Traumatic pedestrian and bicyclist injuries associated with intoxication.

BACKGROUND: Drug and alcohol use are risk factors for trauma among operators of motor vehicles and contribute to trauma in pedestrians and bicyclists. We describe the prevalence of drug and alcohol use and clinical consequences in a cohort of pedestrians and bicyclists with trauma. METHODS: We analyzed a 25-month data set of 916 trauma team activations from January 2017-January 2019 at an urban, level I trauma center. Blood ethanol levels and urine toxicology screens were obtained in 94 pedestrian and bicyclist trauma activations. We compared pedestrians or bicyclists with a positive urine or blood screen (n = 69) to those with negative screens (n = 25). We conducted a retrospective chart review to determine mechanism of injury, injury pattern, and disposition from the emergency department (ED). RESULTS: Overall, 38 (55%) of injured patients with positive screen were pedestrians and 31 (45%) were bicyclists. Fentanyl was the most commonly detected drug (n = 38; 40%), followed by opiates (n = 27; 29%), and tetrahydrocannabiol (THC) (n = 23; 25%). Twenty-one patients were positive for ethanol. Pedestrians and bicyclists with positive toxicology screens were significantly more likely to sustain fractures (p < .01), require an operative procedure (p < .05), or intensive care unit admission (p < .05). CONCLUSION: Our study builds on previous literature which suggests that intoxicated bicyclists and pedestrians suffer frequent and more severe injury than their sober counterparts. Public health campaigns should educate bicyclists and pedestrians about the risks of cycling or walking in areas of road traffic while under the influence of alcohol or illicit drugs.

Surgical treatment of phlegmons of the digital flexor tendon sheaths at the early stage: Lavage by conventional open technique versus ultrasound-guided percutaneous technique.

The aim of this work was to analyze the results of a percutaneous drainage technique with 2 catheters during surgical treatment of phlegmons of the finger flexor tendon sheath. Our series included 32 patients with a phlegmon of flexor tendon sheaths, including 19 men and 13 women, mean age 43.4years. The first 16 patients (group I) were treated by a conventional open technique for the lavage and drainage of the affected tendon sheath. The last 16 (group II) were treated by an ultrasound-guided percutaneous lavage technique with 2 catheters: one proximal and one distal. In the case of impermeability of the digital canal, conversion by open technique was carried out. In group II, the ultrasound-guided percutaneous lavage was 5 times successful. Failure of the proximal catheter alone was noted once, whereas failure of the distal catheter alone was noted 7 times. The failure of both catheters was noted 3 times. At a mean follow-up of 19.7 days, mean handgrip strength was 56.5% compared to the contralateral side in group I and 82% in group II (P<0.05). However, there was no significant difference for pain, QuickDASH, total active mobility between group I and group II. Pain was at 1.4/10 for group I and 1.4/10 for group II. QuickDASH was measured at 27/100 for group I and 22.27/100 for group II. Total active mobility was 227° for group I and 243° for group II. In conclusion, surgical treatment of the phlegmons of the finger flexor tendon sheath with an ultrasound-guided percutaneous lavage technique gives significantly better short-term grip strength than the conventional open technique.

Cementless and locked prosthesis for the treatment of 3-part and 4-part proximal humerus fractures: prospective clinical evaluation of hemi- and reverse arthroplasty.

INTRODUCTION: Cemented stem remains the gold standard for prosthesis in trauma. The purpose of this study was to evaluate the functional and radiological outcomes of a cementless, trauma-specific locked stem (hemi and reverse) for 3- and 4-part proximal humeral fractures. MATERIALS AND METHODS: One hundred and thirty-four 3- and 4-part fractures have been treated by locked stem, 69 with hemiarthroplasty [mean age 68 years (50-90)] and 65 with reversed [mean age 78 years (66-91)]. The length of the stem was 15 cm with a proximal coating of HA automatic locking system (two screws) and four different diameters. Preliminary cadaver study allowed us to validate the system (22 shoulders, no injuries of nerves, locking system efficient). RESULTS: In the group of hemi, Constant score with ponderation reached 72 (11-120) and QDash 31.2 (4.5-77.27) with a mean FU of 25 months (6-96). In the group of reversed, Constant score with ponderation reached 77.6 (28.8-119) and QDash 36.2 (2-84) with a mean FU of 15 months (6-41). Specific complications due to locking system reached 3% but without reoperation. Other complications were capsulitis and infection. DISCUSSION: In this population of elderly patient, new fall with periprosthetic fracture or infection led the surgeon to remove the stem. At shoulder level, the removal of a cemented stem remains a highly demanding procedure with sometimes bad functional results and elevated level of complications. This series is the first one of locked stem without significant complications. Locked stem remains a new but logical tool in trauma.

