Modeling iatrogenic intraoperative hyperthermia from external warming in children: A pooled analysis from two prospective observational studies.

BACKGROUND: Maintenance of normothermia is an important quality metric in pediatric anesthesia. While inadvertent hypothermia is effectively prevented by forced-air warming, this therapeutic approach can lead to iatrogenic hyperthermia in young children. AIMS: To estimate the influence of external warming by forced air on the development of intraoperative hyperthermia in anesthetized children aged 6 years or younger. METHODS: We pooled data from two previous clinical studies. Primary outcome was the course of core temperature over time analyzed by a quadratic regression model. Secondary outcomes were the incidence of hyperthermia (body core temperature >38°C), the probability of hyperthermia over the duration of warming in relation to age and surface-area-to-weight ratio, respectively, analyzed by multiple logistic regression models. The influence of baseline temperature on hyperthermia was estimated using a Cox proportional hazards model. RESULTS: Two hundred children (55 female) with a median age of 2.1 [1st -3rd quartile 1-4.2] years were analyzed. Mean temperature increased by 0.43°C after 1 h, 0.64°C after 2 h, and reached a peak of 0.66°C at 147 min. Overall, 33 children were hyperthermic at at least one measurement point. The odds ratios of hyperthermia were 1.14 (95%-CI: 1.07-1.22) or 1.13 (95%-CI: 1.06-1.21) for every 10 min of warming therapy in a model with age or surface-area-to weight ratio (ceteris paribus), respectively. Odds ratio was 1.33 (95%-CI: 1.07-1.71) for a decrease of 1 year in age and 1.63 (95%-CI: 0.93-2.83) for an increase of 0.01 in the surface-to-weight-area ratio (ceteris paribus). An increase of 0.1°C in baseline temperature increased the hazard of becoming hyperthermic by a factor of 1.33 (95%-CI: 1.23-1.43). CONCLUSIONS: In children, external warming by forced-air needs to be closely monitored and adjusted in a timely manner to avoid iatrogenic hyperthermia especially during long procedures, in young age, higher surface-area-to-weight ratio, and higher baseline temperature.

Chronic Scrotal Content Pain: a Review of the Literature and Management Schemes.

PURPOSE OF REVIEW: Chronic scrotal content pain (CSCP) is a complex condition with multiple etiologies that requires a thorough understanding of its pathophysiology, workup, and treatment options. We performed a comprehensive and contemporary review to augment our current understanding of CSCP. RECENT FINDINGS: We discuss new advances in CSCP-specific pain questionnaires, modern studies of microscopic spermatic cord denervation and its variations, and novel techniques including electric nerve stimulation and cryoablation in addition to randomized control trials with significant negative findings. We also present literature focusing on the prevention of CSCP secondary to surgical iatrogenic causes. The constantly evolving literature of CSCP has led to the significant evolution in its diagnosis and treatment, from oral medications to salvage options after microscopic spermatic cord denervation. With each advance, we come closer to developing a more thorough, evidence-based algorithm to guide urologists in treatment of CSCP.

Introduction to host microbiome symbiosis in health and disease.

Humans share a core intestinal microbiome and yet human microbiome differs by genes, species, enterotypes (ecology), and gene count (microbial diversity). Achievement of microbiota metagenomic analysis has revealed that the microbiome gene count is a key stratifier of health in several immune disorders and clinical conditions. We review here the progress of the metagenomic pipeline analysis, and how this has allowed us to define the host-microbe symbiosis associated with a healthy status. The link between host-microbe symbiosis disruption, the so-called dysbiosis and chronic diseases or iatrogenic conditions is highlighted. Finally, opportunities to use microbiota modulation, with specific nutrients and/or live microbes, as a target for personalized nutrition and therapy for the maintenance, preservation, or restoration of host-microbe symbiosis are discussed.

Managing central venous access during a health care crisis.

