Factors Affecting the Second Complete Atypical Femoral Fracture after the First Atypical Fracture.

OBJECTIVES: Atypical femoral fracture (AFF) is an atypical low-energy subtrochanteric and diaphyseal femoral fracture. Even if bone fusion is achieved in patients with AFF, the risk of AFF in the contralateral femur must be considered. This study aimed to investigate the factors affecting complete AFF in the contralateral femur and conservatively treated incomplete AFF. SUBJECT AND METHODS: Radiographs of 111 femurs in 104 AFF cases were examined, and the femurs were classified as follows: 85 contralateral femurs with complete AFF; 18 contralateral femurs with incomplete AFF; 8 femurs with incomplete AFF without surgical treatment. Various patients' clinical data were collected, and we investigated the factors affecting the second complete AFF. RESULTS: Complete fractures occurred in 10 (9.7%) of 103 femurs without incomplete AFF at the first visit and in 3 (37.5%) of 8 femurs with incomplete AFF. The Kaplan-Meier curve revealed that lateral cortical bone thickening and thigh pain were associated with significantly poorer prognoses (p = 0.026 and p = 0.013, respectively). Multivariate analyses revealed that eldecalcitol usage after AFF onset (p = 0.0094) and previous use of bisphosphonate or denosumab (p = 0.0126) were protective factors for second complete AFF and that the presence of thigh pain (p = 0.0134) was a risk factor for second complete AFF. CONCLUSIONS: Eldecalcitol administration after bone union of first AFF may prevent AFF recurrence. In addition, painful incomplete AFF has a high risk of developing a complete fracture.

Calcium channel blockers, angiotensin II receptor antagonists and alpha-blockers accentuate blood pressure reducing caused by dental local anesthesia.

OBJECTIVE: The primary aim of this study was to investigate the effect associated with patients' factor such as systemic disease on the blood pressure of patients in dental procedure. The secondary aim of this study was to investigate the effect associated with systemic disease and antihypertensive on the blood pressure changes with local anesthesia. METHODS: The blood pressure was measured before and after local anesthesia injection for dental treatment. The effect associated with patients' factor such as systemic disease on the blood pressure and the effect on blood pressure changes of the type of antihypertensive drugs and the systemic disease were analyzed using a multivariate analysis of variance test. RESULTS: We analyzed 1306 patients scheduled for the dental procedure. Age and some systemic diseases such as hypertension and angina pectoris affected blood pressure before local anesthesia. On the other hand, age and systemic diseases did not affect blood pressure changes. And, some antihypertensive affected systolic blood pressure changes. CONCLUSIONS: The blood pressure change with local anesthesia was not associated with systemic diseases and age but was associated with antihypertensive agents. In particular, calcium channel blockers, angiotensin II receptor antagonists and alpha-blockers accentuate blood pressure reducing caused by local anesthesia. CLINICAL RELEVANCE: The blood pressure change with local anesthesia was associated with antihypertensive agents. This study was registered with the University Hospital Medical Information Network Clinical Trials Registry (number UMIN000030695).

Evaluation of the Nature and Etiologies of Risk Factors for Diaphyseal Atypical Femoral Fractures.

OBJECTIVES: Differences in mechanisms of subtrochanteric and diaphyseal atypical femoral fractures (AFFs) are speculated in studies that analyzed differences in the patients' background. However, the etiologies of each type of AFF have not been studied in detail. This study aimed to investigate the nature and etiologies of the risk factors for diaphyseal AFFs. MATERIALS AND METHODS: Eighty consecutive Japanese patients with 91 diaphyseal AFFs (AFF group) and 110 age-matched women with osteoporosis (non-AFF control group) were included. Their clinical data were compared; factors affecting AFFs were investigated, and the etiologies of the risk factors for diaphyseal AFFs were examined. RESULTS: Multivariate analysis revealed that femoral serrated changes, bisphosphonate or denosumab usage, and lateral and anterior femoral curvatures were risk factors for diaphyseal AFFs (p < 0.0011, p = 0.0137, and p < 0.0001, respectively). Multivariate analyses revealed that serrated changes and low serum 25(OH)D levels affected the lateral curvature (p = 0.0088 and 0.0205, respectively), while serrated changes affected the anterior curvature (p = 0.0006), each significantly affected the femoral curvature. High serum calcium (Ca) levels, lateral femoral curvature, and anterior femoral curvature were predictors of serrated changes (p = 0.0146, 0.0002, and 0.0098, respectively). CONCLUSION: Risk factors for diaphyseal AFFs were bone resorption inhibitor usage, a strong femoral curvature, and serrated changes. Low serum 25(OH)D levels and serrated changes are risk factors for lateral curvature, while a high serum Ca level is a risk factor for serrated changes.

