Penthrox Is an Effective Analgesic but Is It Patient Approved?

Background Penthrox is a handheld inhaler that administers methoxyflurane. Its use is approved for analgesia in moderate-to-severe trauma-related pain in adults in the ED. The literature currently lacks methodologically robust qualitative data on individual patient experiences. Using a structured qualitative study, we set out to address this shortcoming. Methods Five patients were selected as a focus group to identify key themes they felt were important to explore, and these were included in the questionnaire design. We retrospectively identified all uses of Penthrox in the ED from June to August 2021. Qualitative data was gathered using the Trickett short interview method, and responses were grouped into positive and negative descriptors. In addition, quantitative data concerning their experience using the 5-point Likert scale was also gathered. Results A total of 101 participants responded to the questionnaire. Penthrox was utilised mainly for the manipulation of fractures, most commonly those of the ankle and wrist. Around 90% reported an overall satisfaction of ≥ good, and 97% reported the ease of use to be ≥ good. Its analgesic effectiveness was rated as excellent by 52%, and ≥ good by 89%. The most reported side effects were drowsiness (13%) and nausea (7%). The majority reported no side effects (74%). About 94% of the participants said they would take it again if required. An NVivo word cloud (Lumivero, Denver, CO, USA) was created visually, confirming an overall positive experience amongst the patients. Conclusions This study shows that Penthrox is a well-tolerated and user-friendly means of alleviating trauma-related pain in the ED. It highlights the importance of taking into consideration the individual patient journey alongside robust evidence-based data on safety and efficacy for the development of a holistic treatment.

Identification of repetitive atrial activation patterns in persistent atrial fibrillation by direct contact high-density electrogram mapping.

INTRODUCTION: Recent studies have characterized drivers in persistent atrial fibrillation using automated algorithm detection with panoramic endocardial mapping by means of basket catheters. We aimed to identify repetitive atrial activation patterns (RAAPs) during ongoing atrial fibrillation (AF) based upon automated annotation of unipolar electrograms (EGMs) recorded with a high-density regional endocardial contact mapping catheter. METHODS: In 14 persistent AF patients, high-resolution EGMs were recorded for 30 seconds at sequential PentaRay (Biosense Inc) positions covering the entire biatrial surface. All recordings were reviewed off-line with dedicated software allowing automated annotation of the local activation time of the unipolar fibrillatory EGMs (CARTOFINDER; Biosense Inc). RAAPs were defined as a consistent activation pattern (for ≥3 consecutive beats) of either focal activity with centrifugal spread (RAAPfocal ) or rotational activity across the PentaRay splines spanning the AF cycle length (RAAProtational ). RESULTS: A total of 498 PentaRay recordings were analyzed (35.6 ± 7.6 per patient). The number of PentaRay recordings displaying RAAP was 9.8 ± 3.1 per patient (range = 3-15), of which 2.4 ± 2.4 RAAProtational (range = 0-7), and 7.4 ± 4.4 RAAPfocal (range = 1-13). 77% of RAAPs portrayed focal firing. The median number of repetitions per 30 second recording was 11 (range = 3-225) per recording. RAAPs were observed both in the right atrium (RA) (35%) and left atrium (LA) (65%), with the majority being near the left PVs/appendage (35% of all RAAPs) and the superior vena cava/right appendage (23% of all RAAPs). CONCLUSION: High-resolution, sequential endocardial EGM-based mapping allows identification of RAAPs in persistent AF. In our series, focal firing was the most frequently observed pattern.

Unusual Presentation of a Sigmoid Mass with Chicken Bone Impaction in the Setting of Metastatic Lung Cancer.

