Safety of regadenoson positron emission tomography stress testing in orthotopic heart transplant patients.

OBJECTIVES: We sought to determine the safety of regadenoson (REG) stress testing in patients who have undergone orthotopic heart transplantation (OHT). BACKGROUND: Routine screening for cardiac allograft vasculopathy (CAV) is necessary after OHT. Adenosine stress is contraindicated after heart transplantation due to supersensitivity in denervated hearts. Safety of regadenoson stress following OHT has not been well studied. METHODS: We retrospectively reviewed data from OHT patients (N = 123) who were referred to REG stress testing. Medical records were reviewed to determine hemodynamic and ECG response to regadenoson and to identify adverse reactions. RESULTS: No serious adverse events occurred. No life-threatening arrhythmias or hemodynamic changes occurred. Common side-effects related to regadenoson were observed, dyspnea being the most frequent (66.7%). On average the heart rate rose from 82.8 ± 12 to 95.7 ± 13.4 bpm (P < 0.001), systolic blood pressure decreased from 138.7 ± 20.9 to 115.9 ± 23.9 mmHg (P < 0.001) and mean arterial pressure decreased from 103.5 ± 14.1 to 84.72 ± 15.90 mmHg (P < 0.001) during stress protocol. There was no sustained ventricular tachycardia, ventricular fibrillation, or second-or third-degree atrioventricular block. CONCLUSION: Regadenoson stress testing appears to be well tolerated and safe in OHT patients.

Relationship of non-invasive quantification of myocardial blood flow to arrhythmic events in patients with implantable cardiac defibrillators.

BACKGROUND: Ischemia contributes to arrhythmogenesis though its role is incompletely understood. Abnormal myocardial perfusion measured by PET imaging may predict ventricular arrhythmias (VAs) in a high-risk population. METHODS: Patients with implantable cardiac defibrillators who had undergone rubidium-82 cardiac PET imaging were identified. Patients were stratified by median MBF and MFR values for analysis. The Cox proportional hazards model was used to assess the impact of myocardial perfusion on survival free of VT independent of critical covariates. RESULTS: A total of 159 patients (124 (78%) males, median age 65.9 years, IQR [56.76-72.63]) were followed for 1.43 years IQR [0.83-2.21]. VA occurred in 29 patients (23.7%). After adjustment for ejection fraction, age, and sex, impaired stress MBF was associated with an increased risk of VA (adjusted HR per ml/min/g 1.52, 95% CI (1.01-2.31), P = 0.04). Summed rest and stress scores were not predictive of VA. Among patients with severe LV dysfunction, stress MBF remained an independent predictor of VA (adjusted HR per 1 ml/min/g HR 1.69, 95% CI (1.03-11.36), P = 0.03), while residual EF, summed rest, and summed stress scores were not (P > 0.05). CONCLUSIONS: Impaired stress myocardial blood flow was associated with less survival free of ventricular arrhythmias.

Safety of regadenoson stress testing in patients with pulmonary hypertension.

OBJECTIVES: We sought to determine the safety of regadenoson stress testing in patients with PH. BACKGROUND: PH is increasingly recognized at more advanced ages. As many as one-third of patients with PH have coronary artery disease. Because of their physical limitations, patients with PH are unable to adequately exercise. Regadenoson can potentially have an adverse impact due to their tenuous hemodynamics. Current guidelines suggest performing a coronary angiography in patients with PH who have angina or multiple coronary risk factors. METHODS: We identified 67 consecutive patients with confirmed PH by catheterization (mean PA > 25 mmHg not due to left heart disease) who underwent MPI with regadenoson stress. Medical records were reviewed to determine hemodynamic and ECG response to regadenoson. RESULTS: No serious events occurred. Common side effects related to regadenoson were observed, dyspnea being the most common (70.6%). No syncope occurred. Heart rate increased from 74.6 ± 14 to 96.3 ± 18.3 bpm, systolic blood pressure increased from 129.8 ± 20.9 to 131.8 ± 31 mmHg, and diastolic blood pressure decreased from 77.1 ± 11.4 to 72.9 ± 15.3 mmHg. There was no ventricular tachycardia, ventricular fibrillation, or second- or third-degree atrioventricular block. CONCLUSION: Regadenoson stress MPI appears to be well tolerated and safe in patients with PH.

