Comparison of phenobarbital monotherapy to a benzodiazepine-based regimen for management of alcohol withdrawal syndrome in trauma patients.

BACKGROUND: Alcohol withdrawal syndrome (AWS) is associated with increased morbidity and mortality in the trauma population. Benzodiazepines (BZDs) are standard of care for AWS; however, given the risk of delirium with BZDs and reports of BZD-refractory withdrawal, phenobarbital (PHB) has emerged as an alternative therapy for AWS. Safety and efficacy studies of PHB for AWS in trauma patients are lacking. Our aim was to compare a BZD versus PHB protocol in the management of AWS in trauma patients. METHODS: We performed a retrospective cohort study at a level 1 trauma center of patients at risk for AWS managed with either a BZD or a low-dose oral PHB regimen. Patients were excluded if they were taking BZDs or barbiturates before admission, received propofol or dexmedetomidine before initiation of the study drug, presented with delirium tremens or seizures, or died or discharged within 24 hours of presentation. The primary outcome was complicated AWS (seizures or alcohol withdrawal delirium/delirium tremens). Secondary outcomes included uncomplicated AWS; therapy escalation; oversedation; delirium-, intensive care unit-, and ventilator-free days; and length of stay. RESULTS: A total of 411 patients were identified; 118 received BZD, and 293 received PHB. The odds of developing complicated AWS with PHB versus BZD-based therapy were not statistically significant (odds ratio [OR], 0.52; 95% confidence interval [CI], 0.21-1.39); however, patients receiving PHB were less likely to develop uncomplicated AWS (OR, 0.08; 95% CI, 0.04-0.14) and less likely to require escalation of therapy (OR, 0.45; 95% CI, 0.24-0.84). The PHB group had a length of stay 3.1 days shorter than the BZD group ( p = 0.002). There was no difference in intensive care unit-, ventilator-, or delirium-free days. CONCLUSION: A PHB-based protocol for the management of AWS is a safe and effective alternative to BZD-based regimens in trauma patients. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Angiotensin-II for vasoplegia following cardiac surgery.

INTRODUCTION: The objective of this study was to describe the implementation and outcomes of a protocol outlining angiotensin-II utilization for vasoplegia following cardiac surgery. METHODS: This was a retrospective chart review at a single-center university hospital. Included patients received angiotensin-II for vasoplegia refractory to standard interventions, including norepinephrine 20 mcg/min and vasopressin 0.04 units/min, following cardiac surgery between April 2021 and April 2022. RESULTS: 30 patients received angiotensin-II for refractory vasoplegia. Adjunctive agents at angiotensin-II initiation included corticosteroids (26 patients; 87%), epinephrine (26 patients; 87%), dobutamine (17 patients; 57%), dopamine (9 patients; 30%), milrinone (2 patients; 7%), and hydroxocobalamin (4 patients; 13%). At 3 hours, the median mean arterial pressure increased from baseline (70 vs 61.5 mmHg, p = .0006). Median norepinephrine doses at angiotensin-II initiation, 1 hour, 3 hours, and angiotensin-II discontinuation were 0.22, 0.16 (p = .0023), 0.10 (p < .0001), and 0.07 (p < .0001) mcg/kg/min. Median dobutamine doses decreased throughout angiotensin-II infusion from eight to six mcg/kg/min (p = .0313). Other vasoactive medication doses were unchanged. Three patients (10%) subsequently received hydroxocobalamin. Thirteen (43.3%) and five (16.7%) patients experienced mortality by day 28 and venous or arterial thrombosis events, respectively. CONCLUSIONS: The administration of angiotensin-II to vasoplegic patients following cardiac surgery was associated with increased mean arterial pressure, reduced norepinephrine dosages, and reduced dobutamine dosages.

Study of a 532/1064 Fractional Picosecond Laser for Facial Rejuvenation.

BACKGROUND AND OBJECTIVES: Picosecond (ps) fractional lasers create small wounds, presumably by laser-induced optical breakdown. We studied a ps fractional laser in the treatment of wrinkles and mottled pigment. MATERIALS AND METHODS: This was a single center, prospective, open-label clinical trial. Patients with at least 2 facial areas, with visible wrinkles and dyschromia, were enrolled in the study and received 3 treatments at monthly intervals and appeared at 3 follow-up visits at 1, 3, and 6 months after treatment. The laser is an 800 ps fractional system with nominal 10 mm macrospot diameter. Both 532 nm and 1,064 nm wavelengths were applied in each subject. Wrinkle and pigmentation clearance were assessed by 2 blinded investigators using a 5-point clearance scale. Skin improvement was assessed by investigators using the 5-point Global Aesthetic Improvement (GAI) Scale based on before/after photographs for the following categories: (1) fine lines/wrinkles and (2) pigmentation. RESULTS: A total of 18 healthy subjects at a single site were enrolled. At least moderate pigmentation and fine line/wrinkles improvement were observed in 93% and 79% of patients at 1 month after the last treatment according to GAI, respectively. Pigment clearance approached a mean of approximately 40%. CONCLUSION: A ps 1,064/532 fractional laser achieves reduction in fine lines and pigment.

