Haemodynamic effects of a prehospital emergency anaesthesia protocol consisting of fentanyl, ketamine and rocuronium in patients with trauma: a retrospective analysis of data from a Helicopter Emergency Medical Service.

OBJECTIVES: Prehospital rapid sequence induction (RSI) of anaesthesia is an intervention with significant associated risk. In this study, we aimed to investigate the haemodynamic response over time of a prehospital RSI protocol of fentanyl, ketamine and rocuronium in a heterogeneous population of trauma patients. DESIGN, SETTING AND PARTICIPANT: We performed a retrospective study of all trauma patients who received a prehospital RSI for trauma by a physician staffed Helicopter Emergency Medical Service in the UK between 1 June 2018 and 1 February 2020. PRIMARY OUTCOME MEASURE: Primary outcome was defined as the incidence of clinically relevant hypotensive (systolic blood pressure (SBP) or mean arterial pressure (MAP) >20% below baseline, with an absolute SBP <90 mm Hg or MAP <65 mm Hg) or hypertensive (SBP or MAP >20% above baseline) episodes in the first 10 minutes post-RSI. RESULTS: In total, 322 patients were included. 204 patients (63%) received a full-dose induction of 3 µg/kg fentanyl, 2 mg/kg ketamine and 1 mg/kg rocuronium, whereas 128 patients (37%) received a reduced-dose induction. Blood pressures decreased on average 12 mm Hg (95% CI 7 to 16) in the full-dose group and 6 mm Hg (95% CI 1 to 11) in the reduced-dose group, p=0.10). A hypotensive episode (mean SBP drop 53 mm Hg) was noted in 29 patients: 17 (8.3%) receiving a full dose and 12 (10.2%) receiving a reduced-dose induction, p=0.69. The blood pressure nadir was recorded on average 6-8 min after RSI. A hypertensive episode was present in 22 patients (6.8%). The highest blood pressures were recorded in the first 3 min after RSI. CONCLUSION: Prehospital induction of anaesthesia for trauma with fentanyl, ketamine and rocuronium is not related to a significant change in haemodynamics in most patients. However, a (delayed) hypotensive response with a significant drop in SBP should be anticipated in a minority of patients irrespective of the dose regimen chosen.

Tofacitinib for Biologic-Experienced Hospitalized Patients With Acute Severe Ulcerative Colitis: A Retrospective Case-Control Study.

BACKGROUND & AIMS: Despite rescue therapy, more than 30% of patients with acute severe ulcerative colitis (ASUC) require colectomy. Tofacitinib is a rapidly acting Janus kinase inhibitor with proven efficacy in ulcerative colitis. Tofacitinib may provide additional means for preventing colectomy in patients with ASUC. METHODS: A retrospective case-control study was performed evaluating the efficacy of tofacitinib induction in biologic-experienced patients admitted with ASUC requiring intravenous corticosteroids. Tofacitinib patients were matched 1:3 to controls according to gender and date of admission. Using Cox regression adjusted for disease severity, we estimated the 90-day risk of colectomy. Rates of complications and steroid dependence were examined as secondary outcomes. RESULTS: Forty patients who received tofacitinib were matched 1:3 to controls (n = 113). Tofacitinib was protective against colectomy at 90 days compared with matched controls (hazard ratio [HR], 0.28, 95% confidence interval [CI], 0.10-0.81; P = .018). When stratifying according to treatment dose, 10 mg three times daily (HR, 0.11; 95% CI, 0.02-0.56; P = .008) was protective, whereas 10 mg twice daily was not significantly protective (HR, 0.66; 95% CI, 0.21-2.09; P = .5). Rate of complications and steroid dependence were similar between tofacitinib and controls. CONCLUSIONS: Tofacitinib with concomitant intravenous corticosteroids may be an effective induction strategy in biologic-experienced patients hospitalized with ASUC. Prospective trials are needed to identify the safety, optimal dose, frequency, and duration of tofacitinib for ASUC.

Predictors of surgical site skin infection and clinical outcome at caesarean section in the very severely obese: A retrospective cohort study.

