Quinine for muscle cramps.

BACKGROUND: Muscle cramps can occur anywhere and for many reasons. Quinine has been used to treat cramps of all causes. However, controversy continues about its efficacy and safety. This review was first published in 2010 and searches were updated in 2014. OBJECTIVES: To assess the efficacy and safety of quinine-based agents in treating muscle cramps. SEARCH METHODS: On 27 October 2014 we searched the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL, MEDLINE and EMBASE. We searched reference lists of articles up to 2014. We also searched for ongoing trials in November 2014. SELECTION CRITERIA: Randomised controlled trials of people of all ages with muscle cramps in any location and of any cause, treated with quinine or its derivatives. DATA COLLECTION AND ANALYSIS: Three review authors independently selected trials for inclusion, assessed risk of bias and extracted data. We contacted study authors for additional information. For comparisons including more than one trial, we assessed the quality of the evidence using Grading of Recommendations Assessment, Development and Evaluation (GRADE). MAIN RESULTS: We identified 23 trials with a total of 1586 participants. Fifty-eight per cent of these participants were from five unpublished studies. Quinine was compared to placebo (20 trials, n = 1140), vitamin E (four trials, n = 543), a quinine-vitamin E combination (three trials, n = 510), a quinine-theophylline combination (one trial, n = 77), and xylocaine injections into the gastrocnemius muscle (one trial, n = 24). The most commonly used quinine dosage was 300 mg/day (range 200 to 500 mg). We found no new trials for inclusion when searches were updated in 2014.The risk of bias in the trials varied considerably. All 23 trials claimed to be randomised, but only a minority described randomisation and allocation concealment adequately.Compared to placebo, quinine significantly reduced cramp number over two weeks by 28%, cramp intensity by 10%, and cramp days by 20%. Cramp duration was not significantly affected.A significantly greater number of people suffered minor adverse events on quinine than placebo (risk difference (RD) 3%, 95% confidence interval (CI) 0% to 6%), mainly gastrointestinal symptoms. Overdoses of quinine have been reported elsewhere to cause potentially fatal adverse effects, but in the included trials there was no significant difference in major adverse events compared with placebo (RD 0%, 95% CI -1% to 2%). One participant suffered from thrombocytopenia (0.12% risk) on quinine.A quinine-vitamin E combination, vitamin E alone, and xylocaine injections into gastrocnemius were not significantly different to quinine across all outcomes, including adverse effects. Based on a single trial comparison, quinine alone was significantly less effective than a quinine-theophylline combination but with no significant differences in adverse events. AUTHORS' CONCLUSIONS: There is low quality evidence that quinine (200 mg to 500 mg daily) significantly reduces cramp number and cramp days and moderate quality evidence that quinine reduces cramp intensity. There is moderate quality evidence that with use up to 60 days, the incidence of serious adverse events is not significantly greater than for placebo in the identified trials, but because serious adverse events can be rarely fatal, in some countries prescription of quinine is severely restricted.Evidence from single trials suggests that theophylline combined with quinine improves cramps more than quinine alone, and the effects of xylocaine injections into gastrocnemius are not significantly different to quinine across all outcomes. Low or moderate quality evidence shows no significant difference between quinine and vitamin E or quinine and quinine-vitamin E mixture. Further research into these alternatives, as well other pharmacological and non-pharmacological treatments, is thus warranted.There is no evidence to judge optimal dosage or duration of quinine treatment. Further studies using different dosages and measurement of serum quinine levels will allow a therapeutic range to be defined for muscle cramp. Because serious adverse events are not common, large population studies are required to more accurately inform incidence. Longer lengths of follow-up in future trials will help determine the duration of action following cessation of quinine as well as long-term adverse events. The search for new therapies, pharmacological and nonpharmacological, should continue and further trials should compare vitamin E, quinine-vitamin E combination, and quinine-theophylline mixture with quinine.

Do Patients Accurately Represent Their Experiences After Hip and Knee Replacements?

