The association of air pollution with congenital anomalies: An exploratory study in the northern Netherlands

Background

There are a growing number of reports on the association between air pollution and the risk of congenital anomalies. However, the results are inconsistent and most studies have only focused on the association of air pollution with congenital heart defects and orofacial clefts.

Comparison of different pain scoring systems in critically ill patients in a general ICU

Background

Pain in critically ill patients in the intensive care unit (ICU) is common. However, pain assessment in critically ill patients often is complicated because these patients are unable to communicate effectively. Therefore, we designed a study (a) to determine the inter-rater reliability of the Numerical Rating Scale (NRS) and the Behavioral Pain Scale (BPS), (b) to compare pain scores of different observers and the patient, and (c) to compare NRS, BPS, and the Visual Analog Scale (VAS) for measuring pain in patients in the ICU.

Methods

We performed a prospective observational study in 113 non-paralyzed critically ill patients. The attending nurses, two researchers, and the patient (when possible) obtained 371 independent observation series of NRS, BPS, and VAS. Data analyses were performed on the sample size of patients (n = 113).

Results

Inter-rater reliability of the NRS and BPS proved to be adequate (kappa = 0.71 and 0.67, respectively). The level of agreement within one scale point between NRS rated by the patient and NRS scored by attending nurses was 73%. However, high patient scores (NRS ≥4) were underestimated by nurses (patients 33% versus nurses 18%). In responsive patients, a high correlation between NRS and VAS was found (r_s = 0.84, P < 0.001). In ventilated patients, a moderate positive correlation was found between the NRS and the BPS (r_s = 0.55, P < 0.001). However, whereas 6% of the observations were NRS of greater than or equal to 4, BPS scores were all very low (median 3.0, range 3.0 to 5.0).

Conclusion

The different scales show a high reliability, but observer-based evaluation often underestimates the pain, particularly in the case of high NRS values (≥4) rated by the patient. Therefore, whenever this is possible, ICU patients should rate their pain. In unresponsive patients, primarily the attending nurse involved in daily care should score the patient's pain. In ventilated patients, the BPS should be used only in conjunction with the NRS nurse to measure pain levels in the absence of painful stimuli.     

Fixation of osteochondral fragments in the human knee using Meniscus Arrows?

The aim of this study is to compare the hold in bone of Meniscus Arrows^? and Smart Nails^?, followed by the report of the results of the clinical application of Meniscus Arrows^? as fixation devices. First, pull-out tests were performed to analyse the holdfast of both nails in bone. Statistical analysis showed no significant difference; therefore, the thinner Meniscus Arrow^? was chosen as fixation device in the patient series of two patients with a symptomatic Osteochondritis dissecans fragment and three patients with an osteochondral fracture of a femur condyle. The cartilage margins were glued with Tissuecoll^?. All fragments consolidated. Second look arthroscopy in three patients showed fixed fragments with stable, congruent cartilage edges. At an average follow-up period of 5 years no pain, effusion, locking, restricted range of motion or signs of osteoarthritis were reported. Based on the results of the pull-out tests and available clinical studies, Meniscus Arrows^? and Smart Nails^? are both likely to perform adequately as fixation devices in the treatment of Osteochondritis dissecans and osteochondral fractures in the knee. They both provide the advantage of one stage surgery. However, based on their smaller diameter, the Meniscus Arrows^? should be preferred for this indication.     

Effects of the Ikr-Blocker Almokalant and Predictors of Conversion of Chronic Atrial Tachyarrhythmias to Sinus Rhythm. A Prospective Study

Purpose: To assess the efficacy of the I_kr-blocker almokalant attempting to convert chronic atrial tachyarrhythmias, and to find predictors of conversion, to sinus rhythm.Methods: The electrophysiological effects of a 6-hour infusion of almokalant, to a total dose of 25 ± 4 mg, were assessed by ECG and transesophageal atrial electrograms (TAE) in 100 consecutive patients with atrial fibrillation / flutter (n = 95 / 5) of 8 ± 12 months' duration (range 1 to 99 months).Results: The conversion rate was 32%. The time to conversion was 3.5 ± 2.2 hours. During infusion increases in QT_top (292 ± 35 to 335 ± 44 ms, p < 0.001, after 30 minutes), QT (387 ± 40 to 446 ± 60 ms, p < 0.001), corrected QT (425 ± 30 to 487 ± 44 ms, p < 0.001), and QT dispersion (21 ± 12 to 29 ± 31 ms, p = 0.02), were paralleled by decreases in T wave amplitude (0.31 ± 0.19 to 0.23 ± 0.16 mV, p < 0.001), and atrial rate (425 ± 78 to 284 ± 44 beats per minute (bpm) on ECG, and 396 ± 72 to 309 ± 44 bpm on TAE), with no differences between converters to sinus rhythm and non-converters. Patients with aberrantly conducted beats, and T wave variation, also increased. Calcium antagonists were more common among converters. A decreasing T wave amplitude predicted conversion. Four patients developed torsades de pointes.Conclusions: This study demonstrates class III action of almokalant, with a conversion rate of 32% of long-standing, chronic atrial tachyarrhytmias. An early decrease in T wave amplitude was associated with conversion to sinus rhythm.     

Effectiveness of indometacin to prevent ovulation in modified natural-cycle IVF: A randomized controlled trial

Modified natural-cycle IVF has a lower pregnancy rate per started cycle as compared with IVF with ovarian stimulation due to, for example, premature ovulation. Indometacin administered before ovulation prevents follicle rupture. Therefore, addition of indometacin may improve the effectiveness of modified natural-cycle IVF. This double-blind, randomized, placebo-controlled trial with indometacin or placebo in 120 women aged 27–36 years compared the number of patients without premature ovulation as compared with the number of patients with one or more ovulations in a maximum of six cycles. Indometacin had no significant influence on the probability of a premature ovulation in patients during the six cycles (OR 2.38, 95% CI 0.94–6.04). A subgroup analysis showed a significant influence of indometacin in decreasing the probability of a premature ovulation in cycles without LH surge at the day of human chorionic gonadotrophin administration (OR 8.29, 95% CI 1.63–42.3, P = 0.009). Although this study could not detect a significantly lower ovulation rate in the indometacin group versus the placebo group, the data suggest that a subgroup of patients without LH surge prior to oocyte retrieval might benefit from indometacin in modified natural-cycle IVF.Modified natural-cycle IVF is a mild form of IVF, with a lower pregnancy rate per started cycle as compared with IVF with ovarian stimulation because of several unfavourable cycle events, such as ovulation before oocyte retrieval. Indometacin is a cheap drug, commonly used to reduce fever, pain and swelling caused by inflammation. It has been shown that indometacin administered before ovulation prevents this from happening. Therefore, it has been suggested that indometacin may improve the effectiveness of modified natural-cycle IVF. In this study, we assigned 120 women aged 27–36 years randomly to an indometacin group (60 women) and a group of women who used placebo (also 60 women). We evaluated whether indometacin could indeed prevent ovulation during a maximum of six modified natural-cycle IVF cycles. When we compared the two groups of women, indometacin did not seem to prevent ovulation compared with women who used placebo. Within these groups, however, the patients with a low level of LH (a hormone involved in ovulation) on the day that administration indometacin or placebo was started, indometacin did decrease the chance of an untimely ovulation. So although we could not detect a lower ovulation rate in the indometacin group versus the placebo group, our data suggest that a subgroup of patients with low LH concentrations prior to oocyte retrieval might benefit from indometacin in modified natural-cycle IVF.