Impact of oxygen therapy algorithm on oxygen usage in the emergency department.

BACKGROUND: Although oxygen is one of the oldest drugs available, it is still one of the most inappropriately administered drugs leading to over utilization of this very expensive resource. MATERIALS AND METHODS: This prospective observational study was done in a large emergency department (ED) in India. The pattern of oxygen usage was studied before and after the strict implementation of an oxygen treatment algorithm. The algorithm was taught to all doctors and nurses and its implementation was monitored regularly. The main outcome measures were proportion of patients receiving oxygen therapy, inappropriate usage, and avoidable direct medical cost to the patient. RESULTS: The 3-week pre-protocol observation phase in April 2016 included 3769 patients and the 3-week post-protocol observation phase in April 2017 included 4608 patients. The baseline demographic pattern was similar in both the pre-protocol and post-protocol groups. After the strict implementation of the algorithm, the number of patients receiving oxygen therapy decreased from 9.63% to 4.82%, a relative decrease of 51.4%. The average amount of total oxygen used decreased from 55.4 liters per person in pre-protocol group to 42.1 liters per person in the post-protocol group with a mean difference of 13.28 (95% CI 5.30-21.26; P = 0.001). Inappropriate oxygen usage decreased from 37.2% to 8.6%. There was a significant decrease in inappropriate oxygen use for indications like low sensorium (60.8% vs 21.7%) and trauma (88.5% vs 15.8%). The mortality rate in the pre-protocol phase was 2.7% as compared with 3.2% in the post-protocol phase. The total duration of inappropriate oxygen usage significantly decreased from 987 h to 89 h over the 21-day study period. CONCLUSION: The implementation of an oxygen therapy algorithm significantly reduces inappropriate oxygen use and decreases treatment cost to the patient with no additional mortality risk.

Outcomes of surgical management of TMJ ankylosis: A systematic review and meta-analysis.

BACKGROUND: Temporomandibular joint (TMJ) ankylosis can be surgically managed by a number of approaches. This systematic review compared the clinical outcomes among various treatment options, i.e., gap arthroplasty (GA), interpositional gap arthroplasty (IGA), reconstruction arthroplasty (RA) and distraction osteogenesis (DO). METHODS: PubMed, Ovid, Embase, Web of Science, Scopus and Cochrane central register of controlled trials were searched till April 2018. Randomized controlled trials, cohort studies and retrospective studies in subjects with acquired TMJ ankylosis reporting re-ankylosis with a follow-up period of ≥12 months were included. RESULTS: Twenty-six studies with 1197 subjects were included. The higher recurrence rate was observed with GA compared to both IGA and RA (p < 0.05). Comparable results were obtained with IGA, RA and DO (p > 0.05). Among interpositional materials, alloplastic materials showed higher recurrence rate compared to autogenous materials (p < 0.05). However, for reconstruction, both autogenous grafts and alloplastic prosthetic implants gave similar results (p > 0.05). The highest improvements in MMO (maximum mouth opening) resulted with IGA but the differences regarding post-operative changes in MMO were clinically similar in all other groups. CONCLUSION: IGA with autogenous material and reconstruction using either autogenous grafts or total joint replacement by alloplastic prosthetic implants provide similar clinical outcomes for TMJ ankylosis management.

Cutaneous hyperpigmentation and familial gastrointestinal stromal tumour associated with KIT mutation.

Gastrointestinal stromal tumours (GISTs) are mesenchymal tumours arising in the gastrointestinal tract. Early detection, before metastasis occurs, is important as complete surgical excision achieves cure. Approximately 85% of GISTs are associated with mutations in the KIT gene, and although the majority of GISTs are sporadic, familial GISTs have been identified. Several families with multiple GIST tumours have also been described with various cutaneous findings including hyperpigmentation, multiple lentigines, vitiligo and urticaria pigmentosa. We discuss a 6-year-old boy who presented with an unusual pattern of hyperpigmentation in association with a family history of GIST. A causative KIT mutation was identified in DNA from the pigmented skin and from the resected GIST, and the patient was referred to the Paediatric Gastroenterology department for GIST screening. The term 'GIST cutaneous hyperpigmentation disease' has been suggested previously for the association of familial GIST with cutaneous hyperpigmentation caused by a germline KIT mutation.

Recent Review on Subclass B1 Metallo-ß-lactamases Inhibitors: Sword for Antimicrobial Resistance.

