Intravenous paracetamol as adjunctive treatment for postoperative pain after cardiac surgery: a double blind randomized controlled trial.

BACKGROUND: Nonsteroidal anti-inflammatory drugs and opioids are routinely used after cardiac surgery in order to mitigate postoperative pain; however, these drugs are burdened by side effects. Tramadol and paracetamol are believed to be lacking in such side effects. The aim of this study was to examine the efficacy of intravenous paracetamol as an adjunctive analgesic to a tramadol-based background analgesia after cardiac surgery. METHODS: A total of 113 patients participated in this single center, placebo-controlled, double-blind, randomized trial. Fifty-six patients were randomized to receive paracetamol and 57 to placebo. Intravenous study drug (1 g) was administered 15 min before the end of surgery and every 6h for 72 h. Standard analgesia (tramadol) and anti-emetic prophylactic regimen (ondansetron) were available to both patient groups. Postoperative pain was evaluated by visual analog scale, and it was measured at rest and during a deep breath. A rescue dose of 2-5 mg of intravenous morphine was administered whenever the VAS score was greater than 3. RESULTS: Baseline characteristics were equivalent between the two groups. At 12, 18, 24 h after the end of operation, patients who received paracetamol had significantly less pain at rest (p=0.0041, 0.0039, 0.0044, respectively); after this time the two groups did not differ. During a deep breath the difference was significant only at 12 h (p=0.0040). Paracetamol group required less cumulative morphine than placebo group (48 mg vs 97 mg) even if the difference did not reach statistical significance (p=0.274). CONCLUSIONS: In patients undergoing cardiac surgery, intravenous paracetamol in combination with tramadol provides effective pain control.     

Femoral anastomotic pseudoaneurysms

In this paper the Authors discuss about femoral anastomotic pseudoaneurysms. They throughly consider the etiopathogenesis of this late complication of arterial prothesic surgery, pointing out the different hypothesis currently discussed. Particularly from this analysis it can be concluded that the choice of appropriate prothesic grafts and the weakness of an eventually endarterectomized arterial wall are the principal determinants in causing pseudoaneurysms. Between the different therapeutic choices the opportunity of an interposition graft is underlined, except for (rare) cases when an extra-anatomic bypass must be preferred.     

Noninvasive evaluation of cardiac index and ejection fraction in ischemic heart disease. Comparison of thoracic bioimpedance, thermodilution and cineventriculography]

Aim of the study was to verify the reliability of thoracic bioimpedance cardiography (TEB) in detection, non-invasively, cardiac index (IC) and ejection fraction (FE), compared to simultaneous evaluation by invasive thermodilution (TD) in 39 patients with acute myocardial infarction in Killip class I-II (group I), and by cineventriculography (CVG) in 26 patients with chronic coronary artery disease in NYHA class I-II (group II). In order to define the reproducibility of TEB values, in the latter patients, the above mentioned parameters were evaluated 6 times more, running the first evaluation. The statistical analysis was performed by the linear regression test and the Student's "t" test and by the test of variance for the reproducibility evaluation. Results (mean +/- SD) were as follows: group I: TEB-IC 2.89 +/- 0.63; TD-IC 2.83 +/- 0.56 (1/min/m2); r = 0.68; p < 0.01. Group II: TEB-IC 2.88 +/- 0.71; CVG-IC 3.48 +/- 0.66; r = 0.77; p < 0.001; TEB-FE 57.7 +/- 6.8%; CVG-FE 58.1 +/- 13.7%; r = 0.40; p = ns. Results of the reproducibility referred to the 6 measurements (mean +/- SD) were the follows: TEB-IC (1/min/m2) (1) 2.83 +/- 0.76; (2) 2.85 +/- 0.73; (3) 2.8 +/- 0.79; (4) 2.83 +/- 0.71; (5) 2.87 +/- 0.81; (6) 2.88 +/- 0.8, p = ns, the variability was assesses within +/- 9.3%. TEB-FE (%): (1) 56.7 +/- 6.2; (2) 55.8 +/- 5; (3) 57.1 +/- 5.5; (4) 56.1 +/- 6.1; (5) 55.4 +/- 5.8; (6) 57.3 +/- 6.3, p = ns; the variability was assessed within +/- 9.1%. The analysis of the results showed a good correlation in the IC detection among TEB and the compared techniques, conversely TEB evaluation of FE appear of poor values in this kind of patients. Relatively to the results of the reproducibility this unquestionable characteristic of TEB was demonstrated.     

