Management of epistaxis in patients on novel oral anticoagulation therapy.

BACKGROUND: Individuals on anticoagulation therapy are at increased risk of bleeding, including epistaxis. There is a lack of available reversal agents for novel oral anticoagulation therapy. OBJECTIVE: This paper reviews the current literature on epistaxis in the context of novel oral anticoagulation use, in order to recommend guidelines on management. METHOD: A comprehensive search of published literature was conducted to identify all relevant articles published up to April 2019. RESULTS: Patients on oral anticoagulation therapy are over-represented in individuals with epistaxis. Those on novel oral anticoagulation therapy were more likely to relapse compared to patients on classic oral anticoagulants or non-anticoagulated patients. Idarucizumab is an effective antidote for bleeding associated with dabigatran use. Recommendations for epistaxis management in patients on novel oral anticoagulation therapy are outlined. CONCLUSION: Clinicians need to be aware of the potential severity of epistaxis and the increased likelihood of recurrence. High-quality studies are required to determine the efficacy and safety of andexanet alfa and ciraparantag, as well as non-specific reversal agents.

SPOTS: A Model for the Creation of Sustainable, Population-Based, Occupational Therapy Fieldwork Sites.

This paper describes a model for the creation of sustainable, population-based, occupational therapy fieldwork sites (SPOTS). An example of a population-based fieldwork site was created with Appalachian Mountain People in Kentucky and its outcomes are presented. Outcomes were gathered using a wide variety of evaluation feedback forms. The results indicate that all staff, student, and college feedback were extremely favorable as detailed and suggest that others may use the SPOTS Model to develop population-based occupational therapy services that address public health issues for people with disabilities identified in Healthy People 2020 and create scholarly opportunities for students and faculty.

Evaluation and environmental correction of ambient CO2 measurements from a low-cost NDIR sensor.

Non-dispersive infrared (NDIR) sensors are a low-cost way to observe carbon dioxide concentrations in air, but their specified accuracy and precision are not sufficient for some scientific applications. An initial evaluation of six SenseAir K30 carbon dioxide NDIR sensors in a lab setting showed that without any calibration or correction, the sensors have an individual root mean square error (RMSE) between ~5 and 21 parts per million (ppm) compared to a research-grade greenhouse gas analyzer using cavity enhanced laser absorption spectroscopy. Through further evaluation, after correcting for environmental variables with coefficients determined through a multivariate linear regression analysis, the calculated difference between the each of six individual K30 NDIR sensors and the higher-precision instrument had an RMSE of between 1.7 and 4.3 ppm for 1 min data. The median RMSE improved from 9.6 for off-the-shelf sensors to 1.9 ppm after correction and calibration, demonstrating the potential to provide useful information for ambient air monitoring.

Serum Prolactin Level of Subfertile Women.

Subfertility is a major reproductive health problem all over the world as well as Bangladesh, and the problem is increasing day by day. This study was done to estimate the serum prolactin concentration in primary and secondary subfertile women. Laboratory investigation included serum prolactin level, as well as LH, FSH, TSH blood glucose (2 hours after 75 gm glucose load) of 50 women who attended infertility unit, Department of Obstetrics and Gynaecology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from March 2009 and February 2010. In most cases, common age group 26-30 years (52%), primary subfertility (74%), duration of marriage >5 years (60%), trying to conceive duration ≤5 years (54%), BMI >25 kg/m² (60%), menstrual cycle regular (58%), history of abortion absent (90%), and history of menstrual regulation absent (94%). Common investigation findings was normal serum follicle stimulating hormone (FSH) 1.0-10.0 mIU/ml in 82%, normal serum luteinizing hormone (LH) 1.0-10.0 mIU/ml in 50%, normal serum prolactin 1.9-25.0 ng/ml in 36%, normal serum thyroid stimulating hormone (TSH) 0.4-4.0 µIU/ml in 56%, and normal blood glucose level (2 hours after breakfast) (<7.8 mmol/) in 66% women. Ultrasonographic finding of lower abdomen was normal in 14% women. Common finding of semen analysis husbands of the study women was normozoospermia in 88% cases. Serum prolactin concentration may have role to play in subfertility of women.

