A randomised controlled trial of prehabilitation in patients undergoing elective cardiac surgery.

The feasibility, safety and efficacy of prehabilitation in adult patients awaiting elective cardiac surgery are unknown. A total of 180 participants undergoing elective cardiac surgery were allocated randomly to receive either standard pre-operative care or prehabilitation, consisting of pre-operative exercise and inspiratory muscle training. The primary outcome was change in six-minute walk test distance from baseline to pre-operative assessment. Secondary outcomes included change in inspiratory muscle strength (maximal inspiratory pressure); sarcopenia (handgrip strength); quality of life and compliance. Safety outcomes were pre-specified surgical and pulmonary complications and adverse events. All outcomes were assessed at baseline; at pre-operative assessment; and 6 and 12 weeks following surgery. Mean (SD) age was 64.7 (10.2) years; 33/180 (18%) were women. In total, 65/91 (71.4%) participants who were allocated to prehabilitation attended at least four of eight supervised in-hospital exercise classes; participants aged > 50 years were more likely than younger participants to attend (odds ratio (95%CI) of 4.6 (1.0-25.1)). Six-minute walk test was not significantly different between groups (mean difference (95%CI) -7.8 m (-30.6-15.0), p = 0.503) in the intention-to-treat analysis. Subgroup analyses based on tests for interaction indicated improvements in six-minute walk test distance were larger amongst sarcopenic patients in the prehabilitation group (p = 0.004). Change in maximal inspiratory pressure from baseline to all time-points was significantly greater in the prehabilitation group, with the greatest mean difference (95%CI) observed 12 weeks after surgery (10.6 cmH2 O (4.6-16.6) cmH2 O, p < 0.001). There were no differences in handgrip strength or quality of life up to 12 weeks after surgery. There was no significant difference in postoperative mortality (one death in each group), surgical or pulmonary complications. Of 71 pre-operative adverse events, six (8.5%) were related to prehabilitation. The combination of exercise and inspiratory muscle training in a prehabilitation intervention before cardiac surgery was not superior to standard care in improving functional exercise capacity measured by six-minute walk test distance pre-operatively. Future trials should target patients living with sarcopenia and include inspiratory muscle strength training.

Torsades de pointes associated with high dose levomethadyl acetate (ORLAAM).

A patient undergoing management of heroin dependency with high dosages of the long-acting methadone derivative, levomethadyl acetate HCl (LAAM; ORLAAM) developed a prolonged QTc interval and polymorphic QRS complexes on EKG consistent with torsades de pointes (TdP). The patient was taking other drugs known to prolong the QTc interval (fluoxetine and IV cocaine), and those known to antagonize the activity of the P450 enzymes responsible for the metabolism of LAAM and its active metabolite (fluoxetine, cocaine and marijuana). No previous reports have appeared in the literature attributing this adverse event to LAAM therapy; however, five similar cases have been reported to the manufacturer. Animal studies indicate that LAAM and metabolites prolong the action potential duration of myocardial cells. We propose that predisposed patients on high doses of LAAM may be at risk for developing TdP. Patients being treated with LAAM should receive dosages consistent with guidelines and be evaluated for concomitant diseases, interacting drug therapies, and EKG abnormalities.

Use of combined oral narcotic and benzodiazepine for control of pain associated with bone marrow examination.

BACKGROUND: Bone marrow aspirate and biopsy is universally recognized as being painful. Few descriptions of effective analgesia or premedication for this procedure exist. In this study, we assessed an oral narcotic and benzodiazepine combination in controlling pain associated with bone marrow examination. METHODS: Twenty-four consecutive ambulatory, adult patients referred for bone marrow examination received oral medications 90 minutes before the scheduled procedure. Patients reported perceived pain, using both Likert numerical and "Faces Pain Rating Scale," immediately after bone marrow examination and within 1 week after the procedure. Physicians' and nurses' evaluations of patient tolerance and the patients' memories of the aspiration and biopsy were recorded. RESULTS: Two thirds (66%) of the respondents reported none or only mild pain (3 or less on a scale of 1 to 10). Memory of the procedure was vague or nonexistent in approximately half of the patients. There were no complications of biopsies or premedication. CONCLUSIONS: Premedication with oral narcotic and benzodiazepine is effective in preventing or lessening pain associated with bone marrow examination in adults. Premedication induces amnesia for some or most of the procedure in about half of the patients.