OBJECTIVE: During the COVID-19 pandemic, central venous access line teams were implemented at many hospitals throughout the world to provide access for critically ill patients. The objective of this study was to describe the structure, practice patterns, and outcomes of these vascular access teams during the COVID-19 pandemic. METHODS: We conducted a cross-sectional, self-reported study of central venous access line teams in hospitals afflicted with the COVID-19 pandemic. To participate in the study, hospitals were required to meet one of the following criteria: development of a formal plan for a central venous access line team during the pandemic; implementation of a central venous access line team during the pandemic; placement of central venous access by a designated practice group during the pandemic as part of routine clinical practice; or management of an iatrogenic complication related to central venous access in a patient with COVID-19. RESULTS: Participants from 60 hospitals in 13 countries contributed data to the study. Central venous line teams were most commonly composed of vascular surgery and general surgery attending physicians and trainees. Twenty sites had 2657 lines placed by their central venous access line team or designated practice group. During that time, there were 11 (0.4%) iatrogenic complications associated with central venous access procedures performed by the line team or group at those 20 sites. Triple lumen catheters, Cordis (Santa Clara, Calif) catheters, and nontunneled hemodialysis catheters were the most common types of central venous lines placed by the teams. Eight (14%) sites reported experience in placing central venous lines in prone, ventilated patients with COVID-19. A dedicated line cart was used by 35 (59%) of the hospitals. Less than 50% (24 [41%]) of the participating sites reported managing thrombosed central lines in COVID-19 patients. Twenty-three of the sites managed 48 iatrogenic complications in patients with COVID-19 (including complications caused by providers outside of the line team or designated practice group). CONCLUSIONS: Implementation of a dedicated central venous access line team during a pandemic or other health care crisis is a way by which physicians trained in central venous access can contribute their expertise to a stressed health care system. A line team composed of physicians with vascular skill sets provides relief to resource-constrained intensive care unit, ward, and emergency medicine teams with a low rate of iatrogenic complications relative to historical reports. We recommend that a plan for central venous access line team implementation be in place for future health care crises.

Aristolochia Herbs and Iatrogenic Disease: The Case of Portland's Powders.

Aristolochia herbals have a 2500-year history of medicinal use. We focused this article on Portland's Powders, an 18th-century British gout medicine containing Aristolochia herbs. The powders constitute an 18th-century iteration of an herbal remedy, which was used, with variations, since at least the fifth century BCE. The use of Portland's Powders in Great Britain may appear to be an unusual choice for investigating a public health problem currently widespread in Asia. Yet it exemplifies long-term medicinal use of Aristolochia herbs, reflecting our argument that aristolochic acid nephropathy (AAN) is a historically persistent iatrogenic disease. Moreover, we provide compelling evidence that individuals taking Portland's Powders for gout would have ingested toxic quantities of aristolochic acid, which causes AAN and cancer. Several factors, including long history of use, latency of toxic effects, and lack of effective regulation, perpetuate usage of Aristolochia herbals to the present day.

Catheter Ablation of Idiopathic Ventricular Arrhythmias Originating from the Para-Hisian area - QRS Morphology Change and Late Effect of the Ablation: Case Series.

INTRODUCTION: Radiofrequency catheter ablation of idiopathic ventricular arrhythmias originating in the para-Hisian region could be challenging because of a potential risk of iatrogenic atrioventricular block. Uncommonly, shift of the exit site during the ablation can be observed. Consequently, different approaches of radiofrequency catheter ablation of para-Hisian ventricular foci can be needed. CASE SERIES PRESENTATION: Three patients (2 males) underwent electroanatomical mapping and catheter ablation for idiopathic premature ventricular contractions originating near the His bundle. Patients underwent 24-h ECG Holter monitoring during follow-up. All patients had premature ventricular contractions with left bundle branch block morphology and inferior or horizontal axis. However, change of QRS morphology during ablation was observed, due to a change in the exit site. In two patients there was reduction of the arrhythmia burden after initially unsuccessful procedure. Mapping and ablation in the aortic root were needed in one patient. There were no complications. DISCUSSION: Radiofrequency catheter ablation of para-Hisian ventricular arrhythmias is feasible and safe when performed cautiously. A change in the premature ventricular contractions' morphology and exit site during ablation may ensue; therefore, extensive mapping on both sides of the interventricular septum as well as in the aortic root may be warranted.

Decreasing Hypoglycemia following Insulin Administration for Inpatient Hyperkalemia.