E-Nose and e-Tongue combination for improved recognition of fruit juice samples.

There are many important challenges related to food security analysis by application of chemical and electrochemical sensors. One critical parameter is the development of reliable tools, capable of performing an overall sensory analysis. In these systems, as much information as possible is required in relation to smell, taste and colour. Here, we investigated the possibility of using a multisensor data fusion approach, which combines an e-Nose and an e-Tongue, adept in generating combined aroma and taste profiles. In order to shed light on this concept, classification of various Tunisian fruit juices using a low-level of abstraction data fusion technique was attempted. Five tin oxide-based Taguchi Gas Sensors were applied in the e-Nose instrument and the e-Tongue was designed using six potentiometric sensors. Four different commercial brands along with eleven fruit juice varieties were characterised using the e-Nose and the e-Tongue as individual techniques, followed by a combination of the two together. Applying Principal Component Analysis (PCA) separately on the respective e-Nose and e-Tongue data, only few distinct groups were discriminated. However, by employing the low-level of abstraction data fusion technique, very impressive findings were achieved. The Fuzzy ARTMAP neural network reached a 100% success rate in the recognition of the eleven-fruit juices. Therefore, data fusion approach can successfully merge individual data from multiple origins to draw the right conclusions that are more fruitful when compared to the original single data. Hence, this work has demonstrated that data fusion strategy used to combine e-Nose and e-Tongue signals led to a system of complementary and comprehensive information of the fruit juices which outperformed the performance of each instrument when applied separately.

Comparative efficacy of subcutaneous versus oral methotrexate in active rheumatoid arthritis.

This prospective study was conducted in rheumatology clinic under the department of medicine of Bangabandhu Sheikh Mujib Medical University from December 2004 to December 2005 to asses the efficacy, safety and compliance of subcutaneous methotrexate (MTX) in active rheumatoid arthritis (RA) patients. A total of 92 active rheumatoid arthritis patients according to American College of Rheumatology (ACR) criteria were recruited for the trial for six months. Among them 46 cases belonged to injectable MTX group and 46 cases belonged to oral MTX group. Mean±SD age of patients was 45.54±12.42 vs. 44.63±13.99 years in subcutaneous group and oral group respectively. In the subcutaneous group 41 were female and 5 male; in the oral group 34 were female and 12 male. Mean duration of the disease was 49.74 months in subcutaneous group and 49 months in oral group. RA test was positive in 35 cases in both groups whereas Rose Waaler test was positive in 19 patients in subcutaneous group and 14 patients in oral group. At 24 week, response rate of ACR 20 was significantly higher in subcutaneous MTX than oral MTX group (93% vs. 80%, p=0.02). Similarly ACR 50 response was significantly higher in subcutaneous MTX than in oral group (89% vs. 72%, p=0.03). ACR 70 response was not significantly higher in SCMTX group then oral group (11% vs. 9 %, p=0.72). Adverse effects were relatively less in subcutaneous MTX and most common side effects were nausea (37% vs. 63%), vomiting (11% vs. 30%), dyspepsia (29% vs. 48%), dizziness (4l% vs. 52%) and alopecia (72% vs. 85%). The results of the study demonstrated that subcutaneous MTX was significantly more effective than oral MTX at the same dosage in active Rheumatoid arthritis patients with no increase in side effects.

Coronary angiographic profile in bangladeshi patients with metabolic syndrome and ischemic heart disease.

