Evaluation of Acute Pelvic Pain in Women.

Acute pelvic pain is defined as noncyclic, intense pain localized to the lower abdomen and/or pelvis, with a duration of less than three months. Signs and symptoms are often nonspecific. The differential diagnosis is broad, based on the patient's age and pregnancy status and gynecologic vs. nongynecologic etiology. Nongynecologic etiologies include gastrointestinal, urinary, and musculoskeletal conditions. Urgent gynecologic conditions include ectopic pregnancy, ruptured ovarian cyst, adnexal torsion, and pelvic inflammatory disease. Approximately 40% of ectopic pregnancies are misdiagnosed at the presenting visit. Urgent nongynecologic conditions include appendicitis and pyelonephritis. Less urgent etiologies include sexually transmitted infections, pelvic floor myofascial pain, dysmenorrhea, and muscle strain. Approximately 15% of untreated chlamydia infections lead to pelvic inflammatory disease. History and physical examination findings guide laboratory testing. Questions should focus on the type, onset, location, and radiation of pain; timing and duration of symptoms; aggravating and relieving factors; and associated symptoms. Performing a urine pregnancy test or beta human chorionic gonadotropin test is an important first step for sexually active, premenopausal patients. Imaging options should be considered, with transvaginal ultrasonography first, followed by computed tomography. Magnetic resonance imaging can be useful if ultrasonography and computed tomography are nondiagnostic.

Factors associated with time to defecate and outcomes in critically ill patients: a prospective, multicentre, observational study.

Delayed defecation is common in patients on intensive care. We aimed to determine factors associated with time to defecation after admission to intensive care and in turn its association with length of stay and mortality. We studied 396 adults admitted to one of five intensive care units in whom at least 2 days' invasive ventilation was anticipated during an expected stay of at least 3 days. The median (IQR [range]) time to defecate by the 336 out of 396 (84%) patients who did so before intensive care discharge was 6 (4-8 [1-18]) days. Defecation was independently associated with five factors, hazard ratio (95%CI), higher values indicating more rapid defecation: alcoholism, 1.32 (1.05-1.66), p = 0.02; laxatives before admission, 2.35 (1.79-3.07), p < 0.001; non-invasive ventilation, 0.54 (0.36-0.82), p = 0.004; duration of ventilation, 0.78 (0.74-0.82), p < 0.001; laxatives after admission, 1.67 (1.23-2.26), p < 0.001; and enteral nutrition within 48 h of admission, 1.43 (1.07-1.90), p = 0.01. Delayed defecation was associated with prolonged intensive care stay but not mortality.

[Bilateral breast reduction and obesity: What is the ideal resection enabling significant improvement in back pain according to the body mass index?] / Mastoplastie bilatérale de réduction et obésité : quel est le poids de résection idéal pour obtenir une amélioration significative des douleurs rachidiennes en fonction de l'indice de masse corporelle ?

INTRODUCTION: Dorsal pain is the first symptoms about which patients with macromasty complain. Health insurance reimbursement takes place if the resection weight is at least 300grams per breast. However, this weight is not correlated with the body mass index (BMI). In this context, we sought to determine the ideal resection weight leading to significant BMI-based improvement. MATERIALS AND METHODS: This is a multicentre prospective study of patients operated between November 2016 and July 2017. In the year following the surgical procedure, we studied overall improvement using the INDIC questionnaire. Any INDIC improvement of at least 50% was considered positive. These data were then compared to tissue resection weights and BMI. In order to refine our results, age, bra size, comorbidities and complications were also identified. RESULTS: Forty-one patients were included in our study. Average age was 41.5±11.4years. Average BMI was 27.9±4.1kg/m2. The bra cap chosen after the procedure were C. Average resection weight was 663±352g per breast. The preoperative and postoperative INDIC scores were 734.9±226.6 points and 225.3±319.1 points, respectively (P=0.001). Significant improvement was achieved at 12months in 71.8% of patients. A correlation of 38.7g/kg/m2 was found between breast resection weight and BMI. CONCLUSION: This study clarifies the correlation between the breast resection weight required to relieve optimal back pain and BMI. It defines three categories of patients: patients with standard weights (1830). Overweight and obese patients require greater tissue excretion to be relieved optimally. These findings underline a need to adjust the health insurance threshold for these types of patients.