Antimicrobial Susceptibilities of Clostridium difficile Isolates from 12 Asia-Pacific Countries in 2014 and 2015.

Clostridium (Clostridioides) difficile causes toxin-mediated diarrhea and pseudomembranous colitis, primarily among hospital inpatients. Outbreaks of C. difficile infection (CDI) have been caused by strains with acquired antimicrobial resistance, particularly fluoroquinolone resistance, including C. difficile ribotype (RT) 027 in North America and Europe and RT 017, the most common strain in Asia. Despite being the most common cause of hospital-acquired infection in high-income countries, and frequent misuse of antimicrobials in Asia, little is known about CDI in the Asia-Pacific region. We aimed to determine the antimicrobial susceptibility profiles of a collection of C. difficile isolates from the region. C. difficile isolates (n = 414) from a 2014 study of 13 Asia-Pacific countries were tested for susceptibility to moxifloxacin, amoxicillin-clavulanate, erythromycin, clindamycin, rifaximin, metronidazole, vancomycin, and fidaxomicin according to the Clinical and Laboratory Standards Institute's agar dilution method. All isolates were susceptible to metronidazole, vancomycin, amoxicillin-clavulanate, and fidaxomicin. Moxifloxacin resistance was detected in all countries except Australia, all RT 369 and QX 239 strains, and 92.7% of RT 018 and 70.6% of RT 017 strains. All C. difficile RT 012, 369, and QX 239 strains were also resistant to erythromycin and clindamycin. Rifaximin resistance was common in RT 017 strains only (63.2%) and was not detected in Australian, Japanese, or Singaporean isolates. In conclusion, antimicrobial susceptibility of C. difficile varied by strain type and by country. Multiresistance was common in emerging RTs 369 and QX 239 and the most common strain in Asia, RT 017. Ongoing surveillance is clearly warranted.

The number and kind of antiepileptics affect propofol dose requirement for anesthesia: observational study.

The propofol dose requirement and the emergence time are affected by antiepileptic use. The effects on anesthesia of the number and kind of antiepileptic agents have not been reported. We investigated the relationship between the kind and number of antiepileptic agents and the propofol dose requirement for anesthesia and emergence time in intravenous general anesthesia for dental treatment for patients with neurological disorders. We studied 247 patients with neurological disorders who underwent dental treatment under intravenous general anesthesia. Patients were categorized according to the number of antiepileptics (none, single agent, two kinds, and three or more kinds of antiepileptics) and the kind of antiepileptic (carbamazepine, valproate, phenobarbital, phenytoin, zonisamide, clobazam, or topiramate) being received. The propofol dose requirement for anesthesia, emergence time, and predicted blood propofol concentration at emergence were evaluated. Patients on three or more kinds of antiepileptics had significantly lower propofol dose requirement (reduction in 25%, compare with no use) and predicted blood propofol concentration at emergence (reduction in 41%) and significantly longer emergence time (extension in 50%) (P < 0.05). Valproate and clobazam reduced the propofol dose (valproate 9% and clobazam 19%) and predicted blood propofol concentration at emergence (valproate 18% and clobazam 33%), while phenobarbital increased these parameters (30% and 125%) (P < 0.05). The number and kind of antiepileptics effects propofol dose requirement. In particular, valproate and clobazam reduce the propofol dose requirement, while phenobarbital increases this.Clinical trial registration UMIN No. UMIN000014179.

