Fatal anaphylaxis with neuromuscular blocking agents: a risk factor and management analysis.

BACKGROUND: Anaphylactic reactions to neuromuscular blocking agents (NMBAs) can be severe and even fatal. Our aim was to evaluate mortality rate in France from anaphylactic reactions to NMBAs, to identify risk factors for a fatal outcome, and to describe management of the cases that proved fatal. METHODS: The French National Pharmacovigilance Database was queried for reports of NMBA anaphylaxis that occurred between January 2000 and December 2011. A questionnaire was sent to regional pharmacovigilance centers to obtain further information on the management of cases with a fatal outcome. RESULTS: Two thousand and twenty-two cases of NMBA hypersensitivity were retrieved, of which 84 were fatal (4.1%). Among the 1247 cases of severe NMBA anaphylaxis (grades 3 and 4), independent risk factors associated with a fatal outcome in a multivariate analysis were male gender (female gender: OR = 0.4; 95% CI 0.2-0.7; P = 0.0004), an emergency setting (OR = 2.6; 95% CI 1.5-4.6; P = 0.0007), a history of hypertension (OR = 2.5; 95% CI 1.5-4.4; P = 0.0010) or of other cardiovascular disease (OR = 4.4; 95% CI 2.4-8.1; P < 0.0001), obesity (OR = 2.4; 95% CI 1.1-5.3; P = 0.0376), and ongoing beta-blocker treatment (OR = 4.2; 95% CI 1.8-9.8; P = 0.0011). All 31 patients with a fatal outcome received epinephrine in a titrated manner according to international guidelines. CONCLUSION: Obese males with a history of cardiovascular disease receiving ongoing beta-blocker treatment and undergoing surgery in an emergency setting were at high risk of a fatal outcome after NMBA-induced anaphylaxis. Some epinephrine-resistant cases may play a role in our high mortality rate. New therapeutic approaches need to be developed to treat these cases.

An Aharonov-Bohm interferometer for determining Bloch band topology.

The geometric structure of a single-particle energy band in a solid is fundamental for a wide range of many-body phenomena and is uniquely characterized by the distribution of Berry curvature over the Brillouin zone. We realize an atomic interferometer to measure Berry flux in momentum space, in analogy to an Aharonov-Bohm interferometer that measures magnetic flux in real space. We demonstrate the interferometer for a graphene-type hexagonal optical lattice loaded with bosonic atoms. By detecting the singular π Berry flux localized at each Dirac point, we establish the high momentum resolution of this interferometric technique. Our work forms the basis for a general framework to fully characterize topological band structures.

[Suicidal attempts without borders?]. / Conduites suicidaires sans frontières?

A series of 450 subjects having committed suicidal attempts were examined at the Principal Hospital in Dakar, Senegal between January 1992 and June 1996. Study of the resulting data confirms previous findings indicating that suicidal attempts occur essentially in younger and younger women, rarely after the age of 40. In 42% of cases, the triggering factor involved familial problems, the leading motive being conjugopathy in 15% of cases. At the present time, 90% of people attempting suicide are interviewed by a hospital psychiatrist. In a systemic approach the family is involved as soon as possible. In most cases the acting out implicates a concept of social misconduct. It is linked to the notion of belonging and, while this problem constitutes of marker of social disarray, it is in this area that a transcultural point of view can lead to a more productive dialogue between societies where this warning signal is even stronger and more persistent.

Third party reimbursement: is therapeutic recreation too late?

The Social Security Amendments of 1983 have brought added concerns about the feasibility of securing third-party reimbursement for therapeutic recreation services. Retrospective, cost-based reimbursement is compared with prospective payment systems, and potential impacts on therapeutic recreation services are explored. Present status of third-party reimbursement for therapeutic recreation is outlined, and suggestions are offered for therapeutic recreation managers to utilize in responding to the changing health care industry.