Can we reduce morphine use in elderly,proximal femoral fracture patients using a fascia iliac block?

Proximal femoral fractures are becoming increasingly common with an ageing population. Many patients have multiple comorbidities increasing their risk of opiate complications. 40 consecutive patients presenting with a proximal femoral fracture to a trauma centre in the UK were given either a Fascia Iliaca Block (FIB) with oral analgesia or just oral analgesia to control their pre-operative pain. Numeric pain scores and morphine consumption were used as outcome measures. Patients receiving a FIB had significant reduction in their pain scores compared to patients only receiving oral pain relief. There was also a significant reduction in both the actual oral morphine taken and the renal calculated level of morphine products in the group receiving the FIB. Patients undergoing a FIB required almost 50 mg less oral morphine pre-operatively. Nerve blocks should be used routinely to help pre-operative pain in proximal femoral fracture patients and to reduce the amount of morphine products prescribed. This prevents potential opiate complications in a highly susceptible cohort of patients often suffering with impaired renal function as a co-morbidity.     

The changing demographics of women living with HIV/AIDS in southern Alberta from 1982 to 2006

INTRODUCTION:

Women account for a growing proportion of HIV infections in Canada. This has implications with respect to prevention, diagnosis and treatment.

OBJECTIVE:

To describe the female population presenting for HIV care in southern Alberta and to examine the impact of opt-out pregnancy screening.

METHODS:

A retrospective review of demographic and clinical characteristics of all patients presenting to the Southern Alberta HIV Clinic (SAC) care program from 1982 to 2006, was performed.

RESULTS:

The proportion of newly diagnosed patients who were female increased from 7.5% before 1998 to 21.5% after 1998. Women were more likely to be from vulnerable populations, such as intravenous drug users (31.3% versus 13.7%, P<0.001), aboriginals/Métis (21.5% versus 8.7%, P<0.001), blacks (28.9% versus 4.9%, P<0.001) and immigrants (36.6% versus 14.7%, P<0.001). Heterosexual intercourse was the main risk factor for HIV acquisition (43.7%). Women were less likely than men to have requested HIV testing (20.9% versus 37.8%, P<0.001). Opt-out pregnancy screening accounted for 12.7% of HIV-positive tests in women, following its introduction in 1998. Of the women diagnosed by pregnancy screening, 62.1% were from HIV-endemic countries. There was an association between reason for testing and CD4 count at presentation; women who requested their HIV test had higher median CD4 counts than those diagnosed because of illness (478 cells/mL, interquartile range [IQR]=370 cells/mL versus 174 cells/mL, IQR=328 cells/mL, P<0.001) or pregnancy screening (478 cells/mL, IQR=370 cells/mL versus 271 cells/mL, IQR=256 cells/mL, P=0.001).

CONCLUSIONS:

Women were less likely than men to have requested HIV testing and were more likely to be diagnosed by population-based screening methods. Women, especially vulnerable groups, account for a growing number and proportion of newly diagnosed HIV infections in Alberta. The implications of expanded screening in this population merit further consideration.     

Lichen planus and lupus erythematosus overlap syndrome

A 45-year-old woman with livid plaques showing central atrophy and erythematous vesicular borders over both dorsa of feet and buttocks, and follicular and papular lesions over buttocks and lumbar area, was difficult to diagnose as either lichen planus (LP) or lupus erythematosus (LE). The histological studies from two places showed features of both LE and LP. Laboratory findings were within normal limits first, but follow up studies for two years showed persistent albuminurea, leucopenia, arthritis and erythema over the exposed areas with same histology suggesting that eruption may be an unusual variant of LE.     

Sexually transmitted infections among female sex workers in Kupang,Indonesia: searching for a screening algorithm to detect cervical gonococcal and chlamydial infections

BACKGROUND AND GOAL: Notifications of HIV infection in Indonesia are increasing, but there are few data on other sexually transmitted infections (STIs), especially in the eastern islands of Indonesia. We aimed to measure the prevalence of STIs among female sex workers (FSWs) in Kupang, West Timor, and to develop screening algorithms to detect cervical infections with Neisseria gonorrhoeae and/or Chlamydia trachomatis (NG/CT). STUDY DESIGN: During 6 months in 1999, we recruited all the FSWs at Kupang's only brothel complex and a smaller number of independent FSWs. The women were examined at dedicated clinics and most laboratory tests were performed at provincial laboratories. Algorithms based on the strongest associations of variables with NG/CT were compared with the laboratory diagnoses. RESULTS: We recruited 288 women. The prevalence of N gonorrhoeae infection was 31%, that of C trachomatis infection was 24%, that of Trichomonas vaginalis infection was 5%, and that of syphilis was 13%. No case of HIV infection was detected. Few women had symptoms of STI. The only variables significantly associated with NG/CT after logistic regression analysis were the presence of cervical discharge (either yellow or clear) and a high count of polymorphonuclear leukocytes on gram-stained endocervical smear. Several algorithms to screen for NG/CT achieved high (>80%) sensitivity, but the highest specificity among these was only 50%. CONCLUSIONS: Although several of the generated algorithms may be useful in the absence of simple, accurate, affordable diagnostic tests, the high rates of STIs in this population could justify a more aggressive strategy incorporating periodic presumptive treatment to rapidly reduce prevalence.     

