Timing of tracheostomy in acute traumatic spinal cord injury: A systematic review and meta-analysis.

BACKGROUND: Patients with acute traumatic cervical or high thoracic level spinal cord injury (SCI) typically require mechanical ventilation (MV) during their acute admission. Placement of a tracheostomy is preferred when prolonged weaning from MV is anticipated. However, the optimal timing of tracheostomy placement in patients with acute traumatic SCI remains uncertain. We systematically reviewed the literature to determine the effects of early versus late tracheostomy or prolonged intubation in patients with acute traumatic SCI on important clinical outcomes. METHODS: Six databases were searched from their inception to January 2020. Conference abstracts from relevant proceedings and the gray literature were searched to identify additional studies. Data were obtained by two independent reviewers to ensure accuracy and completeness. The quality of observational studies was evaluated using the Newcastle Ottawa Scale. RESULTS: Seventeen studies (2,804 patients) met selection criteria, 14 of which were published after 2009. Meta-analysis showed that early tracheostomy was not associated with decreased short-term mortality (risk ratio [RR], 0.84; 95% confidence interval [CI], 0.39-1.79; p = 0.65; n = 2,072), but was associated with a reduction in MV duration (mean difference [MD], 13.1 days; 95% CI, -6.70 to -21.11; p = 0.0002; n = 855), intensive care unit length of stay (MD, -10.20 days; 95% CI, -4.66 to -15.74; p = 0.0003; n = 855), and hospital length of stay (MD, -7.39 days; 95% CI, -3.74 to -11.03; p < 0.0001; n = 423). Early tracheostomy was also associated with a decreased incidence of ventilator-associated pneumonia and tracheostomy-related complications (RR, 0.86; 95% CI, 0.75-0.98; p = 0.02; n = 2,043 and RR, 0.64; 95% CI, 0.48-0.84; p = 0.001; n = 812 respectively). The majority of studies ranked as good methodologic quality on the Newcastle Ottawa Scale. CONCLUSION: Early tracheostomy in patients with acute traumatic SCI may reduce duration of mechanical entilation, length of intensive care unit stay, and length of hospital stay. Current studies highlight the lack of high-level evidence to guide the optimal timing of tracheostomy in acute traumatic SCI. Future research should seek to understand whether early tracheostomy improves patient comfort, decreases duration of sedation, and improves long-term outcomes. LEVEL OF EVIDENCE: Systematic Review, level III.

Contrast-enhanced spectral mammography versus MRI: Initial results in the detection of breast cancer and assessment of tumour size.

OBJECTIVES: To compare mammography (MG), contrast-enhanced spectral mammography (CESM), and magnetic resonance imaging (MRI) in the detection and size estimation of histologically proven breast cancers using postoperative histology as the gold standard. METHODS: After ethical approval, 80 women with newly diagnosed breast cancer underwent MG, CESM, and MRI examinations. CESM was reviewed by an independent experienced radiologist, and the maximum dimension of suspicious lesions was measured. For MG and MRI, routine clinical reports of breast specialists, with judgment based on the BI-RADS lexicon, were used. Results of each imaging technique were correlated to define the index cancer. Fifty-nine cases could be compared to postoperative histology for size estimation. RESULTS: Breast cancer was visible in 66/80 MG, 80/80 CESM, and 77/79 MRI examinations. Average lesion largest dimension was 27.31 mm (SD 22.18) in MG, 31.62 mm (SD 24.41) in CESM, and 27.72 mm (SD 21.51) in MRI versus 32.51 mm (SD 29.03) in postoperative histology. No significant difference was found between lesion size measurement on MRI and CESM compared with histopathology. CONCLUSION: Our initial results show a better sensitivity of CESM and MRI in breast cancer detection than MG and a good correlation with postoperative histology in size assessment. KEY POINTS: • Contrast-enhanced spectral mammography (CESM) is slowly being introduced into clinical practice. • Access to breast MRI is limited by availability and lack of reimbursement. • Initial results show a better sensitivity of CESM and MRI than conventional mammography. • CESM showed a good correlation with postoperative histology in size assessment. • Contrast-enhanced spectral mammography offers promise, seemingly providing information comparable to MRI.

Volumetric breast density assessment: reproducibility in serial examinations and comparison with visual assessment.

