Acute Traumatic Subdural Hematoma and Anticoagulation Risk.

BACKGROUND: Anticoagulation is used to prevent thromboembolic events. It is a common practice to hold anticoagulation in the first few days following a traumatic brain injury (TBI) with intracranial hemorrhage. However, traumatic subdural hematomas (SDH) are prone to re-hemorrhage long after the trauma. Data are scarce in the literature on the best timing to resume anticoagulation following a TBI. METHODS: Review of 95 consecutive patients admitted to a level 1 trauma center with a diagnosis of traumatic SDH and requiring anticoagulation. The reasons for anticoagulation, the amount of time without anticoagulation, CT characteristics, and the incidence of thromboembolic events or SDH re-hemorrhage were collected. RESULTS: 41.3% used anticoagulation for coronary artery disease and peripheral vascular disease, 24% for atrial fibrillation, 12% for cardiac valve replacement, and 12% for venous thromboembolic events. Anticoagulation was held a median of 67 days. For most patients (82.1%), anticoagulation was re-introduced once the SDH had completely resolved. For 17.9%, anticoagulation was restarted while the SDH had not completely resolved. One (1.1%) patient suffered from an atrial clot while anticoagulation was held. For those with residual SDH, 41.2% suffered from a SDH re-hemorrhage and 17.6% required surgery. The risk of re-hemorrhage climbed to 62.5% if the SDH remnant was large. CONCLUSION: Anticoagulation while there is a residual SDH was associated with a significant risk of re-hemorrhage. This risk should be weighed against the risk of holding anticoagulation.

The challenge of living with diabetes in women and younger adults: A structural equation model.

BACKGROUND: Attitudes toward diabetes care are different between genders and age-groups. Furthermore, diabetes related challenges may cause psychosocial problems. Therefore, we were to compare the psychosocial status and glycemic control in women and men with type 2 diabetes (T2D) in different age-groups. METHODS: 441 adults with T2D were recruited. Demographic, self-care behavior, resources and affective variables as well as the health related quality of life (HRQoL) were measured. The median age of 55 was used as the cut-off for the age comparison. Structured equation modeling (SEM) investigated the relationship between age, gender, psychosocial factors and glycemic control. RESULTS: Finally, 203 women and 177 men completed the study (86.1%). There was no significant difference in mean duration of T2D, or glycemic control between genders or age-groups. Women, especially those below the median age of 55, had significantly higher level of diabetes-related distress (2.16±0.94 vs. 1.92±0.81), depression (9.67±5.37 vs. 7.54±5.06), and anxiety (19.81±12.04 vs. 12.81±9.04, P<0.05 for all comparisons), while people above the age of 55 reported better self-management and patient-physician relationship. HRQoL was lower in women compared to men (0.77±0.23 vs. 0.81±0.18, P=0.02). The final SEM suggested that the effect (standardized ß coefficient) of gender and age on affective variables was 0.25 and -0.19 (P<0.05), respectively, though psychosocial factors did not directly influence HbA1c. CONCLUSIONS: This study shows that psychosocial factors are associated with age and gender in patients with T2D; with younger women demonstrating higher level of depressive symptoms, anxiety, and diabetes-related distress independent of status of glycemic control.

Double-Blind, Placebo-Controlled, Randomized Phase I/IIa Study (Safety and Efficacy) with Buspirone/Levodopa/Carbidopa (SpinalonTM) in Subjects with Complete AIS A or Motor-Complete AIS B Spinal Cord Injury.

BACKGROUND: No drug treatment capable of restoring locomotor capabilities in patients suffering a motor-complete spinal cord injury (SCI) has ever been developed. We assessed the safety and efficacy of an activator of spinal locomotor neurons in humans, which were shown in paraplegic animals to elicit temporary episodes of involuntary walking. METHODS: Single administration of buspirone/levodopa/carbidopa (SpinalonTM), levodopa/carbidopa (ratio 4: 1), and buspirone or placebo was performed using a dose-escalation design in 45 subjects placed in supine position who had had an SCI classified as complete (AIS A) or motor-complete/sensory incomplete (AIS B) for at least 3 months. Blood samples before and at regular intervals (15, 30, 60, 120, 240 min) after treatment were collected for hematological and pharmacokinetic (PK) analyses. Electromyographic (EMG) activity of eight muscles (four per leg) was monitored prior to and at several time points after drug administration. RESULTS: SpinalonTM (10-35 mg buspirone/100-350 mg levodopa/25-85 mg carbidopa) displayed no sign of safety concerns - only mild nausea was found in 3 cases. At higher doses, 50 mg/500 mg/125 mg SpinalonTM was considered to have reached maximum tolerated dose (MTD) since 3 out of 4 subjects experienced related adverse events including vomiting. PK analyses showed comparable data between groups suggesting no significant drugdrug interaction with SpinalonTM. Only the SpinalonTM-treated groups displayed significant EMG activity accompanied by locomotor-like characteristics - that is with rhythmic and bilaterally alternating bursts. CONCLUSION: Therefore, this study provides evidence of safety and preliminary efficacy following a single administration of SpinalonTM in subjects with SCI.

