Natural drugs, not so natural effects: Neonatal abstinence syndrome secondary to 'kratom'.

BACKGROUND: Mitragyna speciosa, also known as kratom, is obtained from the coffee plant family 'Rubiaceae.' Kratom is available in the form of capsules, whole, processed and powdered leaves, and as liquids. Secondary to its 'natural herb' status and opioid effects, it is misconceived to be a safe alternative for the treatment of chronic pain. The use of kratom has increased by tenfold in the United States since 2010. METHODS AND RESULTS: We report a term neonate who was born to a chronic kratom user and required treatment with opiates for neonatal drug withdrawal. CONCLUSION: Physicians should be aware of these herbal supplements and its potential withdrawal effects in newborn which cannot be picked up by the standard toxicology screen.

Magnetic resonance imaging quantification and biodistribution of magnetic nanoparticles using T1-enhanced contrast.

Magnetic iron oxide nanoparticles have been used for various applications such as in the treatment of iron deficiency, as theranostic agents, and as drug carriers. The effective delivery of magnetic iron oxide nanoparticles into the lesion and iron quantification are vital for in vivo theranostic application. To determine the feasibility of using T1 contrast to non-invasively quantify and monitor the IONPs in vivo, monodispersed Gd-doped iron oxide nanoparticles (GdIONPs) with 4 nm core size were fabricated and were used as T1-weighted contrast agents to quantify iron contents based on MRI longitudinal relaxation times (T1). Signal enhancement in positive T1 contrast caused by GdIONPs was observed in this work. The in vivo T1 relaxivity of GdIONPs in a tumor matched well with both in vitro T1 relaxivity and ICP-MS results, demonstrating that the concentration of iron at the tumor site can be directly read from real-time in vivo MRI T1 relaxivity. Hence, by using this strategy, the Fe content in the lesion can be accurately monitored based on MRI longitudinal relaxation times, and this may shed light on effective magnetic hyperthermia cancer therapy in future.

Apnea, bradycardia and desaturation spells in premature infants: impact of a protocol for the duration of 'spell-free' observation on interprovider variability and readmission rates.

OBJECTIVE: To study the impact of implementing a protocol to standardize the duration of observation in preterm infants with apnea/bradycardia/desaturation spells before hospital discharge on length of stay (LOS) and readmission rates. STUDY DESIGN: A protocol to standardize the duration of in-hospital observation for preterm infants with apnea, bradycardia and desaturation spells who were otherwise ready for discharge was implemented in December 2013. We evaluated the impact of this protocol on the LOS and readmission rates of very low birth weight infants (VLBW). Data on readmission for apnea and an apparent life-threatening event (ALTE) within 30 days of discharge were collected. The pre-implementation epoch (2011 to 2013) was compared to the post-implementation period (2014 to 2016). RESULTS: There were 426 and 368 VLBW discharges before and after initiation of the protocol during 2011 to 2013 and 2014 to 2016, respectively. The LOS did not change with protocol implementation (66±42 vs 64±42 days before and after implementation of the protocol, respectively). Interprovider variability on the duration of observation for apneic spells (F-8.8, P=0.04) and bradycardia spells (F-17.4, P<0.001) decreased after implementation of the protocol. The readmission rate for apnea/ALTE after the protocol decreased from 12.1 to 3.4% (P=0.01). CONCLUSION: Implementing an institutional protocol for VLBW infants to determine the duration of apnea/bradycardia/ desaturation spell-free observation period as recommended by the American Academy of Pediatrics clinical report did not prolong the LOS but effectively reduced interprovider variability and readmission rates.

Utility of the PALM-COEIN classification of abnormal uterine bleeding for Indian gynecologists.