The metabolic syndrome, which is characterized by a constellation of fasting hyperglycemia, hypertriglyceridemia, low HDL cholesterol, hypertension, and/or abdominal obesity, is a risk factor for the development of coronary artery disease (CAD) and cardiovascular events. We evaluated interrelationships between angiographic CAD and the metabolic syndrome, in 478 patients who were referred for coronary angiography to evaluate suspected myocardial ischemia in the department of cardiology of BSMMU between June 2007 and May 2008. We applied the criteria for the metabolic syndrome proposed by ATP III guideline. Study populations were divided into two groups on the basis of presence or absence of metabolic syndrome. Age was similar in both groups. Body mass index (BMI) was higher (26.22 ± 1.94 vs. 22.07 ± 1.55) in metabolic syndrome group (p ≤ 0.0001). All parameters, waist circumference (103.16 ± 10.21 vs. 91.45 ± 7.61) cm, blood pressure both systolic (141.34 ± 21.49 vs. 127.94 ± 13.01) and diastolic (86.8 5 ± 8.42 vs. 79.28 ± 7.77) mm of Hg, serum triglyceride (248.32 ± 77.88 vs. 128.35 ± 19.00)mg/dl, fasting blood glucose (125.40 ± 22.86 vs. 95.65 ± 10.63)mg/dl were significantly higher in metabolic syndrome group (p value=0.0001), whereas HDL (33.10 ± 6.55 vs. 39.30 ± 6.17)mg/dl was lower (p value = 0.0001). More subjects in metabolic syndrome were having type B (55.60% vs. 31.00%) and type C (9.50% vs. 2.70%) lesion as compared to non-metabolic syndrome group. Involvement of left main artery was more (4.80% vs. 0.90%) in metabolic syndrome group. Metabolic syndrome has primary predictive ability for CAD. A metabolic profile should form part of the risk assessment in all patients with coronary disease, not just those who are obese.

Calcineurin inhibitor sparing with mycophenolate mofetil in liver transplantion: a systematic review of randomized controlled trials.

Liver transplant recipients are at high risk of developing acute and chronic renal failure. Moreover, introduction of the model for end-stage liver disease (MELD) score for primary allocation of liver grafts favors patients with pretransplant kidney dysfunction, which in turn have a higher risk of posttransplant renal failure. Calcineurin inhibitors (CNI) further increase the risk of renal failure and therefore sparing CNI with the use of mycophenolate mofetil (MMF) may improve renal function. MMF may either be used de novo in the immediate posttransplant period in combination with low-dose CNI (scenario 1) or patients that receive immunosuppression based on CNI may be converted to MMF in combination with minimization or elimination of CNI (scenario 2). Although many retrospective cohort studies and nonrandomized trials have implicated efficacy of this approach the evidence from randomized controlled studies has not been summarized. In the current review we report the results of a systematic review and meta-analysis of randomized controlled trials.

Extravascular migration of a guide wire with perforation of the heart eight months after percutaneous coronary intervention: consequence of a conservative approach.

Impingement of a guide wire is not unusual during complex percutaneous coronary intervention procedures. It is mostly retrieved by endovascular procedures. If not possible, conservative therapy is frequently the next option, leaving the guide wire in place. This case describes the consequence of such an approach 9 months after initial percutaneous coronary intervention. The guide wire migrated through the abdominal cavity and finally perforated the heart. We therefore defend a more aggressive approach if a guide wire is locked in or lost. Surgical retrieval seems to be the best choice. Fixation of the guide wire with a stent is an acceptable alternative in high-risk patients.

Outcome of metformin treatment in polycystic ovary syndrome.

The polycystic ovary syndrome (PCOS) is a clinical diagnosis. During one year period, 50 women suffering from PCOS were treated with either 850 mg/twice daily or 500 mg/thrice daily along with clomiphene citrate and/or letrozole, with advice for exercise and dietary therapy. Diagnosis of the PCOS patients was made by the presence of two out of the following three criteria: (a) oligo and/or anovulation, (b) hyperandrogenism (clinical and/or biochemical), and (c) polycystic ovaries, with the exclusion of other aetiologies. The mean±SD age of our patients was 26.74±3.85 years, BMI 26.64±2.64 kg/m2, pulse 80.56±4.61 b/min, systolic blood pressure 113.80±4.40 mmHg and diastolic blood pressure 76.10±4.77 mmHg, duration of marriage 6.19±3.20 years, and parity was 43(86%) nulliparous and 7(14%) primiparous. Oligomenorrhoea was present in 100%, hypomenorrhoea in 38%, secondary amenorrhoea in 28% and acne in 70% women. Results showed that 92% women followed advice on exercise and dietary therapy, in maximum number of women progesterone level was 31.40 nmol/L (66%), weight loss was 2 kg (44%), menstrual cycle regular (90%) and pregnancy test negative (90%). Only in 5 cases (10%) pregnancy test was positive.

