Acupuncture-D" - Bilateral Pneumothoraces Following Dry Needling.

Presentation A 24-year-old newly graduated junior doctor presented to the emergency department with acute onset chest pain, haemoptysis and exertional dyspnoea following a dry needling session. Diagnosis Chest x-ray showed bilateral pneumothoraces, worse on the right side. Treatment The bilateral pneumothoraces were treated conservatively with supplemental oxygen initially. On the second day of admission, repeat chest x-ray demonstrated a worsening right sided pneumothorax. While vitally stable, the patient however had become increasingly dyspnoeic, and a needle aspiration was performed on the right side with good effect. Conclusion The anatomical location targeted along with the patients low-normal BMI makes her high-risk when considering the skin-to-pleura distance. Although the incidence of pneumothorax is low, it is imperative that we improve awareness both for the treating physician and the diagnosing clinician. We must begin to fill the distinct lack in available literature surrounding the potential adverse effects of dry needling.

A randomized clinical trial to evaluate the efficacy and safety of rivaroxaban in patients with bioprosthetic mitral valve and atrial fibrillation or flutter: Rationale and design of the RIVER trial.

The efficacy and safety of rivaroxaban in patients with bioprosthetic mitral valves and atrial fibrillation or flutter remain uncertain. DESIGN: RIVER was an academic-led, multicenter, open-label, randomized, non-inferiority trial with blinded outcome adjudication that enrolled 1005 patients from 49 sites in Brazil. Patients with a bioprosthetic mitral valve and atrial fibrillation or flutter were randomly assigned (1:1) to rivaroxaban 20 mg once daily (15 mg in those with creatinine clearance <50 mL/min) or dose-adjusted warfarin (target international normalized ratio 2.0-30.); the follow-up period was 12 months. The primary outcome was a composite of all-cause mortality, stroke, transient ischemic attack, major bleeding, valve thrombosis, systemic embolism, or hospitalization for heart failure. Secondary outcomes included individual components of the primary composite outcome, bleeding events, and venous thromboembolism. SUMMARY: RIVER represents the largest trial specifically designed to assess the efficacy and safety of a direct oral anticoagulant in patients with bioprosthetic mitral valves and atrial fibrillation or flutter. The results of this trial can inform clinical practice and international guidelines.

Rivaroxaban in Patients with Atrial Fibrillation and a Bioprosthetic Mitral Valve.

BACKGROUND: The effects of rivaroxaban in patients with atrial fibrillation and a bioprosthetic mitral valve remain uncertain. METHODS: In this randomized trial, we compared rivaroxaban (20 mg once daily) with dose-adjusted warfarin (target international normalized ratio, 2.0 to 3.0) in patients with atrial fibrillation and a bioprosthetic mitral valve. The primary outcome was a composite of death, major cardiovascular events (stroke, transient ischemic attack, systemic embolism, valve thrombosis, or hospitalization for heart failure), or major bleeding at 12 months. RESULTS: A total of 1005 patients were enrolled at 49 sites in Brazil. A primary-outcome event occurred at a mean of 347.5 days in the rivaroxaban group and 340.1 days in the warfarin group (difference calculated as restricted mean survival time, 7.4 days; 95% confidence interval [CI], -1.4 to 16.3; P<0.001 for noninferiority). Death from cardiovascular causes or thromboembolic events occurred in 17 patients (3.4%) in the rivaroxaban group and in 26 (5.1%) in the warfarin group (hazard ratio, 0.65; 95% CI, 0.35 to 1.20). The incidence of stroke was 0.6% in the rivaroxaban group and 2.4% in the warfarin group (hazard ratio, 0.25; 95% CI, 0.07 to 0.88). Major bleeding occurred in 7 patients (1.4%) in the rivaroxaban group and in 13 (2.6%) in the warfarin group (hazard ratio, 0.54; 95% CI, 0.21 to 1.35). The frequency of other serious adverse events was similar in the two groups. CONCLUSIONS: In patients with atrial fibrillation and a bioprosthetic mitral valve, rivaroxaban was noninferior to warfarin with respect to the mean time until the primary outcome of death, major cardiovascular events, or major bleeding at 12 months. (Funded by PROADI-SUS and Bayer; RIVER ClinicalTrials.gov number, NCT02303795.).

Vancomycin area under the curve to minimum inhibitory concentration ratio predicting clinical outcome: a systematic review and meta-analysis with pooled sensitivity and specificity.