Cross-sectional study of emergency department presentation triage categories at Goondiwindi Hospital and their effect on the treatment of acute emergencies.

OBJECTIVE: The objective of this study was to investigate the number and proportion of non-acute presentations to a district hospital emergency department in Goondiwindi, a rural Queensland town, both in the treatment of emergency cases and potential barriers patients have in seeing a medical practitioner in the general practice setting. DESIGN: Occasions of service to Goondiwindi Hospital were collated from administrative records according to Australasian Triage Scale categories and analysed by Student's t-test for monthly variations in triage category presentations. SETTING: Outpatient clinic (emergency department of a public district hospital). PARTICIPANTS: All patients presenting to Goondiwindi Hospital Emergency Department from 1 January 2013 to 30 June 2013. MAIN OUTCOME MEASURE: Proportion of high and low triage category presentations in Goondiwindi Hospital during the study period. RESULTS: Triage category 4 and 5 presentations comprised 35.9% (mean = 225 per month) and 44.4% (mean = 278 per month), respectively, of all occasions of service at the Goondiwindi Hospital Emergency Department during this 6 month period. Life-threatening presentations (Triage Category 1 and 2) comprised <5% of all occasions of service at Goondiwindi Hospital. There were statistically insignificant differences between total occasions of service by month of presentation. CONCLUSIONS: Although patients of all acuities presented to Goondiwindi Hospital, low-acuity presentations were more common than reported at larger hospitals. Frequent interruptions impairing attention to more urgent tasks were noted at Goondiwindi Hospital, causing delayed treatment of sick patients. Educating the local community in the appropriate use of public health services would help direct more attention to the most ill seeking medical care at rural emergency departments such as Goondiwindi Hospital.

Saccharomyces boulardii does not prevent relapse of Crohn's disease.

BACKGROUND & AIMS: Saccharomyces boulardii is a probiotic yeast that has been shown to have beneficial effects on the intestinal epithelial barrier and digestive immune system. There is preliminary evidence that S boulardii could be used to treat patients with Crohn's disease (CD). We performed a randomized, placebo-controlled trial to evaluate the effects of S boulardii in patients with CD who underwent remission during therapy with steroids or aminosalicylates. METHODS: We performed a prospective study of 165 patients who achieved remission after treatment with steroids or salicylates; they were randomly assigned to groups given S boulardii (1 g/day) or placebo for 52 weeks. The primary end point was the percentage of patients in remission at week 52. Time to relapse, Crohn's disease activity index scores, and changes in parameters of inflammation were secondary end points. RESULTS: CD relapsed in 80 patients, 38 in the S boulardii group (47.5%) and 42 in the placebo group (53.2%, a nonsignificant difference). The median time to relapse did not differ significantly between patients given S boulardii (40.7 weeks) vs placebo (39.0 weeks). There were no significant differences between groups in mean Crohn's disease activity index scores or erythrocyte sedimentation rates or in median levels of C-reactive protein. In a post hoc analysis, nonsmokers given S boulardii were less likely to experience a relapse of CD than nonsmokers given placebo, but this finding requires confirmation. CONCLUSIONS: Although the probiotic yeast S boulardii is safe and well tolerated, it does not appear to have any beneficial effects for patients with CD in remission after steroid or salicylate therapies.

Case study of thrombosis and thrombocytopenia syndrome following administration of the AstraZeneca COVID-19 vaccine.

Cerebral venous sinus thrombosis is a complication of the ChAdOx1 nCoV-19 vaccine that should elicit a high index of suspicion when patients present with persistent headache post vaccination.

Acute Effects of Ketamine Infusion on Postoperative Mood Scores in Patients Undergoing Dilation and Curettage: A Randomized Double-Blind Controlled Study.