An emerging crisis of antibiotic resistance for microbial pathogens is alarming all the nations, posing a global threat to human health. The production of the metalloß-lactamase enzyme is the most powerful strategy of bacteria to produce resistance. An efficient way to combat this global health threat is the development of broad/non-specific type of metalloß-lactamase inhibitors, which can inhibit the different isoforms of the enzyme. Till date, there are no clinically active drugs against metallo- ß-lactamase. The lack of efficient drug molecules against MBLs carrying bacteria requires continuous research efforts to overcome the problem of multidrug-resistance bacteria. The present review will discuss the clinically potent molecules against different variants of B1 metalloß-lactamase.

Jejunal perforation: an unusual presentation of metastatic cutaneous squamous cell carcinoma (SCC) in an immunosuppressed patient.

We report the rare occurrence of a small bowel perforation secondary to a metastatic cutaneous squamous cell carcinoma (cSCC). A 70-year-old woman, who had previously undergone renal transplantation, presented with severe, sudden-onset abdominal pain. She was peritonitic on initial examination, with evidence of free intra-abdominal air on radiographic imaging. During an exploratory laparotomy, she was found to have a perforated jejunum secondary to disseminated metastases seen throughout her peritoneum. Following histopathological analysis, as well as further imaging studies, the primary malignancy was eventually identified as a cSCC on her upper back. Palliative care was started and the patient died 8 weeks following her initial presentation.

Pyoderma gangrenosum-like ulcer caused by Helicobacter cinaedi in a patient with x-linked agammaglobulinaemia.

Cutaneous lesions of the legs have been linked to Helicobacter species in a number of patients with X-linked agammaglobulinaemia (XLA), a primary immunodeficiency. We describe a 26-year-old patient with XLA, who was referred with an extensive skin ulcer that enlarged gradually over the course of 7 years. The ulcer resembled pyoderma gangrenosum (PG), and extended from below the knee to the ankle. The man (who has sex with men) was negative for human immunodeficiency virus. Helicobacter cinaedi was identified by 16S ribosomal (r)DNA PCR analysis from a biopsy of the lesion. This fastidious organism has been implicated previously in causing unexplained skin macules in one other patient with XLA. We suggest that early consideration of infection with Helicobacter species in immunocompromised patients who present with unexplained cutaneous lesions is important, as a prolonged antibiotic course can lead to clinical improvement.

A Comparative Evaluation of Fixation Techniques in Anterior Mandibular Fractures Using 2.0 mm Monocortical Titanium Miniplates Versus 2.4 mm Cortical Titanium Lag Screws.

OBJECTIVE: To compare the efficacy and surgical outcome of treatment of anterior mandibular fracture using either 2.0 mm titanium miniplate or 2.4 mm titanium lag screw technique. MATERIALS AND METHODS: A total of 30 patients were managed by open reduction and internal fixation utilizing the miniplate and lag screw technique for fractures of anterior mandible. The patients were randomly divided into two groups. Group I: (15 patients) were treated with Leibinger, 2.0 mm titanium mini plates system with self-tapping screws and Group II: (15 patients) were treated with 2.4 mm cortical lag screw (Synthes). Intraoperatively duration of surgery was measured from the time incision was placed till the closure of wound. Subsequent follow up was done at 3, 6, 12, 24 weeks, postoperatively. During every follow up, patients were assessed clinically for malocclusion, neurosensory deficit, biting efficiency, implant failure, mal-union/non-union. Pre and postoperative radiographs were taken to assess the gap between fracture segments. Results were evaluated using Chi square and the unpaired t test. RESULTS: In our study, the mean duration of surgery (hours) was 1.97 ± 0.52 for group I and 1.26 ± 0.55 for group II. The difference was found to be statistically significant (p value 0.001). i.e. more time was taken in case of surgery with mini-plates when compared to the lag screw. Short surgical procedure reduces the incidence of infectious complications, which significantly lowers the financial burden. The mean post-operative radiographic distance between all measuring points were considerably more in case of mini-plate group as compared to lag screw group. Lag screw group showed faster improvement in terms of biting efficiency as compared to mini-plate group which showed a tendency to masticate only medium hard food items by 24 weeks. In both groups, no postoperative malocclusion was noted. In initial weeks, neurosensory deficit was seen more in mini-plate group as compared to lag screw group but after six weeks all patients showed improvement in neurosensory function without any permanent nerve damage. CONCLUSION: According to this prospective study, rigid internal fixation provided by lag screw technique for anterior mandibular fracture offers several advantages over conventional bone plating. It is an excellent means of achieving rapid and safe fixation which is followed by primary bone healing in anterior mandibular fractures, without any major complications.

