Impact of Prehospital Pain Management on Emergency Department Management of Injured Children.

OBJECTIVE: Provision of analgesia for injured children is challenging for Emergency Medical Services (EMS) clinicians. Little is known about the effect of prehospital analgesia on emergency department (ED) care. We aimed to determine the impact of prehospital pain interventions on initial ED pain scale scores, timing and dosing of ED analgesia for injured patients transported by EMS. METHODS: This is a planned, secondary analysis of a prospective multicenter cohort of children with actual or suspected injuries transported to one of 11 PECARN-affiliated EDs from July 2019-April 2020. Using Wilcoxon rank sum for continuous variables and chi-square testing for categorical variables, we compared the change in EMS-to-ED pain scores and timing and dosing of ED-administered opioid analgesia in those who did and those who did not receive prehospital pain interventions. RESULTS: We enrolled 474 children with complete prehospital and ED pain management data. Prehospital interventions were performed on 262/474 (55%) of injured children and a total of 88 patients (19%) received prehospital opioids. Children who received prehospital opioids with or without adjunctive non-pharmacologic pain management experienced a greater reduction in pain severity and were more likely to receive ED opioids in higher doses earlier and throughout their ED care. Non-pharmacologic pain interventions alone did not impact ED care. CONCLUSIONS: We demonstrate that prehospital opioid analgesia is associated with both a significant reduction in pain severity at ED arrival and the administration of higher doses of opioid analgesia earlier and throughout ED care.

The impact of prescribed opioids on CD4 cell count recovery among HIV-infected patients newly initiating antiretroviral therapy.

OBJECTIVES: Certain prescribed opioids have immunosuppressive properties, yet their impact on clinically relevant outcomes, including antiretroviral therapy (ART) response among HIV-infected patients, remains understudied. METHODS: Using the Veterans Aging Cohort Study data, we conducted a longitudinal analysis of 4358 HIV-infected patients initiating ART between 2002 and 2010 and then followed them for 24 months. The primary independent variable was prescribed opioid duration, categorized using pharmacy data as none prescribed, short-term (< 90 days) and long-term (≥ 90 days). Outcomes included CD4 cell count over time. Analyses adjusted for demographics, comorbid conditions, ART type and year of initiation, and overall disease severity [ascertained with the Veterans Aging Cohort Study (VACS) Index]. Sensitivity analyses examined whether effects varied according to baseline CD4 cell count, achievement of viral load suppression, and opioid properties (i.e. dose and known immunosuppressive properties). RESULTS: Compared to those with none, patients with short-term opioids had a similar increase in CD4 cell count (mean rise per year: 74 vs. 68 cells/µL; P = 0.11), as did those with long-term prescribed opioids (mean rise per year: 74 vs. 75 cells/µL; P = 0.98). In sensitivity analysis, compared with no opioids, the effects of short-term prescribed opioids were statistically significant among those with a baseline CD4 cell count ≥ 500 cells/µL (mean rise per year: 52 cells/µL for no opioids vs. 20 cells/µL for short-term opioids; P = 0.04); findings were otherwise unchanged. CONCLUSIONS: Despite immunosuppressive properties intrinsic to opioids, prescribed opioids appeared to have no effect on CD4 cell counts over 24 months among HIV-infected patients initiating ART.

Comparison of insufflated talc under thoracoscopic guidance with standard tetracycline and bleomycin pleurodesis for control of malignant pleural effusions.

The standard palliation of malignant pleural effusions involves tube thoracostomy drainage with chemical pleurodesis. The insufflation of intrapleural talc under thoracoscopic guidance (n = 39) was evaluated against documented controls that consisted of patients (n = 85) who participated in a randomized study with tube thoracostomy drainage followed by either bleomycin or tetracycline sclerosis. Under local anesthesia, which was supplemented by intravenous sedation, patients in the talc group underwent complete pleural fluid evacuation. The talc was then insufflated evenly on the entire pleural surface under thoracoscopic guidance. Of the patients in the talc group who survived their disease process, 97% had a successful pleurodesis at 30 days and 95% at 90 days. In comparison, the bleomycin group demonstrated a success rate of 64% at 30 days and 70% at 90 days (p = 0.003 and p = 0.047 versus the talc group). The tetracycline group had successful pleurodesis in only 33% at 30 days and 47% at 90 days (p < 0.001 and p < 0.001 versus the talc group). There were only two patients in the talc group in whom pleurodesis was not successful, and both were subsequently found to have extraluminal compression of the right lower lobe bronchus, which prevented lung reexpansion. These data demonstrate that the insufflation of talc into the pleural cavity under thoracoscopic guidance is a safe and efficacious procedure in the control of malignant pleural effusions.

Cutaneous inoculation tuberculosis secondary to 'jailhouse tattooing'.

Cutaneous inoculation tuberculosis is rare in the United States today. When seen, it usually occurs in individuals whose occupations or environments place them at increased risk for exposure to Mycobacterium tuberculosis. The reaction of the skin to M tuberculosis infection is polymorphous and depends upon the interplay of bacterial virulence and host immunity. Thus, both a high index of suspicion and positive cultures are required to make the diagnosis. Herein, we report a case of cutaneous inoculation tuberculosis occurring in a tattoo.

Kinetic characterization of two classes of dog liver alcohol dehydrogenase isoenzymes.

In order to relate the catalytic properties of alcohol dehydrogenase (ADH), the rate-limiting enzyme for alcohol metabolism, with the pharmacokinetics of ethanol elimination in vivo, the multiple molecular forms of dog liver ADH were purified and their steady state kinetics investigated. Two different classes of ADH forms were identified by starch gel electrophoresis: the class I isoenzymes migrate to the cathode and the class II forms migrate to the anode. Three different patterns of the cathodic class I isoenzymes were identified in different liver specimens. Three molecular forms were observed for patterns A and C, and five for B. The two classes of isoenzymes were separated by affinity chromatography and purified by column chromatography. The three predominant class I isoenzymes, A1, B2, and C1, in type A, B, and C livers, respectively, were isolated by high performance cation-exchange chromatography. The steady state kinetic constants of the A1, B2, and C1 isoenzymes are similar, but differ substantially from those of the class II enzyme. The class II enzyme is much less sensitive to pyrazole inhibition, Ki = 2 mM, than the class I forms, Ki = 0.6 microM. Methanol is not a substrate for the class II enzyme, whereas it is oxidized by the class I isoenzymes. The class I isoenzymes exhibit a lower Km and substrate inhibition Ki for ethanol, 0.4 and 160 mM, respectively, than values for the class II enzyme, 10 and 610 mM, respectively. The properties of class I and II dog liver ADH are similar to those of the respective isoenzymes purified from human and monkey liver.(ABSTRACT TRUNCATED AT 250 WORDS)

Polyarteritis nodosa: chronic renal failure with spontaneous recovery.

A 57-year-old male developed acute oliguric renal failure due to polyarteritis nodosa (PAN). He went on rapidly to chronic renal failure. After nine months of home hemodialysis, he recovered renal function with creatinine clearance of 30 ml/min. This patient was not treated with drugs of any type for his illness. He represents a spontaneous remission from severe renal PAN and underscores the need for further evaluation of the current recommended drug therapy for this disease.