INTRODUCTION: The optimal surgical approach for caesarean section is uncertain in women with very severe obesity (body mass index (BMI) >40kg/m2). We aimed to assess maternal and surgical predictors of surgical site skin infection (SSSI) in very severely obese women and to undertake an exploratory evaluation of clinical outcomes in women with a supra-panniculus transverse compared to an infra-panniculus transverse skin incision. MATERIAL AND METHODS: Using a retrospective cohort design, case-records were reviewed of very severely obese women with a singleton pregnancy delivered by caesarean between August 2011 and December 2015 (n = 453) in two maternity hospitals in Scotland. Logistic regression analysis was used to determine predictors for SSSI. Outcomes were compared between women who had a supra-panniculus transverse compared to infra-panniculus transverse skin incision. RESULTS: Lower maternal age was predictive of SSSI, with current smoking status and longer wound open times being marginally significant. Maternal BMI, suture method and material demonstrated univariate associations with SSSI but were not independent predictors. Women with a supra-panniculus transverse skin incision were older (32.9 (4.4), vs. 30.6 (5.7), p = 0.002), had higher BMI (49.2 (7.1), vs. 43.3 (3.3), p<0.001), shorter gestation at delivery (days) (267.7 (14.9), vs. 274.8 (14.5), p<0.001) and higher prevalence of gestational diabetes mellitus (42.6% vs. 21.9%, p = 0.002). SSSI rates did not differ between supra-panniculus transverse (13/47; 27.7%) and infra-panniculus transverse (90/406; 22.2%; p = 0.395) skin incisions. CONCLUSION: SSSI rates are high in very severely obese women following caesarean section, regardless of location of skin incision.

Persistence of viable cysts in neurocysticercosis: a serial imaging study / Persistência de cistos viáveis na neurocisticercose: um estudo seriado de imagem

Introduction: Cysticercosis is an endemic disease in developing countries and is the most common parasitic infection of the central nervous system. The diagnosis is difficult and imaging may contribute to the confirmation. Objective: To report the evolution of brain lesions and the clinical response of a patient with a definitive diagnosis of neurocysticercosis (NCC). Methods: We analyzed six computed tomography (CT) and three magnetic resonance imaging (MRI) exams, performed in a period of six years. Results: The serial imaging study revealed the involution of nine viable cysts and two degenerating cysts out of 39 lesions. It occurred after six years of disease and four courses of treatment with Albendazole. The other 28 lesions were calcified. Clinically, there was reduction in frequency of seizures after treatment with Albendazole and the onset of regular use of anticonvulsants (six per year to 1.8 per year). Conclusion: This case illustrates an instance of partial NCC efficacy to antiparasitic therapy, and demonstrates the role of serial imaging studies in the monitoring the evolution of NCC lesions and in characterizing the diversity of lesion appearance over time.

Introdução: A cisticercose é uma doença endêmica nos países em desenvolvimento. Representa a infecção parasitária mais comum dosistema nervoso central. O diagnóstico é difícil e o exame de imagem pode contribuir para a confirmação. Objetivo: Relatar a evolução das lesõesencefálicas, assim como avaliar a resposta clínica de um paciente com um diagnóstico definitivo do NCC. Métodos: Foram analisadas seistomografias computadorizadas (TC) e três ressonâncias magnéticas (RM) realizadas durante o período de seis anos. Resultados: O estudode imagem seriada revelou a involução de nove cistos viáveis e dois cistos em degeneração de 39 lesões. Isso ocorreu após seis anos de evolução da doença e quatro cursos de tratamento com albendazol. As outras 28 lesões encontravam-se calcificadas e aumentaram para 36 em número. Clinicamente, houve redução na frequência das crises após o tratamento com albendazol e do início do uso regular de anticonvulsivantes (seis por ano para 1,8 por ano). Conclusão: O caso demonstra a importância dos estudos da imagem seriada no acompanhamento das lesões da neurocisticercose (NCC), considerando a possibilidade de resistência medicamentosa e a necessidade da repetição do tratamento.