Life-threatening postpartum hemolysis, elevated liver functions tests, low platelets syndrome versus thrombocytopenic purpura - Therapeutic plasma exchange is the answer.

The differential diagnosis of life-threatening microangiopathic disorders in a postpartum female includes severe preeclampsia-eclampsia, hemolysis, elevated liver functions tests, low platelets syndrome and thrombotic thrombocytopenic purpura. There is considerable overlapping in the clinical and laboratory findings between these conditions, and hence an exact diagnosis may not be always possible. However, there is considerable maternal mortality and morbidity associated with these disorders. This case underlines the complexity of pregnancy-related microangiopathies regarding their differential diagnosis, multiple organ dysfunction and role of therapeutic plasma exchange in their management.

A new 2D-based method for myocardial velocity strain and strain rate quantification in a normal adult and paediatric population: assessment of reference values.

BACKGROUND: Recent advances in technology have provided the opportunity for off-line analysis of digital video-clips of two-dimensional (2-D) echocardiographic images. Commercially available software that follows the motion of cardiac structures during cardiac cycle computes both regional and global velocity, strain, and strain rate (SR). The present study aims to evaluate the clinical applicability of the software based on the tracking algorithm feature (studied for cardiology purposes) and to derive the reference values for longitudinal and circumferential strain and SR of the left ventricle in a normal population of children and young adults. METHODS: 45 healthy volunteers (30 adults: 19 male, 11 female, mean age 37 +/- 6 years; 15 children: 8 male, 7 female, mean age 8 +/- 2 years) underwent transthoracic echocardiographic examination; 2D cine-loops recordings of apical 4-four 4-chamber (4C) and 2-chamber (2C) views and short axis views were stored for off-line analysis. Computer analyses were performed using specific software relying on the algorithm of optical flow analysis, specifically designed to track the endocardial border, installed on a Windows based computer workstation. Inter and intra-observer variability was assessed. RESULTS: The feasibility of measurements obtained with tissue tracking system was higher in apical view (100% for systolic events; 64% for diastolic events) than in short axis view (70% for systolic events; 52% for diastolic events). Longitudinal systolic velocity decreased from base to apex in all subjects (5.22 +/- 1.01 vs. 1.20 +/- 0.88; p < 0.0001). Longitudinal strain and SR significantly increased from base to apex in all subjects (-12.95 +/- 6.79 vs. -14.87 +/- 6.78; p = 0.002; -0.72 +/- 0.39 vs. -0.94 +/- 0.48, p = 0.0001, respectively). Similarly, circumferential strain and SR increased from base to apex (-21.32 +/- 5.15 vs. -27.02 +/- 5.88, p = 0.002; -1.51 +/- 0.37 vs. -1.95 +/- 0.57, p = 0.003, respectively). Values of global systolic SR, both longitudinal and circumferential, were significantly higher in children than in adults (-1.3 +/- 0.2, vs. -1.11 +/- 0.2, p = 0.006; -1.9 +/- 0.6 vs. -1.6 +/- 0.5, p = 0.0265, respectively). No significant differences in longitudinal and circumferential systolic velocities were identified for any segment when comparing adults with children. CONCLUSION: This 2D based tissue tracking system used for computation is reliable and applicable in adults and children particularly for systolic events. Measured with this technology, we have established reference values for myocardial velocity, Strain and SR for both young adults and children.

Salicylate for the treatment of Kawasaki disease in children.

