24-hour Observation Period Research Articles

Safety Profile of Abelmoschus Manihot (L.) Medik Ethanol Leaf Extract: Acute Toxicity Study in Animal Models

Abelmoschus Manihot (L.) Medik, commonly known as Abelmoschus manihot, is a traditional medicinal plant from Palu, Central Sulawesi, Indonesia, widely utilized for its potential health benefits. This research aims to evaluate the acute toxicity of ethanol extract from Abelmoschus manihot leaves, focusing on determining the lethal dose (LD50) in rats. The study involved extracts being administered at a range of doses of 500 mg/kg, 1000 mg/ kg, and 2000 mg/Kg of body weight (BB) in a rat population. Rats were observed for 24 hours to look for signs of toxicity and death. The LD50 value, which determines the dose required to cause death in 50% of the test population, is calculated based on the results. This research provides insights into the safety profile of ethanol extract from Abelmoschus manihot leaves and contributes to understanding its potential risks when used in traditional medicine. No significant deaths were observed at lower doses, but higher doses resulted in observable toxic effects, indicating the need for careful dosing in therapeutic applications. The results show that although Abelmoschus Manihot did not exhibit acute toxic effects on rats at doses of 500 mg/kg, 1000 mg/kg, and 2000 mg/kg body weight. No significant deaths or severe toxic symptoms were observed during the 24-hour observation period up to the 14-day observation, and there were no differences in the body weight of the rats during the 14-day observation

Incidence of intra-abdominal injuries in hemodynamically stable blunt trauma patients with a normal computed tomography scan admitted to the emergency department

ObjectivesBlunt abdominal trauma is a common cause of emergency department admission. Computed tomography (CT) scanning is the gold standard method for identifying intra-abdominal injuries in patients experiencing blunt trauma, especially those with high-energy trauma. Although the diagnostic accuracy of this imaging technique is very high, patient admission and prolonged observation protocols are still common practices worldwide. We aimed to evaluate the incidence of intra-abdominal injury in hemodynamically stable patients with high-energy blunt trauma and a normal abdominal CT scan at a Level-1 Trauma Center in Colombia, South America, to assess the relevance of a prolonged observation period.MethodsWe performed a retrospective study of patients admitted to the emergency department for blunt trauma between 2021 and 2022. All consecutive patients with high-energy mechanisms of trauma and a normal CT scan at admission were included. Our primary outcomes were the incidence of intra-abdominal injury identified during a 24-hour observation period or hospital stay, ICU admission, and death.ResultsWe included 480 patients who met the inclusion criteria. The median age was 33 (IQR 25.5, 47), and 74.2% were male. The most common mechanisms of injury were motor vehicle accidents (64.2%), falls from height (26%), and falls from bikes (3.1%). A total of 99.2% of patients had a Revised Trauma Score of 8. Only 1 patient (0.2%) (95% CI: 0.01–1.16) presented with an abdominal injury during the observation period. No ICU admissions or deaths were reported.ConclusionThe incidence of intra-abdominal injury in patients with hemodynamically stable blunt trauma and a negative abdominal CT scan is extremely low, and prolonged observation may not be justified in these patients.

The prevalence of clinically relevant delayed intracranial hemorrhage in head trauma patients treated with oral anticoagulants is very low: a retrospective cohort register study

BackgroundCurrent guidelines from Scandinavian Neuro Committee mandate a 24-hour observation for head trauma patients on anticoagulants, even with normal initial head CT scans, as a means not to miss delayed intracranial hemorrhages. This study aimed to assess the prevalence, and time to diagnosis, of clinically relevant delayed intracranial hemorrhage in head trauma patients treated with oral anticoagulants.MethodUtilizing comprehensive two-year data from Region Skåne’s emergency departments, which serve a population of 1.3 million inhabitants, this study focused on adult head trauma patients prescribed oral anticoagulants. We identified those with intracranial hemorrhage within 30 days, defining delayed intracranial hemorrhage as a bleeding not apparent on their initial CT head scan. These cases were further defined as clinically relevant if associated with mortality, any intensive care unit admission, or neurosurgery.ResultsOut of the included 2,362 head injury cases (median age 84, 56% on a direct acting oral anticoagulant), five developed delayed intracranial hemorrhages. None of these five cases underwent neurosurgery nor were admitted to an intensive care unit. Only two cases (0.08%, 95% confidence interval [0.01–0.3%]) were classified as clinically relevant, involving subdural hematomas in patients aged 82 and 87 years, who both subsequently died. The diagnosis of these delayed intracranial hemorrhages was made at 4 and 7 days following initial presentation to the emergency department.ConclusionIn patients with head trauma, on oral anticoagulation, the incidence of clinically relevant delayed intracranial hemorrhage was found to be less than one in a thousand, with detection occurring four days or later after initial presentation. This challenges the effectiveness of the 24-hour observation period recommended by the Scandinavian Neurotrauma Committee guidelines, suggesting a need to reassess these guidelines to optimise care and resource allocation.Trial registrationThis is a retrospective cohort study, does not include any intervention, and has therefore not been registered.

