The Mediterranean Diet: Lost in Translation.

PURPOSE OF REVIEW: Despite substantive evidence documenting the efficacy of the Mediterranean diet to reduce cardiovascular events, underutilization is common. An overview of the data set supporting the role of the Mediterranean diet as confirmed in both observational and interventional trials should stimulate greater clinician interest in the diet. Additionally, the availability of patient-friendly tools that enable prompt and easy adoption of the Mediterranean diet, that are able to be used by clinicians who claim no special expertise in diet knowledge, should simplify the path to successful dietary change. RECENT FINDINGS: A large recently published (2018) prospective study of the Mediterranean diet for primary prevention of cardiovascular events confirmed that compared to control, Mediterranean diet is associated with reduced risk for cardiovascular events in high risk patients. Of the tools available to clinicians that might reduce cardiovascular risk, dietary intervention is the one least utilized. The evidence supports the value of dietary intervention with the Mediterranean diet, and methods to effectively employ it within the confines of typical office practice are readily at hand.

Feasibility, Acceptability, and Performance of a Continuous Temperature Monitor in Older Adults and Staff in Congregate-Living Facilities.

OBJECTIVES: Residents of congregate-living facilities are susceptible to disability and mortality from infection given the presence of advanced age, multimorbidity, and frailty-as demonstrated in the recent COVID pandemic. This study assessed the feasibility, acceptability, and applicability of a continuous temperature monitoring device in a congregate-living facility with residents of independent living, assisted living, and their care-providing staff. We hypothesized that a wearable device compared with daily manual temperature assessment would be well tolerated and more effective at detecting temperature variances than current standard of care body temperature assessment. DESIGN: Feasibility study. SETTING AND PARTICIPANTS: Residents of assisted and independent living and staff of a retirement community. METHODS: Thirty-five participants, including residents in assisted- and independent-living facilities (25) and staff (10) were enrolled in a 90-day feasibility study and wore a continuous temperature sensor from March to July 2021. Primary outcomes included study completion, ability to reapply the sensor, temperature data acquisition, and data availability from the sensors. A secondary analysis of the temperature data involved comparing the method of obtaining temperature using the continuous monitoring device against standard of care using traditional manual thermometers. RESULTS: Overall, 91.3% of residents, who were in the study during the first reapplication, were able to apply the device without assistance (21 of 23), and 80% of resident participants completed the study (20 of 25). For staff participants, completion rates and reapplication rates were 100%. Data acquisition rates from the continuous temperature devices were much higher than manual temperatures. Four episodes of fever were detected by the devices; manual temperature checks did not identify these events. CONCLUSIONS AND IMPLICATIONS: Continuous temperature monitoring in an older adult population and the staff in congregate-living facilities is feasible and acceptable. This approach identified fever undetected by current standard of care indicating the capability of this device for earlier detection of fevers.

Potent inhibitors of HIV-1 integrase display a two-step, slow-binding inhibition mechanism which is absent in a drug-resistant T66I/M154I mutant.

Two-metal binding HIV-1 integrase inhibitors (INIs) are potent inhibitors of HIV-1 in vitro and in patients. We report here for the first time the kinetics of inhibition of integrase-catalyzed strand transfer. First, the IC(50) values for each of six structurally distinct INIs decreased when a preincubation was included: S-1360 (1.3 microM vs 0.12 microM), L-731,988 (130 nM vs 9 nM), L-870,810 (130 nM vs 4 nM), raltegravir (300 nM vs 9 nM), elvitegravir (90 nM vs 6 nM), and GSK364735 (90 nM vs 6 nM). When reactions with these INIs were initiated with integrase, progress curve analyses indicated time-dependent inhibition, which could be fitted to a two-step mechanism of binding. Overall fitted K(i) values matched the IC(50) values measured with a preincubation: S-1360 (0.17 microM), L-731,988 (34 nM), L-870,810 (2.4 nM), raltegravir (10 nM), elvitegravir (4.0 nM), and GSK364735 (2.5 nM). To begin to understand the mechanism for this slow onset of inhibition and its possible impact on drug resistance, studies of resistance mutations were initiated. T66I/M154I exhibited little if any time-dependent inhibition by any of the six INIs, as measured by differences in potency upon preincubation or by progress curve analysis. These data demonstrate that slow binding is a signature of two-metal binding INIs, and that the second slow step is required for full potency. We discuss a possible structural explanation of the second slow step of inhibition and also the relationship between loss of time-dependent inhibition and drug resistance of this important new class of HIV-1 antiretroviral drugs.

Modification of the forearm tourniquet techniques of intravenous regional anaesthesia for operations on the distal forearm and hand.

Our aim was to find out if a modified intravenous regional anaesthetic block technique, used for invasive surgical procedures on the distal forearm and hand, results in a drier operative field than traditional methods. Twenty consenting adult (age > 18) patients who were to have an operation on the distal forearm or hand were randomised into two groups (n=10 in each). The first group was using a traditional bier block, with a double upper arm tourniquet. The second group was using a modified regional anaesthetic block technique, with a single upper arm tourniquet, and a single forearm tourniquet. All operative fields were recorded photographically and judged by the operating surgeon as "wet" or "dry". Analgesic requirements and subjective pain were recorded. Plasma lignocaine concentrations were measured. "Wet" operative fields were seen in 6 of the conventional and 0 of the modified group (p=0.01). Patients in the modified group were more comfortable during the procedures (p=0.004). This benefit was not sustained postoperatively (p=0.57). Plasma lignocaine concentrations were higher in the conventional group (p=0.004). The modified technique was as safe as the conventional technique but has the benefits of a drier surgical field and improved intraoperative comfort for patients.