Antibiotic-associated diarrhoea in emergency department observation unit patients.

Clostridium difficile diarrhoea is an urgent threat to patients, but little is known about the role of antibiotic administration that starts in emergency department observation units (EDOUs). We studied risk factors for antibiotic-associated diarrhoea (AAD) and C. difficile infection (CDI) in EDOU patients. This prospective cohort study enrolled adult patients discharged after EDOU antibiotic treatment between January 2013 and 2014. We obtained medical histories, EDOU treatment and occurrence of AAD and CDI over 28 days after discharge. We enrolled and followed 275 patients treated with antibiotics in the EDOU. We found that 52 (18·6%) developed AAD and four (1·5%) had CDI. Patients treated with vancomycin [relative risk (RR) 0·52, 95% confidence interval (CI) 0·3-0·9] were less likely to develop AAD. History of developing diarrhoea with antibiotics (RR 3·11, 95% CI 1·92-5·03) and currently failing antibiotics (RR 1·90, 95% CI 1·14-3·16) were also predictors of AAD. Patients with CDI were likely to be treated with clindamycin. In conclusion, AAD occurred in almost 20% of EDOU patients with risk factors including a previous history of diarrhoea with antibiotics and prior antibiotic therapy, while the risk of AAD was lower in patients receiving treatment regimens utilizing intravenous vancomycin.

Severe colchicine poisoning treated successfully with kidney replacement therapy and plasmapheresis: a case report.

Colchicine is commonly prescribed for treatment of inflammatory conditions but has a narrow therapeutic window and dangerous toxicity profile. Here we describe a case of survival after massive unintentional colchicine overdose treated with plasmapheresis and renal replacement therapy. A 37 year old male with history of pericarditis presented to the Emergency Department with a chief complaint of nausea, vomiting, and diarrhea after unintentionally ingesting 36 mg of colchicine 17 h prior to arrival. An initial colchicine concentration resulted at 5.1 ng/mL (30 h post-ingestion) and peaked at 12 ng/mL (40 h post-ingestion). He was treated with continuous kidney replacement therapy (CKRT) beginning on his first day of hospitalization and with plasmapheresis on hospital days two through four. The patient's course was complicated by multiorgan failure including coagulopathy, respiratory failure, neuropathy, renal failure, pancytopenia, and heart failure. He was discharged to inpatient rehabilitation on hospital day 24. On clinical follow up four months after discharge the patient was found to have no significant persistent morbidity related to colchicine overdose.

Oral sedation in dentistry: evaluation of professional practice of oral hydroxyzine in the University Hospital of Rennes, France.

PURPOSE: Management of a child's anxiety early in their treatment is essential in dentistry. Sedative medications are used to overcome increased anxiety from previous appointments and to promote the cooperation of children during treatment. Hydroxyzine is currently prescribed to young patients as part of the first level of conscious sedation. The main objective was to evaluate the professional practice of oral hydroxyzine, when prescribed for children presenting anxiety during dental treatment procedure performed by students and senior practitioners. METHODS: A retrospective study of dental records and questionnaires was conducted at the Dental Care Centre of the University Hospital of Rennes, France. Parameters related to the prescription of hydroxyzine in children were evaluated as potential predictors of the dental session success, with adjustments on potential confounders. RESULTS: The therapeutic outcome was very encouraging with 78.3% of success during dental sessions under sedation with oral hydroxyzine. Anxiety levels before the dental procedure and the medication compliance of the child were the main predictors of success. On the other hand, lower age (< 6 years old) and longer treatments (such as pulpotomy) worsened the outcome. CONCLUSIONS: Careful analysis of the literature and results of this work showed the safety of hydroxyzine within the maximum dose authorized without adverse effects, compared to other molecules described and commonly used in dentistry. No adverse effects during dental procedure were noted. This allows for minimal sedation with efficiency for the great majority of pediatric treatment. This solution should be the first step in sedation to help practicing clinicians.