Mallampati test with phonation, tongue protrusion and supine position is most correlated with Cormack-Lehane test.

Many modified Mallampati tests have been developed to date. Samsoon's modified Mallampati test (standard Mallampati test) is currently widely used. We newly designed seven types of assessment protocol of Mallampati test, in addition to standard Mallampati test. In this study, we studied the correlation between eight types of protocol (standard and seven alternative protocols) of Mallampati test and Cormack-Lehane test. We newly designed assessment protocols as new Mallampati test. These are different protocols depending on the presence or absence of phonation, those of protrusion of tongue, and sitting position or supine position. The oropharyngeal structures visualized by these eight types of Mallampati test for total of 145 patients undergoing dental oral surgery were evaluated. The scores derived via eight types of Mallampati test were recorded. The influence of phonation, tongue protrusion and body position on Mallampati test score was analyzed, respectively. The relationships between eight types of Mallampati test and Cormack-Lehane test were analyzed. Tongue protrusion, phonation and sitting position tended to lower the score of Mallampati test (p < 0.001, respectively). The standard Mallampati test was not correlated with Cormack-Lehane test. In the new Mallampati tests, assessment protocol with tongue protrusion, phonation and sitting position, that with tongue protrusion and supine position, or that with tongue protrusion, phonation and supine position were significantly correlated with Cormack-Lehane test, respectively. (p = 0.020, p = 0.007 and p = 0.004, respectively). The standard Mallampati test did not correlate with Cormack-Lehane test. Mallampati test with phonation, tongue protrusion and supine position were most correlated with Cormack-Lehane test.

Influence of the marvelous™ three-way stopcock on the natural frequency and damping coefficient in blood pressure transducer kits.

Two types of Planecta™ ports are commonly used as sampling ports in blood pressure transducer kits: a flat-type port (FTP) and a port with a three-way stopcock (PTS). Recently, a new type of three-way stopcock (Marvelous™) has been released as a Planecta™ counterpart, but its effects on the frequency characteristics and reliability of blood pressure monitoring have not been investigated. We assessed the influence of the Marvelous™ stopcock on the frequency characteristics of the pressure transducer kit. The basic pressure transducer kit, DT4812J, was modified by replacing one or two of the original three-way stopcocks with Marvelous™ stopcocks. The frequency characteristics (i.e., natural frequency and damping coefficient) of each kit were determined using wave parameter analysis software, and subsequently evaluated on a Gardner chart. Replacement of the original blood pressure transducer kit stopcocks with Marvelous™ stopcocks decreased the natural frequency (48.3 Hz) to 46.3 Hz or 44.8 Hz, respectively; the damping coefficient was not significantly changed. Plotting the data on a Gardner chart revealed that the changes fell within the adequate dynamic response region, indicating they were within the allowable range. Insertion of Marvelous™ stopcocks slightly affects the natural frequency of the pressure transducer kit, similar to inserting a PTS. The results indicate that the Marvelous™ stopcock is useful for accurate monitoring of arterial blood pressure, and may be recommended when insertion of two or more closed-loop blood sampling systems is necessary.

Acoustic method respiratory rate monitoring is useful in patients under intravenous anesthesia.

Respiratory depression can occur during intravenous general anesthesia without tracheal intubation. A new acoustic method for respiratory rate monitoring, RRa® (Masimo Corp., Tokyo, Japan), has been reported to show good reliability in post-anesthesia care and emergency units. The purpose of this study was to investigate the reliability of the acoustic method for measurement of respiratory rate during intravenous general anesthesia, as compared with capnography. Patients with dental anxiety undergoing dental treatment under intravenous anesthesia without tracheal intubation were enrolled in this study. Respiratory rate was recorded every 30 s using the acoustic method and capnography, and detectability of respiratory rate was investigated for both methods. This study used a cohort study design. In 1953 recorded respiratory rate data points, the number of detected points by the acoustic method (1884, 96.5 %) was significantly higher than that by capnography (1682, 86.1 %) (P < 0.0001). In the intraoperative period, there was a significant difference in the LOA (95 % limits of agreement of correlation between difference and average of the two methods)/ULLOA (under the lower limit of agreement) in terms of use or non-use of a dental air turbine (P < 0.0001). In comparison between capnography, the acoustic method is useful for continuous monitoring of respiratory rate in spontaneously breathing subjects undergoing dental procedures under intravenous general anesthesia. However, the acoustic method might not accurately detect in cases in with dental air turbine.

