Phenobarbital and Alcohol Withdrawal Syndrome: A Systematic Review and Meta-Analysis.

Alcohol withdrawal syndrome (AWS) is a complication frequently encountered among patients who are chronic alcohol abusers. It is considered to have a significant impact on the United States healthcare system. It not only has a toll on the healthcare spending but also contributes to significant morbidity and mortality. Benzodiazepines are considered first line in the treatment of AWS. Since patients with alcohol use disorder have downregulated gamma aminobutyric acid (GABA) receptors, this often leads to benzodiazepine resistance. Phenobarbital is also used in the management of alcohol withdrawal syndrome. Here we present a systematic review and meta-analysis of the efficacy and safety of the drug. We conducted an electronic database search for relevant studies published between the inception of the project and November 20, 2022, in three databases, including Medline/PubMed, Embase, and Cochrane Library. Our study included all original studies with prime focus on the baseline characteristics of patients admitted to the intensive care unit (ICU) for alcohol withdrawal syndrome and management/monitoring protocol implemented for its treatment. The primary outcomes that were the focus of our study consisted of changes in the length of hospital stay, length of ICU stay, and changes in scoring systems (for alcohol withdrawal assessment and monitoring) following the implementation of phenobarbital. The secondary outcomes included complications such as intubation and mortality. Based on our analysis, the mean difference in hospital stay was statistically significant at -2.6 (95% CI, -4.48, -0.72, P=0.007) for phenobarbital compared to the benzodiazepine group. We were unable to comment on the heterogeneity in our meta-analysis due to the standard deviation not being reported in one study. There was no statistically significant difference regarding the length of stay in the intensive care unit compared to the control/comparative arm, with a mean difference of -1.17 (95% CI, -1.17, 0.09, P=0.07), with considerable heterogeneity (I2=77%, P=0.002). Our meta-analysis also investigated the risk of intubation between the phenobarbital and the control/comparative group. There was statistically significant difference in the incidence of intubation, relative risk (RR) 0.52 (95% CI, 0.25, 1.08, P=0.08), with considerable heterogeneity (I2=80%, P=0.0001). Our study concludes that phenobarbital is an effective tool in the management of AWS in an ICU setting. However, various studies have reported contradictory results, and vital information appears to be lacking. Moreover, there is a lack of uniformity in terms of phenobarbital dosing. Drug administration should be adapted according to the severity of the symptoms. Further studies need to be conducted discussing the safety profile and adverse effects of the drug when it comes to the management of alcohol withdrawal syndrome.

Co-relation of Monocyte Count in High vs. Low Thrombus Burden ST-Segment Elevated Myocardial Infarction (STEMI) Patients Undergoing Primary Percutaneous Coronary Intervention.

Introduction Primary percutaneous coronary intervention (PPCI) in ST-elevation myocardial infarction (STEMI) patients can lead to poor outcomes. Intra-coronary thrombus development due to atherosclerotic plaque rupture and coronary blood flow blockage causes STEMI. Intracranial thrombosis in STEMI patients is fatal. It was our goal to establish how often patients with STEMI underwent PPCI with a high thrombus burden versus a low thrombus burden and to compare the mean monocyte count between the two groups. Material and methods This cross-sectional study was conducted at KRL Hospital Islamabad from October 2021 to March 2022. At a 95% level of confidence, a 5% margin of error, and keeping a population size of 330, a sample size of 178 was obtained using the Raosoft sample size calculator (Raosoft, Inc., Seattle, WA). The non-probability consecutive sampling method was used. All patients with STEMI undergoing PPCI, aged between 18 and 80 years, and presenting within 24 hours of symptoms were included in our study. Pre-PPCI pharmacological treatment given within three hours of the onset of a heart attack to stabilize patients with myocardial infarction included aspirin, clopidogrel, and an intravenous bolus of 70 U/kg of body weight of un-fractionated heparin. The collected data were analyzed using SPSS version 26.0 (IBM Corp., Armonk, NY). Fisher's exact test was employed, and a p-value of less than 0.05 was deemed statistically significant. The odds ratio and confidence interval were also calculated. Results A total of 178 participants were included in the research, out of which males were predominant with more than half of the study population. The mean age in patients having a low thrombus burden was 37.75 ± 6.39 years and that of patients with a high thrombus burden was mean 56.04 ± 7.98 years. In high thrombus burden patients, diabetes mellitus was found in 98.3%, hypertension in 120 patients (100%), obesity in (60%), and tobacco consumption in 120 patients (100%). The mean monocyte count in high burden patients was 70.27 ± 3.24, whereas it was 61.89 ± 5.71 in low burden patients. Only five patients had a Thrombolysis In Myocardial Infarction (TIMI) score of 5 while 34.8% of patients arrived in three to six hours and 12.9% arrived in less than three hours. Patients with a high monocyte count have 1.3 times more chances of developing the disease when the monocyte count was high (OR = 1.318, 95% CI = 1.140-1.524). Conclusion Patients with STEMI undergoing PPCI had a higher monocyte count upon admission, which was an independent clinical predictor of a high thrombus burden. Our findings suggest that admission monocyte count may be available for early risk stratification of high-thrombus burden in acute STEMI patients and might allow the optimization of anti-thrombotic therapy to improve the outcomes of PPCI.

