Mixing short- and long-acting local anaesthetics in peripheral nerve blocks: Protocol for a systematic review and meta-analysis.

INTRODUCTION: This protocol describes a systematic review and meta-analysis to evaluate the clinical effects of mixing short- and long-acting local anaesthetics in peripheral nerve blocks. Clinicians often combine short- and long-acting local anaesthetics to achieve a briefer onset time. However, this may come with a prize, namely a shorter total duration of the block, which is of clinical importance. OBJECTIVE: This systematic review aims to strengthen the knowledge of the clinical effects associated with this practice. The primary outcome is the duration of block analgesia. Secondary outcomes are block onset time, sensory and motor block duration. Exploratory outcomes are postoperative pain scores, cumulative 24-h opioid consumption and the prevalence of serious adverse events. METHODS: We will conduct a meta-analysis of the extracted data, and the risk of bias for each study will be evaluated. We will perform a Trial Sequential Analysis, subgroup, and sensitivity analyses and assess the overall risk of publication bias. Finally, we will evaluate the review using the GRADE principles.

Peripheral nerve blocks for closed reduction of distal radius fractures-A protocol for a systematic review.

BACKGROUND: Current methods of anaesthesia used for closed reduction of distal radial fractures may be insufficient for pain relief and muscle relaxation, potentially compromising reduction quality and patient satisfaction. Peripheral nerve blocks have already been implemented for surgery of wrist fractures and may provide optimal conditions for closed reduction due to complete motor and sensory blockade of the involved nerves. However, existing literature on peripheral nerve blocks for closed reduction is sparse, and no updated systematic review or meta-analysis exists. AIMS: This protocol is developed according to the PRISMA-P statement. The systematic review and meta-analysis aim to consolidate the literature regarding the effect and harm of peripheral nerve blocks compared with other anaesthesia modalities for closed reduction of distal radius fractures in adults. METHODS: The two primary outcomes are the proportion of participants needing surgery after closed reduction and pain during closed reduction. We will only include randomised clinical trials. Two review authors will each independently screen literature, extract data, and assess risk of bias with Risk of Bias 2 Tool. Meta-analysis will be carried out with Rstudio. We will also perform a Trial Sequential Analysis. The certainty of evidence will be judged using GRADE guidelines. DISCUSSION: We will use up-to-date methodology when conducting the systematic review outlined in this protocol. The results may guide clinicians in their decision-making regarding the use of anaesthesia for closed reduction of distal radius fractures in adults.

Predictors of outcomes in emergency department patients with suspected infections and without fulfillment of the sepsis criteria.

BACKGROUND: Data on patient characteristics and determinants of serious outcomes for acutely admitted patients with infections who do not fulfill the sepsis criteria are sparse. The study aimed to characterize acutely admitted emergency department (ED) patients with infections and a composite outcome of in-hospital mortality or transfer to the intensive care unit without fulfilling the criteria for sepsis and to examine predictors of the composite outcome. METHODS: This was a secondary analysis of data from a prospective observational study of patients with suspected bacterial infection admitted to the ED between October 1, 2017 and March 31, 2018. A National Early Warning Score 2 (NEWS2) ≥ 5 within the first 4 h in the ED was assumed to represent a sepsis-like condition with a high risk for the composite endpoint. Patients who achieved the composite outcome were grouped according to fulfillment of the NEWS2 ≥ 5 criteria. We used logistic regression analysis to estimate the unadjusted and adjusted odds ratio (OR) for the composite endpoint among patients with either NEWS2  < 5 (NEWS2-) or NEWS2  ≥ 5 (NEWS2+). RESULTS: A total of 2055 patients with a median age of 73 years were included. Of these, 198 (9.6%) achieved the composite endpoint, including 59 (29.8%) NEWS2- and 139 (70.2%) NEWS2+ patients, respectively. Diabetes (OR 2.23;1.23-4.0), a Sequential Organ Failure Assessment (SOFA) score ≥ 2 (OR 2.57;1.37-4.79), and a Do-not-attempt-cardiopulmonary-resuscitation order (DNACPR) on admission (OR 3.70;1.75-7.79) were independent predictive variables for the composite endpoint in NEWS2- patients (goodness-of-fit test P = 0.291; area under the receiver operating characteristic curve for the model (AUROC) = 0.72). The regression model for NEWS2+ patients revealed that a SOFA score ≥ 2 (OR 2.79; 1.59-4.91), hypothermia (OR 2.48;1.30-4.75), and DNACPR order on admission were predictive variables for the composite endpoint (goodness-of-fit test P = 0.62; AUROC for the model = 0.70). CONCLUSION: Approximately one-third of the patients with infections and serious outcomes during hospitalization did not meet the NEWS2 threshold for likely sepsis. Our study identified factors with independent predictive values for the development of serious outcomes that should be tested in future prediction models.

