Use of slow-release oral morphine for the treatment of opioid dependence

AIMS: In addition to methadone, other synthetic opioids are now available for the treatment of opioid dependence. The study investigated the treatment satisfaction of oral slow-release morphine for maintenance therapy in opioid-dependent patients in an open-label 3-week study. DESIGN: We evaluated the treatment satisfaction of oral slow-release morphine hydrochloride for 3 weeks in 110 patients meeting the diagnosis of opioid dependence (DSM-IV 304.0) or polysubstance dependence (DSM-IV 304.9). MEASUREMENTS: Primary outcome measures were the study retention rate, urinalysis for additional illicit consumption other than heroin, cravings and withdrawal symptoms 24 h after the last intake of the medication (duration of action of treatment). FINDINGS: In total, 103 patients completed the study, representing a retention rate of 94%. Patients reported significant improvements in somatic complaints, as well as significant reductions in heroin and cocaine cravings (p < 0.0001) and in additional consumption of cocaine in supervised urinalysis (p = 0.0083). Additional illicit consumption of benzodiazepines remained unchanged. CONCLUSIONS: The high study retention rate implies a good acceptance of slow-release acting oral morphine. However, randomised, double-blind, double-dummy studies with a longer investigational period are needed to meet criteria for evidence-based medicine.     

Whole genome sequencing identifies influenza A H3N2 transmission and offers superior resolution to classical typing methods

Objectives

Influenza with its annual epidemic waves is a major cause of morbidity and mortality worldwide. However, only little whole genome data are available regarding the molecular epidemiology promoting our understanding of viral spread in human populations.

Methods

We implemented a RT-PCR strategy starting from patient material to generate influenza A whole genome sequences for molecular epidemiological surveillance. Samples were obtained within the Bavarian Influenza Sentinel. The complete influenza virus genome was amplified by a one-tube multiplex RT-PCR and sequenced on an Illumina MiSeq.

Results

We report whole genomic sequences for 50 influenza A H3N2 viruses, which was the predominating virus in the season 2014/15, directly from patient specimens. The dataset included random samples from Bavaria (Germany) throughout the influenza season and samples from three suspected transmission clusters. We identified the outbreak samples based on sequence identity. Whole genome sequencing (WGS) was superior in resolution compared to analysis of single segments or partial segment analysis. Additionally, we detected manifestation of substantial amounts of viral quasispecies in several patients, carrying mutations varying from the dominant virus in each patient.

Conclusion

Our rapid whole genome sequencing approach for influenza A virus shows that WGS can effectively be used to detect and understand outbreaks in large communities. Additionally, the genomic data provide in-depth details about the circulating virus within one season.

     

The cardiac impulse: a new look at an old art

The value and limitations of precordial palpation have been reviewed in the light of recent information. A markedly enlarged heart in the absence of significant increase in volume load signifies poor myocardial function. It is often difficult to differentiate a fourth heart sound from similar auscultatory phenomena, but a palpable presystolic kick is a reliable clinical clue to an elevated left ventricular end-diastolic presure. A hyperkinetic apical impulse is seen in slim, anxious patients, those with hyperkinetic states, and typically those with left ventricular volume overload. However, a sustained systolic apical impulse need not necessarily mean increased pressure load on the left ventricle, as it could be encountered with combined volume and pressure load and in patients with markedly dilated left ventricle. A bifid systolic apical impulse has little significance. A trifid impulse (one presystolic and double systolic waves) is most often seen in idiopathic hyperkinetic subaortic stenosis.The left parasternal impulse is normally characterized by a brief gentle early systolic lift followed by systolic retraction. A rocking movement with a lift starting in diastole and peaking in early systole is typical of right ventricular volume overload. A midsystolic gentle heave is seen in patients with decreased anteroposterior chest diameter, in those with right ventricular pressure overloaded, and occasionally in those with anterior wall dyskinesia.A late systolic lift is encountered typically in patients with mitral regurgitation, and also with myocardial aneurysm. An example of the value of careful precordial palpation is in differentiating mitral regurgitation from aortic stenosis when the auscultatory findings are often indistinguishable. Mitral regurgitation gives a hyperkinetic apical impulse and a late systolic left parasternal lift, whereas aortic stenosis gives a sustained apical impulse and a gentle systolic retraction in the left parasternal area.Also, precordial palpation helps to differentiate constrictive pericarditis from restrictive cardiomyopathy. The first leads to systolic precordial retraction while the latter produces a palpable systolic outward movement.     

Comparison of virtual non-contrast dual-energy CT and a true non-contrast CT for contouring in radiotherapy of 3D printed lung tumour models in motion: a phantom study