Multinephron Segment Diuretic Therapy to Overcome Diuretic Resistance in Acute Heart Failure: A Single-Center Experience.

BACKGROUND: The concept of multinephron segment diuretic therapy (MSDT) has been recommended in severe diuretic resistance with only expert opinion and case-level evidence. The purpose of this study was to investigate the safety and efficacy of MSDT, combining 4 diuretic classes, in acute heart failure (AHF) complicated by diuretic resistance. METHODS AND RESULTS: A retrospective analysis was conducted in patients hospitalized with AHF at a single medical center who received MSDT, including concomitant carbonic anhydrase inhibitor, loop, thiazide, and mineralocorticoid receptor antagonist diuretics. Subjects served as their own controls with efficacy evaluated as urine output and weight change before and after MSDT. Serum chemistries, renal replacement therapies, and in-hospital mortality were evaluated for safety. Patients with severe diuretic resistance before MSDT were analyzed as a subcohort. A total of 167 patients with AHF and diuretic resistance received MSDT. MSDT was associated with increased median 24-hour urine output in the first day of therapy compared with the previous day (2.16 L [0.95-4.14 L] to 3.08 L [1.74-4.86 L], P = .003) in the total cohort and in the Severe diuretic resistance cohort (0.91 L [0.43-1.43 L] to 2.08 L [1.13-3.96 L], P < .001). The median cumulative weight loss at day 7 or discharge was -7.4 kg (-15.3 to -3.4 kg) (P = .02). Neither serum sodium, chloride, potassium, bicarbonate, or creatinine changed significantly relative to baseline (P > .05 for all). CONCLUSIONS: In an AHF cohort with diuretic resistance, MSDT was associated with increased diuresis without changes in serum chemistries or kidney function. Prospective studies of MSDT in AHF and diuretic resistance are warranted.

Factors Associated With Prolonged Antibiotic Use in the Setting of Suspected Pneumonia and Negative Bronchoalveolar Lavage Cultures.

Background: Diagnostic criterion for pneumonia includes clinical data and bronchoalveolar lavage cultures (BALCx) to identify pathogens. Although ~60% of BALCx are negative, there may be reluctance to discontinue antibiotics, leading to prolonged antibiotic use (PAU). Objective: The purpose of this study is to compare outcomes of subjects with negative BALCx with PAU versus without prolonged antibiotic use (nPAU). Methods: A retrospective cohort study was conducted including subjects admitted to the intensive care unit (ICU), with suspected pneumonia, and negative BALCx. Data were compared based on length of exposure to antibiotics, PAU (antibiotics >4 days) versus nPAU (antibiotics <4 days). Results: A total of 128 subjects were included, 57 in the PAU group and 71 in the nPAU group. Baseline demographics were similar between groups. Severity of illness measured by multiple organ dysfunction scores at time of bronchoalveolar lavage (BAL) collection to final result showed a statistically significant decrease in the PAU group but not in the nPAU group. No differences were found in ICU days, ventilator-free days, or mortality; however, length of stay was longer for PAU (23 vs. 17, p = .04). In the PAU group, there were fewer BALCx results of "no growth" (23% vs. 45%, p = .04), more positive gram stains (83% vs. 60%, p = .01) and more positive non-BALCx (40% vs. 14%, p = .01). In a multivariate analysis, factors associated with PAU were positive BAL gram stains (adjusted odds ratio [aOR] 3.1, p = .037) and positive non-BALCx (aOR 4.7, p = .002). Conclusion: For subjects with suspected pneumonia and negative BALCx, positive non-BALCx and positive BALCx gram stain influenced the length of exposure of antibiotics.

Use of Tissue Plasminogen Activator Alteplase Purge Solution in an Impella 5.5 Heart Pump.

Standardized Impella purge solutions have traditionally consisted of 5-40% dextrose with or without unfractionated heparin as a means of anticoagulation. Such a solution serves to create a pressure barrier preventing entry of blood into the pump's motor housing with heparin providing adequate purge pathway patency in the event of this occurring. We present a case of tissue plasminogen activator (tPA, Activase) utilization in lieu of the recommended purge solution due to concern for thrombus formation of the purge pathway in a 51-year-old male with cardiogenic shock status-post Impella 5.5 heart pump placement for hemodynamic support while awaiting heart transplantation. The purge solution was successfully administered for 48 hours without complication and a reduction in average purge pressure with increase in purge flow rate was observed.

Treatment of Alcohol Withdrawal Syndrome: Phenobarbital vs CIWA-Ar Protocol.