Closet hypoglycemia.

An elderly nondiabetic woman was found stuporous and unresponsive at home. In the emergency department, testing revealed that she had a serum glucose of 40 mg/dL (2.2 mmol/L). No underlying metabolic cause could be determined. An inspection of her medications disclosed a professional medication sample bottle labeled as containing a nonsteroidal anti-inflammatory drug (NSAID) that actually contained chlorpropamide tablets. Drugs, notably sulfonylureas, must be considered as a possible cause of unexplained severe hypoglycemia.

Hypersensitivity and anaphylactoid reactions to ciprofloxacin.

OBJECTIVE: To report three cases of life-threatening hypersensitivity reactions to the oral administration of ciprofloxacin. CASE SUMMARY: Life-threatening hypersensitivity reactions to oral ciprofloxacin, characterized by diffuse, erythematous, nonpruritic, blanching rash, with fever and hypotension, occurred in two HIV-infected patients. One of these reactions was considered anaphylactoid. A similar hypersensitivity reaction was documented in a non-HIV-infected patient. DISCUSSION: Premarketing clinical trials described no reports of life-threatening anaphylactoid hypersensitivity reactions to ciprofloxacin. However, postmarketing surveillance studies have documented their occurrence. Seven cases of anaphylactoid reaction to ciprofloxacin have now been documented in HIV-infected patients. CONCLUSIONS: As with trimethoprim/sulfamethoxazole, HIV-infected people treated with ciprofloxacin may be at special risk for hypersensitivity reactions.

Death by embolization of prosthetic aortic valve.

This report describes a case in which a young woman died from embolization of her prosthetic aortic valve. The discussion includes the embolization's association with chronic intravenous narcotism, recurrent bacterial endocarditis, and acute cocaine toxicity.

Current issues in NSAID therapy.

More than a dozen NSAIDs are commercially available in the United States. Diclofenac may not be as effective for dysmenorrhea. Although most are equally efficacious, indomethacin is the preferred agent for hemicrania continua and chronic paroxysmal hemicrania. Although all NSAIDs should theoretically be beneficial in gout, the greatest experience is with indomethacin. Sulindac may be the preferred agent for diabetic neuropathy. Fenoprofen appears to be the most offensive NSAID in terms of nephrotoxicity. NSAIDs may antagonize antihypertensive therapy, although this effect may not persist beyond 1 month. Generally, use of NSAIDs in pediatric patients is limited to naproxen and tolmetin. Concomitant therapy with methotrexate, lithium, and AZT should be approached with caution. NSAIDs have similar propensities to cause gastrointestinal side effects. Sucralfate has consistently proved beneficial as cytoprotective therapy for use with NSAIDs without impairing absorption of the NSAID, NSAIDs generally should be avoided prior to surgery, although sulindac or nonacetylated salicylates have a negligible effect on platelet function and may be used if continued NSAID therapy is required. Hepatotoxicity, although rare with NSAIDs, is most common with phenylbutazone and least common with the fenamates.

Effect of concurrent sucralfate administration on the absorption of erythromycin.

To determine the influence of sucralfate on the absorption of erythromycin, prior to evaluating its efficacy in decreasing erythromycin-associated gastrointestinal (GI) intolerance, we assessed pharmacokinetic parameters in six healthy adult volunteers. Erythromycin ethylsuccinate administered alone or with sucralfate as a single dose was compared. Sucralfate did not significantly alter the elimination rate constant, half-life, or area under the curve for erythromycin ethylsuccinate. It is therefore unlikely that efficacy of erythromycin ethylsuccinate will be altered when sucralfate is coadministered.

Selecting nonsteroidal anti-inflammatory drugs: pharmacologic and clinical considerations.

An increasing number of nonsteroidal anti-inflammatory drugs (NSAIDs) are available to treat a variety of conditions. There exist little comparative data examining efficacy for all NSAIDs for a particular illness. The major factors governing selection of these agents relate to the patient's condition and the drug's characteristics. Once efficacy has been established, selection of an NSAID is then determined by side-effect profile, potential for drug interactions, dosing frequency, and cost. This review presents a listing of commercially available NSAIDs, cost comparisons for average daily doses of NSAIDs, and the conditions and drug characteristics that might influence the choice of an NSAID.