BACKGROUND: Ingestion of foreign bodies can cause various gastrointestinal tract complications including abscess formation, bowel obstruction, fistulae, haemorrhage, and perforation. While these foreign body-related complications can occur in normal bowel, diseased bowel from inflammation, strictures, or malignancy can cause diagnostic difficulties. Endoscopy is useful in visualising the bowel from within, providing views of the mucosa and malignancies arising from here, but its ability in diagnosing extramural malignancies arising beyond or external to the mucosa of the bowel as in the case of metastatic extramural disease can be limited. CASE SUMMARY: We present the case of a 60-year-old female with an impacted chicken bone in the sigmoid colon with formation of a sigmoid mass, on a background of metastatic lung cancer. On initial diagnosis of her lung cancer, there was mild Positron Emission Tomography (PET) avidity in the sigmoid colon which had been evaluated earlier in the year with a colonoscopy with findings of diverticular disease. Subsequent computed tomography (CT) scans demonstrated thickening of the sigmoid colon with a structure consistent with a foreign body distal to this colonic thickening. A repeat PET scan revealed an intensely fluorodeoxyglucose (FDG) avid mass in the sigmoid colon which was thought to be inflammatory. She was admitted for a flexible sigmoidoscopy and removal of the foreign body which was an impacted chicken bone. She had a fall and suffered a fractured hip. During her admission for her hip fracture, she had an exacerbation of her abdominal pain. She developed a large bowel obstruction, requiring laparotomy and Hartmann's procedure to resect the sigmoid mass. Histopathology confirmed metastatic lung cancer to the sigmoid colon. CONCLUSION: This unusual presentation highlights the challenges of diagnosing ingested foreign bodies in patients with metastatic disease.

Identification of Repetitive Activation Patterns Using Novel Computational Analysis of Multielectrode Recordings During Atrial Fibrillation and Flutter in Humans.

OBJECTIVES: The purpose of this study was to assess computational analysis of 64-electrode basket catheter (BC) recordings of atrial fibrillation (AF) and atrial flutter using novel software, CARTOFINDER (CF). BACKGROUND: Repetitive patterns have been recorded during AF and reported to be an important mechanism of AF. CF was used to identify rotational repetitive activation patterns (RAPs) in the right (RA) and left atrium (LA). METHODS: To assess for presence of RAPs, multiple 1-min BC maps of the RA and LA were obtained before and after radiofrequency ablation (RFA) around the pulmonary veins in 14 patients undergoing AF ablation. Validation of the CF algorithm was based on analysis of BC recordings of the cavotricuspid isthmus flutter. RESULTS: There were 2.9 rotational RAPs per patient (1.3 RA; 1.6 LA). No RAPs were noted in 2 patients. RFA was delivered on top of (n = 10), within 5 mm (n = 5), or distant (n = 10) from any RAP. Reproducibility of the BC to identify the same RAP was 82%. Post-pulmonary vein (PV) isolation, there was a 45% reduction in RAP versus pre-RFA. CF was validated by 4 electrophysiologists blindly reviewing 32 RA CF maps. Electrophysiologists correctly categorized presence/absence of RAP in 122 of 128 maps (95%). CONCLUSIONS: CF is novel software incorporated into CARTO that identifies rotational RAP in the RA and LA with 82% reproducibility. PV RFA results in 45% reduction of RAP, suggesting that RFA beyond PV isolation is required to eliminate the bulk of RAP. Electrophysiologists who were first-time users of CF could readily identify RAPs.

Analysis of global systolic and diastolic left ventricular performance using volume-time curves by real-time three-dimensional echocardiography.