Background To investigate discrepancies, if any, between the complications that patients report on the patient-reported outcome measures (PROMs) questionnaire and what is formally recorded in their medical records. Methodology A retrospective analysis of PROMs-reported complications was performed at a single elective center for all patients who had an elective primary total knee or hip replacement between April 2016 and March 2017. Corresponding patient medical records were then analyzed to correlate the PROMs with any documentation of postoperative complications, which similar to the PROMs data were categorized into wound complications, urinary complications, readmission, and further operative procedures. Results A set of 54 complete patient records were compared to the corresponding PROMs data. The combined overall positive predictive value was 0.47 while the overall negative predictive value was 0.91. Concordance between patients and the medical records was 70.4% for wound complication, 66.7% for urinary complications, 83.3% for readmission, and 96.3% for reoperation. Conclusion PROMs data are becoming increasingly important in auditing and planning healthcare provision. This study highlights a significant level of discrepancy between the PROMs-reported complication rates and those documented in the medical records. There is a visible disparity between patient perception and the medical definition of postoperative complications. Further patient education and empowerment are required in preparation for arthroplasty.

Quinine for muscle cramps.

BACKGROUND: Muscle cramps can occur anywhere and for many reasons. Quinine has been used to treat cramps of all causes. However, controversy continues about its efficacy and safety. OBJECTIVES: To assess the efficacy and safety of quinine in treating muscle cramps. SEARCH STRATEGY: We searched The Cochrane Neuromuscular Disease Group Register, The Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 3, 2010), MEDLINE, EMBASE and reference lists of articles up to July 2010. SELECTION CRITERIA: Randomised controlled trials of people of all ages with muscle cramps in any location and of any cause, treated with quinine or its derivatives. DATA COLLECTION AND ANALYSIS: Three authors independently selected trials for inclusion, assessed risk of bias and extracted data. We contacted study authors for additional information. MAIN RESULTS: We identified 23 trials with a total of 1586 participants. Fifty-eight per cent of these participants were from five unpublished studies. Quinine was compared to placebo (20 trials, n =1140), vitamin E (four trials, n = 543), a quinine-vitamin E combination (three trials, n = 510), a quinine-theophylline combination (one trial, n = 77), and xylocaine injections into the gastrocnemius muscle (one trial, n = 24). The most commonly used quinine dosage was 300 mg/day (range 200 to 500 mg).Compared to placebo, quinine significantly reduced cramp number over two weeks by 28%, cramp intensity by 10%, and cramp days by 20%. Cramp duration was not significantly affected.A significantly greater number of people suffered minor adverse events on quinine than placebo (risk difference +3%, 95% confidence intervals 0% to 6%), mainly gastrointestinal symptoms. Overdoses of quinine have been reported elsewhere to cause potentially fatal adverse effects, but in the included trials there was no significant difference in major adverse events compared with placebo (risk difference 0%, 95% confidence intervals -1% to 2%). One participant suffered from thrombocytopenia (0.12% risk) on quinine.A quinine-vitamin E combination, vitamin E alone, and xylocaine injections into gastrocnemius were not significantly different to quinine across all outcomes, including adverse effects. Based on a single trial comparison, quinine alone was significantly less effective than a quinine-theophylline combination but with no significant differences in adverse events. AUTHORS' CONCLUSIONS: There is moderate quality evidence that quinine significantly reduces cramp frequency, intensity and cramp days in dosages between 200 and 500 mg/day. There is moderate quality evidence that with use up to 60 days, the incidence of serious adverse events is not significantly greater than for placebo in the identified trials. Further research is required on the optimal dose and duration of use, and also on alternative treatments.

Search and rescue in collapsed structures: engineering and social science aspects.

This paper discusses the social science and engineering dimensions of search and rescue (SAR) in collapsed buildings. First, existing information is presented on factors that influence the behaviour of trapped victims, particularly human, physical, socioeconomic and circumstantial factors. Trapped victims are most often discussed in the context of structural collapse and injuries sustained. Most studies in this area focus on earthquakes as the type of disaster that produces the most extensive structural damage. Second, information is set out on the engineering aspects of urban search and rescue (USAR) in the United States, including the role of structural engineers in USAR operations, training and certification of structural specialists, and safety and general procedures. The use of computational simulation to link the engineering and social science aspects of USAR is discussed. This could supplement training of local SAR groups and USAR teams, allowing them to understand better the collapse process and how voids form in a rubble pile. A preliminary simulation tool developed for this purpose is described.