Bone marrow in HIV infection. A comparison of fluorescent staining and cultures in the detection of mycobacteria.

Fifty-one bone marrow aspirates and biopsies from 47 human immunodeficiency virus-(HIV) infected patients (42 with acquired immune deficiency syndrome [AIDS], 5 with AIDS-related complex [ARC]) were processed by standard methods for smears and paraffin sections. Aspirates were cultured for Mycobacteria. The sections, imprints, and smears were examined by fluorescent microscopy with the use of Truant's modification of the auramine-rhodamine stain. Mycobacterial cultures had positive results from 35%. Sensitivity of fluorescent staining was 72% and specificity was found to be 94%. If the fluorescent stain had positive results, the positive predictive value for recovering Mycobacteria on culture was 87%. Fluorescent microscopy with the use of Truant's auramine-rhodamine staining of routinely processed bone marrow aspirates and biopsies is a fairly sensitive, very specific, and rapid technique for determining the presence of Mycobacteria in bone marrow specimens from patients with HIV infection.

Infections caused by central venous catheters in patients with acquired immunodeficiency syndrome.

We assessed infectious complications of long-term percutaneous central venous catheterization in patients with acquired immunodeficiency syndrome (AIDS). We evaluated 98 consecutive patients, accounting for 6,298 catheter days. Catheter-associated bacteremia occurred in 3% of patients, a rate of 0.128%/patient-catheter day. Only bacterial pathogens--Pseudomonas, Serratia, and Staphylococcus species--were isolated. Five patients had infection at the catheter exit site. The length of time catheters were indwelling was not significantly different in patients with and those without infections. Percutaneous, multiple-use central venous catheters are safe and well accepted by patients with AIDS.

Abdominal pain and sicklemia in a patient with sickle cell trait.

We have presented a case of thrombotic thrombocytopenic purpura initially misdiagnosed as sickle cell crisis. Based on the "history" of hemoglobin S disease, anemia, and the presence of apparent sickled cells on the peripheral blood smear, the diagnosis of sickle cell crisis seemed reasonable. The patient is described because of unusual features of the case, to emphasize again a hazard of sickle cell screening and the value of reviewing the peripheral blood smear in cases of anemia.

Abdominal cryptococcoma in AIDS: a case report.

Cryptococcosis is a recognized opportunistic pathogen in the acquired immune deficiency syndrome. Although central nervous system infection and disseminated cryptococcosis is common in acquired immune deficiency syndrome, localized infection is rare. We present a case of massive retroperitoneal and mesenteric adenopathy in a male homosexual patient with acquired immune deficiency syndrome with clinical and radiologic features suggestive of lymphoma. However, this was proven pathologically to represent cryptococcal infiltration of the lymph nodes. Our experience indicates that Cryptococcus neoformans should be included in the differential diagnosis of massive abdominal adenopathy in the acquired immune deficiency syndrome.

Role of long-acting cephalosporins in ambulatory therapy.

Selected patients with community-acquired infections can be discharged from the hospital, when afebrile and stable, with parenteral antibiotic therapy continued on an ambulatory basis. This therapy is currently possible because of the availability of long-acting cephalosporins that can be administered once daily, often with substantial reductions in hospital costs. Cefonicid and ceftriaxone both have sufficiently long half-lives and either may be administered intramuscularly once daily. Their antibacterial spectra encompass many of the pathogens encountered in community-acquired infections of the lower respiratory tract, skin and soft tissue, bone, and urinary tract. Ceftriaxone, a third-generation cephalosporin, has a broader spectrum than the second-generation agent cefonicid. Ceftriaxone should generally be reserved for the treatment of gonococcal disease and of community- or hospital-acquired infections due to organisms resistant to the narrower-spectrum and less expensive long half-life agent cefonicid.

Hypertension and intussusception.

Two unusual cases of intussusception in children less than a year old are presented. Each patient was brought to the author's attention because of altered level of activity, and both were found to be hypertensive. The hypertension resolved after the intussusception was reduced. Diagnosis of hypertension in children, when associated with gastrointestinal dysfunction, is discussed.