BACKGROUND: Acute hyperkalemia (serum potassium ≥ 5.1 mEq/L) is often treated with a bolus of IV insulin. This treatment may result in iatrogenic hypoglycemia (glucose < 70 mg/dl). OBJECTIVES: The aims of this study were to accurately determine the frequency of iatrogenic hypoglycemia following insulin treatment for hyperkalemia, and to develop an electronic health record (EHR) orderset to decrease the risk for iatrogenic hypoglycemia. DESIGN: This study was an observational, prospective study. SETTING: The setting for this study was a university hospital. PATIENTS: All nonobstetric adult inpatients in all acute and intensive care units were eligible. INTERVENTION: Implementation of a hyperkalemia orderset (Orderset 1.1) with glucose checks before and then one, two, four, and six hours after regular intravenous insulin administration. Based on the results from Orderset 1.1, Orderset 1.2 was developed and introduced to include weight-based dosing of insulin options, alerts identifying patients at higher risk of hypoglycemia, and tools to guide decision-making based on the preinsulin blood glucose level. MEASUREMENTS: Patient demographics, weight, diabetes history, potassium level, renal function, and glucose levels were recorded before, and then glucose levels were measured again at one, two, four, and six hours after insulin was administered. RESULTS: The iatrogenic hypoglycemia rate identified with mandatory glucose checks in Orderset 1.1 was 21%; 92% of these occurred within three hours posttreatment. Risk factors for hypoglycemia included decreased renal function (serum creatinine >2.5 mg/dl), a high dose of insulin (>0.14 units/kg), and re-treatment with blood glucose < 140 mg/dl. After the introduction of Orderset 1.2, the rate of iatrogenic hypoglycemia decreased to 10%. CONCLUSIONS: The use of an EHR orderset for treating hyperkalemia may reduce the risk of iatrogenic hypoglycemia in patients receiving insulin while still adequately lowering their potassium.

[Prevention of iatrogenic risk and screening of chronic kidney disease]. / Maladie rénale chronique : prévention des risques de iatrogénies médicamenteuses et dépistage de la maladie.

Ten percent of the world's population is affected by chronic kidney disease that can lead to kidney failure. In France, nearly three million people are concerned, half of whom are undiagnosed, 85,000 people are on dialysis or waiting for a kidney transplant. Each year, 11,000 new diagnoses of severe renal failure are made, one third of which had not been treated before. Kidney failure is constantly increasing due to the aging of the population and the resurgence of chronic diseases, including obesity and cardiovascular diseases such as high blood pressure and diabetes, two conditions that impair renal function. The pharmacist, a local actor, is well placed to help patients adhere to their treatment and manage it to the best of their quality of life. It is up to the pharmacist to check the dosages according to the degree of renal involvement, ideally noted on the prescription or, failing that, by asking the patient the results of his recent biological examinations. The consultation of the pharmaceutical file and, ultimately, the shared medical file, will make it possible, in a concerted management of the patient's care pathway, to also detect possible drug interactions. By dispensing the prescribed drugs, the pharmacist can also warn against those known to be known for their nephrotoxicity, especially nonsteroidal anti-inflammatory drugs. In the case of over-the-counter products, the pharmacist may discourage a person at risk from taking certain drugs containing nonsteroidal anti-inflammatory drugs, including aspirin and ibuprofen. Because of their potential renal toxicity, the pharmacist is competent to alert, especially on certain food supplements, herbal products, and is legitimate to participate in screening campaigns.

Prediction Model for Choosing Needle Length to Minimize Risk of Median Nerve Puncture With Dry Needling of the Pronator Teres.

OBJECTIVE: The aim of this study was to relate forearm anthropometric measures to ultrasound pronator teres depth to determine the necessary needle length to prevent median nerve (MN) injury during pronator teres dry needling. METHODS: We conducted a study employing a diagnostic accuracy prediction model (NCT03308279) at a Spanish university center. The study recruited 65 participants to predict the depth of the MN (measured with ultrasound) in the pronator teres using a decision tree algorithm to reduce the risk of MN puncture using 2 needle lengths (13 mm or 25 mm). The decision tree was developed by automatically selecting a cutoff for body mass index, forearm length and circumference, and pronator teres thickness. RESULTS: For forearm circumferences ≤27.5 cm, the predictive value for the 13-mm needle was 92%. For forearm circumferences >27.5 cm and forearm lengths ≤26.75 cm, the predictive value for the 25-mm needle was 100%. CONCLUSION: Based upon the findings of this study, we suggest that needle length should be selected according to forearm anthropometric measures to prevent MN injury during pronator teres dry needling.