BACKGROUND: Emotional and psychological effects following abortion are more common than physical side effects and can range from mild regret to more serious complications such as depression. In the last decade, it has been suggested that low dose of ketamine is a fast-acting antidepressant. PURPOSE: The aim of this study was to investigate the impact of intraoperative ketamine infusion on postoperative mood score in patients undergoing Dilation and Curettage (D&C) under spinal anesthesia. We hypothesized that a single low-dose administration of ketamine infusion during D&C surgery can improve mood scores in the immediate postoperative period. METHODS: A prospective, randomized, double-blind, parallel-group, placebo-controlled trial. The study included a total of 60 patients, ≥18 years, physical status ASA II, with up to 12-week gestation undergoing elective D&C surgery. Patients were divided randomly into a ketamine group (group K) and a control group (group C). In group K, 0.4 mg/kg ketamine was given as a continuous infusion over 20 min intraoperatively. Main Outcome Measure. Profile of Mood States (POMS) was recorded preoperatively and 2 hours postoperatively. RESULTS: There were no differences in preoperative POMS between the two groups. Mean postoperative POMS of group K was lower than that of group C indicating mood improvement. Ketamine group patients showed higher sedation score and increased, although self-limiting, psychedelic phenomena than the control group. CONCLUSION: Observed data here support an acute effect of ketamine on mood but any further claim will be speculative. Further future studies exploring postoperative mood scores after 24 hours post-infusion are needed. This trial is registered with PACTR201907779292947.

Nefopam pharmacokinetics in patients with end-stage renal disease.

BACKGROUND: Treatment of intense postoperative pain in patients with end-stage renal disease (ESRD) is a recurrent problem for anesthesiologists because of the risk of accumulation of numerous molecules and their metabolites. Nefopam is a potent analgesic metabolized by the liver and weakly eliminated intact in urine that may offer advantages for use in patients with ESRD because it lacks respiratory-depressive effects. However, the effects of renal failure on nefopam disposition have never been investigated. METHODS: We studied 12 ESRD patients (creatinine clearance < 20 mL/min, mean age 57 ± 13 years) having surgery under general anesthesia to create or repair an arteriovenous fistula. Postoperatively, after complete recovery from anesthesia, each patient received a single 20-mg dose of nefopam IV over 30 minutes. Nefopam and desmethyl-nefopam concentrations in plasma samples obtained over 48 hours were determined by liquid chromatography-tandem mass spectrometry. The pharmacokinetic parameter values obtained were compared with those of 12 healthy 50- to 60-year-old volunteers who also received a single 20-mg nefopam infusion over 30 minutes using a population pharmacokinetic approach. RESULTS: Healthy volunteers and ESRD patients had comparable demographic characteristics. In comparison with those volunteers, ESRD patients had a lower volume of central compartment (115 and 53 L vs. 264 L for patients not yet hemodialyzed and on chronic hemodialysis, respectively; P < 0.001) and lower mean nefopam clearance (37.0 and 27.3 L/h vs. 52.9 L/h, P < 0.001), resulting in higher mean nefopam peak concentration (121 and 223 ng/mL vs. 61 ng/mL, P < 0.001). CONCLUSIONS: Nefopam distribution and elimination are altered in patients with ESRD, resulting in heightened exposure. To avoid too-high concentration peaks, it is suggested that the daily nefopam dose be reduced by 50%.

Diagnosis of type 2 diabetes using serial fasting plasma glucose versus HbA1c in the primary care setting

BACKGROUND AND OBJECTIVE: There are few studies investigating the diagnostic accuracy of type 2 diabetes mellitus (T2DM) by comparing fasting plasma glucose (FPG) with glycated haemoglobin (HbA1c). This proof-of-concept study looked at the correlation between FPG and HbA1c in the early diagnosis of T2DM. METHODS: A case series of 30 consecutive patients met the criteria for T2DM with FPG (>7 mM) or HbA1c (>6.5%), but not both. RESULTS: Average FPG in patients who met that criterion was 7.57 mM ± 0.53 mM (average HbA1c 5.81% ± 0.37%). Average HbA1c in patients meeting that criterion was 6.54% ± 0.05% (average FPG 6.18 mM ± 0.8 mM). DISCUSSION: Serial FPG testing may lead to earlier diagnosis of T2DM than by HbA1c. A higher-powered study could confirm this supposition.

Feasibility of Using Gluconolactone, Trehalose and Hydroxy-Propyl Gamma Cyclodextrin to Enhance Bendroflumethiazide Dissolution Using Lyophilisation and Physical Mixing Techniques.