Adenocarcinoma of the appendix presenting as bilateral ureteric obstruction.

BACKGROUND: Adenocarcinoma of the vermiform appendix is a rare neoplasm of the gastrointestinal tract. Presentation mimics acute appendicitis, but right iliac fossa mass and intestinal obstruction have also been reported. These presentations reflect various stages of a locally expanding tumour causing luminal obstruction of appendix. The investigation and subsequent management with a review of the literature is presented. CASE PRESENTATION: We report a case of appendicular adenocarcinoma found unexpectedly in a 43 year old male who presented with urinary symptoms. Cystoscopy and uretero-renoscopy showed normal bladder but external compression of the ureters and therefore bilateral stents were inserted. CT scan showed a caecal mass. After colonoscopy, that showed external compression, and diagnostic laparoscopy the patient underwent right hemicolectomy. Histopathology revealed well differentiated adenocarcinoma with signet ring morphology with multiple lymph node involvement. The patient was referred for chemotherapy where he received infusional 5 fluorouracil but died 7 months after surgery. CONCLUSION: Patients with atypical manifestations related to right lower abdominal quadrant should be thoroughly investigated with an open mind. Every attempt should be made to make a precise diagnosis through all the available means to direct the treatment along correct lines.

Multifactorial analysis of dissatisfaction after primary total knee replacement.

BACKGROUND: The aims of this study were to identify the prevalence and causes of dissatisfaction in a cohort of private practice patients, and to compare the psychological characteristics of dissatisfied patients to matched, satisfied controls. METHODS: Unilateral TKR patients were evaluated to identify those dissatisfied with their TKR. Dissatisfied and satisfied patients were matched in terms of age, gender, follow-up duration and body mass index (BMI). Psychological evaluation was performed using the Pain Catastrophizing Scale (PCS), Depression, Anxiety and Stress Scale (DASS) and the Multidimensional Health Locus of Control (MHLC) scale. The preoperative grade of osteoarthritis, prevalence of comorbidities, and postoperative functional outcomes, were also compared. RESULTS: A cohort comprised 301 patients (response rate 71%), with 24 patients (eight percent) dissatisfied at a mean follow-up of 37months (range eight to 74months). Persistent pain was the most common reason for dissatisfaction (n=10). Dissatisfied patients reported a significantly higher mean PCS score (P=0.03), higher depression component of the DASS (P=0.02) and lower internal locus of control (P=0.02). The dissatisfied group exhibited reduced improvement (P<0.05) in the Oxford Knee Score (OKS) and range of motion (ROM), as well as a lower preoperative grade of osteoarthritis compared to satisfied patients. CONCLUSIONS: Dissatisfied patients exhibit an altered psychological profile to matched satisfied controls. In addition, they have lesser improvements in the OKS and ROM. Thus, both physical as well as psychological factors contribute to dissatisfaction. Identification of these factors may help in planning focused interventions to address dissatisfaction.

Medial Patellofemoral Ligament Reconstruction in a Below-Knee Amputee.

Patellar instability is a common finding in patients with below-knee amputation and yet management options are not commonly described in the literature. We describe the first reported case of a medial patellofemoral ligament reconstruction using allograft in a patient with a below-knee amputation. Clinical outcome at two-year follow-up remains very good.

A Bizarre, Unexplained, and Progressive External Rotation of the Shoulder as a Presentation of a Metastatic Deposit in the Rotator Cuff.

We describe the first reported case of a tumour deposit within the rotator cuff presenting as a bizarre, progressive, and fixed external rotation deformity of the shoulder. It is also the first reported case to our knowledge of an oesophageal primary metastasising to the rotator cuff.