Serotonin reuptake inhibitors and bleeding risks in major orthopedic procedures.

BACKGROUND: Risk of abnormal bleeding in surgery patients prescribed serotonin reuptake inhibitors (SRIs) is unclear. Considering the quantity of literature on abnormal gastrointestinal (GI) bleeding with SRIs, relatively little exists on SRI bleeding risks in surgical procedures. We investigated whether SRIs increase the risk of surgical bleeding in patients undergoing knee and hip total joint replacement. METHODS: RA retrospective case-control study was conducted among subjects undergoing primary total hip and knee replacement surgeries from January 2005 to March 2011 at a single institution. The experimental group was defined by utilization of SRIs at the time of surgery (the independent variable). The control group was matched for age, sex, ethnicity, and type of surgery (hip or knee). Any case with preoperative hematocrit <30, platelets <100,000; abnormal prothrombin time, partial-prothrombin time, and international normalized ratio (INR), primary bleeding disorder, medical conditions, or medications associated with increased bleeding was excluded. All cases were randomly selected. RESULTS: RA total of 194 subjects (hip 104, knee 90) were included. Statistical analysis was performed on the SRI group (n = 71) and the control, non-SRI group (n = 123). No difference was found between the groups in estimated blood loss, hemoglobin, hematocrit, platelets, PT, PTT, and INR from preoperative to postoperative day 1, 2, and 3. Furthermore, no subjects in either group required blood transfusions. CONCLUSION: SRIs were not associated with increased risk of bleeding in primary knee or hip replacement surgeries in this study. The hypothesis that SRIs increase the risk of bleeding based on presumptions about their action on platelet aggregation is uncertain and warrants further study.

Corneal abrasions in young infants.

OBJECTIVES: We sought to determine the prevalence of corneal abrasions and possible associations with fingernail length, demographic information, sleeping, and crying among young infants. METHODS: Parents of 1- to 12-week-old infants without symptoms who were presenting for well-child visits completed a brief questionnaire on age, gender, race, fingernail-trimming practices, and sleeping and crying in the preceding 24-hour period. Fingernail length was measured, and eyes were examined through staining with fluorescein and illumination/magnification with a Bluminator (Eidolon Optical, Natick, MA). Patients with corneal abrasions were given orally administered acetaminophen and erythromycin ointment. Masked interrater reliability for abrasions was measured. Logistic regression analyses determined the association of corneal abrasions with potential covariates. RESULTS: Ninety-six subjects were enrolled, including 47 girls (49%), with a mean age of 32.2 days (SD: 21.7 days). Forty-seven infants (49%) had abrasions. Demographic variables and mean crying times (114.8 +/- 124.9 vs 86.5 +/- 111.7 minutes; P < .24) were not significantly different for infants with and without abrasions. Infants with abrasions slept more (15.9 +/- 3.3 vs 14.5 +/- 3.6 hours; P = .054). Associations of fingernail-trimming method and fingernail length with corneal abrasions were not statistically significant. Masked interrater reliability was high, with agreement between the primary investigator and the associate investigator for 20 (91%) of 22 eyes and agreement between the primary investigator and a pediatric ophthalmologist for 9 (90%) of 10 eyes. CONCLUSIONS: Corneal abrasions are extremely common among 1- to 12-week-old infants and have unclear clinical significance. Primary care physicians should be careful about attributing unexplained persistent crying to corneal abrasions, potentially missing a more-serious problem.

A prospective, randomized trial of intravenous prochlorperazine versus subcutaneous sumatriptan in acute migraine therapy in the emergency department.

