Aspirin compared to enoxaparin or rivaroxaban for thromboprophylaxis following hip and knee replacement.

Background The risk of venous thromboembolism following major orthopaedic surgery is among the highest for all surgical specialties. Our hospital guidelines for thromboprophylaxis following elective primary total hip or knee replacement are based on American College of Chest Physicians guidance. The most recent change to local guidelines was the introduction of the extended aspirin regimen as standard thromboprophylaxis. Objective To establish the appropriateness of this regimen by comparing venous thromboembolism rates in patients receiving extended aspirin to previous regimens. Setting The largest dedicated orthopaedic hospital in Ireland. Methods This was a retrospective cohort study. Data were collected from patient record software. All eligible patients undergoing primary total hip or knee replacement between 1st January 2010 and 30th June 2016 were included. Main outcome measure Venous thromboembolism up to 6 months post-operatively. Results Of the 6548 participants (55.3% female, mean age 65.4 years (± 11.8 years, 55.8% underwent total hip replacement), venous thromboembolism occurred in 65 (0.99%). Venous thromboembolism rate in both the inpatient enoxaparin group (n = 961) and extended aspirin group (n = 3460) was 1.04% and was 0.66% in the modified rivaroxaban group (n = 1212). Non-inferiority analysis showed the extended aspirin regimen to be equivalent to the modified rivaroxaban regimen. History of venous thromboembolism was the only significant demographic risk factor for post-operative venous thromboembolism (0.87% vs. 3.54%, p  = 0.0002). Conclusion In daily clinical practice, extended aspirin regimen is at least as effective as modified rivaroxaban for preventing clinically important venous thromboembolism among patients undergoing hip or knee arthroplasty who are discharged from the hospital without complications. Aspirin can be considered a safe and effective agent in the prevention of venous thromboembolism after total hip or total knee replacement.

A Prospective Study of Stingray Injury and Envenomation Outcomes.

BACKGROUND: Stingray injuries result in thousands of emergency department visits annually. OBJECTIVES: This study aimed to assess the complication rate and outcome of field treatment with hot water immersion. METHODS: This was an on-site, prospective, observational study. Subjects were enrolled after having been stung by a stingray. A trained researcher obtained the following information: age, sex, health conditions and medications, and wound description. The efficacy of hot water immersion on pain was recorded. Patients were contacted on postinjury days 3, 7, and 14 for follow up. RESULTS: Twenty-two subjects were included. No obvious foreign bodies were observed in wounds. Ten subjects were treated with hot water immersion and povidone-iodine, 12 with hot water immersion alone. Ongoing symptoms or complications were noted at the 3-day follow-up in 6 of 22 subjects (27.3%). One subject was diagnosed with cellulitis on post-sting day 8 and was treated with antibiotics. Ongoing symptoms or complications were reported more commonly in patients treated with hot water and povidone-iodine compared with those treated with hot water alone (p = 0.056). There was a significant difference in wound size between those with and without ongoing symptoms at the 3-day follow-up (p = 0.0102). No wounds <1 cm developed any complications. Average duration of water immersion was 73.6 min (range 35-145 min). The mean pain score pretreatment was 7.36 and posttreatment was 2.18, with an average decrease of 5.18 (95% confidence interval 4.22-6.15). CONCLUSION: Stingray injuries responded well to hot water immersion for pain control. Skin and soft tissue infection was diagnosed in 1 of 22 patients (4.55%).

Inadvertent Methylergonovine Administration to a Neonate.

BACKGROUND Methylergonovine is an ergot alkaloid used to treat post-partum hemorrhage secondary to uterine atony. Mistaking methylergonovine for vitamin K with accidental administration to the neonate is a rare iatrogenic illness occurring almost exclusively in the delivery room setting. Complications of ergot alkaloids in neonates include respiratory depression, seizures, and death. CASE REPORT A term infant was inadvertently given 0.1 mg of methylergonovine intramuscularly in the right thigh. The error was only noted when the vial of medication was scanned, after administration, identifying it as methylergonovine rather than vitamin K. The local poison center was notified, and the infant was transferred to the neonatal intensive care unit for observation. Two hours after transfer, the infant was noted to have oxygen desaturations and required oxygen via nasal cannula. Supplemental oxygen was continued for 4 hours until the neonate was able to maintain normal oxygen saturations in room air. Feeding was started by 10 hours of life, and the infant was discharged home in good condition after a 72-hour stay without further complications. CONCLUSIONS Because of the potential for serious adverse events, vigilance is required to prevent accidental administration of methylergonovine to the neonate as a result of possible confusion with vitamin K in the early post-partum period.

Propofol Use for Toxin-Related Seizures.

BACKGROUND: The use of propofol as treatment of toxin-induced seizures is unclear. The goal of this study was to characterize the use of propofol for toxin-related seizures as reported to a statewide poison system. METHODS: This study was a retrospective review of the electronic records from a poison control system from 2009 to 2012. Inclusion criteria were patient age (≥ 18 yrs) and cases coded with "seizure" that contained the term "propofol." The age, sex, reported toxin(s) involved, recurrence of seizure activity following/during propofol use, and mortality were extracted. RESULTS: Records review identified 235 poisoning cases, all of which involved adjunctive therapy with propofol. The age range was 18-82 years (53% female). A total of 155 different toxins were identified. Recurrent seizures occurred in 15.7% (n=37) of cases following propofol administration. The mortality rate was 6.8% (n=16) in cases with known outcomes. CONCLUSIONS: Propofol is being used as an anticonvulsant in poisoned patients and appears to have some utility as an adjunct in terminating toxin-related seizures once airway control has been established. Less clear, however, is at what point propofol therapy should be initiated. Prospective controlled studies are warranted to identify the role of propofol in controlling toxin-induced seizures.