Количественная оценка антиадгезивного и антибактериального эффектов биологически активной добавки Уронекст® в отношении уропатогенов: микробиологическое исследование.

Introduction. Antibacterial drugs are the basis of pharmacotherapy of lower urinary tract infections (UTI), and there is a growing interest in alternative nonantibacterial methods of their treatment and prevention. Purpose of the study. Quantitative evaluation of the anti-adhesive and antibacterial effects of the dietary supplement «Uronext®» containing D-mannose, vitamin D3 and cranberry extract against uropathogens isolated from patients with recurrent UTI. Materials and Methods. 124 strains of uropathogens isolated from the urine of women with recurrent UTI were studied. At the first stage of the study we determined the sensitivity of microorganisms to Uronext dietary supplement. In its presence, uropathogens were the material for the second stage of the study, during which the minimum inhibitory concentration of «Uronext®», its effect on the adhesion index (AI) of uropathogens, as well as the degree and duration of antimicrobial activity were evaluated. Results. The direct antibacterial effect of «Uronext®» against 53.7% of Gram-negative and 51.7% – of Gram-positive microorganisms strains was revealed. A pronounced anti-adhesive effect of the investigated product was noted, especially against Gram-negative bacteria. The anti-adhesive effect of «Uronext®» was the greatest in the first 4 hours and lasted for the whole 24-hour observation period. The minimum inhibitory concentration of «Uronext®» for Gram-negative bacteria was 8 times lower than for Gram-positive bacteria. Antibacterial activity of «Uronext®» was manifested already 1 hour after the product was added to the cell culture, reached the highest value in 2 hours and remained at the maximum level during 5 hours of observation. The mentioned tendency was characteristic for all investigated microorganisms. Conclusion. The conducted study allowed to establish and quantitatively evaluate the expression of anti-adhesive and antibacterial action of the product «Uronext®» against the main uropathogens. The presence of these effects determines the pathogenetic validity of the prescription of the dietary supplement «Uronext®» to patients with recurrent UTI.

Evaluation of myocardial infarction by a 12-lead routine electrocardiogram: a case report of an ST-segment elevation.

The spiked helmet sign (SHS) is a type of ST-segment elevation associated with critical cardiac disease and a high risk of death. We report a case of SHS caused by an ECG artifact. A 60-year-old male patient presented to the clinic after suffering an electric shock. The initial 12-lead routine elec-trocardiogram showed an SHS. The patient received appropriate intravenous fluid replacement therapy, and after 30 minutes, the ST-T changes of the 12-lead electrocardiogram were all restored to normal. The patient was discharged after a 24-hour observation period in the emergency room.Recent studies have pointed out that there may be two different types of SHS. One is the mechanical factor, and the other is the significant prolongation of the QT interval. The two types have different clinical significance. In our report, the radial artery of the patient’s right wrist pulsed strongly, and after the occurrence of SHS, the SHS disappeared after adjusting the contact position of the electrode in his right arm. This SHS caused by mechanical traction was an ECG artifact.Although the SHS may be an essential indicator of critical illness, there are mechanical factors that lead to the appearance of ECG artifacts. Therefore, in clinical work, obtaining a complete medical history and primary conditions of the patient at the time of ECG sampling is necessary to help the diagnosis and thus avoid er-roneous treatment.

PSI-6 Effect of Calcium Magnesium Carbonate And/or Tylosin Phosphate Supplementation on Behavior and Rumination Activity in Yearling Beef Steers Fed a Finishing Diet

