Real-time heart rate entropy predicts the need for lifesaving interventions in trauma activation patients.

BACKGROUND: Heart rate complexity (HRC), commonly described as a "new vital sign," has shown promise in predicting injury severity, but its use in clinical practice has been precluded by the absence of real-time data. This study was conducted to evaluate the utility of real-time, automated, instantaneous, hand-held heart rate entropy analysis in predicting the need for lifesaving interventions (LSIs). We hypothesized that real-time HRC would predict LSIs. METHODS: Prospective enrollment of patients who met criteria for trauma team activation was conducted at a Level I trauma center (September 2011 to February 2012). A novel, hand-held, portable device was used to measure HRC (by sample entropy) and time-domain heart rate variability continuously in real time for 2 hours after the moment of presentation. Electric impedance cardiography was used to determine cardiac output. Patients who received an LSI were compared with patients without any intervention (non-LSI). Multivariable analysis was performed to control for differences between the groups. RESULTS: Of 82 patients enrolled, 21 (26%) received 67 LSIs within 24 hours of hospital arrival. Initial systolic blood pressure was similar in both groups. LSI patients had a lower Glasgow Coma Scale (GCS) score (9.2 [5.1] vs. 14.9 [0.2], p < 0.0001). The mean (SD) HRC value on presentation was 0.8 (0.6) in the LSI group compared with 1.5 (0.6) in the non-LSI group (p < 0.0001). With the use of logistic regression, initial HRC was the only significant predictor of LSI. A cutoff value for HRC of 1.1 yields sensitivity, specificity, negative predictive value, and positive predictive value of 86%, 74%, 94%, and 53%, respectively, with an accuracy of 77% for predicting an LSI. CONCLUSION: Decreased HRC on hospital arrival is an independent predictor of the need for LSI in trauma activation patients. Real-time HRC may be a useful adjunct to standard vital signs monitoring and predicts LSIs. LEVEL OF EVIDENCE: Prognostic and diagnostic study, level III.

Hepatitis C virus induces abnormalities in surface and intraocular pressure: a comparative study.

OBJECTIVES: Various ocular lesions are associated with hepatitis C virus (HCV). Few studies have focused on untreated patients. This study aims to describe ocular lesions in untreated HCV-infected patients without ophthalmic symptoms by means of a comprehensive ophthalmologic examination. MATERIALS AND METHODS: Ninety-five consecutive naive HCV chronically infected patients and 54 controls (blood donors) were enrolled in a prospective, cross-sectional, single-center study. The following variables were analyzed: age, sex, HCV viral load and genotype, liver fibrosis, visual acuity, biomicroscopy of the anterior segment, lacrimal function (tear break-up time) and Schirmer's tests), posterior segment examination, and intraocular pressure. RESULTS: HCV-infected patients presented an almost four times higher risk of lacrimal function involvement by tear break-up time [odds ratio (OR)=3.76; 95% confidence interval (CI) 1.75-8.04, P=0.001] and Schirmer's test (OR=4.17; 95% CI 1.83-9.50, P=0.001) than the controls. The chances of palpebral biomicroscopic lesions (blepharitis) were also higher (OR=3.21; 95% CI 1.49-6.94, P=0.003). Mean tonometry was higher in HCV patients (right eye 14.4±2.3 vs. 12.2±1.5, P<0.001 and left eye 14.5±2.3 vs. 12.0±1.4, P<0.001). CONCLUSION: Naive HCV patients even with no ophthalmic complaints presented a greater prevalence of lacrimal function abnormalities and a higher frequency of blepharitis compared with the control group. As never formerly described, intraocular pressure in HCV patients was higher than that in controls.

Using micropower impulse radar technology to screen for pneumothorax: an international bi-institutional study.

