Unrecognized "crack" cocaine abuse in pregnancy

We report a case of "crack" cocaine abuse in a pregnant patient associated with haematuria, proteinuria, haemolytic anaemia, renal impairment, thrombocytopenia and pulmonary oedema. The case illustrates the problems for clinicians where unrecognized cocaine abuse interferes with the diagnosis and management of a complicated pregnancy. In addition, we discuss the principles for the safe conduct of anaesthesia in the pregnant cocaine abuser.      

Quality of life in migraine and chronic daily headache patients

Primary chronic headache can affect a patient's health-related quality of life (HQL). The Medical Outcomes Study Short Form (SF-36) questionnaire has been used to address this issue. We compare the impact of headache on the HQL of patients with migraine and chronic daily headache (CDH) using the SF-36 instrument. We analyzed a group of 115 consecutive patients; 62 migraine patients and 53 CDH patients completed the questionnaire. Patterns of disability were similar between the two groups, but CDH was marked by a lower level of health scales. Patients with CDH had a significantly worse pain score in physical functioning, role functioning (physical), bodily pain, general health perceptions, and mental health than patients with migraine headache. Our results in the migraine group were similar to findings in other publications, with the lowest scores in role functioning (physical) and bodily pain. There is no previous experience in CDH patients, but the present data suggest that the SF-36 questionnaire is valuable in determining the differences in functional status among headache types. These data suggest that the SF-36 is a reliable and valid measure of the HQL of patients with CDH, and may indeed prove to be valuable in studying the efficacy of therapeutic agents for this type of headache.     

Validity and reliability of the Migraine-Treatment Optimization Questionnaire

Our aim was to establish the validity and reliability of a patient-rated Migraine Treatment Optimization Questionnaire (M-TOQ) in primary care. Patients who met International Classification of Headache Disorders, 2nd edn criteria for migraine completed a 19-item questionnaire containing candidate items for the M-TOQ, and three questionnaires designed to test convergent/construct validity [Migraine Disability Assessment Scale (MIDAS), Headache Impact Test (HIT)-6 and Migraine-Specific Quality of Life Scale (MSQoL)]. A 15-item (M-TOQ-15) and a five-item (M-TOQ-5) questionnaire were derived. Two hundred and fifty-three adult patients were recruited. Five treatment optimization domains were identified: functioning, rapid relief, consistency of relief, risk of recurrence and tolerability; with Cronbach alphas of 0.70–0.84. The Cronbach α for M-TOQ-15 was 0.85, and it correlated well with MIDAS, HIT-6 and MSQoL ( r  = 0.33–0.44). The Cronbach α for M-TOQ-5 was 0.66, and it also correlated well with the three questionnaires ( r  = 0.33–0.41). The utility of the M-TOQ for assessing treatment benefit in research (M-TOQ-15) and primary care (M-TOQ-5) should be further validated.     

Challenging boundaries: an enhanced recovery programme for radical cystectomy

Introduction

The implementation of enhanced recovery programmes (ERPs) in colorectal surgery has seen improvements in the length of inpatient stay with no increase in complications. We investigated the role of ERP in radical cystectomy at our institution.

Methods

Prospective data were collected from 26 consecutive patients prior to the introduction of the ERP and 51 patients who underwent open radical cystectomy within an ERP. Individuals in the ERP cohort did not receive bowel preparation or nasogastric drainage but received preoperative carbohydrate drinks, perioperative epidural analgesia and immediate mobilisation on day 1. Primary outcome measures included duration of intensive care unit (ICU) stay and length of hospital stay. Secondary outcome measures included the time to the passage of flatus and faeces, and time to mobilisation. Other measures that were analysed included operation time and complications.

Results

Baseline characteristics for both groups were similar. The median length of hospital stay fell from 11.5 days to 10.4 days and the mean ICU stay dropped from 2.4 days to 1.0 days (p=0.01). Time to removal of nasogastric tube, and time to passage of flatus and faeces were significantly shorter in the ERP group, as was the time to full oral diet. Clavien complication rates and 30-day mortality rates were similar in both groups. There were no readmissions.

Conclusions

ERP in radical cystectomy is safe and not associated with any increase in complications or readmissions. It is associated with reductions in ICU stay, and could also reduce length of hospital stay and duration of postoperative ileus.     

Attachment of glycosaminoglycans to collagenous matrices modulates the tissue response in rats

Biocompatibility and tissue regenerating capacity are essential characteristics in the design of collagenous biomaterials for tissue engineering. Attachment of glycosaminoglycans (GAGs) to collagen may add to these characteristics by creating an appropriate micro-environment. In this study, porous type I collagen matrices were crosslinked using 1-ethyl-3-(3-dimethyl aminopropyl)carbodiimide, in the presence and absence of chondroitin sulfate and heparan sulfate. The tissue response to these matrices was evaluated after subcutaneous implantation in rats. Biocompatibility of the matrices was established by the induction of a transitional inflammatory response, and the generation of new host tissue. Non-crosslinked collagen was gradually resorbed and replaced by collagenous connective tissue. By contrast, crosslinked matrices, with and without GAGs. retained their scaffold integrity during implantation, and supported the interstitial deposition and organization of extracellular matrix. In addition, crosslinking decreased tissue reactions at late time intervals. No calcification in any of the implants was observed. The presence of GAGs preserved porous lamellar matrix structures. Heparan sulfate in particular promoted angiogenesis at weeks 2 and 4, predominantly at the matrix periphery. The almost complete absence of macrophages and giant cells associated with collagen-GAG matrices, after 10 weeks implantation, indicated a reduced foreign body reaction. It is concluded that attachment of GAGs to collagen matrices modulates the tissue response. The potential of these biocompatible scaffolds for tissue engineering is increased by preserving porous matrix integrity. promoting angiogenesis and reducing foreign body reactions.