BACKGROUND: Vancomycin is a first-line antibiotic for methicillin-resistant Staphylococcus aureus infections or other Gram-positive infections. The area under the curve (AUC) to minimum inhibitory concentration (MIC) ratio is proposed as a therapeutic drug-monitoring parameter. How well clinical efficacy is predicted by this measure has not been established. OBJECTIVE: Determine the test performance characteristics (TPC) of AUC:MIC of vancomycin for prediction of positive outcome. DATA SOURCES: PubMed and Ovid Medline (1946 to 2018) and EMBASE (1974 to 2018). Study Eligibility Criteria and Participants: Studies of patients treated with vancomycin for any type of infection in peer reviewed publications. All patient populations were included. INTERVENTIONS: Vancomycin AUC:MIC or AUC was related to patient clinical outcome. METHODS: Searches of medical databases using relevant terms were performed. Screening, study reviewing, data extracting and assessing data quality was performed independently by two reviewers. Studies were stratified by type of primary outcome for calculation of pooled sensitivity, specificity and construction of hierarchical summary receiver operating characteristic (HSROC) curves. RESULTS: Nineteen studies including 1699 patients were meta-analysed. Pooled sensitivity and specificity were 0.77 (95% CI 0.67-0.84) and 0.62 (95% CI 0.53-0.71) respectively for the seven studies with primary outcome of mortality and 0.65 (95% CI 0.53-0.75), 0.58 (95% CI 0.48-0.67) for studies with composite or clinical cure outcome (n = 12). HSROC curves suggested considerable heterogeneity. An additional 11 studies were described but could not be included for meta-analysis because data were not available. The majority of these studies (9/11) failed to demonstrate a relationship between AUC:MIC and positive clinical outcome. CONCLUSIONS: Vancomycin AUC:MIC performance was modest and inconsistent. Analysis was limited by studies without sufficient data; therefore, meta-analytic results may overestimate TPC values. Given this, as well as the lack of standardization of methods, widespread adoption of AUC:MIC as the preferred vancomycin monitoring parameter may be premature.

Terapia anticoagulante no tromboembolismo venoso / Anticoagulant therapy in venous thromboembolism

Introdução: O tromboembolismo venoso (TEV), incluindo a embolia pulmonar (EP) e a trombose venosa profunda (TVP), é a terceira causa de mortalidade em todo o mundo. O diagnóstico ainda é subestimado nas emergências. Os fatores desencadeantes são bem definidos, o que auxilia a estratificação de risco e o diagnóstico de TEV provocada ou não e influenciará muito o tempo de tratamento. O aumento do ventrículo direito e de marcadores biológicos tem desempenhado grande papel no prognóstico. O quadro clínico é bem definido e tem várias ferramentas, tanto para o diagnóstico como para a estratificação de risco, tais como os critérios de Wells e de Genebra, além de outros. Os exames complementares atualmente estão bem definidos, com a angiografia pulmonar sendo o padrão de referência; porém, com a melhora da tecnologia e a alta sensibilidade e especificidade, a angiotomografia computadorizada ocupou um lugar de destaque. Outros exames ainda são importantes em várias situações, como o D-dímero e outros biomarcadores, a radiografia de tórax, a cintilografia de perfusão/ventilação, eletrocardiograma, ecocardiografia e doppler venoso de membros inferiores. Método: Neste artigo, revisamos aspectos básicos de epidemiologia, diagnóstico e estratificação de risco. O foco principal foi o tratamento com a terapia anticoagulante, sobre a qual revisamos os seis estudos clínicos descritos entre 2009 e 2013, que abordam os novos anticoagulantes orais, hoje denominados anticoagulantes orais diretos. Esses estudos têm desenhos diferentes, com três deles começando com anticoagulantes orais desde o início do quadro agudo de TVP e EP (rivaroxabana e edoxabana). Os outros três iniciaram com enoxaparina e varfarina durante os primeiros dias e depois seguiram com a medicação do grupo em avaliação (dabigatrana e apixabana). Resultados: Nos estudos analisados, todos obtiveram uma redução (valor de p de não inferioridade) dos eventos de recorrência de TEV com relação à varfarina. Nos desfechos de segurança, definidos como sangramento fatal, clinicamente relevante e outros, os novos anticoagulantes orais obtiveram uma diminuição significativa. Conclusões: Os anticoagulantes orais diretos tiveram redução da recorrência de eventos tromboembólicos (periférico e pulmonar), com redução significativa dos índices de sangramentos fatais ou não. A segurança coloca-os como opção segura e eficaz para o tratamento desses pacientes com risco baixo e intermediário de TEV