BACKGROUND: Pneumothoraces (PTXs) are a common entity in thoracic trauma. Micropower impulse radar (MIR) has been able to detect PTXs in surgical patients. However, this technology has not been tested previously on trauma patients. The purpose of this study was to determine the sensitivity and specificity of MIR to detect clinically significant PTXs. We hypothesized that MIR technology can effectively screen trauma patients for clinically significant PTXs. METHODS: This was a prospective observational study in Level I trauma centers in Boston, Massachusetts, and Bern, Switzerland. All trauma patients undergoing a chest computed tomographic (CT) scan were eligible for the study. Consent was obtained, and readings were performed within 30 minutes before or after the CT scan. The patients had eight lung fields tested (four on each side). The qualitative and quantitative MIR results were blinded and stored on the device. We then compared the results of the MIR to the CT scan and the need for chest tube drainage. We defined PTXs as clinically significant if they required a chest tube. RESULTS: Seventy-five patients were enrolled, with a mean age of 46 ± 16 years. Eighty-four percent were male. The screening test took approximately 1 minute. All but two patients had blunt chest trauma. Six true-positives, 6 false-positives, 63 true-negatives, and 0 false-negatives resulted in an overall sensitivity of 100%. CONCLUSION: MIR is an easy to use handheld technology that effectively screened patients for clinically significant PTXs, with a sensitivity and negative predictive value of 100%. MIR may be used for rapid, repeatable, and ongoing surveillance of trauma patients. LEVEL OF EVIDENCE: Diagnostic study, level III.

HOMA-AD in Assessing Insulin Resistance in Lean Noncirrhotic HCV Outpatients.

Introduction. There is an association between HCV and insulin resistance (IR), which is currently assessed by HOMA-IR. There is evidence that HOMA-adiponectin (HOMA-AD) is more accurate, but its role in HCV patients is unknown. The purpose of this study was to evaluate IR in an HCV sample and controls, in order to compare the accuracy of HOMA-IR and HOMA-AD. Methods. Ninety-four HCV outpatients aged <60 years who met the criteria of nondiabetic, nonobese, noncirrhotic, and nonalcohol abusers were included and compared to 29 controls. Fasting glucose, insulin, adiponectin, and lipid profiles were determined. IR was estimated by HOMA-IR and HOMA-AD. Results. The groups were similar regarding sex and BMI, but the HCV patients were older. The median insulin level was higher in the HCV group (8.6 mU/mL (6.5-13.7) versus 6.5 (4.3-10.7), P = 0.004), as was median HOMA-IR (1.94 (1.51 to 3.48) versus 1.40 (1.02 to 2.36), P = 0.002) and the prevalence of IR (38.3% versus 10.3% (P = 0.009)). No differences were found in adiponectin levels (P = 0.294) and HOMA-AD (P = 0.393). Conclusion. IR is highly prevalent even in low-risk HCV outpatients. Adiponectin is not influenced by the presence of HCV. HOMA-AD does not seem to be useful in assessing IR in HCV patients.

Emergent cricothyroidotomies for trauma: training considerations.

BACKGROUND: Emergent cricothyroidotomy remains an uncommon, but life-saving, core procedural training requirement for emergency medicine (EM) physician training. We hypothesized that although most cricothyroidotomies for trauma occur in the emergency department (ED), they are usually performed by surgeons. METHODS: We conducted a retrospective analysis of all emergent cricothyroidotomies for trauma presentations performed at 2 large level I trauma centers over 10 years. Operators and assistants for all procedures were identified, as well as mechanism of injury and patient demographics were examined. RESULTS: Fifty-four cricothyroidotomies were analyzed. Patients had a mean age of 50 years, 80% were male, and 90% presented as a result of blunt trauma. The most common primary operator was a surgeon (n = 47, 87%), followed by an emergency medical services (EMS) provider (n = 6, 11%) and an EM physician (n = 1, 2%). In all cases, except those performed by EMS, the operator or assistant was an attending surgeon. All EMS procedures resulted in serious complications compared with in-hospital procedures (P < .0001). CONCLUSIONS: (1) Prehospital cricothyroidotomy results in serious complications. (2) Despite the ubiquitous presence of EM physicians in the ED, all cricothyroidotomies were performed by a surgeon, which may present opportunities for training improvement.