Objectives:This work aims to investigate whether virtual non-contrast (VNC) dual-energy CT(DECT) of contrasted lung tumours can be used as an alternative for true non-contrast (TNC) images in radiotherapy. Two DECT techniques and a TNC CT were compared and influences on gross tumour volume (GTV) volume and CT number from motion artefacts in three-dimensional printed lung tumour models (LTM) in amotion phantom were examined.Methods:Two spherical LTMs (diameter 3.0 cm) with different inner shapes were created in a three-dimensional printer. The inner shapes contained water or iodine (concentration 5 mg ml⁻¹) and were scanned with a dual-source DECT (ds-DECT), single-source sequential DECT (ss-DECT) and TNC CT in a respiratory motion phantom (15 breaths/min, amplitude 1.5 cm). CT number and volume of LTMs were measured. Therefore, two GTVs were contoured.Results:Deviations in GTV volume (outer shape) of LTMs in motion for contrast-enhanced ss-DECT and ds-DECT VNC images compared to TNC images are not significant (p > 0.05). Relative GTV volume and CT number deviations (inner shapes) of LTMs in motion were 6.6 ± 0.6% and 104.4 ± 71.2 HU between ss-DECT and TNC CT and −8.4 ± 10.6% and 25.5 ± 58.5 HU between ds-DECT and TNC, respectively.Conclusion:ss-DECT VNC images could not sufficiently subtract iodine from water in LTMs inmotion, whereas ds-DECT VNC images might be a valid alternative to a TNC CT.Advances in knowledge:ds-DECT provides a contrasted image for contouring and a non-contrasted image for radiotherapy treatment planning for LTM in motion.     

Coronary artery disease as an independent predictor of survival in patients with type 2 diabetes and Charcot neuro-osteoarthropathy

Aims

Charcot neuro-osteoarthropathy (CN) is a rare complication of diabetic foot syndrome associated with chronic inflammation of the foot and severe, limb-threatening musculoskeletal deformities. Aim of this study was to investigate patients with CN for comorbidities, amputations, ulcers, secondary diseases and mortality.

Methods

The study was conducted at a specialized German hospital for patients with diabetes. One-hundred and eleven patients were enrolled, and their course was followed over a period of 15 years. Association of CN with comorbidity, foot ulcers, amputations and mortality was assessed. Clinical course of patients was followed using two standardized questionnaires.

Results

Presence of CN was significantly associated with diabetic retinopathy (p = 0.047), plantar (p < 0.001), tarsal (p = 0.032) and middle-foot ulcers (p = 0.01). A significant correlation between the presence of CN and a history of amputations was seen (p = 0.022). Patients were at increased risk to suffer from subsequent amputations during follow-up when micro- and macrovascular comorbidities such as retinopathy (p = 0.01) and peripheral artery disease (p < 0.001) were present. Additionally, coronary artery disease (CHD) was identified as an independent predictor of mortality in the cohort of this study (OR 6.192, 95 % CI 1.155–33.208, p = 0.033). Median overall survival of patients with CN and CHD was significantly shorter than OS of patients without CHD (7.8 vs. 13.1 years, p = 0.0045, HR 2.8437, 95 % CI 0.9818–8.2364).

Conclusions

In our study, CHD was the most important factor of survival in CN patients. For optimal management of CN, adequate diagnostics and treatment of CHD according to current guidelines should be considered.     

Recommendations for initial examination,differential diagnosis,and management of concussion and other head injuries in high-level football

Head injuries can result in substantially different outcomes, ranging from no detectable effect to transient functional impairments to life-threatening structural lesions. In high-level international football (soccer) tournaments, on average, one head injury occurs in every third match. Making the diagnosis and determining the severity of a head injury immediately on-pitch or off-field is a major challenge for team physicians, especially because clinical signs of a brain injury can develop over several minutes, hours, or even days after the injury. A standardized approach is useful to support team physicians in their decision whether the player should be allowed to continue to play or should be removed from play after head injury. A systematic, football-specific procedure for examination and management during the first 72 hours after head injuries and a graduated Return-to-Football program for high-level players have been developed by an international group of experts based on current national and international guidelines for the management of acute head injuries. The procedure includes seven stages from the initial on-pitch examination to the graduated Return-to-Football program. Details of the assessments and the consequences of different outcomes are described for each stage. Criteria for emergency management (red flags), removal from play (orange flags), and referral to specialists for further diagnosis and treatment (persistent orange flags) are provided. The guidelines for return to sport after concussion-type head injury are specified for football. Thus, the present paper presents a comprehensive procedure for team physicians after a head injury in high-level football.     

“Push as Hard as You Can” Instruction for Telephone Cardiopulmonary Resuscitation: A Randomized Simulation Study

Background

The medical priority dispatch system (MPDS®) assists lay rescuers in protocol-driven telephone-assisted cardiopulmonary resuscitation (CPR).

Objective

Our aim was to clarify which CPR instruction leads to sufficient compression depth.

Methods

This was an investigator-blinded, randomized, parallel group, simulation study to investigate 10 min of chest compressions after the instruction “push down firmly 5 cm” vs. “push as hard as you can.” Primary outcome was defined as compression depth. Secondary outcomes were participants exertion measured by Borg scale, provider's systolic and diastolic blood pressure, and quality values measured by the skill-reporting program of the Resusci^® Anne Simulator manikin. For the analysis of the primary outcome, we used a linear random intercept model to allow for the repeated measurements with the intervention as a covariate.

Results

Thirteen participants were allocated to control and intervention. One participant (intervention) dropped out after min 7 because of exhaustion. Primary outcome showed a mean compression depth of 44.1 mm, with an inter-individual standard deviation (SD_b) of 13.0 mm and an intra-individual standard deviation (SD_w) of 6.7 mm for the control group vs. 46.1 mm and a SD_b of 9.0 mm and SD_w of 10.3 mm for the intervention group (difference: 1.9; 95% confidence interval −6.9 to 10.8; p = 0.66). Secondary outcomes showed no difference for exhaustion and CPR-quality values.

Conclusions

There is no difference in compression depth, quality of CPR, or physical strain on lay rescuers using the initial instruction “push as hard as you can” vs. the standard MPDS^® instruction “push down firmly 5 cm.”