal structures of Ortho-7 and HL?-7 in complex with AChE that is conjugated to an intact tabun. These structures were determined by our new strategy of combining crystallographic and mass spectrometric analyses of AChE crystals. The results explain the relative reactivation potencies of the two oximes and offer insights into improving known medical antidotes.     

Management of access to branded psychotropic medications in private health plans

BACKGROUND: In the past decade, health insurers have increased their reliance on cost control policies such as prior authorization and 3-tier formularies. Little is known about how these policies are being applied to psychotropic medications, many of which have low rates of patient adherence. OBJECTIVE: This study reports on plans' cost-sharing tier placement and authorization policies for 12 brand only psychotropic medications in 3 classes: antidepressants, anti-psychotics, and medications for attention deficit/hyperactivity disorder (ADFID). METHODS: Data were from a nationally representative survey of private health plans regarding mental health and substance-abuse services in 2003; 368 plans responded (83% response rate). Results were weighted and represent national estimates of health-plan characteristics. RESULTS: The majority of insurance products provided unrestricted placement on Tier 2 (medium copayment) for at least 2 brand-only antidepressants and at least 2 brand-only antipsychotics. This approach allows clinicians some limited leeway in initial medication selection. However, most patients who did not respond to the Tier-2 options typically faced a substantial escalation in copayment (Tier 3), possibly leading to premature medication discontinuation. For ADHI)5 the options were considerably more limited, with 22.1% of products applying some restriction to all 3 medications and only 15.9% of products leaving all 3 medications unrestricted. Plans with specialty contracts for mental health were considerably more likely to use Tier 3 (highest copayment) as their only restriction approach. CONCLUSIONS: Based on the results of this analysis,private plans were managing psychotropic costs using copayment incentives rather than administrative controls. This approach was less intrusive for clinicians, but resulting higher copayments could worsen already high rates of nonadherence; future research should examine this issue.     

Weaning from prolonged mechanical ventilation using an antipsychotic agent in a patient with acute stress disorder

OBJECTIVE: To report the use of a second-generation antipsychotic agent to assist weaning from prolonged mechanical ventilation in an anxious patient. DESIGN: Case report. SETTING: Medical intensive care unit at the Hospital of the University of Pennsylvania. PATIENT: A 39-yr-old white female whose severe anxiety prohibited weaning from prolonged mechanical ventilation. INTERVENTIONS: Initiation of quetiapine as treatment for severe anxiety that was unresponsive to sedative hypnotics. MEASUREMENTS AND MAIN RESULTS: Once a therapeutic dose of quetiapine was reached, ventilator support was removed within 24 hrs. CONCLUSIONS: A second-generation antipsychotic agent was successfully used to facilitate weaning in a very anxious patient, possibly secondary to anxiolysis or direct effect on respiratory drive. Further investigations of pharmacologic intervention should be done to inform practice guidelines in difficult-to-wean patients suffering from severe anxiety.     

中药制剂临床应用的不良反应原因及对策分析

目的:探究中药制剂临床应用的不良反应产生原因并分析相应对策.方法:选取我院于2016年5月～2017年5月上报的80例中药制剂临床应用不良反应报告,对患者的性别、年龄、用药类型、给药途径、药品剂量、不良反应分类以及临床中的不良反应表现进行统计分析,从而探究导致临床应用中药制剂时产生不良反应的原因,并试图探究出相应对策.结果:从不良反应易发人群来看,老年人与儿童较中青年患者更容易产生不良反应,女性产生不良反应可能性大于男性(P<0.05),从用药方式来看,多为静脉滴注方式,从临床表现来看,多为皮肤与消化系统的不良反应.结论:在应用中医制剂时,要对不同体质的病例制定不同的中药制剂治疗方案,合理判断药品剂量,选择安全可靠的给药途径,从而减少患者产生不良反应,更加安全地施用中药制剂.     

