Epidemiological and clinical features of malignant hyperthermia: A scoping review.

Malignant hyperthermia (MH) is a potentially fatal inherited pharmacogenetic disorder related to pathogenic variants in the RYR1, CACNA1S, or STAC3 genes. Early recognition of the occurrence of MH and prompt medical treatment are indispensable to ensure a positive outcome. The purpose of this study was to provide valuable information for the early identification of MH by summarizing epidemiological and clinical features of MH. This scoping review followed the methodological framework recommended by Arksey and O'Malley. PubMed, Embase, and Web of science databases were searched for studies that evaluated the epidemical and clinical characteristics of MH. A total of 37 studies were included in this review, of which 26 were related to epidemiology and 24 were associated with clinical characteristics. The morbidity of MH varied from 0.18 per 100 000 to 3.9 per 100 000. The mortality was within the range of 0%-18.2%. Identified risk factors included sex, age, disorders associated with MH, and others. The most frequent initial clinical signs included hyperthermia, sinus tachycardia, and hypercarbia. The occurrence of certain signs, such as hypercapnia, delayed first temperature measurement, and peak temperature were associated with poor outcomes. The epidemiological and clinical features of MH varied considerably and some risk factors and typical clinical signs were identified. The main limitation of this review is that the treatment and management strategies were not assessed sufficiently due to limited information.

Infective Endocarditis in an Intravenous Drug User Leading to Myocardial Rupture and Hemopericardium.

Introduction: Infective endocarditis (IE) is an infectious disorder of the innermost lining of the heart that can be fatal if left untreated. Infective endocarditis can spread beyond the endocardium into the myocardium and cause arrhythmias and myocardial wall rupture. Individuals with a history of intravenous drug use are at increased risk of developing IE and are at higher risk of dying, given their limited access to health care and adherence to treatment. Methods: A medicolegal autopsy was performed on a 30-year-old woman with a history of intravenous drug use and recent assault after a hospital admission during which she did not survive resuscitation. Results: The cause of death was found to be myocardial rupture in the setting of transmural IE. Postmortem imaging showed hemopericardium which was identified grossly with valvular vegetations in the heart. A ventricular wall defect along with transmural abscess formation was identified. Perimortem toxicology was positive for fentanyl, methamphetamine, and benzoylecgonine, a metabolite of cocaine. Postmortem blood cultures were positive for coagulase-negative Staphylococci, Staphylococcus aureus, Candida tropicalis, and Viridians group Streptococci. Postmortem tissue cultures taken from the heart was positive for Candida glabrata and Streptococcus mitis. Discussion: The decedent had significant risk factors for IE, such as intravenous drug use and a prior admission to hospital for IE. The organisms identified on culture are in-keeping with the gross findings of IE and the terminal event of myocardial rupture was likely the result of tissue damage resulting from IE.

Interdependence and the cost of uncoordinated responses to COVID-19.

Social distancing is the core policy response to coronavirus disease 2019 (COVID-19). But, as federal, state and local governments begin opening businesses and relaxing shelter-in-place orders worldwide, we lack quantitative evidence on how policies in one region affect mobility and social distancing in other regions and the consequences of uncoordinated regional policies adopted in the presence of such spillovers. To investigate this concern, we combined daily, county-level data on shelter-in-place policies with movement data from over 27 million mobile devices, social network connections among over 220 million Facebook users, daily temperature and precipitation data from 62,000 weather stations, and county-level census data on population demographics to estimate the geographic and social network spillovers created by regional policies across the United States. Our analysis shows that the contact patterns of people in a given region are significantly influenced by the policies and behaviors of people in other, sometimes distant, regions. When just one-third of a state's social and geographic peer states adopt shelter-in-place policies, it creates a reduction in mobility equal to the state's own policy decisions. These spillovers are mediated by peer travel and distancing behaviors in those states. A simple analytical model calibrated with our empirical estimates demonstrated that the "loss from anarchy" in uncoordinated state policies is increasing in the number of noncooperating states and the size of social and geographic spillovers. These results suggest a substantial cost of uncoordinated government responses to COVID-19 when people, ideas, and media move across borders.

A Review of Enhanced Recovery After Surgery Principles Used for Scheduled Caesarean Delivery.

There is an increasing body of evidence to support the success of Enhanced Recovery After Surgery (ERAS) for a wide range of surgical procedures. There has been little formalized application, however, of ERAS principles in obstetrical surgery. The aim of this review was to examine the evidence base of perioperative care for patients undergoing Caesarean delivery (CD) and to determine the feasibility of developing an ERAS Society guideline for this obstetrical care plan. The literature on enhanced recovery programs was reviewed, including fast-track surgery and perioperative care components in the preoperative, intraoperative, and postoperative phases of CD. These studies included randomized controlled trials (RCTs), prospective cohort studies, non-RCT studies, meta-analyses, systematic reviews, reviews, and case studies. This is not a systematic review because each ERAS topic area would require a new question. Certain ERAS elements have the potential to benefit patients undergoing CD. These elements include patient education, preoperative optimization, prophylaxis against thromboembolism, antimicrobial prophylaxis, postoperative nausea and vomiting prevention, hypothermia prevention, perioperative fluid management, postoperative analgesia, ileus prevention, breastfeeding promotion, and early mobilization. ERAS has the potential to be successfully implemented in CD on the basis of the evidence obtained from this review. Knowledge transfer and implementation will require multidisciplinary coordination in the preoperative, intraoperative, and postoperative phases and the development of a formalized ERAS guideline.

In Potential Stroke Patients on Warfarin, the International Normalized Ratio Predicts Ischemia.

BACKGROUND: Stroke can occur in patients on warfarin despite anticoagulation. Patients with a low international normalized ratio (INR) should theoretically be at greater risk for ischemia than those who are therapeutic. Therefore, INR may be able to indicate whether new neurological deficits are more likely strokes or stroke mimics in patients on warfarin. This study evaluates the association and predictive value of INR in determining the likelihood of ischemia. METHODS: Patients were identified using the acute stroke registry at a Primary Stroke Center from January 2013 through December 2014. All adult patients undergoing evaluation for acute stroke with prior documented use of warfarin and an INR level at presentation were included. Data were collected regarding patient demographics, medical comorbidities, stroke severity, reason for anticoagulation, and laboratory studies including INR. Student t tests and χ2 analysis were used to evaluate factors associated with increased likelihood of ischemia (stroke or transient ischemic attack) versus mimic. Significant results were entered into a multivariable regression analysis. Sensitivity and specificity analyses were conducted to determine the predictive value of INR for ischemic risk. RESULTS: 116 patients were included; 46 were diagnosed with ischemia, 70 were diagnosed as mimics. 75% of patients were on warfarin for atrial fibrillation versus 25% for venous thrombosis. A statistically significant difference in mean INR for patients with ischemia (n = 46) versus mimics (n = 70) was observed (1.7 vs. 2.8; p < 0.001). In multivariable analysis, both sub-therapeutic INR (p < 0.001) and atrial fibrillation (p = 0.014) were predictors of ischemia. In patients with an INR ≥2, the predictive value of having a non-ischemic etiology was 79%. No patient with an INR of ≥3.6 was found to have ischemia. CONCLUSIONS: Sub-therapeutic INR and atrial fibrillation are strongly associated with ischemia in patients on warfarin presenting with acute neurologic symptoms. Ischemia is far less likely in patients with an INR of ≥2 and rare in those with an INR ≥3.6. This study shows that the INR value of a patient on warfarin can help stratify patients' risk for acute ischemic stroke and guide further neurologic imaging and workup.