Biphasic insulin Aspart 30 vs. NPH plus regular human insulin in type 2 diabetes patients; a cost-effectiveness study.

BACKGROUND: The aim of this study was to compare the efficacy, safety, costs, and cost-effectiveness of biphasic insulin aspart 30 (BIAsp 30) with NPH plus regular human insulin (NPH/Reg) in patients with type 2 diabetes mellitus (T2DM). METHODS: It was a Single-center, parallel-group, randomized, clinical trial (Trial Registration: NCT01889095). One hundred and seventy four T2DM patients with poorly controlled diabetes (HbA1c ≥ 8 % (63.9 mmol/mol)) were randomly assigned to trial arms (BIAsp 30 and NPH/Reg) and were followed up for 48 weeks. BIAsp 30 was started at an initial dose of 0.2-0.6 IU/Kg in two divided doses and was titrated according to the glycemic status of the patient. Similarly, NPH/Reg insulin was initiated at a dose of 0.2-0.6 IU/Kg with a 2:1 ratio and was subsequently titrated. Level of glycemic control, hypoglycemic events, direct and indirect costs, quality adjusted life year (QALY) and incremental cost-effectiveness ratio have been assessed. RESULTS: HbA1c, Fasting plasma glucose (FPG), and two-hour post-prandial glucose (PPG) were improved in both groups during the study (P < 0.05 for all analyses). Lower frequencies of minor, major, and nocturnal hypoglycemic episodes were observed with BIAsp 30 (P < 0.05). Additionally, BIAsp 30 was associated with less weight gain and also higher QALYs (P < 0.05). Total medical and non-medical costs were significantly lower with BIAsp 30 as compared with NPH/Reg (930.55 ± 81.43 USD vs. 1101.24 ± 165.49 USD, P = 0.004). Moreover, BIAsp 30 showed lower ICER as a dominant alternative. CONCLUSIONS: Despite being more expensive, BIAsp 30 offers the same glycemic control as to NPH/Reg dose-dependently and also appears to cause fewer hypoglycemic events and to be more cost-effective in Iranian patients with type 2 diabetes.

Morphine Suppository versus Indomethacin Suppository in the Management of Renal Colic: Randomized Clinical Trial.

Background. Renal colic is a medical emergency due to the rapid onset and devastating nature of its pain. Opioids and nonsteroidal anti-inflammatory drugs (NSAIDs) are both used as first-line choices in its management. Aim. This study aimed to compare the efficacy and safety of opioids and NSAIDs in the management of acute renal colic. Methods. One hundred and fifty-eight patients were divided into two groups (n = 79) and received either 10 mg morphine or 100 mg indomethacin suppositories. The severity of pain was measured using verbal numeric rating scale at baseline and 20, 40, 60, and 90 minutes after the administration of analgesics. Drug side effects as well as patients' vital signs were also recorded. Results. The mean decrease in the pain score during the first 20 minutes was significantly higher among those who received morphine suppository. However, no significant difference was observed between the two groups regarding the mean decrease in pain score during the first 40, 60, and 90 minutes after the admission. Prevalence of drug side effects or changes in the vital signs was not significantly different between the two groups. Conclusions. Morphine suppositories seem to be more efficient in achieving rapid pain relief comparing to indomethacin.

Association Between Lifestyle and Hypertension in Patients Referred to Health Care Centers of Ilam City in 2014.

INTRODUCTION: Lifestyle is referred to an individual's healthy and unhealthy behaviors that can affect their health statues. The present study aim was association between lifestyle and hypertension in patients referred to healthcare centers of Ilam city in 2014. MATERIALS & METHODS: This research study was a case-control study. The data were collected through a standard questionnaire of health-promoting lifestyle profile (HPLPII) as well as the researcher's direct visit to the health care centers in the city of Ilam. After the questionnaires were collected and classified, the data were entered into SPSS software and analyzed by descriptive statistics, chi-square tests, T-Tests and logistic regression. RESULTS: The mean and the standard deviation of the age of the main and the control groups were 57.1 (2.22) and 56.5 (2.99) years old, respectively. 10.9%of the control group and 25.5. % of the cases was smoking cigarettes or hookah. The results of the data analysis showed that the mean scores obtained by the main and the control groups on measures of physical activity, psychological growth, stress and total lifestyleare significantly different, so that the obtained score in the dimensions in patients with hypertension was significantly lower than the score obtained among the healthy individuals. CONCLUSIONS: According to the results it seems that educational interventions in the field of healthy lifestyle for individuals with hypertension risk can have an effect on controlling this disease and reducing its incidence.

Selecting emergency medicine: rationales from perspective of Iranian residents.