Chronic abdominal wall sinus and recurrent abscesses caused by a foreign body after laparotomy.

The prolonged failure of a wound to heal due to the existence of a foreign body can result in chronic sinuses and fistulae and is a situation that should be avoided through thorough assessment of the wound in the first instance.

Desensitization of the platelet aggregation response to ADP: differential down-regulation of the P2Y1 and P2cyc receptors.

Platelets activated by ADP become refractory to restimulation, but the mechanism of this process is not well understood. A normal platelet response to ADP requires coactivation of the P2Y(1) receptor responsible for shape change and the P2cyc receptor, responsible for completion and amplification of the response. The aim of the present study was to characterize the desensitization of platelets to ADP and to determine whether or not these two receptors are desensitized simultaneously through identical pathways when platelets become refractory to ADP. It was found that full inhibition of platelet aggregation in response to restimulation by ADP required the presence of ADP in the medium or use of a high concentration (1 mM) of its non-hydrolysable analogue ADPbetaS. Platelets incubated for 1 h at 37 degrees C with 1 mM ADPbetaS and resuspended in Tyrode's buffer containing apyrase displayed a stable refractory state characterized by the inability to aggregate or change shape in response to ADP. ADPbetaS treated platelets loaded with fura-2/AM showed complete blockade of the calcium signal in response to ADP, whereas the capacity of ADP to inhibit PGE1 stimulated cAMP accumulation in these platelets was only diminished. Consequently, serotonin was able to promote ADP induced aggregation through activation of the Gq coupled 5HT(2A) receptor while adrenaline had no such effect. These results suggested that the refractory state of ADPbetaS treated platelets was entirely due to desensitization of the P2Y(1) receptor, the P2cyc receptor remaining functional. Binding studies were performed to determine whether the P2Y(1) and/or P2cyc binding sites were modified in refractory platelets. Using selective P2Y(1) and P2cyc antagonists (A3P5P and AR-C66096 respectively), we could demonstrate that the decrease in [33P]2MeSADP binding sites on refractory platelets corresponded to disappearance of the P2Y(1) sites with no change in the number of P2cyc sites, suggesting internalization of the P2Y(1) receptor. This was confirmed by flow cytometric analysis of Jurkat cells expressing an epitope-tagged P2Y(1) receptor, where ADPbetaS treatment resulted in complete loss of the receptor from the cell surface. We conclude that the P2Y(1) and P2cyc receptors are differently regulated during platelet activation.

Late referral of end-stage renal failure.

We studied all new patients accepted for renal replacement therapy (RRT) in one unit from 1/1/96 to 31/12/97 (n = 198), to establish time from nephrology referral to RRT, evidence of renal disease prior to referral and the adequacy of renal management prior to referral. Sixty four (32.3%, late referral group) required RRT within 12 weeks of referral. Fifty-nine (29.8%) had recognizable signs of chronic renal failure > 26 weeks prior to referral. Patients starting RRT soon after referral were hospitalized for significantly longer on starting RRT (RRT within 12 weeks of referral, median hospitalization 25.0 days (n = 64); RRT > 12 weeks after referral, median 9.7 days (n = 126), (p < 0.001)). Observed survival at 1 year was 68.3% overall, with 1-year survival of the late referral and early referral groups being 60.5% and 72.5%, respectively (p = NS). Hypertension was found in 159 patients (80.3%): 46 (28.9%) were started on antihypertensive medication following referral, while a further 28 (17.6%) were started on additional antihypertensives. Of the diabetic population (n = 78), only 26 (33.3%) were on an angiotensin-converting-enzyme inhibitor (ACEI) at referral. Many patients are referred late for dialysis despite early signs of renal failure, and the pre-referral management of many of the patients, as evidenced by the treatment of hypertension and use of ACEI in diabetics, is less than optimal.