STUDY OBJECTIVE: Intravenous (IV) prochlorperazine with diphenhydramine is superior to subcutaneous sumatriptan in the treatment of migraine patients presenting to the emergency department (ED). METHODS: In this randomized, double-blind, placebo-controlled trial, after providing written informed consent, patients presenting to the ED with a chief complaint of migraine received a 500-mL bolus of IV saline solution and either 10 mg prochlorperazine with 12.5 mg diphenhydramine IV plus saline solution placebo subcutaneously or saline solution placebo IV plus 6 mg sumatriptan subcutaneously. Pain intensity was assessed with 100-mm visual analog scales (visual analog scale at baseline and every 20 minutes for 80 minutes). The primary outcome was change in pain intensity from baseline to 80 minutes or time of ED discharge if subjects remained in the ED for fewer than 80 minutes after treatment. Sedation and nausea were assessed every 20 minutes with visual analog scale scales, and subjects were contacted within 72 hours to assess headache recurrence. RESULTS: Sixty-eight subjects entered the trial, with complete data for 66 subjects. Baseline pain scores were similar for the prochlorperazine/diphenhydramine and sumatriptan groups (76 versus 71 mm). Mean reductions in pain intensity at 80 minutes or time of ED discharge were 73 mm for the prochlorperazine/diphenhydramine group and 50 mm for those receiving sumatriptan (mean difference 23 mm; 95% confidence interval 11 to 36 mm). Sedation, nausea, and headache recurrence rates were similar. CONCLUSION: IV prochlorperazine with diphenhydramine is superior to subcutaneous sumatriptan in the treatment of migraine.

Reduction of conscious sedation requirements by olfactory stimulation: a prospective randomized single-blinded trial.

OBJECTIVES: This study investigated the possibility that olfactory stimulation would decrease sedation needed for colonoscopy and therefore decrease the recovery time needed after conscious sedation. MATERIALS AND METHODS: Patients were randomized to receive a cherry-flavoredscent in oxygen flowing at a 4 L per minute rate via nasal cannula or oxygen alone. The scent was provided in a cherry-flavored oil. A Bispectral Index (BIS) monitor (Aspect Medical Systems, Newton, MA) was placed and scores were recorded every 5 minutes during the procedure to control for different sedation patterns between different endoscopists. The recovery area nurse was unaware of whether a given patient was in the aroma or plain oxygen group, and based each patient's discharge on preexisting standardized criteria. RESULTS: Two hundred and eighty-four (284) patients completed the study. Both the procedure times and the recovery times were not statistically significant between the two groups. The doses of sedatives used, BIS scores at 5 minute intervals, and rate of change in BIS scores were also not statistically significant between the two groups. CONCLUSIONS: Overall, there is no difference between olfactory stimulation and inhaled oxygen with regard to amount of sedation used and recovery times for colonoscopy. An inhaled cherry- scent may not have as great a calming effect as other scents that have been studied.

The impact of pregnancy on the individual and military organization: a postpartum active duty survey.

Using a postpartum survey, comparing singles to married, we sought to expand existing information on pregnancy occurring among active duty service women. The study instrument was a 59-question survey distributed in the initial 24 hours postpartum and collected prior to discharge. The majority affirmed that pregnancy had not changed career plans. Singles did not consider their commands supportive during pregnancy, (p=.04). Eighty-two percent of pregnancies among singles were unplanned, (p=.006). The majority of single pregnancies occurred while assigned to operational units, (p=.004); and during their first enlistment, (p<.001). Three-quarters of all singles required Women Infants and Children (WIC) financial support, (p<.001); and fewer fathers were, or planned to be involved, (p<.001). Unplanned pregnancy, contraceptive failure, and pregnancy complications highlight areas of organizational and individual concern warranting further study among active duty.

Prochlorperazine vs. promethazine for headache treatment in the emergency department: a randomized controlled trial.

Headache is a very common medical complaint. Four to six percent of the population will have a debilitating headache in their lifetime; and 1-2% of all Emergency Department (ED) visits involve patients with headaches. Although promethazine is used frequently, it has never been studied as a single-agent treatment in undifferentiated headache. We hypothesized that promethazine would be superior to prochlorperazine in the treatment of headache. We conducted a prospective, double-blinded, randomized, controlled trial on patients presenting to our ED between May and August 2005 with a chief complaint of headache. Each subject was randomized to receive either intravenous promethazine 25 mg or prochlorperazine 10 mg, and graded the intensity of their headache on serial 100-mm visual analog scales (VAS). Patients with dystonic reactions or akathesia were treated with diphenhydramine. Adequate pain relief was defined as an absolute decrease in VAS score of 25 mm. After discharge from the ED, patients were queried regarding the recurrence of headache symptoms, the need for additional pain medications, and the occurrence of any side effects since discharge. Thirty-five patients were enrolled in each group. Both drugs were shown to be effective in treatment of headaches. Prochlorperazine provided a faster rate of pain resolution and less drowsiness when compared to promethazine. Both medications were individually effective as abortive therapy for headache. Prochlorperazine was superior to promethazine in the rate of headache reduction and rate of home drowsiness, with similar rates of akathesia, nausea resolution, patient satisfaction, and headache recurrence within 5 days of discharge.