Harm in Hypnosis: Three Understandings From Psychoanalysis That Can Help.

Over 50 years of empirical data demonstrate unequivocally that psychotherapy can cause harm as well as good. Two therapist factors increasing harm risk are inadequate assessment of patients' vulnerabilities and certain attitudes/affects. Adding hypnosis as a technique within psychotherapy heightens risk for harm because: (a) trance can unexpectedly expose patient vulnerabilities (through loosening reality orientation, lessening structure, generating unfamiliar sensations and perceptions, and intensifying access to interior information such as emotions and imagery); and (b) trance can unexpectedly increase porousness to therapist's attitudes/affects (through heightening mental receptivity to the internal states of others). A century of clinical data from psychoanalysis offers guidance for protecting against such risks. Concepts of structure, interiority, and countertransference are explicated and translated into practical clinical suggestions for harm prevention.

The Hospital-Acquired Conditions (HAC) reduction program: using cranberry treatment to reduce catheter-associated urinary tract infections and avoid Medicare payment reduction penalties.

OBJECTIVE: The Affordable Care Act (ACA) established the Hospital-Acquired Condition (HAC) Reduction Program. The Centers for Medicare and Medicaid Services (CMS) established a total HAC scoring methodology to rank hospitals based upon their HAC performance. Hospitals that rank in the lowest quartile based on their HAC score are subject to a 1% reduction in their total Medicare reimbursements. In FY 2017, 769 hospitals incurred payment reductions totaling $430 million. This study analyzes how improvements in the rate of catheter-associated urinary tract infections (CAUTI), based on the implementation of a cranberry-treatment regimen, impact hospitals' HAC scores and likelihood of avoiding the Medicare-reimbursement penalty. METHODS: A simulation model is developed and implemented using public data from the CMS' Hospital Compare website to determine how hospitals' unilateral and simultaneous adoption of cranberry to improve CAUTI outcomes can affect HAC scores and the likelihood of a hospital incurring the Medicare payment reduction, given results on cranberry effectiveness in preventing CAUTI based on scientific trials. The simulation framework can be adapted to consider other initiatives to improve hospitals' HAC scores. RESULTS: Nearly all simulated hospitals improved their overall HAC score by adopting cranberry as a CAUTI preventative, assuming mean effectiveness from scientific trials. Many hospitals with HAC scores in the lowest quartile of the HAC-score distribution and subject to Medicare reimbursement reductions can improve their scores sufficiently through adopting a cranberry-treatment regimen to avoid payment reduction. LIMITATIONS: The study was unable to replicate exactly the data used by CMS to establish HAC scores for FY 2018. The study assumes that hospitals subject to the Medicare payment reduction were not using cranberry as a prophylactic treatment for their catheterized patients, but is unable to confirm that this is true in all cases. The study also assumes that hospitalized catheter patients would be able to consume cranberry in either juice or capsule form, but this may not be true in 100% of cases. CONCLUSION: Most hospitals can improve their HAC scores and many can avoid Medicare reimbursement reductions if they are able to attain a percentage reduction in CAUTI comparable to that documented for cranberry-treatment regimes in the existing literature.

Reducing hospital-acquired pressure ulcers using bundle methodology in pediatric and neonatal patients receiving extracorporeal membrane oxygenation therapy: An integrative review and call to action.