OBJECTIVE: To study the clinical utility of the PALM-COEIN classification for abnormal uterine bleeding in day-to-day practice in India. METHODS: Between April and November 2014, a cross-sectional survey was undertaken of gynecologists practicing in Chittoor and Nellore. Doctors possessing a postgraduate degree in gynecology and obstetrics, and postgraduate students in the gynecology department of medical colleges were invited to participate. A validated questionnaire containing 15 questions was distributed, the opinions were collated, and the results analyzed. RESULTS: Among 150 invited gynecologists, 120 agreed to participate, and 119 completed the survey fully. Overall, 95 (79.8%) respondents were aware of the classification, and 56 (47.1%) responded that the PALM-COEIN system is very good, 46 (38.7%) that it is average, and 17 (14.3%) that it is poor. By subgroup, 16 of 20 (80.0%) faculty members, 46 of 56 (82.1%) postgraduate students, and 33 of 43 (76.7%) practitioners responded that the system is useful. CONCLUSION: Indian doctors generally believe that the PALM-COEIN system is clinically useful and a step forward in the management of abnormal uterine bleeding.

Comparison of 2 days versus 5 days of octreotide infusion along with endoscopic therapy in preventing early rebleed from esophageal varices: a randomized clinical study.

BACKGROUND: Variceal bleeding is a medical emergency with 20% mortality at 6 weeks. The role of vasoactive agents in achieving hemostasis and preventing rebleeding has been well documented. The optimal duration of these agents has not been well established. There are no previous studies yielding the exact duration of octreotide to be administered to prevent rebleed and mortality from esophageal varices. The aim of this study is to evaluate the effect of combination therapy (octreotide and endoscopy), the exact duration of octreotide infusion, its cost-effectiveness, and the outcome in terms of rebleed and mortality. PATIENTS AND METHODS: This was a randomized clinical trial including 124 patients with acute variceal bleeding who underwent endoscopic therapy; they were assigned randomly to 2 days (n=62) and 5 days (n=58) of continuous octreotide infusion (50 µg/kg). Early rebleeding (within 42 days of index bleed according to Baveno IV consensus guidelines), transfusion requirement, and mortality were assessed. RESULTS: The study had predominantly male patients, average age 47 years. Among the patients in the 2-day group, 3 (4.8%) showed early rebleed versus 5 (8.6%) in the 5-day group, but the difference was not statistically significant (P>0.05). Among the patients in the 2-day group, one patient died after 3 weeks and all the patients in the 5-day group survived till 6 weeks on follow-up, and the survival rates were comparable (P>0.05). The treatment in the 5-day group was 2.5 times costlier than that for the 2-day group as shown by a cost-wise analysis. CONCLUSION: Two days of octreotide infusion following endoscopic therapy is sufficient and as efficacious as 5 days of infusion in preventing early rebleed, with reasonably better cost-effectiveness.

Capsule endoscopy for obscure gastrointestinal bleeding in the tropics: report from India.

BACKGROUND: Capsule endoscopy (CE) is useful in patients with obscure gastrointestinal bleeding (OGIB). Experience in CE in OGIB in the tropics is limited. METHODS: Eighty-six patients with OGIB were evaluated clinically and using CE (Given Imaging, Yoqneam, Israel) 89 times (twice in three patients) during a 64-month period. Images were downloaded and examined by a single investigator using software (Rapid Reader; Given Imaging, Yoqneam, Israel). Patients received specific treatment and were followed up. Intraoperative findings, response to specific treatment and outcome on follow up (10.3±14.1 months) were considered to confirm CE findings. RESULTS: Of 86 patients (aged 54.5±16.3 years, 63 males), 64 and 22 had OGIB-overt and OGIB-occult, respectively. Lesions were equally detected in OGIB-overt and OGIB-occult patients (48/64, 75% vs 18/22, 81.8%, P= ns). Lesions were detected in 64 of 86 (74.4%) patients [vascular malformations with or without fresh bleeding in 24 (37.5%), tumors in 12 (18.8%), strictures in 15 (23.4%), ulcers in five (7.8%), hookworm in five (7.8%), and more than one lesion in three patients (4.7%)]. Endoscopic insertion of the capsule was required in four patients, and in six it was retained, although none developed intestinal obstruction (surgical removal in two). The sensitivity, specificity, positive and negative predictive values of CE to detect the lesion(s) were 92.9%, 68.2%, 84.8%, and 83.3%, respectively. CONCLUSION: CE is safe and is equally effective in detecting lesion(s) in occult and overt OGIB. Worm infestation and small bowel tuberculosis are unique and important causes of OGIB in the tropics.