Delta radiomics analysis of Magnetic Resonance guided radiotherapy imaging data can enable treatment response prediction in pancreatic cancer.

BACKGROUND: Magnetic Resonance Image guided Stereotactic body radiotherapy (MRgRT) is an emerging technology that is increasingly used in treatment of visceral cancers, such as pancreatic adenocarcinoma (PDAC). Given the variable response rates and short progression times of PDAC, there is an unmet clinical need for a method to assess early RT response that may allow better prescription personalization. We hypothesize that quantitative image feature analysis (radiomics) of the longitudinal MR scans acquired before and during MRgRT may be used to extract information related to early treatment response. METHODS: Histogram and texture radiomic features (n = 73) were extracted from the Gross Tumor Volume (GTV) in 0.35T MRgRT scans of 26 locally advanced and borderline resectable PDAC patients treated with 50 Gy RT in 5 fractions. Feature ratios between first (F1) and last (F5) fraction scan were correlated with progression free survival (PFS). Feature stability was assessed through region of interest (ROI) perturbation. RESULTS: Linear normalization of image intensity to median kidney value showed improved reproducibility of feature quantification. Histogram skewness change during treatment showed significant association with PFS (p = 0.005, HR = 2.75), offering a potential predictive biomarker of RT response. Stability analyses revealed a wide distribution of feature sensitivities to ROI delineation and was able to identify features that were robust to variability in contouring. CONCLUSIONS: This study presents a proof-of-concept for the use of quantitative image analysis in MRgRT for treatment response prediction and providing an analysis pipeline that can be utilized in future MRgRT radiomic studies.

Influence of the level of arterial resection on the replanting and revascularization results in hand surgery: prospective study over 22 months.

The objective of this work was to assess whether the injury mechanisms are responsible for histological arterial lesions. This prospective single-center study included adults with wrist or hand arterial injury. Arterial resection of at least 2 mm from the proximal and distal stumps was performed before the arterial anastomosis. Histological analysis of the arterial stumps was performed. An ultrasound was performed 1 month postoperatively to check arterial patency. A clinical and functional evaluation was done at 1 month postoperative, then every 3 months. From 2018 to 2020, 46 patients were included with a maximum follow-up of 13 months. There were 35 cuts, 2 crush injuries, 8 amputation and 1 blast injury. Macroscopically, 37% of the margins were considered damaged. Histological analysis showed significant damage in 59% of the sections (27 out of 46 patients) with 50% for crush injury, 55% for cuts by mechanical tool, 62% for cuts by power tool, 62% for amputations and 100% for blasts. The failure rate was 9%: 2 replantations and 2 asymptomatic thromboses diagnosed by ultrasound. Postoperative pain on VAS was 1.75/10, range of motion was 87%, Quick DASH was 8%, SF36 PCS was 69% and SF36 MCS was 70%. Factors influencing the success or failure of anastomosis were the mechanism of injury (p = 0.02), associated nerve damage (p = 0.014) and length of proximal arterial cut (p = 0.046). Histological arterial lesions seem to correlate with the injury mechanism. Cuts caused by glass or crush injuries do not seem to require arterial resections of more than 2 mm. A continuation of the study with a larger number of subjects may generate statistically significant results.

Chloroquine, hydroxychloroquine and COVID-19.

The media have featured the antimalarials chloroquine (CQ) and hydroxychloroquine (HCQ) to treat coronavirus (COVID-19). Political leaders have touted their use and recommended availability to the public. These anti-inflammatory agents have substantial human toxicity with a narrow therapeutic window. CQ and HCQ poisoning cause myocardial depression and profound hypotension due to vasodilation. Bradycardia and ventricular escape rhythms arise from impaired myocardial automaticity and conductivity due to sodium and potassium channel blockade. With cardiotoxicity, ECGs may show widened QRS, atrioventricular heart block and QT interval prolongation. CQ may also cause seizures, often refractory to standard treatment. Of concern is pediatric poisoning, where 1-2 pills of CQ or HCQ can cause serious and potentially fatal toxicity in a toddler. The treatment of CQ/HCQ poisoning includes high-dose intravenous diazepam postulated to have positive ionotropic and antidysrhythmic properties that may antagonize the cardiotoxic effects of CQ. Infusions of epinephrine titrated to treat unstable hypotension, as well as potassium for severe hypokalemia may be required. Current scientific evidence does not support treatment or prophylactic use of these agents for COVID-19 disease. Regulatory and public health authorities recognize that CQ/HCQ may offer little clinical benefit and only add risk requiring further investigation before wider public distribution.