Predictors for mortality in patients admitted with suspected bacterial infections - A prospective long-term follow-up study.

OBJECTIVE: The aim was to examine predictors for all-cause mortality in a long-term follow-up study of adult patients with infectious diseases of suspected bacterial origin. METHODS: A prospective observational study of patients admitted to the emergency department during 1.10.2017-31.03.2018. We used Cox regression to estimate adjusted hazard ratios (aHR) with 95% confidence intervals for mortality. RESULTS: A total of 2110 patients were included (median age 73 years). After a median follow-up of 2.1 years 758 (35.9%, 95% CI 33.9-38.0%) patients had died. Age (aHR1.05; 1.04-1.05), male gender (aHR 1.21; 1.17-1.25), cancer (aHR 1.80; 1.73-1.87), misuse of alcohol (aHR 1.30; 1.22-1.38), if admitted with sepsis within the last year before index admission (aHR 1.56;1.50-1.61), a Sequential Organ Failure Assessment (SOFA) score ≥2 (aHR 1.90; 1.83-1.98), SIRS criteria ≥2 (aHR 1.23;1.18-1.28) at admission to the ED, length of stay (aHR 1.05; 1.04-1.05) and devices and implants as sources of infection (aHR 7.0; 5.61-8.73) were independently associated with mortality. Skin infections and increasing haemoblobin values reduced the risk of death. CONCLUSIONS: More than one-third of a population of patients admitted to the emergency department with infectious diseases of suspected bacterial origin had died during a median follow up of 2.1 years. The study identified several independent predictors for mortality.

Systematic Review of Complications and Recurrences After Surgical Interventions in Hidradenitis Suppurativa.

BACKGROUND: The possible connection between hidradenitis suppurativa (HS) patients undergoing surgery and higher complications/recurrences has been implied, but inconsistent results reported. OBJECTIVE: To assess the complication and recurrence rates for HS patients undergoing surgery and to evaluate whether known HS comorbidities and habits (smoking, obesity and diabetes) have an effect on the complication and recurrence rates. MATERIALS AND METHODS: A systematic review was conducted by 2 reviewers. PubMed and Embase were searched using a predefined search string created in collaboration between the authors and a librarian on January 23, 2019. RESULTS: Of the 271 references in the original search, 54 relevant articles were identified. This systematic review indicates an overall mean complication rate of 24% and a mean recurrence rate of 20.1% for HS patients undergoing surgery. CONCLUSION: No significant association between the known surgical risk factors and surgical complications-or recurrence rates in this patient group was found. This review revealed a lack of quality and quantity data in studying the complications/recurrences. The heterogeneity of the studies created limitations, and the presented mean complication/recurrence rates should be interpreted with the consequences thereof. It elucidates the need for better studies and a necessity for a standardized definition of postsurgical HS recurrence.

Pediatric toxic epidermal necrolysis treated successfully with infliximab.