Use of a radial artery compression device for noninvasive, near-continuous blood pressure monitoring in the ED

This study's goal was to test a novel device using continuous partial radial artery compression for mean arterial pressure (MAP) measurement. A prospective, nonblind, convenience-sample trial at a level I center (annual ED census 70,000) enrolled 15 adults with indwelling radial arterial catheters and accessible contralateral radial pulse. Subjects had MAPs measured simultaneously by test device (TEST assessments), oscillometric brachial artery cuff (OSC), and arterial line (ART). There was no difference between the three groups' MAP means (P = .98). R(2) values for ART/OSC and ART/TEST were 0.96 and 0.95, respectively (P <.001). TEST and OSC MAP readings were equally likely (P = 0.66) to be within 5 mm Hg of ART in both the overall set of 307 MAPs and in the subset of 120 cases in which ART MAPs were below 80 (P = .47). The TEST device performed at least as well as oscillometric assessment, offering advantages of noninvasive, near-continuous data.     

Response to sirolimus in capillary lymphatic venous malformations and associated syndromes: Impact on symptomatology,quality of life,and radiographic response

Background

Capillary lymphatic venous malformations (CLVM) and associated syndromes, including Klippel–Trenaunay syndrome (KTS) and congenital lipomatous overgrowth, vascular malformation, epidermal nevi, skeletal, and spinal syndrome (CLOVES), are underrecognized disorders associated with high morbidity from chronic pain, recurrent infections, bleeding, and clotting complications. The rarity of these disorders and heterogeneity of clinical presentations make large-scale randomized clinical drug trials challenging. Identification of PIK3CA (phosphatidylinositol-4,5-bisphosphate 3-kinase catalytic subunit alpha [gene]) mutations in CLVM has made targeted medications, such as sirolimus, attractive treatment options. The aim of this study was to investigate the safety and efficacy of sirolimus therapy in CLVM.

Procedure

A combined prospective and retrospective cohort of pediatric and young adult patients with CLVM treated with sirolimus was evaluated for disease response, including symptom improvement, quality of life (QOL), and radiologic response. Sirolimus dosing regimens and toxicities were also assessed.

Results

Twenty-nine patients with CLVM, including KTS and CLOVES, were included. Ninety-three percent of patients reported improved QOL, and 86% had improvement in at least one symptom. Most significantly, improvement was noted in 100% of patients with bleeding and 89% with thrombotic complications with corresponding decreases in mean D-dimer (p = .008) and increases in mean fibrinogen (p = .016). No patients had progressive disease on sirolimus. Most common side effects included neutropenia, lymphopenia, infection, and aphthous ulcers/stomatitis. No toxicities were life-threatening, and none required long-term discontinuation of sirolimus.

Conclusion

Sirolimus appears to be effective at reducing complications and improving QOL in patients with CLVM and associated syndromes. In this patient cohort, sirolimus was well tolerated and resulted in few treatment-related toxicities.     

Propranolol Promotes Bone Formation and Limits Resorption Through Novel Mechanisms During Anabolic Parathyroid Hormone Treatment in Female C57BL/6J Mice

Although the nonselective β-blocker, propranolol, improves bone density with parathyroid hormone (PTH) treatment in mice, the mechanism of this effect is unclear. To address this, we used a combination of in vitro and in vivo approaches to address how propranolol influences bone remodeling in the context of PTH treatment. In female C57BL/6J mice, intermittent PTH and propranolol administration had complementary effects in the trabecular bone of the distal femur and fifth lumbar vertebra (L₅), with combination treatment achieving microarchitectural parameters beyond that of PTH alone. Combined treatment improved the serum bone formation marker, procollagen type 1 N propeptide (P1NP), but did not impact other histomorphometric parameters relating to osteoblast function at the L₅. In vitro, propranolol amplified the acute, PTH-induced, intracellular calcium signal in osteoblast-like cells. The most striking finding, however, was suppression of PTH-induced bone resorption. Despite this, PTH-induced receptor activator of nuclear factor κ-B ligand (RANKL) mRNA and protein levels were unaltered by propranolol, which led us to hypothesize that propranolol could act directly on osteoclasts. Using in situ methods, we found Adrb2 expression in osteoclasts in vivo, suggesting β-blockers may directly impact osteoclasts. Consistent with this, we found propranolol directly suppresses osteoclast differentiation in vitro. Taken together, this work suggests a strong anti-osteoclastic effect of nonselective β-blockers in vivo, indicating that combining propranolol with PTH could be beneficial to patients with extremely low bone density. © 2022 American Society for Bone and Mineral Research (ASBMR).