PURPOSE: Hydrophobic drugs are facing a major challenge in dissolution rate enhancement and solubility in aqueous solutions; therefore, a variety of methods have been used to improve dissolution rate and/or solubility of bendroflumethiazide as a model hydrophobic drug. METHODS: In this study, two main methods (physical mixing and lyophilisation) were used with gluconolactone, hydroxyl propyl γ-ccyclodextrin, and trehalose to explore this challenge. Bendroflumethiazide, practically insoluble in water, was mixed with one of the three excipients gluconolactone, hydroxyl propyl γ-cyclodextrin, and trehalose in three different ratios 1:1, 1:2, 1:5. To the best of our knowledge, the dissolution of the drug has not been previously enhanced by using either these methods or any of the used excipients. Samples containing drug and each of the excipients were characterized via dissolution testing, Fourier Transform infra-red spectroscopy, differential scanning calorimetry, and scanning electron microscopy. RESULTS: The used methods showed a significant enhancement in dug dissolution rate; physical mixing significantly, p < 0.05, increased the percentage of the drug released with time; for example, bendroflumethiazide dissolution in distilled water was improved from less than 20% to 99.79% within 90 min for physically mixed drug-cyclodextrin 1:5. The lyophilisation process was enhanced and the drug dissolution rate and the highest drug dissolution was achieved for (drug-gluconolactone 1:1) with 98.98% drug release within 90 min. CONCLUSIONS: the physical mixing and freeze drying processes significantly increased the percentage of drug release with time.

The validity and reliability of the Arabic version of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU): A prospective cohort study.

BACKGROUND: Accurate diagnosis for Arabic speaking critically ill patients suffering from delirium is limited by the need for a valid/reliable translation of a standardized delirium instrument such as the Confusion Assessment Method for the ICU (CAM-ICU). OBJECTIVE: To determine the validity and reliability of the Arabic version of the CAM-ICU. DESIGN: A prospective cohort study design was used to conduct the current study. SETTINGS: Data collection took place in Geriatric, Emergency and Surgical intensive care units. PARTICIPANTS: Fifty-eight adult patients met the inclusion criteria and participated in the study. Among the participants 22(38%) patients were on mechanical ventilation. METHODS: After translating the CAM-ICU into Arabic language, the Arabic CAM-ICU was administered by two well-trained critical care nurses and compared with reference standard assessments by delirium experts using the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM -IV-TR), along with assessment of severity of illness using Sequential Organ Failure Assessment (SOFA). Concurrent validity was assessed by calculating sensitivity, specificity and positive and negative predictive value (PPV and NPV) for the two Arabic CAM-ICU raters, where calculations were based on considering the DSM-IV-TR criterion as the reference standard. The convergent validity of the Arabic CAM-ICU was explored by comparing the Arabic CAM-ICU ratings and the total score of SOFA (severity of illness) and MMSE (cognitive impairment). RESULTS: A total of 58 ICU patients were included, of whom 27 (47%) were diagnosed with delirium during their ICU stay via DSM-IV criteria. Interrater reliability for the Arabic CAM-ICU, overall and for mechanically ventilated patients assessed using Cohen's kappa (κ) were 0.82 and 1, respectively, p < 0.001. The sensitivities (95% CI) for the two critical care nurses when using the Arabic CAM-ICU compared with the reference standard were 81% (60%-93%) and 85% (65%-95%), respectively, whereas specificity (95% CI) was 81%(62%-92%) for both nurses. High sensitivity and specificity measures were also observed across subgroups; 100% for mechanically ventilated patients, 88% (60%-98%) and 79% (49%-94%) for those aged 65 years or older and 82% (56%-95%) and 75% (43%-93%) for those with SOFA scores at or above the median value. CONCLUSIONS: The Arabic CAM-ICU appeared to be valid and reliable tool for diagnosing delirium. Future investigations may lead to a better understanding of the prevalence, predictors, and consequences of delirium among critically ill Arabic speaking patients.

Potential antibacterial activity of some Saudi Arabia honey.