Hypotonic fluid reduce serum sodium compared to isotonic fluids during anesthesia induction in pediatric patients undergoing maxillofacial surgery-type of infusion affects blood electrolytes and glucose: an observational study.

BACKGROUND: Reportedly, administration of hypotonic fluids containing 30.8-74 mEq/L sodium with 5 % glucose may lead to serious hyponatremia or hyperglycemia. In Japan, hypotonic fluids containing 90 mEq/L sodium with 2.6 % glucose are commonly used. We compared blood electrolyte balance and blood glucose concentration with the use of isotonic (140 mEq/L sodium with 1 % glucose) versus hypotonic fluids in pediatric patients. METHODS: We studied 77 children aged 5 months to 2 years who underwent oro-maxillofacial surgery and dental treatment under general anesthesia. Patients were categorized according to the fluids infused (hypotonic or isotonic). Blood samples were obtained from the dorsalis pedis artery between the conclusion of anesthesia induction and commencement of surgery. We compared blood sodium, potassium and glucose concentrations in the two fluid groups during the pre-anesthesia and post-anesthesia-induction periods. RESULTS: There were no significant differences in pre-anesthesia values between isotonic (n = 35) and hypotonic groups (n = 42). There were significant differences between isotonic and hypotonic groups in post-anesthesia-induction concentrations of sodium (isotonic, 138.7 ± 1.4 mEq/L; hypotonic, 137.5 ± 1.3 mEq/L; p = 0.0003) and glucose (isotonic, 88.0 ± 9.4 mg/dL; hypotonic, 109.9 ± 18.4 mg/dL; p < 0.0001), while potassium concentrations were not significantly different (isotonic, 4.0 ± 0.3 mEq/L; hypotonic, 4.0 ± 0.2 mEq/L; p = 0.6615) between the two groups. CONCLUSION: Isotonic solution administration enables avoidance of serum sodium reduction and serum glucose elevation in infants, and may therefore enhance patient safety in comparison with hypotonic solutions. TRIAL REGISTRATION: University Hospital Medical Information Network Clinical Trials Registry ( UMIN000014648 ), registration 25 July 2014.

Effect of using a Planecta™ port with a three-way stopcock on the natural frequency of blood pressure transducer kits.

Blood pressure transducer kits are equipped with two types of Planecta™ ports-the flat-type Planecta™ port (FTP) and the Planecta™ port with a three-way stopcock (PTS). We reported that FTP application decreased the natural frequency of the kits. However, Planecta™ is an invaluable tool as it prevents infection, ensures technical simplicity, and excludes air. Hence, an ideal Planecta™ port that does not decrease the frequency characteristics is required. As a first step in this direction, we aimed to assess the influence of PTSs on the natural frequency of blood transducer kits. A DTXplus transducer kit (DT4812J; Argon Medical Devices, TX, USA) was used along with ≥1 PTSs (JMS, Hiroshima, Japan), and the frequency characteristics were assessed. The natural frequency and damping coefficient of each kit were obtained by using frequency characteristics analysis software, and these parameters were evaluated by plotting them on Gardner's chart. Regardless of whether one or two PTSs were inserted, the natural frequency of the kits only slightly decreased (from 42.5 to 41.1 Hz, when 2 PTSs were used). Thus, the frequency characteristics of the kits with PTSs were adequate for pressure monitoring. The insertion of ≥2 FTPs in pressure transducer kits should be avoided, as they markedly decrease the natural frequency and lead to underdamping. However, the effect of PTS insertion in pressure transducer kits on the frequency characteristics is minimal. Thus, we found that the use of PTS markedly improved the frequency characteristics as compared to the use of FTP.