PURPOSE: This review focuses on identifying (1) evidence of the effectiveness of care bundle methodology to reduce hospital-acquired pressure ulcers (HAPUs) in pediatric and neonatal patients receiving extracorporeal membrane oxygenation (ECMO) therapy and (2) barriers to implementing HAPU care bundles in this at-risk population. DESIGN AND METHODS: An integrative review was conducted and reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A search of the scientific literature was performed. Studies included were published between January 2011 and February 2016. A total of seven articles met inclusion criteria. Data were extracted from each published article and analyzed to identify common themes, specifically bundle methodology and barriers to implementing HAPU bundles, in this population. RESULTS: There is limited research on effectiveness of care bundle methodology in reducing HAPUs in children, and no research specific to its effectiveness in pediatric or neonatal ECMO patients. No research was identified studying barriers to implementation of HAPU care bundles in this population. PRACTICE IMPLICATIONS: Nurses are well poised to test innovative strategies to prevent HAPUs. Nurses should consider implementing and testing bundle methodology to reduce HAPU in this at-risk population, and conduct research to identify any barriers to implementing this strategy. There is literature to support the use of nurses as unit-based skin care champions to facilitate teamwork and reliable use of the bundle, both critical components to the success of bundle methodology.

Clowning as a Complementary Approach for Reducing Iatrogenic Effects in Pediatrics.

Hospitalized children who undergo painful procedures are more susceptible than others to experiencing iatrogenic effects, such as anxiety, pain, and severe stress. Clowns in clinical setting have been found to be effective in reducing children's experiences of these effects during hospitalization and before procedures. This article provides an overview of clowning in health care settings; reviews major studies conducted on clowning for hospitalized children, discussing evidence that clown interventions decrease pain and distress in pediatric patients; and concludes with a discussion of health care clowning as a profession.

Intervención terapéutica farmacológica del deterioro cognitivo leve / Pharmacological therapeutic intervention in mild cognitive impairment

El deterioro cognitivo leve es un síndrome en el que, además de sintomatología cognitiva, se pueden encontrar sintomatología afectiva y conductual y diferentes subtipos. Se trata de una entidad clínica heterogénea, que tiene heterogeneidad etiológica (degenerativa, vascular, psiquiátrica, patología no neurológica), sintomatología clínica heterogénea y heterogeneidad en el curso clínico. La etiología es múltiple y, por lo mismo, el tratamiento también lo es y se debe combinar con el no farmacológico. Se describen las intervenciones farmacológicas tanto preventivas como terapéuticas: control de factores de riesgo vascular, evitar la iatrogenia, uso de suplementos nutracéuticos, la CDP-colina, el Ginkgo biloba EGb 761(R) y la mejora de órganos de los sentidos (AU)

Mild cognitive impairment (MCI) is a syndrome encompassing affective and behavioural symptoms and various subtypes. MCI is a heterogeneous clinical entity with varied causes (degenerative, vascular, psychiatric, non-neurological disorders), and there is wide variation in symptoms and clinical course. There are multiple causes and consequently various treatments can be applied and should be combined with non-pharmacological measures. This article describes both preventive and therapeutic pharmacological interventions: control of vascular risk factors, avoidance of iatrogeny, use of nutraceuticals, CDP-choline, and Ginkgo biloba EGb 761(R), and improvement in sense organs (AU)

Effects of a pre-operative home-based inspiratory muscle training programme on perceived health-related quality of life in patients undergoing coronary artery bypass graft surgery.

OBJECTIVES: Pre-operative inspiratory muscle training has been shown to decrease the incidence of postoperative pneumonia and length of hospital stay in patients undergoing coronary artery bypass graft surgery (CABG). This study investigated if this decrease acted as a mediator on the time course of quality of life. DESIGN: Complementary analyses of a published randomised controlled trial. SETTING AND PARTICIPANTS: The initial trial included patients awaiting CABG surgery at a Dutch university hospital. The secondary analyses used data from the initial trial for patients who had completed at least one quality-of-life questionnaire. METHODS: Participants were allocated at random to the intervention group or the usual care group. The intervention group followed a home-based pre-operative inspiratory muscle training programme. Quality of life was measured at five time points. Between-group differences in quality-of-life scores were analysed using mixed linear modelling. RESULTS: The secondary analyses used data for 235 patients. In line with the initial trial, pneumonia and length of hospital stay were decreased significantly in the intervention group. The time courses for all patients showed significant improvements in quality of life after surgery compared with baseline. No significant differences in quality of life were observed over time between the two groups. CONCLUSION: Despite decreased incidence of pneumonia and length of hospital stay in the intervention group, this study did not find any improvements in quality of life due to the pre-operative home-based inspiratory muscle training programme. Clinical trial registration number ISRCTN17691887.