BACKGROUND: Benzodiazepine-based therapy for alcohol withdrawal is associated with agitation and respiratory depression. Treatment can be complicated by a need for adjunctive therapy to control these symptoms and in patients requiring mechanical ventilation. Strong evidence for the effectiveness of alternative treatment modalities is lacking, despite the availability of promising pharmacological agents such as phenobarbital. OBJECTIVE: To compare the standard of care for the treatment of alcohol withdrawal-a symptom-triggered benzodiazepine protocol used in conjunction with the revised Clinical Institute Withdrawal Assessment of Alcohol (CIWA-Ar) scale-with a phenobarbital protocol. METHODS: Retrospective cohort study conducted from January 2016 through June 2017 at a 42-bed medical intensive care unit in a private teaching hospital in Nashville, Tennessee. The primary outcome was intensive care unit length of stay. Secondary outcomes included hospital length of stay, incidence of invasive mechanical ventilation, and use of adjunctive pharmacotherapy. RESULTS: Patients who received phenobarbital had significantly shorter stays in the intensive care unit than did those who received therapy based on the CIWA-Ar scale (mean [SD], 2.4 [1.5] vs 4.4 [3.9] days; P < .001). Those who received phenobarbital also had significantly shorter hospital stays (4.3 [3.4] vs 6.9 [6.6] days; P = .004). The incidence of invasive mechanical ventilation was lower in the phenobarbital group (1 [2%] vs 14 [23%] patients; P < .001), as was use of adjunctive agents for symptom control, including dexmedetomidine (4 [7%] vs 17 [28%] patients; P = .002). CONCLUSION: A phenobarbital protocol for the treatment of alcohol withdrawal is an effective alternative to the standard-of-care protocol of symptom-triggered benzodiazepine therapy.

Treatment of eccrine porocarcinoma with Mohs micrographic surgery: a cases series and literature review.

BACKGROUND: Eccrine porocarcinoma (EPC) is a rare malignant tumor of the eccrine sweat gland. It is a potentially fatal neoplasm that is locally aggressive and commonly recurs. Wide surgical excision has traditionally been the treatment of choice and is curative in approximately 70-80% of cases. The disease is metastatic to lymph nodes and distant sites in 20% and 10% of cases, respectively. Metastatic EPC has not shown any great response to adjuvant chemotherapy or radiation. OBJECTIVE: The purpose of this study was to evaluate the efficacy of Mohs micrographic surgery (MMS) for EPC as an alternative to wide local excision. METHODS: Five patients diagnosed with EPS between 2011 and 2014 at the University of Louisville and treated with MMS were studied. Recurrence-free periods subsequent to the treatment of EPC with MMS were measured. RESULTS: The five patients with EPC treated by MMS remained recurrence-free for a mean of 11 months (range: 2-26 months). CONCLUSIONS: Mohs micrographic surgery is a highly effective treatment for EPC. Given the high rate of recurrence, propensity for lymph node metastases, and the often ineffective options for treating advanced disease, MMS should be considered in the treatment of all cases of EPC.

Melatonin and its metabolites accumulate in the human epidermis in vivo and inhibit proliferation and tyrosinase activity in epidermal melanocytes in vitro.

Melatonin and its metabolites including 6-hydroxymelatonin (6(OH)M), N(1)-acetyl-N(2)-formyl-5-methoxykynuramine (AFMK) and 5-methoxytryptamine (5MT) are endogenously produced in human epidermis. This production depends on race, gender and age. The highest melatonin levels are in African-Americans. In each racial group they are highest in young African-Americans [30-50 years old (yo)], old Caucasians (60-90 yo) and Caucasian females. AFMK levels are the highest in African-Americans, while 6(OH)M and 5MT levels are similar in all groups. Testing of their phenotypic effects in normal human melanocytes show that melatonin and its metabolites (10(-5) M) inhibit tyrosinase activity and cell growth, and inhibit DNA synthesis in a dose dependent manner with 10(-9) M being the lowest effective concentration. In melanoma cells, they inhibited cell growth but had no effect on melanogenesis, except for 5MT which enhanced L-tyrosine induced melanogenesis. In conclusion, melatonin and its metabolites [6(OH)M, AFMK and 5MT] are produced endogenously in human epidermis and can affect melanocyte and melanoma behavior.

INTERCONNECTED REPRODUCTIVE AND VEGETATIVE REMAINS OF POPULUS (SALICACEAE) FROM THE MIDDLE EOCENE GREEN RIVER FORMATION, NORTHEASTERN UTAH.

A new specimen from the Middle Eocene Evacuation Creek Member of the Green River Formation in northeastern Utah shows a twig with several leaves of Populus wilmattae Cockrell and a fruiting raceme attached. This specimen establishes for the first time the type of fruits borne by P. wilmattae and provides additional characters with which to assess its taxonomic and evolutionary status. An associated seed shows attached placental hairs like those of extant species of Populus. The Green River fossil differs from extant Populus species in having basically palmate leaf venation and in bearing its fruiting axis on a young twig. In other aspects, the fossil species is remarkably similar to the extant species Populus mexicana.