Helicobacter pylori eradication in functional dyspepsia: HEROES trial.

BACKGROUND: Eradication of Helicobacter pylori in patients with functional dyspepsia continues to be a matter of debate. We studied eradication effects on symptoms and quality of life of primary care patients. METHODS: Helicobacter pylori -positive adult patients with functional dyspepsia meeting the Rome III International Consensus criteria were randomly assigned to receive omeprazole, amoxicillin trihydrate, and clarithromycin, or omeprazole plus placebo for 10 days. Endoscopy and H pylori tests were performed at screening and at 12 months. Outcome measures were at least 50% symptomatic improvement at 12 months using a validated disease-specific questionnaire (primary end point), patient global assessment of symptoms, and quality of life. RESULTS: We randomly assigned 404 patients (78.7% were women; mean age, 46.1 years); 201 were assigned to be treated with antibiotics (antibiotics group) and 203 to a control group. A total of 389 patients (96.3%) completed the study. The proportion of patients who achieved the primary outcome was 49.0% (94 of 192) in the antibiotics group and 36.5% (72 of 197) in the control group (P = .01; number needed to treat, 8). In the patient global assessment of symptoms, 78.1% in the antibiotics group (157 of 201) answered that they were better symptomatically, and 67.5% in the control group (137 of 203) said that they were better (P = .02). The antibiotics group had a significantly larger increase in their mean (SD) Medical Outcomes Study 36-Item Short Form Health Survey physical component summary scores than the control group did (4.15 [8.5] vs 2.2 [8.1]; P = .02). CONCLUSION: Helicobacter pylori eradication provided significant benefits to primary care patients with functional dyspepsia. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00404534.

[Effects of gadolinium chloride on sodium taurocholate-induced pancreatitis in rats]. / Efeitos do cloreto de gadolínio na pancreatite induzida por tauracolato de sódio em ratos.

OBJECTIVE: To evaluate the effects of the use of gadolinium chloride before and after induction of acute pancreatitis with sodium taurocholate 3% in rats. METHODS: Wistar rats were divided into five groups: SF--control with saline intra-ductal and IV; GD control with saline intra-ductal and gadolinium chloride IV; TS--with AP control induced by sodium taurocholate 3% and saline IV; GDTS--pre-treatment with GD (24 hours before the induction of AP) and TSGD--treatment with GD (1 hour after the induction of AP). Analysis was made in serum amylase, transaminases and TNF-α; determination of the MPO activity in lung tissue, lung and pancreatic histology. RESULTS: The number of dead animals before the end of the experiment was significantly higher in TSGD (P = 0.046). The scores of pancreatitis and lung damage were higher in the groups that used sodium taurocholate compared to groups with intra-ductal infusion of saline solution. There were no differences in other variables studied when comparing TS, GDTS and TSGD groups. CONCLUSION: The benefits with the use of gadolinium chloride as a prophylactic and therapeutic drug were not demonstrated.

Efeitos do cloreto de gadolínio na pancreatite induzida por tauracolato de sódio em ratos / Effects of gadolinium chloride on sodium taurocholate-induced pancreatitis in rats

OBJETIVO: Avaliar os efeitos do uso de cloreto de gadolínio como pré-tratamento e tratamento em um modelo experimental de pancreatite em ratos induzida por tauracolato de sódio a 3 por cento. MÉTODOS: Ratos Wistar foram divididos em cinco grupos: grupo SF - controle com solução fisiológica intra-ductal e IV; grupo TS - controle com PA induzida por tauracolato de sódio a 3 por cento e solução fisiológica a 0,9 por cento IV; grupo GD - controle com SF intra-ductal e cloreto de gadolínio IV; grupo GDTS - pré-tratamento com GD (24h antes da indução da PA) e grupo TSGD - tratamento com GD (1h após a indução da PA). Foi realizado dosagem sérica de amilase, transaminases e TNF-á; determinação da atividade da MPO no tecido pulmonar; histologia pancreática e pulmonar. RESULTADOS: O número de animais mortos antes do término previsto do experimento foi significativamente maior no grupo TSGD (p=0,046). Os escores de pancreatite e de dano pulmonar foram mais elevados nos grupos que utilizaram tauracolato em comparação aos grupos com infusão intra-ductal de solução salina. Não houve diferenças nas demais variáveis estudadas na comparação entre os grupos TS; GDTS e TSGD. CONCLUSÃO: Não foram demonstrados benefícios com o uso de cloreto de gadolínio de forma profilática e terapêutica.