Cuff depth and continuous chest auscultation method for determination of tracheal tube insertion depth in nasal intubation: observational study.

BACKGROUND: Incorrect endobronchial placement of the tracheal tube can lead to serious complications. Hence, it is necessary to determine the accuracy of tracheal tube positioning. Markers are included on tracheal tubes, in the process of their manufacture, as indicators of approximate intubation depth. In addition, continuous chest auscultation has been used for determining the proper position of the tube. We examined insertion depth using the cuff depth and continuous chest auscultation method (CC method), compared with insertion depth determined by the marker method, to assess the accuracy of these methods. METHODS: After induction of anesthesia, tracheal intubation was performed in each patient. In the CC method, the depth of tube insertion was measured when the cuff had passed through the glottis, and again when breath sounds changed in quality; the depth of tube insertion was determined from these values. In the marker method, the depth of tube insertion was measured and determined when the marker of the tube had reached the glottis, using insertion depth according to the marker as an index. RESULTS: Insertion depth by the marker method was 26.6 ± 1.2 cm and by the CC method was 28.0 ± 1.2 cm (P < 0.0001). The CC method indicated a significantly greater depth than the marker method. CONCLUSION: This study determined the safe range of tracheal tube placement. Tube positions determined by the CC method were about 1 cm deeper than those determined by the marker. This information is important to prevent accidental one-lung ventilation and accidental extubation. CLINICAL TRIAL REGISTRATION: UMIN No. UMIN000011375.

Required propofol dose for anesthesia and time to emerge are affected by the use of antiepileptics: prospective cohort study.

BACKGROUND: We investigated the impact of the type of neurological disorder on the required propofol dose for anesthesia and the time to emerge from anesthesia during dental treatment in patients with autism (AU), cerebral palsy (CP), and intellectual disability (ID), some of whom also had epilepsy. METHODS: We studied 224 patients with a neurological disorder who underwent dental treatment under intravenous general anesthesia. Patients were categorized according to neurological disorder (AU, CP, and ID; and with or without an antiepileptic). The propofol dose required for anesthesia, time to emerge, and modeled propofol blood concentration at emergence were evaluated. RESULTS: In patients not given an antiepileptic, we found no significant differences in the propofol dose, modeled propofol blood concentration at emergence, or time to emerge among patients with AU, CP, and ID (P > 0.05). When using an antiepileptic, the dose of propofol (5.7 ± 1.51 mg/kg/h) was significantly lower than without an antiepileptic (6.8 ± 1.27 mg/kg/h) (P < 0.0001). The modeled propofol blood concentration at emergence in patients given an antiepileptic (0.5 ± 0.03 µg/ml) was significantly lower than without an antiepileptic (0.7 ± 0.02 µg/ml) (P < 0.0001). The time to emerge in patients given an antiepileptic (29.5 ± 12.5 min) was significantly longer than without an antiepileptic (21.6 min ± 10.0 min) (P < 0.0001). CONCLUSION: The propofol dose required for anesthesia and the time to emerge from anesthesia are not affected by the type of neurological disorder, but are affected by antiepileptic use. TRIAL REGISTRATION: University Hospital Medical Information Network Clinical Trials Registry (UMIN000014179), Date of registration 4 June 2014.

Dexmedetomidine dose-dependently enhances local anesthetic action of lidocaine.

