Creation and Implementation of an Outpatient Pathway for Atrial Fibrillation in the Emergency Department Setting: Results of an Expert Panel

Atrial fibrillation and flutter (AF) is a common condition among emergency department (ED) patients in the United States. Traditionally, ED care for primary complaints related to AF focus on rate control, and patients are often admitted to an inpatient setting for further care. Inpatient care may include further telemetry monitoring and diagnostic testing, rhythm control, a search for identification of AF etiology, and stroke prophylaxis. However, many patients are eligible for safe and effective outpatient management pathways. They are widely used in Canada and other countries but less widely adopted in the United States. In this project, we convened an expert panel to create a practical framework for the process of creating, implementing, and maintaining an outpatient AF pathway for emergency physicians to assess and treat AF patients, safely reduce hospitalization rates, ensure appropriate stroke prophylaxis, and effectively transition patients to longitudinal outpatient treatment settings from the ED and/or observation unit. To support local pathway creation, the panel also reached agreement on a protocol development plan, a sample pathway, consensus recommendations for pathway components, sample pathway metrics, and a structured literature review framework using a modified Delphi technique by a technical expert panel of emergency medicine, cardiology, and other stakeholder groups.     

Miscellaneous hormone therapies for osteoporosis

Miscellaneous hormones, such as oral contraceptives (OCs) and tibolone, have not been evaluated as extensively as other hormonal therapies, but remain an option for the prevention and management of osteoporosis. OCs have been conside red for osteoporosis treatment since the 1970s and have demonstrated significant bone mineral density (BMD) increases with high doses that contained 50 μg of ethinyl estradiol. As OCs have evolved with lower doses of ethinyl estradiol (25–40 μg), the literature continues to report improved or maintained BMD in older women. Data are more controversial about OC fracture prevention abilities, the most clinically important end point in osteoporosis trials. Tibolone has not been approved for use in the United States, but it has been used in Europe for almost two decades for the management of osteoporosis. It has unique tissue-specific effects, including estrogen effects on bone and vaginal tissue, progestational effects on the endometrial tissue, and androgenic effects on the brain and liver tissue. Although fracture data are lacking, patients receiving 1.25 to 2.5 mg of tibolone have shown significant improvements in BMD. Tibolone can be regarded as an alternative to conventional hormone therapy for the prevention of postmenopausal bone loss based on similar BMD efficacy and minimal side effects, but its effects would still be less than bisphosphonates. Data supporting the use of oral contraceptives and tibolone for osteoporosis prevention and management will be discussed in this article.     

A Randomized Controlled Trial of a Literacy-Sensitive Self-Management Intervention for Chronic Obstructive Pulmonary Disease Patients

Background  

Low literacy skills are common and associated with a variety of poor health outcomes. This may be particularly important in patients with chronic illnesses such as chronic obstructive pulmonary disease (COPD) that require appropriate inhaler technique to maintain quality of life and avoid exacerbations.     

Fluoroscopy-guided Sacroiliac Joint Injections with Phenol Ablation for Persistent Sacroiliitis: A Case Series

Abstract: In this article we are reporting on the use of fluoroscopy‐guided 6% Phenol injections for the ablation of the sacroiliac joints (SIJs), utilizing retrospective review of case reports. We reviewed 10 patients (7 male and 3 female) who have known sacroiliitis proven by fluoroscopically guided sacroiliac joint (SIJ) injection (age ranged from 25 to 78). They all had 2 to 4 weeks of relief after the injections utilizing Bupivacaine 0.5% and 80 mg of depomedrol. They all had repeat fluoroscopy‐guided injections of the SIJs with neurolysis of either a unilateral SIJ or bilateral SIJs using 6% Phenol. Phenol 6% with saline 2.5 cc per joint was injected; the needle was cleared with local anesthetic before removing it from the joint. Twenty percent of the patients had a greater than 70% improvement with an average duration of 24 weeks. Sixty percent of the patients had a 50% to 70% improvement with an average duration of 20 weeks. Ten percent had a 20% to 50% improvement with a total duration of 12 1/2 weeks. Ten percent had a less than 20% improvement. With intra‐articular injections of phenol for the ablation of the SIJs, we have found a significant improvement in pain relief accompanied by prolonged duration of relief.     

Three-month sustained-release triptorelin (11.25 mg) in the treatment of central precocious puberty

OBJECTIVE: Depot GnRH agonists are commonly used in the treatment of central precocious puberty (CPP). The triptorelin 11.25 mg 3-month depot, currently used in adult indications, had not previously been evaluated in CPP. DESIGN: This was a multicenter, open-label, 12 month trial conducted in 64 CPP children (54 girls and 10 boys), treated quarterly. METHODS: Children with a clinical onset of pubertal development before the age of 8 years (girls) or 9 years (boys), pubertal response of LH to GnRH > or = 7 IU/l, advanced bone age > 1 year, enlarged uterus (> or = 36 mm) and testosterone level > or = 0.5 ng/ml (boys), were included. Suppression of gonadotropic activation, as determined from serum LH, FSH, estradiol or testosterone, and pubertal signs were assessed at Months 3, 6 and 12. RESULTS: GnRH-stimulated peak LH < or = 3 IU/l, the main efficacy criterion, was met in 53 out of 62 (85%), 60 out of 62 (97%) and 56 out of 59 (95%) of the children at Months 3, 6 and 12 respectively. Serum FSH and sex steroids were also significantly reduced, while pubertal development regressed in most patients. Mean residual triptorelin levels were stable from Month 3 through to Month 12. The triptorelin 3-month depot was well tolerated. Severe injection pain was experienced in only one instance. Five girls experienced mild-to-moderate or severe (one girl) withdrawal bleeding. CONCLUSIONS: The triptorelin 3-month depot efficiently suppresses the pituitary-gonadal axis and pubertal development in children with CPP. This formulation allows a 3-fold reduction, over the once-a-month depot, in the number of i.m. injections required each year.     

Flavonone treatment reverses airway inflammation and remodelling in an asthma murine model

Background and Purpose

Asthma is an inflammatory disease that involves airway hyperresponsiveness and remodelling. Flavonoids have been associated to anti-inflammatory and antioxidant activities and may represent a potential therapeutic treatment of asthma. Our aim was to evaluate the effects of the sakuranetin treatment in several aspects of experimental asthma model in mice.

Experimental Approach

Male BALB/c mice received ovalbumin (i.p.) on days 0 and 14, and were challenged with aerolized ovalbumin 1% on days 24, 26 and 28. Ovalbumin-sensitized animals received vehicle (saline and dimethyl sulfoxide, DMSO), sakuranetin (20 mg kg^–1 per mice) or dexamethasone (5 mg kg^–1 per mice) daily beginning from 24th to 29th day. Control group received saline inhalation and nasal drop vehicle. On day 29, we determined the airway hyperresponsiveness, inflammation and remodelling as well as specific IgE antibody. RANTES, IL-5, IL-4, Eotaxin, IL-10, TNF-α, IFN-γ and GMC-SF content in lung homogenate was performed by Bioplex assay, and 8-isoprostane and NF-kB activations were visualized in inflammatory cells by immunohistochemistry.

Key Results

We have demonstrated that sakuranetin treatment attenuated airway hyperresponsiveness, inflammation and remodelling; and these effects could be attributed to Th2 pro-inflammatory cytokines and oxidative stress reduction as well as control of NF-kB activation.

Conclusions and Implications

These results highlighted the importance of counteracting oxidative stress by flavonoids in this asthma model and suggest sakuranetin as a potential candidate for studies of treatment of asthma.