Introduction: Venous thromboembolism (VTE), including pulmonary embolism (PE) and deep vein thrombosis (DVT), is the third leading cause of death worldwide. The diagnosis is still underestimated in emergencies. The triggering factors are well defined, which assists in the stratification of risk and in the diagnosis of VTE, whether provoked or not, and will greatly influence the treatment time. Increased right ventricle and biological markers have played a large role in the prognosis. The clinical features are well defined, and there are various tools for diagnosis and for risk stratification, such as the Wells and Geneva criteria, among others. Complementary exams are now well defined, with pulmonary angiography being the gold standard, but with improved technology and high sensitivity and specificity, computerized angiotomography has played a prominent role. Other exams are still important in certain situations, such as D-dimer and other biomarkers, chest radiography, perfusion/ventilation scintigraphy, electrocardiogram, echocardiography, and lower limb venous Doppler. Method: In this article we review basic aspects of epidemiology, diagnosis, and risk stratification. The main focus was treatment with anticoagulant therapy, under which we reviewed the six clinical studies described between 2009 and 2013 that address the new oral anticoagulants, now called direct oral anticoagulants. These studies have different designs; three of them start with oral anticoagulants from the onset of acute DVT and PE (rivaroxaban and edoxaban), and the other three start with enoxaparin and warfarin during the first days and then with the medication of the study group being evaluated (dabigatran and apixaban). Results: In the analyzed studies, all of them obtained a reduction (non-inferiority p-value) of the events of VTE recurrence in relation to warfarin. In the safety outcomes, defined as clinically relevant fatal bleeding and others, the new oral anticoagulants achieved a significant reduction. Conclusions: Direct oral anticoagulants had a reduction in the recurrence of thromboembolic events (peripheral and pulmonary), with a significant reduction in rates of fatal or non-fatal bleeding. Their safety makes them a reliable and effective option for the treatment of these patients, with low and intermediate risk of VTE

Inosine supplementation has no effect on aerobic or anaerobic cycling performance.

The two basic aims of this study were to add to the limited literature concerning Inosine as an ergogenic aid, and to determine the effects of Inosine supplementation over a period of 5 and 10 days, at a dosage of 10,000 mg.d-1 on measures associated with aerobic and anaerobic performance. Seven trained, volunteer male subjects (body mass = 63.0 +/- 8.7 kg, VO2max = 67.9 +/- 3.3 ml.kg-1.min-1) participated in this study. The subjects completed three test sessions, each comprising three tests (5 x 6-s sprint, 30-s sprint, and 20-min time trial). Supplementation was carried out in a random, double-blind manner, and the test sessions were undertaken prior to (Baseline, B), on Day 6, and on Day 11. Blood was sampled prior to supplementation as well as on Days 6 and 11 and was analyzed for uric acid and 2,3 DPG. An analysis of the data indicated no performance benefit of supplementation and no improvement in 2,3 DPG concentration. Uric acid concentration increased significantly after both Days 6 and 11 (p < 0.03 and p < 0.004, respectively). It is concluded that Inosine has no ergogenic effects but may cause possible health problems if taken over long periods of time.

The effects of creatine supplementation on high-intensity exercise performance in elite performers.

The aim of this research was to determine whether creatine supplementation at a dose of 20 g x day(-1), given in 4 x 6-g doses (5 g creatine monohydrate and 1 g glucose) for 5 days, was effective in improving kayak ergometer performances of different durations. Sixteen male subjects with the following characteristics [mean (SEM)]: age 21 (1.2) years, height 170.2 (1.7) cm, weight 75.3 (2.3) kg, sigma8 skinfolds 59.3 (2.6) mm, and maximal oxygen consumption 67.1 +/- (4.3) ml x kg x min(-1), undertook three maximal kayak ergometer tests of 90, 150 and 300 s duration on a wind-braked kayak ergometer (CON). Two groups were then randomly formed, with one group taking the supplement (SUP) while the other took a placebo (PLAC). No pre-test differences existed between the SUP and the PLAC groups in any of the variables measured. After supplementation each group then repeated the same kayak ergometer tests as performed previously and after a 4-week "washout period" the groups took either the PLAC or SUP for another 5 days and then completed the final tests. The SUP group completed significantly more work than either the CON or PLAC groups in all of the tests (90 s, P < 0.01; 150 s, P < 0.001; 300 s, P < 0.05). Body mass remained stable throughout the test period in both the CON and PLAC groups, but both were significantly less than the SUP body mass of 77.3 (1.0) kg (P < 0.01). The results of this work indicate that creatine supplementation can significantly increase the amount of work accomplished during kayak ergometer performance at durations ranging from 90 to 300 s.

The effect of hemodilution with albumin or Ringer's lactate on water balance and blood use in open-heart surgery.

To determine the effect of intraoperative albumin administration on blood use, water balance, and postoperative clinical course, we studied two groups of adult cardiac surgical patients. Group I (30 patients) received 25 gm of albumin during withdrawal of 2 units of blood prior to cardiopulmonary bypass (CPB) and 50 gm of albumin in the oxygenator prime. Group II (32 patients) received no albumin prior to the end of CPB. No difference in clinical course could be identified, nor was there a significant difference in blood use. Group I patients had lower hematocrit values intraoperatively from the time of blood withdrawal until the conclusion of operation. Coronary artery bypass operations were associated with greater positive water balance than were heat valve operations. Forty-three percent of the patients having coronary artery bypass grafting had a positive water balance greater than 5 liters, whereas 50% of those undergoing valve procedures had a balance less than 3 liters. We conclude that the principal effect of withholding albumin under these circumstances is to increase net positive water balance. The greater positive water balance does not appear to be detrimental.