PURPOSE: The combination of α2-adrenoceptor agonists, such as dexmedetomidine (DEX) and clonidine, with local anesthetics has been found to extend the duration of peripheral nerve blocks, probably owing to the resultant local vasoconstriction in the peripheral nerves. However, because the clear elucidation of the effect of DEX requires examination of the local anesthetic effect with DEX alone and the combination of various concentrations of DEX with local anesthetics, we evaluated the local anesthetic effect of various concentrations of DEX alone and with a local anesthetic. MATERIALS AND METHODS: The present study assessed the tail-flick (TF) latencies after injection of the appropriate drug in male Sprague-Dawley rats, using an epidural model that allowed constant pain stimulation intensity, dispersion of the anesthetic, and a precise injection site and dose. Lidocaine alone, lidocaine with 2.5-ppm DEX, lidocaine with 5.0-ppm DEX, lidocaine with 7.5-ppm DEX, and DEX alone were administered at the predetermined dose. The TF latency changes over time were compared using repeated measures analysis of variance (ANOVA). Comparisons among the groups were analyzed using ANOVA followed by a post hoc Dunnett's multiple comparison test or Tukey's multiple comparison test. RESULTS: The addition of DEX to lidocaine increased the TF latency and dose-dependently prolonged its duration as follows: 0-ppm DEX, 20 minutes; 2.5-ppm, 40 minutes; 5.0-ppm, 40 minutes; and 7.5-ppm, 50 minutes. DEX alone did not change the TF latency. CONCLUSIONS: Our results have demonstrated that DEX dose-dependently enhances the local anesthetic action of lidocaine in a rat TF model.

[A case of tracheal intubation for apnea with epidural opioid in recovery room after operation under general anesthesia].

We report a 68-year-old, American Society of Anesthesiologists Class I (ASA I), female patient scheduled for malignant uterine adnexal tumor surgery and revascularization for ovarian cancer. An epidural catheter was inserted at T12-L1 for 5 cm. Anesthesia was induced with remifentanil (0.25 microg x kg(-1) x min(-1)), sevoflurane (5%) and rocuronium (30 mg). Anesthesia was satisfactorily maintained after intubation with sevoflurane (1.5%) and remifentanil (0.2 microg x kg(-1) x min(-1)). We extubated the patient because spontaneous breathing and consciousness were observed. We intubated the patient immediately for apnea that occurred after extubation. The patient made an uneventful recovery after naloxone administration. In pharmacokinetic simulation, on the assumption that epidural administrated fentanyl was carried to blood content promptly, effect concentration to cause respiratory depression was not reached. Postoperative apnea was rationalized as follows; tardy respiratory depression with the epidural administration, and unexpected dosage of the residual fentanyl in the catheter.

Persistence of the carteolol hydrochloride/latanoprost fixed-combination ophthalmic solution, compared with the other ß-blocker/prostanoid FP receptor agonist fixed-combination ophthalmic solutions.

PURPOSE: To investigate the treatment persistence of carteolol hydrochloride/latanoprost fixed-combination ophthalmic solution (CAR/LAT) and other ß-blocker/prostanoid FP receptor agonist fixed-combination ophthalmic solutions (BB/FP) in the treatment of glaucoma. STUDY DESIGN: Retrospective observational cohort study. METHODS: A retrospective observational cohort study using JMDC Claims Database. Patients aged 20 years or older diagnosed with glaucoma between February 1, 2017, and March 31, 2020, and prescribed CAR/LAT or another BB/FP were included. RESULTS: A total of 16,612 patients (7423 in the CAR/LAT group and 9189 in the other BB/FP group) were included. The cumulative treatment persistence rate at the end of follow-up was 42.0% (64.9% at 1 year, 53.4% at 2 years, 45.0% at 3 years, and 42.0% at 4 years) in the CAR/LAT group and 34.7% (54.8% at 1 year, 43.6% at 2 years, 37.1% at 3 years, and 34.7% at 4 years) in the other BB/FP group. Treatment persistence was significantly longer in the CAR/LAT group compared to that in the other BB/FP group (hazard ratio 0.747, p < 0.0001). Over the treatment period, the number of patients who discontinued treatment was 3281 (44.2%) in the CAR/LAT group and 4926 (53.6%) in the other BB/FP group; the median duration of treatment was 135 days and 97 days, respectively. CONCLUSION: The study results suggest that persistence rates vary depending on the BB/FP and CAR/LAT appears to be more persistent than other BB/FP.

Ultrasound-Guided Peripheral Nerve Blocks Performed by Orthopedic Surgeons: A Retrospective, Multicenter Study in Akita Prefecture, Japan.