Intratendinous Ganglionic Cyst of Semimembranosus: A Rare Cause of Thigh Swelling.

Ganglionic cysts are common swellings of the hands. Various mechanisms are thought to generate these lesions, such as cystic mucoid degeneration and inflammation. Typically, ganglionic cysts are asymptomatic but can cause pain. They usually originate from soft tissues like ligaments, joint capsules, and sheaths of tendons. We present the case of a 37-year-old man with mid-thigh swelling with intermittent mild pain. However, no systemic symptoms like fever or weight loss were present. Workup unmasked the presence of a rare intratendinous ganglionic cyst. Ultrasonography (USG) and magnetic resonance imaging (MRI) can confirm the presence of ganglionic cysts and estimate their sizes and relationships with the surrounding structures. Treatment options range from observation and conservative management to interventions like aspiration and surgical excision.

The First Reported Case of Post-Atrioventricular Node Ablation Enterococcus Faecalis Bacteremia in a Patient With Colonic Tubular Adenomas and Chronic Steroid Use.

We present the case of a 73-year-old immunosuppressed male with a history of multiple benign, colonic adenomas who was admitted to our hospital with Enterococcus faecalis (E. faecalis) bacteremia. The patient also had a prior history of dual-chamber pacemaker placement for sick sinus syndrome. Two days before the admission, the patient had undergone radiofrequency ablation of the atrioventricular (AV) node for refractory atrial flutter without receiving any peri-procedural antibiotic prophylaxis. Despite high-grade bacteremia and a high NOVA (Number of positive blood cultures, Origin of the bacteremia, previous Valve disease, Auscultation of heart murmur) score, there was no evidence of infective endocarditis on transesophageal echocardiogram (TEE). The patient was treated successfully with appropriate intravenous antibiotics, and he recovered well. To the best of our knowledge, this is the first reported case of post-AV node ablation E. faecalis bacteremia. We conclude that the presence of colonic lesions and immunosuppression can increase the risk of peri-procedural E. faecalis bacteremia, and clinicians should consider antibiotic prophylaxis in this high-risk patient group.

Descriptive study of homeless patients' perceptions that affect medication adherence.

PURPOSE: Results of a study to elucidate perceptions, attitudes, and beliefs about prescribed medications held by hospitalized patients who are homeless are reported. METHODS: A qualitative descriptive study involving semistructured interviews was conducted to gather information and characterize hospitalized homeless patients' views and attitudes regarding medication use, with a focus on medication nonadherence. Medication nonadherence has been shown to be a factor contributing to higher rates of emergency department visits, increased hospital lengths of stay, and increased healthcare costs in homeless populations. Interviews were conducted during patients' admissions to the internal medicine service of a tertiary care, inner-city hospital. Interviews were audio-recorded and transcribed. Data were analyzed using conventional qualitative content analysis to generate data-driven codes and themes. RESULTS: Twelve interviews were conducted (median patient age, 48.5 years). Eight patients (66.7%) were living in a shelter, and 11 (91.7%) had a mental illness. Patients were prescribed a median of 4 medications at the time of hospital admission. Four themes were identified: (1) a new appreciation of medications was acquired during hospitalization, (2) medications were perceived as necessary for maintaining health, (3) there was an interest in receiving medication education, and (4) concerns were expressed regarding medication adverse effects. CONCLUSION: In interviews conducted during hospital admission, homeless patients expressed positive perceptions about the necessity of their medications but also concerns about medication adverse effects. Interventions to improve adherence may be successful if directed toward addressing treatment-related concerns.