BACKGROUND: Kawasaki disease is the most common cause of acquired heart disease in children in developed countries. The coronary arteries supplying the heart can be damaged in Kawasaki disease. The principal advantage of timely diagnosis is the potential to prevent this complication with early treatment. Salicylate (acetyl salicylate acid (ASA), aspirin) and intravenous immunoglobulin (IVIG) are widely used for this purpose. Salicylate is largely otherwise avoided in children because of concerns about serious side effects, particularly the risk of Reyes syndrome. OBJECTIVES: The objective of this review was to evaluate the effectiveness of salicylate in treating and preventing cardiac consequences of Kawasaki disease in children. SEARCH STRATEGY: The Cochrane Peripheral Vascular Disease Group searched their trials register (last searched July 2006) and the Cochrane Central Register of Controlled Trials (CENTRAL) (last searched Issue 3, 2006). We searched MEDLINE (January 1966 to July 2006), EMBASE (January 1980 to July 2006), and CINAHL (1982 to July 2006), and reference list of articles. In addition we contacted experts in the field. SELECTION CRITERIA: Randomised controlled trials (RCTs) of salicylate to treat Kawasaki disease in children were eligible for inclusion. DATA COLLECTION AND ANALYSIS: Two authors independently assessed trial quality and extracted data. Study authors were contacted for additional information. MAIN RESULTS: We found one trial involving 102 children which was described as randomised, but it was not possible to confirm the method of treatment allocation. A second comparative study, possibly with a randomised treatment allocation, was also identified. The one randomised trial reported no association between the addition of ASA to IVIG treatment on the rate of coronary artery abnormalities at follow up, but with wide confidence limits. The second, possibly randomised trial did demonstrate a reduction in duration of fever with high dose ASA compared to low dose ASA, but was insufficiently powered to establish the effect on coronary artery abnormalities at follow up. AUTHORS' CONCLUSIONS: Until good quality RCTs are carried out, there is insufficient evidence to indicate whether children with Kawasaki disease should continue to receive salicylate as part of their treatment regimen.

Intravenous immunoglobulin for the treatment of Kawasaki disease in children.

BACKGROUND: Kawasaki disease is the most common cause of acquired heart disease in children in developed countries. The coronary arteries supplying the heart can be damaged in Kawasaki disease. The principal advantage of timely diagnosis is the potential to prevent this complication with early treatment. Intravenous immunoglobulin (IVIG) is widely used for this purpose. OBJECTIVES: The objective of this review was to evaluate the effectiveness of IVIG in treating, and preventing cardiac consequences, of Kawasaki disease in children. SEARCH STRATEGY: Electronic searches of the Cochrane Peripheral Vascular Disease Group Specialised Register, CENTRAL, MEDLINE, EMBASE, and CINAHL were performed (last searched April 2003). We also searched references from relevant articles and contacted authors where necessary. In addition we contacted experts in the field for unpublished works. SELECTION CRITERIA: Randomised controlled trials of intravenous immunoglobulin to treat Kawasaki disease were eligible for inclusion. DATA COLLECTION AND ANALYSIS: Fifty-nine trials were identified in the initial search. On careful inspection only sixteen of these met all the inclusion criteria. Trials were data extracted and assessed for quality by at least two reviewers. Data were combined for meta-analysis using relative risk ratios for dichotomous data or weighted mean difference for continuous data. A random effects statistical model was used. MAIN RESULTS: The meta-analysis of IVIG versus placebo, including all children, showed a significant decrease in new coronary artery abnormalities (CAAs) in favour of IVIG, at thirty days RR (95% CI) = 0.74 (0.61 to 0.90). No statistically significant difference was found thereafter. A subgroup analysis excluding children with CAAs at enrollment also found a significant reduction of new CAAs in children receiving IVIG RR (95%) = 0.67 (0.46 to 1.00). There was a trend towards benefit from IVIG at sixty days (p=0.06). Results of dose comparisons showed a decrease in the number of new CAAs with increased dose. The meta-analysis of 400 mg/kg/day for five days versus 2 gm/kg in a single dose showed statistically significant reduction in CAAs at thirty days RR (95%) = 4.47 (1.55 to 12.86). This comparison also showed a significant reduction in duration of fever with the higher dose. There was no statistically significant difference noted between different preparations of IVIG. There was no statistically significant difference of adverse effects in any group. REVIEWER'S CONCLUSIONS: Children fulfilling the diagnostic criteria for Kawasaki disease should be treated with IVIG (2 gm/kg single dose) within 10 days of onset of symptoms.

Stress, cognitive factors, and coping resources as predictors of relapse in alcoholics.

One hundred alcohol-dependent individuals attending a detoxification unit were assessed on a variety of psychological, social and demographic variables. Sixty-one participants were contacted at follow-up over 1 year later. Alcohol consumption was assessed through self-report and corroborative information. Self-reported levels of stress and social support were also obtained. High self-efficacy predicted low levels of self reported drinking at follow-up. Negative coping predicted higher levels of drinking as reported by the corroborator. High levels of stress in the month prior to follow-up were related to self-reported poor drinking outcomes, while ongoing social support since treatment was associated with favorable drinking outcomes. Overall, higher levels of self-efficacy during detoxification and social support following treatment were the best predictors of a favourable drinking outcome.