BACKGROUND: Left ventricular (LV) volume-time curves (VTC) have been described to provide quantitative data on the dynamics of global LV performance beyond ejection fraction. However, generation of VTCs by conventional 2-dimensional imaging techniques is inherently limited because of inaccurate geometric volume assumptions. We, therefore, studied whether the new concept of volumetric scanning as realized by real-time 3-dimensional echocardiography (RT-3DE) can be used to provide accurate VTCs. METHODS: In 30 healthy participants, VTCs were generated from 18 to 24 absolute LV volumes per second by transthoracic RT-3DE and compared with magnetic resonance imaging (MRI) used for reference. LVs were traced manually in 9 to 11 parallel, short-axis planes and volumes calculated by disk method. From VTCs, we determined peak ejection rate (PER), peak early filling rate (PFR), time to PER and PFR, and end-diastolic and end-systolic volumes. For initial clinical application, 2 patient groups of coronary (n = 15) and hypertensive heart disease (n = 16) were studied. RESULTS: In healthy participants, VTCs agreed with MRI (mean errors: PER, -39 +/- 67 mL/s; PFR, -18 +/- 84 mL/s; time to PER, 8 +/- 21 milliseconds; time to PFR 4 +/- 18 milliseconds [not significant vs 0]) whereas VTCs in coronary and hypertensive groups revealed significantly impaired diastolic function. Scanning time for VTCs was only 1 to 2 minutes by RT-3DE and 8 +/- 2 minutes by MRI (P <.001) and time for offline analysis was 22 +/- 5 minutes versus 24 +/- 4 minutes by MRI (not significant). CONCLUSIONS: Generation of VTCs by RT-3DE is feasible and shows excellent agreement with MRI used for reference. Thus, VTCs by RT-3DE is a promising new approach providing access to quantitative information on global LV performance such as LV filling rates that is currently unavailable for the cardiologist.

Real-time three-dimensional echocardiography for improved evaluation of diastolic function using volume-time curves.

BACKGROUND: Accurate assessment of left ventricular function is of the greatest importance in clinical cardiology for decision making. Diastolic dysfunction is getting more concern as a cause of heart failure while, currently used non-invasive modalities for diagnosing diastolic abnormalities have significant limitations. Dynamic left ventricular volume change was applied for the evaluation of diastolic function by various techniques that have been demonstrated to be of diagnostic value. However, it has not been accepted into clinical practice because existing techniques are either invasive, inaccurate, expensive or time consuming. REAL-TIME THREE-DIMENSIONAL ECHOCARDIOGRAPHY: Real-time three-dimensional (3-D) echocardiography is a new ultrasound technique that provides transthoracic volumetric images of the heart in real time. Thereby, the acquired images are ideally suited for the assessment of dynamic left ventricular volume change. Generation and analysis of left ventricular volume-time curves by real-time 3-D echocardiography has been demonstrated to be feasible in normal subjects and patients and accuracy of volume-time curves was good compared to magnetic resonance imaging. We compare the new real-time 3-D echo approach with the advantages and limitations of existing noninvasive and invasive techniques.

[Echocardiography diagnosis of diastolic heart failure]. / Echokardiographische Diagnostik der diastolischen Herzinsuffizienz.

BACKGROUND: Left ventricular diastolic dysfunction can be diagnosed if clinical signs of heart failure and normal ejection fraction are found. Beside clinical signs of heart failure and criteria from catheterization studies like abnormal left ventricular relaxation, filling and/or compliance echocardiography provides valuable parameters for the assessment of diastolic dysfunction. ECHOCARDIOGRAPHIC DEGREES OF SEVERITY: By the use of various parameters diastolic dysfunction can be differentiated into four degrees of severity, which are of great prognostic importance. If more than one echocardiographic parameter is used, sensitivity for the assessment of diastolic dysfunction becomes nearly 100%. Conventional parameters include isovolumetric relaxation time (IVRT) measured by pulsed Doppler, the ratio of rapid filling and atrial filling velocity (E/A), deceleration time of rapid mitral inflow as well as the ratio of systolic and diastolic pulmonary venous flow velocities. In patients with signs of diastolic heart failure and a normal E/A ratio pulmonary venous flow pattern can help to unmask "pseudonormalization" as the transition from abnormal relaxation to restriction. These parameters, however, are preload-dependent and do not provide intrinsic left ventricular properties. Even in atrial fibrillation, left ventricular filling pressure can be assessed. NEW METHODS: Two novel approaches, color Doppler M-mode of left ventricular inflow and tissue Doppler of the mitral annulus, are relatively preload-independent and allow direct estimation of relaxation and filling pressure. By the means of real-time 3-D echocardiography we developed a new method for the non-invasive assessment of rapid filling rate (PFR), thereby completing the echocardiographic approaches to determine diastolic dysfunction. CONCLUSION: The broad spectrum of approaches available today makes echocardiography the first choice for the assessment of diastolic dysfunction.