Emergency medicine is a relatively new specialty in Iran. Therefore, the general public and the medical community do not have enough information on its duties, capabilities, its nature, and its work schedule or its degree of occupational difficulty compared to other specialties. Hence, an insight from the early group of residents who selected this specialty can help identify the strengths and weaknesses of this field in order to promote the scientific quality of this field, and attract medical students. It can also help to alleviate deficiencies and strengthen positive aspects of emergency medicine. The aim of this study was to identify the reasons behind choosing emergency medicine as a specialty. A qualitative study was conducted using semi-structured interviews. Maximum variation opportunistic sampling was done, and face-to-face interviews were held with 23 emergency medicine residents and fellows (4 faculty members and 19 residents). Data were analyzed through thematic analysis, and categories and themes were extracted. The main levels extracted were: 1) Individual priorities, 2) the nature of work and the field of study, and 3) professional future. The themes of each main level were extracted and encoded. This study showed that the majority of residents choose emergency medicine specialty to achieve a better social and professional status in one of the most challenging fields of medicine.

Rapid screening of diabetic polyneuropathy: selection of accurate symptoms and signs in an outpatient clinical setting.

Clinical assessment of distal symmetric polyneuropathy (DPN) involves the evaluation of symptoms and signs. Although there are numerous tools to evaluate DPN, there is still a need to determine the most sensitive, specific, and accurate tests to detect DPN in a busy outpatient clinical setting. A total of 107 patients with type 2 diabetes were examined using Michigan Neuropathy Screening Instrument (MNSI). Total score of the instrument was used as a standard to calculate sensitivity, specificity and diagnostic accuracy of every single item of MNSI to find the most accurate and applicable test for evaluation of DPN. In patients' history, the most sensitive (99.4%) and accurate (78%) symptoms were muscle cramp and weakness. Numbness and prickling had lower sensitivity (72.6% and 67.9%, respectively) but greater specificity (65.2% and 47.8%). In physical assessment, the most accurate signs were appearance of feet (81.3%), ankle reflexes (67.2%), and vibration perception (63.5%). Monofilament test had a sensitivity of 16.7%, accuracy of 31.7% with specificity of 87%. Findings show that symptoms such as a muscle cramp, weakness, numbness, and prickling, as well as signs such as ankle reflexes, appearance of feet, and vibration could be used as the most accurate tests for rapid diagnosis of DPN. In addition, the results suggest that monofilament examination may not be the optimum test to detect high risk patients.

Fixed Cut-Off for FEV1/FEV6 and FEV6 in Detection of Obstructive and Restrictive Patterns.

BACKGROUND: Chronic obstructive pulmonary diseases (COPD) have been defined by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) as irreversible conditions which are diagnosed by fixed cut-off points of FEV1/FVC. OBJECTIVE: The aim of this study was to determine the cut-off points for FEV1/FEV6 ratio and FEV6 as alternatives for FEV1/FVC and FVC in detection of airway obstruction and lung restriction, respectively. MATERIALS AND METHODS: A total of 318 Spiro metric examinations of subjects referred to Shariati hospital were analyzed. A subject was considered to have obstruction if FEV1/FVC was lower than 70%. The restriction was defined as FVC < 80% in the absence of obstruction. The Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of FEV1/FEV6 and FEV6 were calculated. RESULTS: This study shows that the current cut-off points used to detect obstruction and restriction can be replaced by FEV1/FEV6 < 71% and FEV6 < 83%, respectively. FEV1/FEV6 had sensitivity of 95.5% and specificity of 99.4%; the PPV and NPVs were 99.3% and 96.3%. The prevalence of obstruction was 49.4%. For restrictive pattern, FEV6 had sensitivity of 93%, specificity of 79.5% with PPV of 18% and NPV of 99.5%. The prevalence of restriction was 6.3%. CONCLUSIONS: The FEV1/FEV6 ratio can be used as a valid surrogate for FEV1/FVC in the diagnosis of airway obstruction, especially for screening purposes in high-risk populations for COPD. Moreover, FEV6 is an acceptable alternative for FVC in detection of restrictive pattern.

A novel approach in eight polyorchidism cases: vasoepidydimal or epididymo-epididymal approximation in single vas deferens duplicated testis.

OBJECTIVE: To discuss the classification systems and pose a rationale for a flexible approach. We also propose our surgical approach for vasoepididymal or epidymo-epididymal approximation. Polyorchidism is a rare congenital anomaly with about 200 cases reported. METHODS: We present 8 cases of polyorchidism treated at our institute from 1992 to 2010. To our knowledge, this is the most numerous single-center experience. We performed vasoepididymal or epidymo-epididymal approximation to restore near-normal anatomy plus stabilization of the testicular and ductal system to facilitate possible future reconstructive surgery. RESULTS: In the case of contralateral anorchia or an atrophic testis, a supernumerary testis can fairly replace the contralateral counterpart. The reproductive potential of the supernumerary testis must not be ignored. Also, the malignant potential of the supernumerary testis should not be overestimated. CONCLUSION: A careful pursuit of the vessel and vasal route during surgery for an undescended testis, judicious use of laparoscopy, and a lower threshold for diagnosis both on imaging studies and during surgery might result in a greater number of cases of polyorchidism in the daily practice of pediatric urology.