Crawling toward obsolescence: The extended lifespan of amylase for pancreatitis.

The correlation between hyperamylasemia and acute pancreatitis was discovered in 1929, yet another test, lipase, was shown to provide better diagnostic performance in the late 1980s and early 1990s. Subsequent studies demonstrated co-ordering amylase with lipase did not provide additional benefit, only added cost. We sought to investigate the impact of studies advocating for the obsolescence of amylase on its clinical demand. We reviewed 1.3 million reportable results for amylase over 14 years (2009-2022). The trend in utilization of amylase over this period declined by 66% along a linear trajectory (R2 = 0.97). Despite demand for amylase decreasing by an average of 17,003 tests per year, the last year of the study (2022) recorded over 100,000 results for amylase. By interpolating the decline of amylase until the utilization reached zero, we calculated amylase orders will continue for 6 more years until 2028. Tests for creatinine and lipase changed <3% over the same period. Despite a multitude of studies advocating for the obsolescence of amylase, robust demand continues. Many important clinical guidelines, a source many practicing physicians rely on, have yet to acknowledge the preference for lipase over amylase. They frequently treat the two tests as equivalent, neglecting their head-to-head comparison studies and subsequent studies advocating against co-ordering both tests simultaneously. To expedite the obsolescence of amylase, which we anticipate lasting 46 years in our case study from its initial call for obsolescence to the last orders placed, metrics created specifically to monitor the utilization of unnecessary tests are also needed.

Comparison of distal radial access versus standard transradial access in patients with smaller diameter radial Arteries(The distal radial versus transradial access in small transradial ArteriesStudy: D.A.T.A - S.T.A.R study).

AIMS: To evaluate safety and efficacy of distal right radial access (DRRA) compared to right radial access (RRA), for coronary procedures, in patients with smaller diameter radial arteries (SDRA) (radial artery diameter (RAD) < 2.1 mm). METHODS AND RESULTS: This is a retrospective analysis of safety and efficacy of DRRA Vs. RRA in patients undergoing coronary procedures at our cardiac catheterization laboratories over a 10- month period between September 2017 and June, 2018 (first 5 calendar months with RRA-first; next 5 calendar months with DRRA-first). All patients underwent pre-procedure ultrasound of arm arteries. All patients had RAD<2.1 mm (mean RAD 1.63 ± 0.27 mm; RAD≤1.6 mm in 73.5%). Baseline characteristics were similar between groups. Primary end-point of puncture success was significantly lower in DRRA vs RRA group [79.5% vs 98.5%, p < 0.0001]. Puncture success was also lower in the subgroup of patients with RAD <1.6 mm Vs. ≥ 1.6 mm in the DRRA group (p < 0.0001). The secondary end-point of puncture time was significantly higher (2.1 ± 1.4 min vs. 1.0 ± 0.45 min, p < 0.00001) in the DRRA Vs. RRA group. The occurrence of vascular access site complications (including access site hematomas), radial artery occlusion (RAO) and distal RAO at day 1 and day 30 were similar between RRA and DRRA groups.Non-vascular access-site complication was seen only in the DRRA group. CONCLUSION: DRRA is a safe and effective access for coronary procedures; though technically challenging in patients with SDRA (RAD<2.1 mm; mean RAD 1.63 ± 0.27 mm), with lower puncture success and higher puncture time compared to RRA.

Primary Klebsiella pneumoniae Osteomyelitis with Bacteremia and Sepsis in a Patient with Cirrhosis.

Osteomyelitis is commonly caused by Staphylococci, Streptococci, Escherichia coli, and anaerobes. There have been cases of rare organisms like Klebsiella pneumoniae (Kp) being initially overlooked as causes of osteomyelitis. We report a case of an elderly cirrhotic adult male transferred for further management of liver failure, who was subsequently diagnosed with Kp osteomyelitis and sepsis. He had a history of blunt leg trauma, and MRI of the leg revealed osteomyelitis, with a negative workup for other sources of infection. Kp osteomyelitis is reported in less than 100 cases, mainly in pediatric and sickle-cell patients. There are no pathognomonic imaging findings. Lesions may be metastatic, with rapid widespread destruction and exuberant periosteal reaction. Kp is a rare, under recognized cause of osteomyelitis in immune-suppressed adults. Given its pathogenicity, early identification is critical.

Protective effect of liposome-encapsulated glutathione in a human epidermal model exposed to a mustard gas analog.

Sulfur mustard or mustard gas (HD) and its monofunctional analog, 2-chloroethyl ethyl sulfide (CEES), or "half-mustard gas," are alkylating agents that induce DNA damage, oxidative stress, and inflammation. HD/CEES are rapidly absorbed in the skin causing extensive injury. We hypothesize that antioxidant liposomes that deliver both water-soluble and lipid-soluble antioxidants protect skin cells from immediate CEES-induced damage via attenuating oxidative stress. Liposomes containing water-soluble antioxidants and/or lipid-soluble antioxidants were evaluated using in vitro model systems. Initially, we found that liposomes containing encapsulated glutathione (GSH-liposomes) increased cell viability and attenuated production of reactive oxygen species (ROS) in HaCaT cells exposed to CEES. Next, GSH-liposomes were tested in a human epidermal model, EpiDerm. In the EpiDerm, GSH-liposomes administered simultaneously or 1 hour after CEES exposure (2.5 mM) increased cell viability, inhibited CEES-induced loss of ATP and attenuated changes in cellular morphology, but did not reduce caspase-3 activity. These findings paralleled the previously described in vivo protective effect of antioxidant liposomes in the rat lung and established the effectiveness of GSH-liposomes in a human epidermal model. This study provides a rationale for use of antioxidant liposomes against HD toxicity in the skin considering further verification in animal models exposed to HD.