Cardiac output monitoring with thermodilution pulse-contour analysis vs. non-invasive pulse-contour analysis.

Intravenous fluid boluses guided by changes in stroke volume improve some outcomes after major surgery, but invasive measurments may limit use. From October 2016 to May 2018, we compared the agreement and trending ability of a photoplethysmographic device (Clearsight) with a PiCCO, calibrated by thermodilution, for haemodynamic variables in 20 adults undergoing major elective surgery. We analysed 4519 measurement pairs, including before and after 68 boluses of 250 ml crystalloid. The bias and precision of stroke volume measurement by Clearsight were -0.89 ± 4.78 ml compared with the invasive pulse-contour cardiac output device. The coefficient of agreement for stroke volume variation after fluid boluses between the two devices was 0.79 ('strong'). Fluid boluses that increased stroke volume by ≥ 10% increased mean absolute volume (SD) and mean percentage (SD) stroke volume measurements similarly for the invasive pulse-contour cardiac output and Clearsight devices: 9 (4) ml vs. 8 (4) ml and 16% (8%) vs. 15% (10%), respectively, p > 0.05. The non-invasive Clearsight pulse-contour analysis was similar to an invasive pulse-contour device in measuring absolute and changing stroke volumes during major surgery.

Ageing and obesity similarly impair antibody responses.

Ageing is characterized by increased low-grade chronic inflammation, which is a significant risk factor for morbidity and mortality of elderly individuals. Similar to ageing, obesity is considered to be an inflammatory predisposition associated with chronic activation of immune cells and consequent local and systemic inflammation. Both ageing and obesity are characterized by reduced innate and adaptive immune responses. This review focuses on B cells, how they may contribute, at least locally, to low-grade chronic inflammation in ageing and obesity and on the mechanisms involved.

Appropriate dosing of sugammadex to reverse deep rocuronium-induced neuromuscular blockade in morbidly obese patients.

In morbidly obese patients, the speed of reversal of neuromuscular blockade with sugammadex based on ideal body weight is still matter of debate. In this single-center, randomised, double-blinded study, neuromuscular blockade was monitored in 50 patients using acceleromyography at the adductor pollicis. At the end of surgery with deep rocuronium-induced neuromuscular blockade, patients randomly received sugammadex 4 mg.kg(-1) (high dose group), 2 mg.kg(-1) (middle dose group), or 1 mg.kg(-1) (low dose group) of ideal body weight. After administration of the first dose of sugammadex, the mean (SD) recovery time (censored at 600 s) from deep neuromuscular blockade was significantly shorter (p < 0.001) in the high-dose group (n = 14; 255 (63) s) vs the middle-dose group (n = 13; 429 (102) s), or low-dose group (n = 4; 581 (154) s). Success rate from neuromuscular blockade reversal defined by a train-of-four ≥ 0.9 within 10 min after sugammadex administration, were 93%, 77% and 22% for these high, middle and low-dose groups respectively (p < 0.05 vs low-dose group). In morbidly obese patients, 4 mg.kg(-1) of ideal body weight of sugammadex allows suitable reversal of deep rocuronium-induced neuromuscular blockade. Monitoring remains essential to detect residual curarisation or recurarisation.

Continuous monitoring of haemoglobin concentration after in-vivo adjustment in patients undergoing surgery with blood loss.