AIM: The aim of this study was to investigate the potential antibacterial activity of some Saudi Arabia honey against selected bacterial strains of medical importance. MATERIALS AND METHODS: A total of 10 Saudi Arabia honey used to evaluate their antimicrobial activity against some antibiotic-resistant pathogenic bacterial strains. The bacterial strains were Staphylococcus aureus, Streptococcus pyogenes, Klebsiella pneumoniae, Escherichia coli, and Pseudomonas aeruginosa. RESULTS: The antibacterial activity of Saudi honey against five bacterial strains showed different levels of inhibition according to the type of honey. The overall results showed that the potential activity was differing according to the pathogen and honey type. CONCLUSION: It could be concluded that the Saudi honey inhibit the growth of bacterial strains and that honey can be used as complementary antimicrobial agent against selected pathogenic bacteria.

A Systematic Review of Factors Associated With Utilization of Monitored Anesthesia Care for Gastrointestinal Endoscopy.

Utilization of monitored anesthesia care (MAC) for gastrointestinal endoscopy has increased markedly over the past decade, leading to significant additional health care expenditures. However, the extent to which certain patient-, provider-, and facility-level factors lead to MAC utilization is unclear. A systematic review of 13 studies evaluating influential factors associated with MAC utilization for colonoscopy and/or esophagogastroduodenoscopy was conducted. Multiple studies revealed significant increases in MAC utilization since the early 2000s, with substantial regional variation. The most influential patient-related factors associated with MAC utilization include female sex and diagnostic procedural indication. Other patient-related factors with weaker associations or conflicting evidence include older age, comorbidity, higher patient income, and white/non-Hispanic race. The impact of patient substance use and/or prescription medication use has been minimally studied. The strongest provider- and facility-level factors associated with MAC use are a surgeon endoscopist and nonhospital site of service. Other factors with weaker associations include facility endoscopy volume and endoscopist years of experience. Further qualitative and quantitative health services research is needed to better understand the root cause of the rising trend of MAC utilization and to develop policies for encouraging appropriate use of MAC.

Hypochlorite converts cysteinyl-dopamine into a cytotoxic product: A possible factor in Parkinson's Disease.

The dopamine oxidation product cysteinyl-dopamine has attracted attention as a contributor to the death of dopaminergic neurons in Parkinson's disease. Treatment of cysteinyl-dopamine with hypochlorite yields an even more cytotoxic product. This product has potent redox-cycling activity and initiates production of superoxide in PC12 cells. Taurine, which scavenges hypochlorite, protects PC12 cells from cysteinyl-dopamine but not from the hypochlorite product, suggesting that the product, not cysteinyl-dopamine itself, is toxic. Furthermore, rotenone, which enhances expression of the hypochlorite-producing enzyme myeloperoxidase, increases the cytotoxicity of cysteinyl-dopamine but not of the hypochlorite product. This suggests that dopamine oxidation to cysteinyl-dopamine followed by hypochlorite-dependent conversion to a cytotoxic redox-cycling product leads to the generation of reactive oxygen species and oxidative stress and may contribute to the death of dopaminergic neurons.

The prophylactic effect of intravenous magnesium infusion on postoperative sore throat after thyroid surgery. A randomized clinical trial / Efecto profiláctico de la infusión de magnesio en dolor de garganta postoperatorio luego de una tiroidectomía. Un ensayo clínico aleatorizado

BACKGROUND: The reported incidence of postoperative sore throat (POST) varies widely from 14.4 to 100% with maximum severity at 4th to 6th postoperative hour. Nonetheless, it has increasingly become a common clinical problem particularly in thyroid surgery. Although POST usually resolves spontaneously in few days, it is likely to be the most common complaint. OBJECTIVES: Driven by the increased number of patients with post-intubation sore throat following thyroid surgery, the aim of the present study was to evaluate the effectiveness of perioperative magnesium infusion in attenuating POST after thyroidectomy. METHODS AND MATERIAL: 80 female patients undergoing thyroid surgery, were preoperatively randomized into one of 2 groups. The magnesium group received magnesium sulfate (30 mg/kg) in 100 ml of isotonic saline over 15 min before induction of anesthesia, followed by a continuous magnesium sulfate infusion (10 mg/kg/h) for the duration of the operation. The control group received the same volume and rate of isotonic saline. RESULTS: This study showed that perioperative magnesium infusion had significantly reduced the overall incidence and severity of POST. The incidence of POST at rest (patients who recorded non-zero POST score after thyroid surgery) in the control group was 75% while the incidence of POST in magnesium group was 37.5% which is lower and that was highly significance. Higher sedation scores were encoun tered on arrival to PACU in Magnesium group when compared to controls. CONCLUSIONS: We concluded that perioperative magnesium sulphate infusion effectively decreased overall POST incidence and severity after thyroidectomy with better hemodynamic stability, albeit higher risk of post operative sedation.