Anorectal symptoms in pregnancy and the postpartum period.

OBJECTIVE: To determine the frequency of anorectal complaints in nulliparous, pregnant women before and after delivery. STUDY DESIGN: This was a prospective, observational study. Nulliparous, pregnant women attending an active-duty prenatal clinic completed a 6-item anorectal symptom questionnaire that assessed anal continence and defecatory symptoms. RESULTS: Seventy-five active-duty, nulliparous women completed 158 questionnaires. Anorectal symptoms were reported both antepartum (AP) and postpartum (PP): straining to defecate (AP: 28-59%; PP: 30%), hard or lumpy stools (AP: 48-59%; PP: 66%), incomplete emptying (AP: 38-53%; PP: 38%), uncontrolled loss of gas or stool from the rectum (AP: 18-29%; PP: 15%), unpreventable soilage of underwear (AP: 15-33%; PP: 13%) and splinting (AP: 3-9%; PP: 9%). Constipation symptoms were reported most frequently in the first trimester (p = 0.031) and anal incontinence most often in the third trimester but loss of gas or stool "often" more in the postpartum period (p = 0.027). Anal incontinence was more frequent in women who delivered by forceps (p = 0.007). CONCLUSION: Anorectal symptoms are common both during pregnancy and in the postpartum period. Anal incontinence is reported more frequently in women who delivered by forceps.

The 80-hour workweek restriction: How are OB/GYN resident procedure numbers affected?

OBJECTIVE: To evaluate the surgical caseload in a military obstetrics and gynecology residency program, prior to and after implementation of an 80-hour workweek. METHODS: A retrospective cohort study evaluating data submitted to the Accreditation Council for Graduate Medical Education (ACGME) for cumulative resident procedures in obstetrics and gynecology for the years before (July 2001-June 2002) and after (July 2002-June 2003) 80-hour workweek implementation. Total obstetric and gynecology procedures were examined using both the Student's paired t-test and a two-way mixed factor analysis of variance. RESULTS: Between July 2001 and June 2002 there were 822 gynecological cases and 3958 deliveries done by 17 OB/GYN residents; these were compared with 827 cases and 3504 deliveries done by 18 OB/GYN residents between July 2002 and June 2003 (p=0.189). The total numbers of obstetric and gynecology cases pre- and post-80-hour workweek intervention were similar when evaluated by month (July through June of 2001/2 vs. 2002/3; p=0.908). There was a significantly greater number of obstetrics cases compared with gynecological cases (p < 0.001) in the pre- vs. post-80-hour workweek groups; the number of gynecological cases remained constant in the post-80-hour workweek group while the obstetric numbers dropped (p=0.001). CONCLUSION: The 80-hour workweek restriction resulted in similar total numbers of obstetrics and gynecology cases, although the total number of obstetric cases per resident declined after implementation.

Increased risk for aplastic anemia and myelodysplastic syndrome in individuals lacking glutathione S-transferase genes.

BACKGROUND: Aplastic anemia (AA) and myelodysplastic syndrome (MDS) are marrow failure states that may be associated with chromosomal instability. An absence of the glutathione S-transferase (GST) enzyme may genetically predispose individuals to AA or MDS. PROCEDURE AND RESULTS: To test this hypothesis, we determined the GSTM1 and GSTT1 genotypes in a total of 196 patients using multiplex PCR. The GSTT1 null genotype was found to be overrepresented in Caucasian, Asian, and Hispanic patients with either AA or MDS. We confirmed a difference in the expected frequency of the GSTM1 null genotype in Caucasian MDS patients. The double null GSTM1/GSTT1 genotype was also overrepresented in Caucasian AA and MDS patients. In our population, 26% of AA patients and 40% of MDS patients had a chromosomal abnormality identified by karyotype or FISH analyses for chromosomes 7 and 8. Patients with AA and the GSTT1 null genotype had an increased frequency of chromosomal abnormalities (P = 0.003). CONCLUSION: There seems to be an increased risk for AA and MDS in individuals lacking GSTT1 or both GSTM1/GSTT1.