Intentional Hydroxychloroquine Overdose Treated with High-Dose Diazepam: an Increasing Concern in the COVID-19 Pandemic.

INTRODUCTION: Recent attention on the possible use of hydroxychloroquine and chloroquine to treat COVID-19 disease has potentially triggered a number of overdoses from hydroxychloroquine. Toxicity from hydroxychloroquine manifests with cardiac conduction abnormalities, seizure activity, and muscle weakness. Recognizing this toxidrome and unique management of this toxicity is important in the COVID-19 pandemic. CASE REPORT: A 27-year-old man with a history of rheumatoid arthritis presented to the emergency department 7 hours after an intentional overdose of hydroxychloroquine. Initial presentation demonstrated proximal muscle weakness. The patient was found to have a QRS complex of 134 ms and QTc of 710 ms. He was treated with early orotracheal intubation and intravenous diazepam boluses. Due to difficulties formulating continuous diazepam infusions, we opted to utilize an intermitted intravenous bolus strategy that achieved similar effects that a continuous infusion would. The patient recovered without residual side effects. DISCUSSION: Hydroxychloroquine toxicity is rare but projected to increase in frequency given its selection as a potential modality to treat COVID-19 disease. It is important for clinicians to recognize the unique effects of hydroxychloroquine poisoning and initiate appropriate emergency maneuvers to improve the outcomes in these patients.

Designing a minimally-invasive, ultrasound-guided, percutaneous flexor tendon sheath lavage technique: a cadaver study.

The goal of this study was to develop a minimally-invasive, ultrasound-guided percutaneous flexor tendon sheath lavage technique on cadaver model. Two catheters were inserted using ultrasound guidance at the proximal and distal ends of the tendon sheath in 20 fingers from cadaveric forearms. Percutaneous injection of a saline solution colored with methylene blue resulted in anterograde lavage of the flexor tendon sheath. The technique was successful in 13 out of 20 cases. The proximal catheter was in the correct position in 17 cases and the distal catheter was correctly positioned in 15 cases. The flexor tendons were continuous in all cases and had puncture wounds in 9 cases. Based on our study, this minimally-invasive, ultrasound-guided percutaneous lavage of the flexor tendon sheath was effective in 65% of cases and safe in 100% of cases in the index, middle and ring fingers. If this percutaneous lavage fails, it is always possible to switch to a conventional open technique.

Primary care physicians' decisions about discharging patients from their practices.

OBJECTIVE: There are few data available about factors which influence physicians' decisions to discharge patients from their practices. To study general internists' and family medicine physicians' attitudes and experiences in discharging patients from their practices. DESIGN: A cross-sectional mailed survey was used. PARTICIPANTS: One thousand general internists and family medicine physicians participated in this study. MEASUREMENTS AND MAIN RESULTS: We studied the likelihood physicians would discharge 12 hypothetical patients from their practices, and whether they had actually discharged such patients. The effect of demographic data on the number of scenarios in which patients were likely to be discharged, and the number of patients actually discharged were analyzed via ANOVA and multiple logistic regression analysis. Of 977 surveys received by subjects, 526 (54%) were completed and returned. A majority of respondents were willing to discharge patients in 5 of 12 hypothetical scenarios. Eighty-five percent had actually discharged at least one patient from their practices. Most respondents (71%) had discharged 10 or fewer patients, but 14% had discharged 11 to 200 patients. Respondents who were in private practice (p < 0.000001) were more likely to discharge both hypothetical and actual patients from their practices. Older physicians (> or =48 years old) were more likely to discharge actual patients from their practices (p = 0.005) as were physicians practicing in rural settings (p = 0.003). CONCLUSIONS: Most physicians in our sample were willing to discharge actual and hypothetical patients from their practices. This tendency may have significant implications for the initiation of pay-for-performance programs. Physicians should be educated about the importance of the patient-physician relationship and their fiduciary obligations to the patient.