Level of occupational stress in male and female rural general practitioners.

General practitioners (GPs) in five rural divisions in New South Wales completed questionnaires designed to assess the degree to which various stressors were present in their work environment; the degree to which these stressors distressed them; their general stress; and their general health. Results published in a previous paper showed that high occupational stress in doctors was associated with high general stress and poor general health. Results reported in this paper showed that male doctors were more stressed than female doctors, GPs working on a full-time basis were more stressed than those working on a part-time basis, GPs who were also working as visiting medical officers were more stressed than those who did not work in this capacity, and younger GPs were more stressed than older GPs. High workload, governments, interference with their work, and family and leisure concerns were the major stressors for rural GPs.

A clinical analysis of 500 medico-legal claims evaluating the causes and assessing the potential benefit of alternative dispute resolution.

OBJECTIVE: 1. To evaluate the common causes of medico-legal dispute in obstetrics and gynaecology. 2. To assess the potential benefit of early alternative dispute resolution. DESIGN: A prospective analysis of over 500 cases submitted from over 100 solicitors between 1984 and 1994 for medical expert opinion on potential medico-legal claims. CASES: Five hundred consecutive cases that met the inclusion criteria: 488 from the United Kingdom and 12 from abroad (Hong Kong, Republic of Ireland). MAIN OUTCOME MEASURES: The main principles underlining medico-legal disputes and causes of such claims. RESULTS: Analysis of 500 claims show 46% were misguided allegations, 19% incompetent care, 12% error of judgement, 9% lack of expertise, 7% failure of communication, 6% poor supervision and 1% inadequate staffing. Of the misguided allegations 119/225 cases (59%) were obstetric and 111/275 (40%) cases were gynaecological. The most common cause of obstetric dispute was "cerebral palsy' (22%), while the commonest cause of gynaecological dispute was failed sterilisation (19%). Settled claims were under-reported by solicitors. CONCLUSION: Because of the high percentage (46%) of misguided allegations, an alternative course of dispute resolution must be a realistic way forward. This course of action, combined with improved communication, could result in a major reduction in the costs of potential medical litigation. Early alternative dispute resolution should be considered in an attempt to reduce the escalating quantum of damages and costs. We recommend recruiting independent, experienced and unbiased consultants in active practice within the appropriate specialty to review such cases at the level of hospital complaints management as an in house review procedure, particularly for small and moderate-sized claims, as a means whereby doctors can retain control of medico-legal disputes, in contrast to control by the legal profession.

Retrospective and prospective psychological and physical health as a function of negative affect and attributional style.

Subjects completed questionnaires designed to assess (a) attributions along internal-external, stable-unstable, and global-specific dimensions subsequent to undersirable events; (b) negative affect; and (c) retrospective psychological and physical health. Subjects then kept weekly records, for 12 weeks, of their visits to doctors and days of illness (prospective physical health) and days they experienced emotional problems (prospective psychological health). Multiple regression analyses that used negative affect and attributional variables as predictors showed that negative affect was the best predictor of retrospective health and that global attributions were the best predictors of prospective health. Analysis of the comparative predictive value of the internal, stable, and global attributions revealed that global attributions were the most significant predictors of retrospective and prospective health.

Comparative predictive value of attributional style, negative affect, and positive affect in predicting self-reported physical health and psychological health.

The main aim of the study was to determine the comparative predictive value of affect and attributions in predicting emotional and physical health. Secondary aims were to determine the comparative value of attributional, affect variables, in predicting health. Two hundred and forty subjects completed scales for the assessment of attributions, and negative and positive affect. Subjects also answered self-report questions on emotional health, physical health, number of visits to doctors for medical advice, illness, and days absent from work. The analysis of relative importance of attributional and affect variables in predicting health revealed that negative affect caused by thoughts was the best predictor of psychological health and physical health; there was some indication that positive affect caused by thoughts was the next best predictor of health. Analysis of the predictive value of attributional variables only, revealed that: (a) attributional style for bad events was a better predictor of health than attributional style for good events; and (b) of all the attributions made for good events and bad events, global attributions for bad events were the best predictor of health. Analysis of the predictive value of affect variables only showed that: (a) negative affect was a better predictor of health than positive affect; and (b) of negative affect and positive affect caused by thoughts and day-to-day experiences, negative affect caused by thoughts was the best predictor of health.