OBJECTIVE: To evaluate the effects of the use of gadolinium chloride before and after induction of acute pancreatitis with sodium taurocholate 3 percent in rats. METHODS: Wistar rats were divided into five groups: SF - control with saline intra-ductal and IV; GD control with saline intra-ductal and gadolinium chloride IV; TS - with AP control induced by sodium taurocholate 3 percent and saline IV; GDTS - pre-treatment with GD (24 hours before the induction of AP) and TSGD - treatment with GD (1 hour after the induction of AP). Analysis was made in serum amylase, transaminases and TNF-á; determination of the MPO activity in lung tissue, lung and pancreatic histology. RESULTS: The number of dead animals before the end of the experiment was significantly higher in TSGD (P = 0.046). The scores of pancreatitis and lung damage were higher in the groups that used sodium taurocholate compared to groups with intra-ductal infusion of saline solution. There were no differences in other variables studied when comparing TS, GDTS and TSGD groups. CONCLUSION: The benefits with the use of gadolinium chloride as a prophylactic and therapeutic drug were not demonstrated.

Considerações sobre a abordagem da mulher fumante pelo profissional de saúde / Considerations on the approach to women smokers by healthcare professionals

Há uma distinção significativa no tratamento de fumantes conforme o gênero, uma vez que a mulher tem uma série de barreiras adicionais que dificultam o abandono do cigarro. O objetivo deste trabalho é discutir a abordagem da paciente fumante. O tratamento do fumante tem como eixo fundamental a abordagem cognitivo-comportamental, com a finalidade de informá-lo sobre os riscos do tabagismo e benefícios de parar de fumar, motivá-lo e apoiá-lo nesse processo, fornecendo orientações para que possa lidar com a síndrome de abstinência, a dependência psicológica e os condicionamentos associados ao hábito de fumar. Essa abordagem pode ser apoiada por medicamentos que diminuem os sintomas da síndrome de abstinência. É importante determinar os níveis de dependência de cada fumante, o grau de motivação para abandonar o hábito de fumar, condições e tempo de exposição ao tabaco, bem como diferenciar as fases de experimentação ou de uso regular do cigarro, a fim de poder avaliaradequadamente o paciente e prepará-lo para deixar o fumo. Nessa abordagem,há cinco passos a serem seguidos: perguntar, avaliar, aconselhar, preparar e acompanhar.

Subtle, but significant distinctions exist in the treatment of smokers of bothgenders. When compared to men, women have some additional difficulties, which make quitting more of a challenge. The aim of this study is to discuss the approach of patients who smoke. Treatment of smokers is based fundamentally on a cognitive-behavioral approach, with the aim of informing them about the risks of smoking and the benefits of giving up, motivating and supporting them during the process of quitting, helping smokers deal with the abstinence syndrome, psychological dependence and the conditioning associated with the habit of smoking. It is important to determine the level of dependence for each smoker, the level of motivation for quitting, the conditions and duration (time period) of exposure to tobacco, as well as to differentiate between mere experimentationand regular cigarette use in order to adequately evaluate smokers and counsel them as best as possible, preparing them to abandon their habit, and following up after they have quit smoking. This approach can be supported by medications which reduce the symptoms of the abstinence syndrome. This cognitive-behavioraltreatment encompasses five steps (the five A´s): Asking, Assessing, Advising,Assisting and Arranging (follow-up).