Analysis of non-HLA genomic risk factors in HLA-matched unrelated donor hematopoietic cell transplantation for chronic myeloid leukemia

Background

Allogeneic hematopoietic cell transplantation is the main curative therapy for patients with chronic myeloid leukemia who do not respond to tyrosine kinase inhibitors. It has been proposed that non-human leukocyte antigen gene polymorphisms influence outcome after hematopoietic cell transplantation and could be used alongside traditional patient-donor and transplant characteristics to create a recipient risk profile associated with allogeneic hematopoietic cell transplantation.

Design and Methods

A previous study from the European Group for Blood and Marrow Transplantation showed that the absence of recipient tumor necrosis factor receptor II, absence of donor interleukin 10 ATA/ACC and presence of donor interleukin 1 receptor antagonist allele 2 genotypes were associated with decreased survival and increased non-relapse mortality in adult patients with chronic myeloid leukemia undergoing myeloablative human leukocyte antigen-identical sibling transplantation. To explore these associations in unrelated donor transplantation, these polymorphisms were genotyped in 383 adult patients with chronic myeloid leukemia who underwent hematopoietic cell transplantation from unrelated donors matched for 10/10 human leukocyte antigens.

Results

The polymorphisms were not associated with overall survival, non-relapse mortality, relapse or acute graft-versus-host disease in the unrelated donor cohort. Comparison of the unrelated donor and human leukocyte antigen-identical sibling cohorts showed differences in survival and clinical characteristics.

Conclusions

We did not confirm that non-human leukocyte antigen polymorphisms were associated with outcomes in myeloablative unrelated donor hematopoietic cell transplantation for chronic myeloid leukemia, possibly because of the strong association between clinical variables and outcome which masked more subtle genetic effects.     

HISTOLOGICAL EVALUATION OF THE EFFECT OF 0.05% TRETINOIN IN THE TREATMENT OF PHOTO DAMAGED SKIN

In a randomised double-blind vehicle controlled trial of 0.05% tretinoin cream in the treatment of photodamaged skin, the histological results of paired biopsies from 28 individuals who applied tretinoin for 26 weeks are compared with 28 paired biopsies from a control group applying vehicle alone. There was a significant increase in epidermal thickness in the tretinoin-treated group (P.001). Epidermal atrophy was reversed in ten patients applying tretinoin cream. Baseline biopsies obtained from participants in Melbourne, Victoria (38° latitude) showed significantly less elastosis than those in Sydney (34° latitude) and Newcastle in N.S.W., although the two groups did not show significant differences in age or sex, and the differences could not be correlated with skin type. Tretinoin cream had no effect on the degree of solar elastosis after 26 weeks application. Tretinoin cream appears effective in reversing epidermal atrophy and clinically diminishes fine wrinkling, mottled hyperpigmentation and skin roughness. Tretinoin cream may not offer a solution to the gross solar damage seen in the Australian population who have marked solar elastosis as a principal, clinical and histologie finding. However it is possible that dermal repair and reversal of solar elastosis may require topical application of tretinoin cream for a longer period than the six months used in this trial.     

A prospective, randomized trial to determine the early and late reactions after the use of iopamidol 340 (Niopam) and iobitridol 350 (Xenetix) in cardiac catheterization

BACKGROUND: Intravascular contrast agents presently used in modern digital catheter laboratories during cardiac catheterization are superior to older agents as regards patient tolerance. There are, however, significant differences between these agents. PURPOSE: The aim of this study was to determine the incidence of early (< 24 hours) and late (> 24 hours to 7 days) reactions to 2 contrast agents currently used during cardiac catheterization: iopamidol 340 (Niopam) and iobitridol 350 (Xenetix). METHODS: This was a prospective, randomized, double-blinded trial. Two thousand and nineteen patients undergoing cardiac catheterization received one of the following contrast agents: iopamidol 340 (Niopam) and iobitridol 350 (Xenetix). Reactions that were possibly related to the contrast agents were recorded during hospital admission (early reaction) and after discharge (late reaction) by means of a questionnaire. RESULTS: The baseline characteristics were matched in both the groups. There was no significant difference in the incidence of heat sensation experienced between the 2 groups, (p = 0.1). Early non-heat reactions occurred in 3.2% of patients receiving iopamidol 340 (Niopam) and 3.6% of those receiving iobitridol 350 (Xenetix), (p = 0.65). Electrocardiographic changes were recorded in 0.7% of patients who received iopamidol 340 (Niopam), and 2.6% of those who received iobitridol 350 (Xenetix), (p = < 0.01). Seven patients (0.8%) receiving iobitridol 350 suffered ventricular fibrillation requiring DC cardioversion compared with none in the iopamidol 340 group (p = < 0.01). Late reactions (post discharge symptoms) occurred in 13.9% of those receiving iopamidol 340 (Niopam) and 18.5% of those receiving iobitridol 350 (Xenetix) (p = 0.02). CONCLUSIONS: Iobitridol 350 (Xenetix) was associated with more ECG changes and, importantly, ventricular fibrillation, than iopamidol (Niopam). There were no features to suggest other benefits from iobitridol 350. These results suggest that iopamidol 340 is a preferable contrast agent in cardiac catheterization.     

The relationship between lymphocyte transformation and immune responses. II. Correlations between transformation and humoral and cellular immune responses

Rabbits were immunized against purified proteins, tissue extracts or sheep erythrocytes, with or without Freund's adjuvant. Skin reactions of the delayed type were found only in animals given antigen with adjuvant, although all rabbits developed serum antibodies and most of them Arthus type reactions. Lymphocytes of all animals, however, showed similar transformation activity when cultured with the immunizing antigen.

Thus the blast transformation phenomenon correlates well with both cellular and humoral immune responses and not with the delayed type hypersensitivity only.