Temporomandibular joint: morphology and signal intensity characteristics of the disk at MR imaging

Magnetic resonance (MR) imaging has been used in the temporomandibular joint (TMJ) primarily to define the disk position. This report examines altered morphology and signal intensity characteristics of the TMJ disk as they relate to the severity of internal derangement. Two hundred sixteen joints in 133 patients with a history of such derangement. were imaged with MR. Disk position, signal intensity, morphology, and the presence of osteoarthritis were determined for each joint. The normal disk was not anteriorly displaced and had a normal "bow-tie" shape. A grade 1 disk was anteriorly displaced and had a normal shape; a grade 2 disk was anteriorly displaced and had an abnormal shape. Forty (19%) joints were considered normal; none of these exhibited osteoarthritis. One hundred thirty-nine (64%) joints were grade 1; osteoarthritis was found in 17%. Thirty-seven (17%) were grade 2; osteoarthritis was found in 95%. All forty normal joints had high or intermediate signal intensity in the disk. Osteoarthritic joints had a higher percentage of disks with diminished intensity (P less than .0001). Severe or untreated osteoarthritis is known to be a complication of TMJ internal derangements; hence this grading system seems to correlate with the severity of internal derangement.     

Variation of the Mycobacterium tuberculosis PE_PGRS 33 gene among clinical isolates

PE_PGRS33, one of about 60 PE_PGRS genes in the Mycobacterium tuberculosis genome, encodes a surface-expressed protein that may be involved in the antigenic variation of M. tuberculosis strains and evasion of the host immune system. While genetic differences between the PE_PGRS33 genes of H37Rv and CDC1551 have been noted, genetic variation in this gene among clinical isolates has not been evaluated. In order to gain a better understanding of the genetic basis for the role of PE_PGRS in antigenic variation and evasion of the host immune system, we investigated the genetic diversity of the PE_PGRS33 gene among 123 clinical M. tuberculosis isolates from a population-based study, using PCR and DNA sequencing. The 123 isolates belonged to principal genetic groups 1, 2, and 3 and had IS6110 copy numbers ranging from 1 to 22. Eighty-four (68.3%) of the 123 isolates were found to have at least one sequence variation in the PE_PGRS33 gene, relative to that of H37Rv. Twenty-five different sequence variations were observed and included three insertions (ranging from 9 to 87 bp), nine deletions (ranging from 1 to 273 bp), one insertion-and-deletion event, and 12 single-nucleotide polymorphisms (six synonymous and six nonsynonymous). Analysis of the relationships among the different PE_PGRS33 gene sequence variations suggests that polymorphisms in the gene are shifting along evolutionary lineages. The observed genetic diversity of the PE_PGRS33 gene supports its role in antigenic variation and can serve as a basis for future investigations of the function of the PE_PGRS33 gene among clinical isolates.     

Diagnostic Testing in Long-Term Care and Resident Emergency Department Visits: A Retrospective Cohort Study

ObjectivesTo investigate the association between rapid access to radiographs, blood tests, urine cultures, and intravenous (IV) therapy in a long-term care (LTC) home with resident transfers to the emergency department (ED).DesignRetrospective cohort study.Setting and Participants21,811 residents living in 162 LTC homes in Ontario, Canada.MethodsWe administered a survey to LTC homes to collect wait times for radiographs, basic blood tests, urine culture, and IV therapy. Rapid availability was defined as typically receiving test results within 1 or 2 days, or same-day IV therapy. We linked the survey results to administrative data and defined a cohort of residents living in survey-respondent homes between January and May 2017. We followed residents in the linked administrative databases for 6 months, until discharge, or death. Two physicians identified diagnostic codes for ED visits that were potentially preventable with rapid availability of each of the 4 resources. Multilevel logistic regression models estimated associations between potentially preventable ED visits and rapid diagnostic tests and intravenous access while controlling for demographic characteristics, illness severity, LTC home size, chain status, and physician availability.ResultsRapid blood tests, radiographs, urine culture, and IV therapy were available in 55%, 47%, 34%, and 45% of LTC homes, respectively. LTC homes that were part of multihome chains were less likely to have rapid access to the 4 resources. Of the 4736 residents (27%) who visited an ED during follow-up, individuals from homes with rapid access to radiographs (odds ratio 0.79, 95% confidence interval 0.66-0.97), urine culture (0.88, 0.72-1.08), blood tests (0.83, 0.69-1.00), and IV therapy (0.93, 0.70-1.23) tended to have fewer potentially preventable ED visits.Conclusions and ImplicationsRapid access to diagnostic testing and IV therapy in LTC reduced ED visits. Improving access to these resources may prevent ED visits and allow residents to stay home.     

Tödliche Flecainidintoxikation eines 17-jährigen Mädchens

A 17-year-old girl was found vomiting and somnolent at home and was taken to a hospital. The girl initially presented with ventricular tachycardia with broad QRS complexes which was very difficult to control. During the course a subsequent cardiogenic shock developed and despite exhaustion of all therapeutic options the fatal outcome could not be averted. The medicolegal autopsy revealed no evidence of any form of violence but the signs of medical treatment. Furthermore, no pathology of internal organs was detected. The toxicological analyses revealed a lethal intoxication with flecainide as the cause of death. The investigations of the police indicated that the girl took flecainide in suicidal intention.