Internet-purchased ibogaine toxicity confirmed with serum, urine, and product content levels.

UNLABELLED: Ibogaine, a psychotropic indole alkaloid, is gaining popularity among medical subcultures for its purported anti addictive properties. Its use has been associated with altered mental status, ataxia, gastrointestinal distress, ventricular arrhythmias, and sudden and unexplained deaths.Its pharmacokinetics in toxic states is not well understood. Case report:A 33-year-old man overdosed on ibogaine in an attempt to quit his use of heroin. He developed altered state of consciousness, tremor, ataxia,nausea, vomiting, and transient QT interval prolongation, which all remitted as he cleared the substance. Ibogaine was confirmed in his urine and serum with a peak serum concentration of 377 ng/mL. Nonlinear elimination kinetics and a formula match to its active metabolite noriobgaine were observed as well. CONCLUSION: This case presents the unique description of serial serum concentrations as well as urine and product-confirmed ibogaine toxicity with transient toxin-related QT interval prolongation.

Cardiopulmonary limited ultrasound examination for "quick-look" bedside application.

Although taking a "quick look" at the heart using a small ultrasound device is now feasible, a formal ultrasound imaging protocol to augment the bedside physical examination has not been developed. Therefore, we sought to evaluate the diagnostic accuracy and prognostic value of a cardiopulmonary limited ultrasound examination (CLUE) using 4 simplified diagnostic criteria that would screen for left ventricular dysfunction (LV), left atrial (LA) enlargement, inferior vena cava plethora (IVC+), and ultrasound lung comet-tail artifacts (ULC+) in patients referred for echocardiography. The CLUE was tested by interpretation of only the parasternal LV long-axis, subcostal IVC, and 2 lung apical views in each of 1,016 consecutive echocardiograms performed with apical lung imaging. For inpatients, univariate and multivariate logistic regression analyses were performed to assess the relations between mortality, CLUE findings, age, and gender. In this echocardiographic referral series, 78% (n = 792) were inpatient and 22% (n = 224) were outpatient. The CLUE criteria demonstrated a sensitivity, specificity, and accuracy for a LV ejection fraction of ≤40% of 69%, 91%, and 89% and for LA enlargement of 75%, 72%, and 73%, respectively. CLUE findings of LV dysfunction, LA enlargement, IVC+, and ULC+ were seen in 16%, 53%, 34%, and 28% of inpatients. The best multivariate logistic model contained 3 predictors of in-hospital mortality: ULC+, IVC+ and male gender, with adjusted odds ratios (95% confidence intervals) of 3.5 (1.4 to 8.8), 5.8 (2.1 to 16.4), and 2.3 (0.9 to 5.8), respectively. In conclusion, a CLUE consisting of 4 quick-look "signs" has reasonable diagnostic accuracy for bedside use and contains prognostic information.

Single-breath counting: a pilot study of a novel technique for measuring pulmonary function in children.

INTRODUCTION: Although peak expiratory flow rate is the conventional way to measure asthma severity in adults, its use is problematic in children because it is effort dependent. Forced expiratory volume in 1 second (FEV1) and the ratio of FEV1 to forced vital capacity (FEV1/FVC) are more accurate, but generally not available in the emergency department (ED). A better test is needed. Single-breath counting (SBC) is the measurement of how far an individual can count in a normal speaking voice after a maximal effort inhalation. The count is in cadence to a metronome set at 2 beats per second. Previous work has suggested that SBC correlates with standard measures of pulmonary function in adults. However, it has never been tested in children. OBJECTIVES: The aims of this study are to determine if SBC can be easily performed by children and to assess the correlation between SBC and standard measures of pulmonary function in a pediatric population. METHODS: This was a prospective observational study of a convenience sample of children presenting to the pulmonary clinic for scheduled pulmonary function testing (PFT). Peak expiratory flow rate, FEV1, FVC, forced expiratory flow 25% to 75%, and FEV1/FVC were measured and recorded. After PFT, subjects were asked to perform SBC. Three attempts were allowed, and the average was recorded. Correlation was determined by the Pearson coefficient. RESULTS: Sixty-seven children (ages 5-18 years, 64% male) were enrolled. All were able to understand and complete the testing. Indications for PFT included asthma and/or allergies (n = 44), cystic fibrosis (n = 9), and other chronic diseases (n = 14). The correlations (r) of SBC to peak expiratory flow rate, FEV1, FVC, forced expiratory flow 25% to 75%, and FEV1/FVC were 0.55, 0.66, 0.71, 0.44, and -0.29, respectively (P < .05 for all results). CONCLUSION: Single-breath counting is easy to perform in children, seems to correlate well with standard measures of pulmonary function, and shows promise for measuring asthma severity in children. Further work to define the range of reference SBC values (as a function of age and/or body size) and an evaluation of the utility of SBC in an ED population of acute asthmatics is indicated.