La incidencia reportada de dolor de garganta postoperatorio (POST) varía ampliamente de 14,4 a 100% con severidad máxima en la 4ta a 6ta hora postoperatoria. Sin embargo, se ha convertido cada vez más en un problema clínico común, particularmente en la cirugía de tiroides. Aunque la POST generalmente se resuelve espontáneamente en pocos días, es probable que sea la queja más común. OBJETIVOS: Impulsado por el mayor número de pacientes con dolor de garganta después de la intubación después de la cirugía de tiroides, el objetivo del presente estudio fue evaluar la efectividad de la infusión perioperatoria de magnesio para atenuar la POST después de la tiroidectomía. MÉTODOS Y METERIAL: 80 pacientes mujeres sometidas a cirugía de tiroides, fueron asignadas al azar preoperatoriamente en uno de los 2 grupos. El grupo de magnesio recibió sulfato de magnesio (30 mg/kg) en 100 ml de solución salina isotónica durante 15 minutos antes de la inducción de la anestesia, seguido de una infusión continua de sulfato de magnesio (10 mg/kg/h) durante la operación. El grupo control recibió el mismo volumen y tasa de solución salina isotónica. RESULTADOS: Este estudio mostró que la infusión perioperatoria de magnesio había reducido significativamente la incidencia general y la gravedad de la POST. La incidencia de POST en reposo (pacientes que registraron una puntuación POST distinta de cero después de la cirugía de tiroides) en el grupo de control fue del 75%, mientras que la incidencia de POST en el grupo de magnesio fue del 37,5%, que es menor y de gran importancia. Se encontraron puntajes de sedación más altos al llegar a la UCPA en el grupo Magnesio en comparación con los controles. CONCLUSIONES: Llegamos a la conclusión de que la infusión perioperatoria de sulfato de magnesio disminuyó efectivamente la incidencia general de POST y la gravedad después de la tiroidectomía con una mejor estabilidad hemodinámica, aunque un mayor riesgo de sedación postoperatoria.

Cross-sectional study of diet and risk factors for metabolic diseases in a Ghanaian population in Sydney, Australia.

Ethnic groups in affluent environments experience higher rates of metabolic diseases than their native counterparts. Our objective was to determine the prevalence of metabolic risk factors in Ghanaians in Sydney, and to investigate the relationship with dietary and lifestyle factors. Cross-sectional design with anthropometry, blood pressure, plasma lipids, glucose and insulin concentrations were measured on two occasions on each subject. Dietary information was obtained by three 24-h dietary recalls. Adults (45 male, 35 female) were recruited from a local association in Sydney, Australia. Overweight was observed in a large proportion of subjects (71% and 66% of men and women, respectively), with 18% of men and 26% of women classified as obese. Abdominal overweight was seen in 63% and 74% of men and women, respectively. Abdominal obesity was seen in 20% of men and 49% of women. Hypertension was detected in 40% of men and 17% of women, 16% of men and 6% of women were diagnosed with definite hypertension. Seventy-one per cent of men and 29% of women were classified as hypercholesterolaemic and 67% of men and 23% of women had elevated low-density lipoprotein cholesterol. In men, low high-density lipoprotein cholesterol and hypertriacylglycerolaemia affected 18% and 13%, respectively. Fasting hyperinsulinaemia was observed in 14% and 9% of men and women, respectively. The majority of subjects (73%) sustained one or more metabolic risk factors. Dietary fat contributed 33% and 35% of total energy intake in men and women, respectively, saturated fat contributing 11% in both sexes. A high prevalence of overweight, diabetes, hypertension and dyslipidaemia exists in this population, particularly in men, highlighting the need for intervention.