Salicylate poisoning.

Salicylate poisoning continues to be an important cause of drug related mortality. The zero order kinetics of salicylates at high doses is responsible in part for cases of iatrogenic poisoning. Serum levels tend to correlate with severity of poisoning in acute overdose cases only. Clinical manifestations include involvement of nervous system, hepatic and pulmonary systems along with metabolic disturbances. Measures at enhancing elimination and reducing absorption, while providing supportive care form the basis of management.

Post-anaesthetic pulmonary oedema following upper airway obstruction.

Twelve cases of post-anaesthetic pulmonary oedema (PO) secondary to upper airway obstruction (UAO) are reported. All were adult male patients undergoing uneventful elective surgical procedure under general anaesthesia. Post-anaesthetic laryngospasm was the single most important factor for the upper airway obstruction (UAO) in 5 (41.6%) patients. PO secondary to partial UAO in drowsy patients was observed in 4 (33.3%) patients. UAO due to foreign body was responsible for PO in two patients. A combination of negative intrathoracic pressure, hypoxia and associated hyperadrenergic state were the most likely causes of PO in these patients with UAO. Early recognition, maintenance of patent airway and adequate oxygenation via face mask or endotracheal tube with mechanical ventilation resolved the syndrome within 6-36 hours in all of these patients. Invasive haemodynamic monitoring or aggressive drug therapy were not applied in any of the patients. A heightened awareness among anaesthesiologists of the varied causes of post-anaesthetic UAO leading to PO may help reduce the occurrence and facilitate early management of the potential complications.

Reduction of duration and cost of mechanical ventilation in an intensive care unit by use of a ventilatory management team.

OBJECTIVE: To test the hypothesis that a formal interdisciplinary team approach to managing ICU patients requiring mechanical ventilation enhances ICU efficiency. DESIGN: Retrospective review with cost-effectiveness analysis. SETTING: A 20-bed medical-surgical ICU in a 450-bed community referral teaching hospital with a critical care fellowship training program. PATIENTS: All patients requiring mechanical ventilation in the ICU were included, comparing patients admitted 1 yr before the inception of the ventilatory management team (group 1) with those patients admitted for 1 yr after the inception of the team (group 2). Group 1 included 198 patients with 206 episodes of mechanical ventilation and group 2 included 165 patients with 183 episodes of mechanical ventilation. INTERVENTION: A team consisting of an ICU attending physician, nurse, and respiratory therapist was formed to conduct rounds regularly and supervise the ventilatory management of ICU patients who were referred to the critical care service. MEASUREMENTS AND MAIN RESULTS: The two study groups were demographically comparable. However, there were significant reductions in resource use in group 2. The number of days on mechanical ventilation decreased (3.9 days per episode of mechanical ventilation [95% confidence interval 0.3 to 7.5 days]), as did days in the ICU (3.3 days per episode of mechanical ventilation [90% confidence interval 0.3 to 6.3 days]), numbers of arterial blood gases (23.2 per episode of mechanical ventilation; p less than .001), and number of indwelling arterial catheters (1 per episode of mechanical ventilation; p less than .001). The estimated cost savings from these reductions was $1,303 per episode of mechanical ventilation. CONCLUSION: We conclude that a ventilatory management team, or some component thereof, can significantly and safely expedite the process of "weaning" patients from mechanical ventilatory support in the ICU.

[Study of the new economic mechanism by students during the transition to the medical insurance system]. / Ob izuchenii studentami novogo khoziaistvennogo mekhanizma v period perekhoda k sisteme strakhovoi meditsiny.

The methodology of delivering lectures and practical studies on the subject of "new economic mechanism in public health" used at the chair is most efficient. The application of tasks for economic estimates and the assessment of physician's performance at polyclinics, hospitals, emergency care stations, the determination of differentiated norms for medical care financing of 1 inhabitant per year, the organisation of territorial health association activity promote the assimilation of such knowledge, the development of proper skills.