Successful management of toxic epidermal necrolysis (TEN) with tumor necrosis factor-α inhibitors has been described in adults. We present a case of a 7-year-old boy with infection-associated TEN, diagnosed by typical clinical and histopathological features, most likely caused by Mycoplasma pneumoniae. Treatment with a single dose of infliximab 5 mg/kg intravenously on day 5 after the onset of symptoms was followed by cessation of all blister formation over 3 days and complete resolution within a week. Sequelae were mild, consisting of postinflammatory hyperpigmentation and dry eyes.

Spatial expression of metallothionein, matrix metalloproteinase-1 and Ki-67 in human epidermal wounds treated with zinc and determined by quantitative immunohistochemistry: A randomised double-blind trial.

Reepithelialisation is fundamental to wound healing, but our current understanding largely relies on cellular and animal studies. The aim of the present randomised double-blind three-arm controlled trial was to correlate genuine epidermal wound healing with key proteins and topical zinc treatment in humans. Sixty wounds were produced using deroofed suction blisters in 30 healthy volunteers and randomised to topical zinc sulphate (n = 20), placebo (n = 20), or control (n = 20) treatment for 4 days. All wounds with perilesional skin were processed for automatic immunostaining of paraffin tissue sections with monoclonal antibodies against Ki-67, metallothionein (MT) and matrix metalloproteinase (MMP)-1. Protein expression was quantified by automated digital image analysis. Epidermal Ki-67 and MT labelling indices were increased in keratinocytes in the neoepidermis (∼1.1 mm) and at the wound edge (0.5 mm) compared to normal skin. Increased MMP-1 immunostaining was restricted to the neoepidermis. MT was robustly upregulated in the upper dermis of the wounds. Zinc treatment enhanced MMP-1 expression beneath the neoepidermis via paracrine mechanisms and MT under the neoepidermis and in the nonepithelialised wound bed via direct actions of zinc as indicated by the induction of MT2A mRNA but not MMP-1 mRNA in cultured normal human dermal fibroblasts by zinc sulphate. The present human study demonstrates that quantitative immunohistochemistry can identify proteins involved in reepithelialisation and actions of external compounds. Increased dermal MT expression may contribute to the anti-inflammatory activities of zinc and increased MMP-1 levels to promote keratinocyte migration.

[Intense pulsed light treatment for hidradenitis suppurativa: a within-person randomized controlled trial]. / Intense pulsed light treatment for hidradenitis suppurativa: a within-person randomized controlled trial.

BACKGROUND: Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease of the intertriginous areas. HS affects hair follicles causing perifollicular inflammation, resulting in the formation of nodules and painful abscesses. Intense pulsed light (IPL) uses selective photothermolysis to destroy the hair follicles. OBJECTIVES: To evaluate the effect of IPL hair removal as treatment for mild-to-moderate HS. MATERIALS & METHODS: We conducted a single-blinded, clinical randomized trial with patients with Hurley Stage I-II. Patients with symmetrical disease were randomized to monthly unilateral treatment of the axilla or groin. The contralateral side served as internal control. Concomitant treatment modalities for HS were not permitted throughout the study. Efficacy was assessed using Hidradenitis Suppurativa Clinical Response (HiSCR), modified Sartorius score (MSS) and patient-reported outcomes. RESULTS: A total of 17 patients completed the trial and were included in the analysis. HiSCR was not evaluated in patients without abscesses or inflammatory nodules pre-treatment. HiSCR was insignificantly different between the intervention side (8/12) and control side (4/10), P=0.467. There was, however, a significant reduction in regional MSS on the intervention side with a median score decreasing from 8.5 (IQR: 6.3-13.5) to 4.5 (IQR 1.8-8.0) post-treatment, P=0.006, and an insignificant score reduction in the control side from 6.0 (IQR: 4.5-8.3) to 5.0 (IQR: 2.5-9.0), post-treatment P=0.492. CONCLUSION: IPL hair removal resulted in a significant reduction on MSS on the treated area with no significant reduction on the control side. Our study suggests that IPL may be an effective treatment for mild-to-moderate HS.