Repeated failure of epidural analgesia: an association with epidural fat?

BACKGROUND AND OBJECTIVES: To report the case of a patient who experienced repeated failed epidural analgesia associated with an unusual amount of fat in the epidural space (epidural lipomatosis). CASE REPORT: A 44-year-old female presented for an elective small bowel resection. An L(1-2) epidural catheter was placed for postoperative analgesia. The patient gave no indication of having pain at the time of emergence from general anesthesia or in the first 2 hours in the recovery room. Assessment of the level of hypoesthesia to ice while the patient was comfortable in the recovery room suggested a functional epidural catheter (cephalad level of T(10)). Two hours after admission to the recovery room the patient began to complain of increasing pain. Another 6 mL 0.25% bupivacaine was administered via the catheter. The patient's pain decreased, but remained substantial, and there was minimal evidence of sensory block above the T(10) level. Subsequently, a T(10) epidural catheter was placed. Testing confirmed proper placement of the catheter in the epidural space at the T(10) level. A test dose of 5 mL 0.25% bupivacaine resulted in prompt and complete relief of the patient's pain. However, the level of hypoesthesia to ice did not exceed the T(10) level. Approximately 1 hour later the patient complained of increasing discomfort again. There was no evidence of any sensory block, and there was no response to a bolus of 8 mL 1% lidocaine. A thorough examination of the patient did not suggest any cause for the pain other than a malfunctioning epidural catheter. A third epidural catheter was placed at the T(8-9) level. This catheter was again confirmed to be in the epidural space with a test dose of 10 mL 0.5% bupivacaine. The level of hypoesthesia to ice was restricted to a narrow bilateral band from T(7)-T(9). Analgesia failed 2 hours later. The epidural catheter was removed and the patient's pain was subsequently managed with intravenous patient-controlled analgesia (PCA) morphine. A magnetic resonance imaging (MRI) scan revealed extensive epidural fat dorsal to the spinal cord from C(5)-C(7) and from T(3)-T(9). An imaging diagnosis of asymptomatic epidural lipomatosis was established. CONCLUSION: We have described a case of repeated failure of epidural analgesia in a patient with epidural lipomatosis.

Chest symptoms following coronary stenting in the first 10 weeks of recovery.

BACKGROUND: Most patients experience the benefits of PTCA and stent quickly, with reduction in symptoms and improvement in functional status, however many patients experience chest symptoms post-procedure. OBJECTIVE: To describe the pattern and characteristics of post-stent chest symptoms in cardiac rehabilitation participants. METHODS: A prospective descriptive study assessing the pattern and presence of chest symptoms in coronary artery stent recipients (N=129) four and ten weeks post-procedure. Patients were interviewed at cardiac rehabilitation or by the phone using a specifically developed questionnaire which incorporated the McGill Pain Questionnaire. RESULTS: Most participants were male, aged on average 60.5 years and received two stents, most often drug eluting. Post-stent chest symptoms were common, experienced by two thirds of patients (68%) at some time during the 10 weeks post-discharge. Chest symptoms were recurrent, with 33% having symptoms on both occasions and occurred more often in younger patients (p<.00). Patients described their symptoms as discomforting and used the descriptors dull, tight, sharp, pressing and flickering. Chest symptoms tended to be brief and/or intermittent (65%) lasting from a few seconds to a few minutes (63%). Most patients felt their symptoms were related to their stent (75%) and were unsure what to do. A small number (5%) interpreted their symptoms as ischaemic and presented to the hospital (4%). CONCLUSIONS: Post-stent chest symptoms are frequent and recurrent out to 10 weeks post-discharge. Although symptoms tended to be brief and intermittent, the location and quality of these symptoms may overlap with existing chest pain guidelines, making it difficult for patients to interpret. Cardiac rehabilitation staff are in an ideal position to support and inform stent recipients about appropriate responses to these symptoms.

Failed spinal anesthesia after a psoas compartment block.

PURPOSE: To report the case of a patient who experienced failed spinal anesthesia following a psoas compartment block (PCB) and discuss its implications. CLINICAL FEATURES: A 70-yr-old male was scheduled for a right total hip arthroplasty. He agreed to a PCB for postoperative analgesia and a spinal anesthetic. The spinal anesthetic was performed after completion of the PCB. Free flow of clear fluid was demonstrated at the beginning and at the end of the presumed intrathecal injection. General anesthesia had to be induced because of failure of the spinal anesthetic. The patient awoke from his general anesthetic with a functional PCB and no evidence of residual neuraxial anesthesia. The possibility of epidural spread of local anesthetic from the PCB impairing the ability to perform spinal anesthesia is discussed and reviewed. We hypothesize that local anesthetic in the epidural space may have falsely reassured the anesthesiologist that the needle was properly placed. CONCLUSION: We describe a case of failed spinal anesthesia following a PCB and discuss its implications.