[Prevention of intraoperative incidental injuries during sphincter-preserving surgery for rectal cancer and management of postoperative complication].

Prevention of intraoperative incidental injuries during radical operation for rectal cancer and management of postoperative complication are associated with successful operation and prognosis of patients. This paper discusses how to prevent such intraoperative incidental injuries and how to manage postoperative complication. (1) Accurate clinical evaluation should be performed before operation and reasonable treatment decision should be made, including determination of the distance from transection to lower margin of the tumor, T and M staging evaluated by MRI, fascia invasion of mesorectum, metastasis of lateral lymph nodes, metastatic station of mesentery lymph node, association between levator ani muscle and anal sphincter, course and length of sigmoid observed by Barium enema, length assessment of pull-through bowel. Meanwhile individual factors of patients and tumors must be realized accurately. (2) Injury of pelvic visceral fascia should be avoided during operation. Negative low and circumference cutting edge must be ensured. Blood supply and adequate length of pull-down bowel must be also ensured. Urinary system injury, pelvic bleeding and intestinal damage should be avoided. Team cooperation and anesthesia procedure should be emphasized. Capacity of handling accident events should be cultivated for the team. (3) intraoperative incidental injuries during operation by instruments should be avoided, such as poor clarity of camera due to spray and smog, ineffective instruments resulted from repeated usage. (4) As to the prevention and management of postoperative complication of rectal cancer operation, prophylactic stoma should be regularly performed for rectal cancer patients undergoing anterior resection, while drainage tube placement does not decrease the morbidities of anastomosis and other complications. After sphincter-preserving surgery for rectal cancer, attentions must be paid to the occurrence of anastomotic bleeding, pelvic bleeding, anastomotic fistula, ileus, intestinal necrosis and anastomotic stenosis. After sphincter-preserving surgery for rectal cancer, if small amount of bleeding happens, titanium clamp or electric coagulation can be used; if delayed pelvic bleeding occurs obviously, embolism should be applied. Conservative treatment may be used for the non-carcinomatous ileus. When small anastomotic stenosis is found, local treatment is available (finger dilation, balloon expansion, transanal radiated cutting or resection), and for severe stenosis, transadominal operation is required.

Addressing Disease-Related Malnutrition in Healthcare: A Latin American Perspective.

Alarmingly high rates of disease-related malnutrition have persisted in hospitals of both emerging and industrialized nations over the past 2 decades, despite marked advances in medical care over this same interval. In Latin American hospitals, the numbers are particularly striking; disease-related malnutrition has been reported in nearly 50% of adult patients in Argentina, Brazil, Chile, Costa Rica, Cuba, Dominican Republic, Ecuador, Mexico, Panama, Paraguay, Peru, Puerto Rico, Venezuela, and Uruguay. The tolls of disease-related malnutrition are high in both human and financial terms-increased infectious complications, higher incidence of pressure ulcers, longer hospital stays, more frequent readmissions, greater costs of care, and increased risk of death. In an effort to draw attention to malnutrition in Latin American healthcare, a feedM.E. Latin American Study Group was formed to extend the reach and support the educational efforts of the feedM.E. Global Study Group. In this article, the feedM.E. Latin American Study Group shows that malnutrition incurs excessive costs to the healthcare systems, and the study group also presents evidence of how appropriate nutrition care can improve patients' clinical outcomes and lower healthcare costs. To achieve the benefits of nutrition for health throughout Latin America, the article presents feedM.E.'s simple and effective Nutrition Care Pathway in English and Spanish as a way to facilitate its use.

Preoperative transcutaneous electrical nerve stimulation for localizing superficial nerve paths.