Two-team management of vascular injuries concomitant with osteo-articular injuries in 36 patients over six years.

BACKGROUND: Patients with both vascular and osteoarticular injuries require multidisciplinary management. Vascular injuries may be function- and/or life-threatening. The lower limbs are predominantly affected. Traffic, domestic, and work-related accidents contribute most of the cases. The primary objective of this study was to describe the management of patients with concomitant vascular and osteo-articular injuries, with special attention to the rates of amputation and fasciotomy. The secondary objective was to suggest a management sequence to optimise our surgical practice. HYPOTHESIS: The management sequence is a crucial consideration in patients with both vascular and osteo-articular injuries. MATERIAL AND METHODS: A 6-year, retrospective, observational study was conducted in patients with concomitant vascular and osteo-articular injuries. RESULTS: The study included 36 patients with a mean age of 40.6±22.1 years. The main sources of injury were traffic accidents (n=19, 52.8%), crush injury (n=8, 22.2%), and falls (n=5, 13.9%). A compound fracture was present in 20 (55.6%) patients. Evidence of ischaemia in 25 (69.4%) patients, and bleeding in 11 (30.6%) patients. Pre-operative imaging, by ultrasonography or computed tomography, was performed in 27 (75.0%) patients. The lower limb was involved in 30 (83.3%) patients, who had osteoarticular injuries to the femur and leg combined with injury to the popliteal artery. Fasciotomy was performed in 11 (30.6%) patients and secondary amputation in 7 (19.4%) patients. The limb salvage rate was 80.6%. Median patient survival was 9.3 [0-74.8] months. DISCUSSION: Coordinated work by two surgical teams is crucial to manage concomitant vascular and osteo-articular injuries. The management sequence must be defined clearly. Computed tomography angiography is the investigation of choice and should be performed at the slightest suspicion of vascular injury. LEVEL OF EVIDENCE: IV, retrospective observational study.

Polyphyletic origins of bacterial Nramp transporters.

The redox-active metals iron and manganese are required for energy metabolism, protection against oxidative stress and defense against infections. In eukaryotes, both divalent metals are transported by Nramp transporters. The sequence of these transporters was remarkably conserved during evolution. Several bacterial Nramp homologs (MntH) are also proton-dependent manganese transporters. Here, we present phylogenetic evidence for the polyphyletic origins of three groups of MntH proteins and for possible Nramp horizontal gene transfer with eukaryotes. We propose that the evolution of the MntH/Nramp family is related to adaptation to oxidative environments, including those arising during infection of animals and plants.

Physicians' decisions to withhold and withdraw life-sustaining treatment.

BACKGROUND: Few data are available about physicians' decisions in regard to withholding or withdrawing life-sustaining measures. We therefore studied internists' views on this subject. METHODS: We surveyed 1000 generalist and subspecialist internists about their views on withholding or withdrawing life-sustaining treatment. Thirty-two hypothetical cases were included. The effect of the demographic data on withholding or withdrawing treatment was analyzed via analysis of covariance and multiple logistic regression. RESULTS: Of 1000 internists, 407 (41%) completed and returned surveys. A majority of respondents (51%) were willing to withhold or withdraw treatment in all 32 scenarios; 49% were unwilling to withhold or withdraw in at least 1 scenario. Respondents were likely to withhold treatment in 14 of 16 scenarios compared with 13.7 of 16 scenarios for withdrawing treatments (P<.001). Respondents withheld or withdrew feeding tubes in 6.6 of 8 scenarios (P<.001) and antibiotics in 6.7 of 8 scenarios (P = .001) compared with ventilators (7.1 of 8 scenarios) and dialysis (7.3 of 8 scenarios). Respondents were less likely to withhold or withdraw treatments in nonterminally ill (12.9 of 16 scenarios) (P = .02) and alert patients (13.2 of 16 scenarios) (P<.001) compared with terminally ill patients (14.9 of 16 scenarios) and patients with dementia (14.5 of 16 scenarios). CONCLUSIONS: A large percentage of internists would be unwilling to adhere to some of patients' wishes to withhold or withdraw life-sustaining treatment. The clinical scenario and type of treatment affect internists' decisions about whether they would withhold or withdraw such treatment.