The shortage of doctors is a societal problem, especially in rural areas such as Akita Prefecture, Japan. Therefore, it is not unusual in Akita for orthopedic surgeons to perform upper and lower limb surgeries under ultrasound-guided peripheral nerve blocks managed by the operators themselves. Multicenter studies of ultrasound-guided peripheral nerve blocks performed by orthopedic surgeons have not been reported. The purpose of this study was to clarify the safety and reliability of ultrasound-guided peripheral nerve blocks performed by orthopedic surgeons in Akita. A total of 1,674 upper extremity surgery cases operated under ultrasound-guided peripheral nerve blocks at 8 hospitals in Akita prefecture from April 2016 to April 2018 were investigated retrospectively. These blocks were performed by a total of 37 orthopedic surgeons, including senior surgeons and residents. In 321 of the 1,674 cases (19%), local anesthetics were added to the surgical field. Two cases with special factors were converted to general anesthesia. There were 2 cases of complications associated with the nerve block, but they were all transient and recovered promptly. The block site and the hospital where the block was performed showed a significant relationship with the addition of local anesthetics to the surgical site (P < 0.001). Surgery time, age at surgery, and surgical site showed no significant relationships with the addition of local anesthetics. The volume of the anesthetic used for the nerve block showed a significant inverse relationship with the addition of local anesthetics (P=0.040). Many orthopedic surgeons in Akita prefecture began to perform ultrasound-guided peripheral nerve blocks, which had a reliable anesthesia effect with no noticeable complications, whether performed by residents or senior orthopedic surgeons, and this is a useful anesthetic technique for orthopedic surgeons.

Evaluation of factors affecting the occurrence of second atypical fracture after bone union of the first atypical fracture.

PURPOSE: Teriparatide is sometimes used in the treatment of atypical femoral fracture (AFF). Even if bone union is achieved, orthopedic physicians must consider the risk of relapse. This study aimed to investigate the factors affecting AFF recurrence, and to determine the appropriate treatment for osteoporosis after bone union. METHODS: One hundred thirty-one consecutive AFFs in 113 Japanese patients were included. Eleven patients had AFF in the unaffected limb (9 patients) after the first AFF or re-fracture at the original fracture site (2 patients) after bone union of the first AFF was confirmed. We divided all patients into two groups: the second fracture group (22 AFFs in 11 patients) and non-second fracture group (109 AFFs in 102 patients). We compared clinical information between the 2 groups and investigated the factors affecting AFF recurrence using the Student t-, Welch t-, and chi-square tests. RESULTS: Although there was no significant difference in clinical characteristics between the 2 groups, multivariate analysis of factors associated with AFF recurrence identified short duration of treatment with teriparatide and active vitamin D3 (p = 0.0408 and 0.0366, respectively) as risk factors. Even in the analysis excluding subtrochanteric AFF, short periods of teriparatide and active vitamin D3 administration were observed as risk factors (p = 0.0484 and 0.0346, respectively). CONCLUSION: The administration of teriparatide for as long as possible after occurrence first AFF and the use of active vitamin D3 after completion of teriparatide therapy may be the most effective strategy to prevent the recurrence of AFF.

Dexmedetomidine 2 ppm Is Appropriate for the Enhancement Effect of Local Anesthetic Action of Lidocaine in Inferior Alveolar Nerve Block: A Preliminary, Randomized Cross-over Study.

OBJECTIVE: Local anesthesia is essential for pain management in dentistry. The duration of anesthetic action of the addition of 5.0 and 7.5 ppm of dexmedetomidine (DEX) was significantly longer than the addition of adrenaline, and the mean duration of anesthetic action of the addition of 2.5 ppm DEX was also longer than the addition of adrenaline. We hypothesized that it is possible to safely achieve an equal local anesthesia effect as with 1:80,000 adrenaline, without using adrenaline or felypressin, by the addition of <2.5 ppm DEX to the local anesthetic solution. MATERIALS AND METHODS: Nineteen healthy volunteers were randomly assigned by a computer to receive 1.8 mL of 1 of 3 drug combinations (1.8% lidocaine with 1.0 ppm [1.8 µg] DEX, lidocaine with 2.0 ppm [3.6 µg] DEX or lidocaine with 1:80,000 [22.5 µg] adrenaline), to produce inferior alveolar nerve block. Pulp latency and lower lip numbness (for assessing onset and duration of anesthesia) were tested, and sedation level, blood pressure, and heart rate were recorded every 2 minutes for 10 minutes, every 5 minutes from 10 to 20 minutes, and every 10 minutes from 20 to 60 minutes. RESULTS: Pulp latency increased compared with the baseline, from 4 minutes until 60 minutes; there were no significant intergroup differences at any timepoint. Anesthesia onset did not differ between groups. Anesthesia duration did not differ between groups. Blood pressure and heart rate did not change in any group. Sedation score did not indicate deep sedation in any of the groups. DISCUSSION: DEX at a concentration of 1.0 to 2.0 ppm enhances the local anesthetic action of lidocaine. DEX at 2.0 ppm produces similar enhancement of local anesthesia effect as the addition of 1:80,000 adrenaline.