During surgery, peripheral nerves are often seen to follow unpredictable paths because of previous surgeries and/or compression caused by a tumor. Iatrogenic nerve injury is a serious complication that must be avoided, and preoperative evaluation of nerve paths is important for preventing it. In this study, transcutaneous electrical nerve stimulation (TENS) was used for an in-depth analysis of peripheral nerve paths. This study included 27 patients who underwent the TENS procedure to evaluate the peripheral nerve path (17 males and 10 females; mean age: 59.9 years, range: 18-83 years) of each patient preoperatively. An electrode pen coupled to an electrical nerve stimulator was used for superficial nerve mapping. The TENS procedure was performed on patients' major peripheral nerves that passed close to the surgical field of tumor resection or trauma surgery, and intraoperative damage to those nerves was apprehensive. The paths of the target nerve were detected in most patients preoperatively. The nerve paths of 26 patients were precisely under the markings drawn preoperatively. The nerve path of one patient substantially differed from the preoperative markings with numbness at the surgical region. During surgery, the nerve paths could be accurately mapped preoperatively using the TENS procedure as confirmed by direct visualization of the nerve. This stimulation device is easy to use and offers highly accurate mapping of nerves for surgical planning without major complications. The authors conclude that TENS is a useful tool for noninvasive nerve localization and makes tumor resection a safe and smooth procedure.

The frequency and impact of hypoglycemia among hospitalized patients with diabetes: A population-based study.

We aimed to evaluate the frequency of hypoglycemia and its impact on the length of stay and all-cause in-hospital mortality in hospitalized patients with diabetes. We used data from the Basic Minimum Data Set of the Spanish National Health System. Hypoglycemia was defined as having an ICD-9-CM code 250.8, 251.0, 251.1, and 251.2, and categorized as primary if it was the main cause of admission and secondary if it occurred during the hospital stay. The association between hypoglycemia and the study outcomes was evaluated in two cohorts - with and without secondary hypoglycemia - matched by propensity scores and using multivariate models. Among the 5,447,725 discharges with a diagnosis of diabetes recorded from January 1997 to December 2010, there were 92,591 (1.7%) discharges with primary hypoglycemia and 154,510 (2.8%) with secondary hypoglycemia. The prevalence of secondary hypoglycemia increased from 1.1% in 1997 to a peak of 3.8% in 2007, while the prevalence of primary hypoglycemia remained fairly stable. Primary hypoglycemia was associated with reduced in-hospital mortality (Odds ratio [OR] 0.06; 95% Confidence interval [CI], 0.03-0.10) and a significant decrease in time to discharge (Hazard ratio [HR] 2.53; 95% CI, 2.30-2.76), while secondary hypoglycemia was associated with an increased likelihood of in-hospital mortality (OR 1.12; 95% CI, 1.09-1.15) and a significant increase in time to discharge (HR 0.80; 95% CI, 0.79-0.80). In conclusion, the prevalence of secondary hypoglycemia is increasing in patients with diabetes and is associated with an increased likelihood of in-hospital mortality and a longer hospital stay.

Dental treatment for high-risk patients with refractory heart failure: a retrospective observational comparison study.

OBJECTIVE: Heart failure affects large population groups. The understanding of the etiology, pathophysiology, and treatment of heart failure has changed considerably within the last few years. The changes have significant implications for the medical management of the disease, as well as on the ability to provide proper dental treatment for these patients. METHOD AND MATERIALS: A retrospective observational study of the outcome following dental treatment of 54 patients was performed: 32 with refractory heart failure stage D (study group) and 22 patients at risk for heart failure stages A to C (control group). Dental management of these patients concentrated on the prevention of iatrogenic, dental setting- induced, and precipitating factors of heart failure. To prevent deterioration of patients' medical condition, a comprehensive, tailored treatment including adequate anxiolysis, close monitoring, profound dental anesthesia, and close follow-up was used. A previously described three-step gradual level protocol (at home, waiting room, and dental chair) was adopted. RESULTS: All the planned dental procedures were successfully completed. Six patients experienced respiratory distress during treatment, and five patients demonstrated arrhythmias during dental treatment. Only minute differences were found between the groups regarding blood pressure and heart rate. CONCLUSION: Use of the suggested protocol facilitated the completion of planned dental treatments for all patients. Thus, providing essential dental treatment for severe heart failure patients with special attention to their medical problems and the use of medications and supporting means to prevent health-compromising situations is recommended.