BACKGROUND AND PURPOSE: Mammographic breast density is the strongest known marker of breast cancer risk. Visual breast density assessment is subject to significant intra- and inter-rater variability. The aim of the present study was to test the reproducibility of automatic breast density assessment and to compare the results to the visual assessment. PATIENTS AND METHODS: Serial mammograms of 141 patients were retrospectively reviewed. Breast density was assessed both visually using a BI-RADS four-category breast density scale and with a software tool for volumetric breast density measurement. RESULTS: The intra- and inter-rater reproducibility as well as inter-examination reproducibility were assessed for both techniques by calculating the intraclass correlation coefficient (ICC). The inter-examination reproducibility of the volumetric measurement of breast percent density was 0.91 (ICC; 95 % CI 0.87 - 0.93). There was no difference in the strength of the correlation between patients with a large vs. small difference in compression force. The intra- and inter-rater reproducibility ranged from 0.81 - 0.84 and 0.71 - 0.77, respectively. The inter-examination reproducibility of visual assessment was 0.75 - 0.81. The agreement of visual assessment with volumetric measurement was similar to the agreement among readers. CONCLUSION: Our results indicate that volumetric breast density measurement provides higher reproducibility in serial examinations than visual assessment and may thus be preferable in the longitudinal assessment of breast density and in the measurement of breast density for risk stratification.

Corticosteroid therapy for patients with acute exacerbations of chronic obstructive pulmonary disease: a systematic review.

OBJECTIVE: To determine whether systemic corticosteroids are of benefit to patients with acute exacerbations of chronic obstructive pulmonary disease (COPD). METHODS: An English-language search of MEDLINE (1966 to February 2002) and the Cochrane Library and a bibliographic review was performed to identify published clinical trials of systemic corticosteroid administration in acute exacerbations of COPD. All relevant English-language, randomized, placebo-controlled clinical trials were considered. Trials investigating the adverse effects of systemic steroids were also retrieved. Studies were assigned a quality rating according to explicit criteria. Clinically relevant end points, such as treatment failure and duration of hospital stay, were considered preferentially. To compare outcomes across all qualifying studies, we considered the difference in spirometric measures between treatment and placebo groups. Potential confounding factors and bias relating to patient selection, treatment protocols, and outcome measurement were considered independently for each study. RESULTS: Among the 8 studies that met all criteria, 5 found that significant improvement in forced expiratory volume in 1 second (>20%) was associated with steroid administration. Two studies found improvement in clinically relevant outcomes. One published study and 2 study abstracts did not find significant improvement in spirometric measures with corticosteroid administration. CONCLUSION: Short courses of systemic corticosteroids in acute exacerbations of COPD have been shown to improve spirometric outcomes (good-quality evidence) and clinical outcomes (good-quality evidence).

Swertia spp: a source of bitter compounes for medicinal use.

Swertia is an important genus used in Indian medicine. A comprehensive review on this genus is presented in this article.

Clinical toxicology of clotrimazole when administered vaginally.

Clotrimazole, a tritylimidazole and a new antimicrobial agent, produced itching and irritation of the vulva and vaginal area in less than 1% of the population (N = 131) studied. No abdominal cramps, headache or lightheadedness, nausea, vomiting, and diarrhea were observed when 200 mg of clotrimazole was inserted deep in the vagina for several days.

Methadone-induced behavioral changes: circular movements, aggression, and electrophysiological aspects.

Behavioral changes are induced in animals by methadone administration. The dose-dependent CM effect is present 2 to 3 minutes after methadone administration. This effect can be partially blocked by nalline. A Complete blockade occurs when the naline-reserpine combination is given prior to the administration of methadone. Atropine sulfate dose not block the CM effect. Methadone withdrawal produces mild symptoms of aggression, and they can be intensified by amphetamine and apomorphine. During the process of development of tolerance and addiction, electrophysiological changes are produced. These changes can be intensified by apomorphine treatment in the methadone-withdrawal animals. On the basis of pharmacological manipulation in our experimental conditions, the involvement of cerebral biogenic amines, especially dopamine, is proposed.

Alkaloids of tobacco and blood coagulation: effect of nicotine on thrombin and fibrinogen.

An alkaloid of tobacco, nicotine, affected the clot-formation property of the enzyme, thrombin, on the substrate, plasma or fibrinogen (thrombin time). Higher concentrations of nicotine retarded the clot-formation property of thrombin. By decreasing the nicotine concentration in the clotting mixture, the clotting time of thrombin was accelerated. Nicotine also modified the clot formation property of plasma or fibrinogen to thrombin, and this effect was dose dependent. From this experimental evidence, it is suggested that nicotine does alter the clot-forming properties of thrombin on fibrinogen.