Clostridioides difficile infection in the Asia-Pacific region.

Clostridioides difficile causes healthcare-related diarrhoea in high-income countries. Highly resistant spores persist in healthcare facilities, primarily infecting patients who have recently received antimicrobials. C. difficile infection (CDI) has been studied in detail in North America and Europe; however, the epidemiology of CDI elsewhere, including the Asia-Pacific region, is largely unknown. A survey of CDI was performed in 13 Asia-Pacific countries. Epidemiological data on 600 cases were collected and molecular typing undertaken on 414 C. difficile isolates. Healthcare facility-associated CDI comprised 53.6% of cases, while community-associated CDI was 16.5%. The median age of cases was 63.0 years and 45.3% were female, 77.5% had used antibiotics in the previous 8 weeks, most frequently third-generation cephalosporins (31.7%), and 47.3% had used proton pump inhibitors. Recurrence (9.1%) and mortality (5.2%) rates were low, while complications including colitis or pseudomembranous colitis (13.8%), colectomy (0.4%), and toxic megacolon (0.2%) were uncommon. Common C. difficile strains were ribotypes 017 (16.7%), 014/020 (11.1%) and 018 (9.9%), with wide variation between countries. Binary toxin-positive strains of C. difficile were detected rarely. Overall, disease severity appeared mild, and mortality and recurrence were low. Continued education about, and surveillance of, CDI in Asia are required to reduce the burden of disease.

[Remifentanil does not increase urine output during oral surgery, contrary to its effect during other surgeries - a cohort study]. / Remifentanil não aumenta a diurese durante cirurgia oral, contrariamente ao seu efeito durante outras cirurgias ­ estudo de coorte.

BACKGROUND: An increase in urine output by remifentanil injection during laparoscopic procedures and surgeries such as cardiac and gynecological procedures, due to suppression of the stress response to surgery, has been reported. The aim of our prospective, observational, cohort study was to assess the effect of remifentanil analgesia on urine output during dental and minor oral surgery by comparing intraoperative urine output under defined infusion volumes with and without the use of remifentanil. METHODS: Dental patients aged 16 years or older, American Society of Anesthesiologists physical status 1, with no renal diseases or abnormal blood values of serum creatinine and BUN, not on treatment with diuretic drugs, and undergoing minor oro-maxillofacial surgery or dental treatment under inhalation general anesthesia were included in this study. Urethral catheterization was performed after anesthesia induction, and urine output was measured every 30minutes. We measured urine volume (mL) and rate of urine output (mL.kg-1.h-1) intraoperatively, and compared these parameters between patients who did and did not receive remifentanil during the intraoperative period. RESULTS: Eighty-seven patients were categorized into the remifentanil group (n=43) or remifentanil non-use group (n=44). Both volume of urine (mL) and rate of urine output (mL.kg-1.h-1) were not significantly different between the two groups (remifentanil group, 372.3±273.5mL, 1.8±1.1mL.kg-1.h-1; remifentanil non-use group, 343.3±283.3mL, 1.9±1.2mL.kg-1.h-1; p=0.63; 0.57). CONCLUSION: Our results show that use of remifentanil during dental and minor oral surgeries does not increase urine output.