Non-invasive monitoring of haemoglobin concentration provides real-time measurement of haemoglobin concentration (SpHb) using multi-wavelength pulse co-oximetry. We hypothesised that in-vivo adjustment using the mean of three haemoglobinometer (HemoCue®) measurements from an arterial blood sample at the first SpHb measurement (HCueART) would increase the accuracy of the monitor. The study included 41 adults for a total of 173 measurements of haemoglobin concentration. In-vivo adjusted SpHb was automatically calculated by the following formula: in-vivo adjusted SpHb = unadjusted SpHb - (SpHb - HCueART). The accuracy of in-vivo adjusted SpHb was compared with SpHb retrospectively adjusted using the same formula, except for haemoglobin level which was assessed at the central laboratory and then compared with all other available invasive methods of haemoglobin measurement (co-oximetry, HbSAT; arterial HemoCue, HCueART; capillary HemoCue, HCueCAP). Compared with laboratory measurement of haemoglobin concentration, bias (precision) for unadjusted SpHb, in-vivo adjusted SpHb, retrospectively adjusted SpHb, HbSAT, HCueART and HCueCAP were -0.4 (1.4), -0.3 (1.1), -0.3 (1.1), -0.6 (0.7), 0.0 (0.4) and -0.5 (1.2) g.dl(-1) , respectively. In-vivo adjustment of SpHb values using the mean of three arterial HemoCue measurements improved the accuracy of the device similar to those observed after a retrospective adjustment using central laboratory haemoglobin level.

Comparison of acoustic and impedance methods with mask capnometry to assess respiration rate in obese patients recovering from general anaesthesia.

Respiratory depression, a potentially serious complication after general anaesthesia, can be detected promptly by close monitoring of both oxygen saturation and respiratory rate. Obese patients have morphological changes that may impair the reliability of monitoring devices. In this study, respiration rate was simultaneously recorded every second for up to 60 min using a computer in 30 adult obese patients (body mass index ≥ 35 kg.m(-2)), by three methods: acoustic; thoracic impedance; and capnometry via a facemask (Capnomask, reference method). Of the 99,771 data triplets collected, only 85,520 (86%) were included; 12,021 (84%) were not studied due to failure of capnometry and 2240 (16%) due to failure of the acoustic method. Compared with capnometry, bias was similar using both the acoustic method and impedance (-0.3 bpm vs. -0.6 bpm, respectively, p = 0.09), but limits of agreement were narrower for the acoustic method (±3.5 bpm vs. ±5.3 bpm, respectively, p = 0.0008). The proportion of respiration rate values obtained with the acoustic method and impedance that differed by at least 10% or 20% for more than 15 s were 11% vs. 23% and 2% vs. 6%, respectively (p = 0.0009 for both comparisons). The acoustic sensor was well tolerated, while the facemask was pulled off on several occasions by four (13%) agitated patients. In obese patients requiring close monitoring of respiration rate, the acoustic method may be more precise than thoracic impedance and better tolerated than capnometry with a facemask.

Comparison of haemoglobin measurement methods in the operating theatre.

BACKGROUND: Various methods of haemoglobin (Hb) measurement are available to guide transfusion including several methods that allow for measurement at the bedside. This study directly compared their absolute and trend accuracy compared with values from the central lab (reference method). METHODS: Adult patients undergoing surgery with expected blood loss wore a rainbow ReSposable sensor connected to a Radical-7 Pulse CO-Oximeter (SpHb). Arterial samples were analysed with a haematology analyser (HbLab), a satellite CO-Oximeter (HbSat), and a point-of-care haemoglobinometer (HemoCue; HcueArt). Concomitantly, ear capillary blood was tested using the same haemoglobinometer (HcueCap). Absolute accuracy and the clinical significance of error were assessed with Bland-Altman plots and three-zone error grids. Trend analysis was performed using a modified polar plot, testing both directionality and magnitude of Hb changes compared with the reference. RESULTS: Two hundred and nineteen measurements from 53 patients with HbLab ranging between 6.8 and 16.3 g dl(-1) (4.2 and 10.1 mmol litre(-1)) were recorded. Compared with the reference method, bias (precision) was 0.2 (0.2) g dl(-1) [0.1 (0.1) mmol litre(-1)] for HcueArt, 0.8 (0.3) g dl(-1) [0.5 (0.2) mmol litre(-1)] for HbSat, 0.5 (0.5) g dl(-1) [0.3 (0.3) mmol litre(-1)] for HcueCap and 1.0 (1.2) g dl(-1) [0.6 (0.7) mmol litre(-1)] for SpHb. None of the devices tested would have led to unnecessary or delayed transfusion according to 2006 ASA transfusion criteria. Trend accuracy was better for HcueArt and HbSat than for HcueCap and SpHb. CONCLUSION: Bedside Hb measurement methods differ in their agreement to a laboratory haematology analyser but none would have led to transfusion errors. Trial Registry Number RCB 2009-AO1144-53.