Radiation exposure and the orthopedic surgeon's hand: Measurement of the equivalent dose over 13 months.

Exposure to ionizing radiation in the operating room is governed by practical prevention and protection measures on the international, national and local levels. We evaluated the equivalent dose to the hand of an orthopedic surgeon over 13 months. An orthopedic surgeon wore a ring dosimeter on the ring finger of his right hand for all surgical procedures requiring intraoperative fluoroscopy between March 2014 and April 2015. Monthly doses were evaluated by the IRSN over the study period. The number and type of procedures were compiled as well as the type of fluoroscopy unit used. Four hundred procedures were performed during this period, including 182 with fluoroscopy. The equivalent cumulative dose at the hand was 4,75 mSv. No correlation was found with the type of procedure or type of fluoroscopy unit (conventional or mini C-arm). Equivalent doses were below the annual regulatory limit in France of 500 mSv. These results are consistent with those reported in the literature. However, recent studies have noted that both younger surgeons in training and more experienced surgeons must remember to use radiation protection measures.

Altered mental status from olanzapine overdose treated with physostigmine.

BACKGROUND: Olanzapine is commonly prescribed to patients with schizophrenia. One retrospective study demonstrates the efficacy of physostigmine in reversing mental status changes induced by olanzapine. We report two patients with delirium due to confirmed olanzapine overdose treated with physostigmine. One patient's mental status transiently returned to normal. The other patient completely recovered. CASE 1: A 25-year-old man ingested 300 mg of olanzapine. On presentation, he was agitated, delirious, tachycardic, had dry skin and mucous membranes, and dilated pupils (6 mm) minimally reactive to light. Physostigmine, 0.5 mg, was given intravenously (IV) without effect. Additional physostigmine doses of 1.5 mg IV administered 5 minutes later and then 1 mg IV resulted in the patient having a clear sensorium and normal mentation. The patient's mental status continued to remain normal for the duration of his hospital stay. Olanzapine was identified in the urine by high performance liquid chromatography. CASE 2: A 20-year-old female ingested 600 mg of olanzapine. On presentation, she was tachycardic, obtunded, and minimally responsive to painful stimuli, with decreased bowel sounds, dry skin and dry mucous membranes. Physostigmine, 2 mg, was given IV. Shortly thereafter she regained full consciousness and began speaking coherently. She remained in this condition for approximately 30 minutes, and then became obtunded. Her serum olanzapine concentration was 1230 ng/mL. No further doses of physostigmine were administered. On day 3 of admission her mental status returned to normal. CONCLUSION: We report two cases of olanzapine-induced mental status changes treated with physostigmine. The utility of physostigmine as a safe or necessary antidote in the setting of olanzapine overdose remains to be determined.

[Treatment of extra-articular distal radius fractures in active elderly patients]. / Traitement des fractures extra-articulaires de l'extrémité distale du radius du sujet âgé autonome.

Extra-articular distal radius fractures in active elderly patients are common and predominantly affect females. The high number of patients lost to follow-up compromises the evaluation of outcomes. Treatment aims to control the comminution and allow fast recovery of pre-injury activity levels. Fixation with volar locking plates is the gold standard. The role of bone substitutes in this type of injury is unclear.

Physicians' willingness to report impaired colleagues.

We surveyed physicians to determine what factors were associated with their reporting of impaired colleagues to Physician Health Programs (PHPs). We conducted a cross-sectional mail survey of 1000 randomly selected practicing physicians in the United States. A survey instrument asked the physicians whether they would report 10 hypothetical impaired colleagues to a PHP. The results show that a majority of the physicians would report physicians to PHPs, but were more likely to report hypothetical physicians involved in substance abuse than those who were emotionally or cognitively impaired (p<0.001). Respondents who felt they had a societal obligation as opposed to an obligation to protect the rights of the individual (p=0.006) were more likely to report hypothetical physicians. Those respondents who stated they knew of guidelines on reporting impaired physicians had more frequently reported impaired colleagues (p<0.001). We conclude that physicians should be educated on the availability and functioning of PHPs and the ethical and legal obligations of assisting impaired colleagues.