[Nutritional rickets in twins: a case report]. / Un caso di rachitismo carenziale in una coppia di gemelli.

Vitamin D deficiency rickets in infants attributable to inadeguate vitamin D intake and decreased exposure to sunligh continue to be reported in the United States and other Western Countries. The American Academy of Pediatrics raccomend that all infants, children and adolescent have a minumin intake of 400 UI of vitamin D per day. We describe a case of deficiency-related rickets in two moroccan twins aged 10 months.

Accuracy of respiratory rate monitoring by capnometry using the Capnomask(R) in extubated patients receiving supplemental oxygen after surgery.

BACKGROUND: Respiratory monitoring is standard after anaesthesia and surgery. Abnormal respiratory rate is a sensitive indicator of respiratory problems, even in patients receiving supplemental oxygen, but the best method for its continuous measurement in spontaneously breathing patients is unclear. This study compared respiratory rate assessment by capnometry using a new oxygen mask with a carbon dioxide sampling port (Capnomask(®)) and thoracic impedance pneumography with clinical measurement (used as a reference method) in extubated patients receiving supplemental oxygen. METHODS: Adult males admitted to the post-anaesthesia care unit after general anaesthesia were studied. Immediately after extubation, a Capnomask(®) connected to a capnometer was positioned appropriately. Respiratory rate was measured by visual inspection of chest movement for 1 min, by capnometry, and thoracic impedance pneumography. One set of measurements was obtained for every patient receiving supplemental oxygen at different flow rates. RESULTS: Twenty men, mean (inter-quartile range) age 54 (23-66) yr and BMI 25 (21-31) kg m(-2), were studied. Compared with visual inspection, the bias and limits of agreement were 0.0 (1.0 to -1.0) bpm for the Capnomask(®) and -2.2 (2.0 to -6.5) bpm for the impedance pneumography. The accuracy of respiratory rate assessment using Capnomask(®) was not influenced by the supplemental oxygen flow rate. CONCLUSIONS: In extubated patients, continuous assessment of respiratory rate with the Capnomask(®) is more accurate than by thoracic impedance pneumography even when supplemental oxygen is delivered at a high flow rate.

Accuracy of respiratory rate monitoring using a non-invasive acoustic method after general anaesthesia.

BACKGROUND: Respiratory rate should be monitored continuously in the post-anaesthesia care unit (PACU) to avoid any delay in the detection of respiratory depression. Capnometry is the standard of care but in extubated patients requires a nasal cannula or a face mask that may be poorly tolerated or can be dislodged, leading to errors in data acquisition and false alarms. The value of a new non-invasive acoustic monitor in this setting has not been fully investigated. METHODS: Adult patients admitted to the PACU after general anaesthesia were included. After tracheal extubation, an adhesive sensor with an integrated acoustic transducer (RRa™) was placed on the patient's throat and connected to its monitor while the patient breathed through a face mask with a carbon dioxide sampling port (Capnomask™) connected to a capnometer. Both the acoustic monitor and the capnometer were connected to a computer to record one pair of data per second for up to 60 min. RESULTS: Fifty-two patients, mean (range) age 54 (22-84) yr and BMI 26 (19-39) kg m(-2), were studied. Compared with capnometry, the bias and limits of agreement of the acoustic method were 0 (-1.4-1.4) bpm. The acoustic sensor was well tolerated while the face mask was removed by eight patients, leading to study discontinuation in two patients. CONCLUSIONS: In extubated patients, continuous assessment of respiration rate with an acoustic monitor correlated well with capnometry.

Peripheral venous catheter colonization after skin disinfection with 0.5% aqueous sodium hypochlorite, preceded or not by one application of 70% ethanol (DACLEAN): a single-centre, randomized, open-label, pilot study.

Few data are available on the efficacy of 0.5% aqueous sodium hypochlorite (SH) for skin disinfection before peripheral catheter insertion. A total of 239 patients were randomly assigned to either one application of SH alone or one application of SH preceded by one application of 70% ethanol (ET-SH). Catheter colonization, defined as a catheter tip culture growing >1000 cfu of a micro-organism per millilitre, occurred in 29 patients (33% of 89 colonizations per 1000 catheter-days) in the SH group and in 31 patients (33% of 126 colonizations per 1000 catheter-days) in the ET-SH group.

In vivo stimulation and restoration of the immune response by the noninflammatory fragment 163-171 of human interleukin 1 beta.

The synthetic nonapeptide VQGEESNDK, corresponding to the fragment 163-171 of human IL-1 beta, showed in vivo immunomodulatory capacities qualitatively and quantitatively comparable to those of the mature human IL-1 beta protein. In fact, both IL-1 beta and the 163-171 fragment stimulated the immune response of normal mice and restored immune reactivities of immunocompromised animals. In addition, the synthetic IL-1 peptide was as efficient as the entire protein in inducing tumor rejection and radioprotection. On the other hand, the 163-171 fragment did not cause any of several inflammation-associated metabolic changes inducible by the whole IL-1 beta molecule in vivo: hypoferremia, hypoglycemia, hyperinsulinemia, increase in circulating corticosterone, SAA and fibrinogen, decrease in hepatic drug-metabolizing enzymes. Furthermore, at variance with IL-1 beta, the 163-171 peptide did not show the toxic effects causing shock and death in adrenalectomized mice. Thus, these results confirm our previous in vitro observations that functional domains are identifiable within the multipotent cytokine IL-1 beta, and demonstrate the biological relevance of this finding in a variety of in vivo systems. The identification of a selectively active fragment of a cytokine may thus represent a significant step towards a better directed and more rational immunotherapeutic approach.

Gabapentin premedication: assessment of preoperative anxiolysis and postoperative patient satisfaction.

BACKGROUND: Gabapentin reduces anxiety in psychiatric patients. In this prospective, randomized, double-blinded, placebo-controlled study, we investigated whether a single dose of gabapentin as a premedicant reduces preoperative anxiety, and improves patient satisfaction. MATERIALS AND METHODS: After Institutional Review Board approval and written consent, 210 patients were randomly allocated into 3 groups of oral premedication: placebo, hydroxyzine 75 mg, or gabapentin 1200 mg. Anxiety level was assessed 3 times, using a 100-mm visual analogue scale: before premedication, in the preoperative holding area, and just before induction of general anaesthesia. In the postoperative period, patients were asked about their satisfaction with their premedicant. Data were presented as mean +/- SD. VAS scores were analyzed by repeated-measures analysis of variance followed by a Bonferroni test as appropriate. The chi-square test was used to analyze categorical data. All p values less than 0.05 was considered statistically significant. RESULTS: Baseline anxiety was not statistically different among the 3 groups. Anxiety level in the gabapentin group was significantly lower in the holding area, and before induction of anaesthesia (20 mm +/- 21), than in the hydroxyzine group (33 mm +/- 26 ; p = 0.023) and in the placebo group (36 mm +/- 28; p = 0.004). Anxiety decreased significantly overtime only in the gabapentin group. The gabapentin and hydroxyzine groups had a higher proportion of "satisfied or extremely satisfied" patients (73% and 70% respectively) as compared to the placebo group (48%, p = 0.006). CONCLUSION: A single dose of gabapentin has proven to be an effective premedication to reduce preoperative anxiety.