Abstract The objective of this study was to evaluate the effects of CaMg(CO3)2 (MIN-AD, Papillon Agricultural Company, Easton, MD; MA) and or tylosin phosphate (Tylan, Elanco, Indianapolis, IN; TY) supplementation on 24-hour behavior and rumination activity of yearling beef steers fed a finishing diet. A 2 × 2 factorial arrangement of treatments was used resulting in 4 dietary treatments: no MA and no TY (-MA/-TY), MA and no TY (MA/-TY), no MA and TY (-MA/TY), or MA and TY (MA/TY). Beef steers (n = 158; 469 ± 18.0 kg) were randomly assigned to dietary treatments with pen (n = 20 pens total, 10 pens/main effect mean, and 5 pens/simple effect mean) serving as the experimental unit. The MA was included at 1.5% of the diet (DM basis) in replacement of dry-rolled corn and TY was provided at 90 mg·animal-1·d-1. Observation began at 0800 h and ended at 0750 h the following day, resulting in a 24-hour observation period. Observations were recorded on a pen basis, with number of animals/type of activity recorded every 10 minutes on d 42 on feed (22 d on finisher). Activity categories included number of animals drinking (DR), eating (EA), active (standing; AC), ruminating (RU), and resting (RE) per pen. Chewing (CHE) was determined as the sum of eating and ruminating activity. Data were analyzed as a randomized complete block design with the fixed effects of MA, TY, and their interaction; block (pen location) was considered a random effect. An interaction was noted between MA and TY for time spent drinking (P = 0.03) and ruminating (P = 0.01). Steers from -MA/TY spent more time drinking compared with the -MA/-TY and MA/TY steers; steers from MA/-TY were intermediate (P < 0.10). Steers from -MA/-TY ruminated 28% longer compared with MA/-TY steers (P = 0.05) and 20% longer than -MA/TY (P = 0.05), steers from MA/TY ruminated 16% longer than steers from MA/-TY (P = 0.05), while steers from -MA/TY were intermediate (P > 0.10). The main effect of MA tended to increase time spent eating by 19.3% (P = 0.06); however, no differences (P ≥ 0.28) were noted for the main effects of MA or TY for minutes/day spent chewing, resting, or active. These results indicate that supplementation of MA may alter feeding behavior, resulting in increased minutes/day spent eating. In addition, supplementation of TY and MA may result in increased water intake, and alter time spent ruminating per day.

PSII-1 Evaluation of Precision Feeding on Animal Behavior in Finishing Beef Cattle

Abstract Charolais × Angus cross steers (n = 80; initial shrunk BW = 505 kg ± 31.6 kg; n = 10 pens; 5 replicate pens/treatment) were used in two 24-hour observations to evaluate animal behavior based on varying degrees of daily feed inclusion over a 28-day period (d 14 and d 42 on feed). Treatments included: 1) A fixed diet inclusion rate for each individual ingredient with a tolerance of 0.454 kg, and 2) Variable inclusion rates (VAR) of diet ingredients that were randomly increased or decreased while maintaining the targeted daily as-fed delivery. Steers were fed twice daily with a slick bunk approach used to manage feed bunks. Diets composition (DM basis) was 48% high moisture corn (HMC), 21% dry-rolled corn (DRC), 5% liquid supplement (LS), 14% dried distillers’ grains plus solubles (DDGS), and 12% grass hay (GH). In the VAR treatment inclusions of HMC, DRC, and DDGS varied independently by assigning a random integer with each integer corresponding to a specific deviation from target. Dietary inclusion of LS was fixed. Inclusion of GH was altered so that the targeted as-fed amount was delivered each day. Inclusion rates of ingredients (HMC, DRC, and DDGS) on an as-fed basis varied from the formulated diet by -20, -15, -10, -5, 0, +5, +10, +15, or +20%. Data from the two 24-hour observations were analyzed using the GLIMMIX procedure of SAS 9.4 (SAS Inst. Inc., Cary, NC) with pen as the experiment unit. Treatment was analyzed as a fixed effect and block (pen location) was a random effect in the model. Varying ingredient inclusion did not affect cattle activity, time spent drinking, resting, eating, or ruminating, or chewing behaviors (P ≥ 0.24) during the initial d 14 observation. Treatment did affect DMI the week preceding that observation period (P = 0.04). During the second 24-hour observation period activity, resting, ruminating, and chewing behaviors along with DMI were unaffected by variation in inclusion of diet ingredients (P ≥ 0.33). Varying inclusion rates of diet ingredients increased time spent drinking (P = 0.05) by 33.3% and decreased time spent eating behaviors (P = 0.01) by 9.4% at the d 42 observation point. Under the conditions of the present experiment, altering dietary ingredient proportions in a finishing diet may influence time spent drinking and eating after 42 d on feed.

Home management of pediatric sulfonylurea ingestions

Introduction Sulfonylureas are oral antidiabetic medications that act by stimulating insulin release from pancreatic beta cells. Unintentional pediatric ingestions may result in hypoglycemia. While guidelines often recommend up to a 24-hour hospital observation period for any ingestion, the Oregon Poison Center has historically managed select patients at home. This study aimed to describe outcomes of home-managed pediatric sulfonylurea exposures and characteristics of ingestions that are appropriate for home monitoring. Methods This is a retrospective chart review of pediatric (≤5 years) sulfonylurea ingestions in a single poison center over a 19-year period (2002–2020). We reviewed 491 individual cases for age, ingestion quantity, witnessed or unwitnessed ingestions, hypoglycemia (<60 mg/dL), disposition, and severe events (seizures or coma). We excluded cases in which missing pills were later found or another agent was identified. Results Of 474 patients meeting inclusion criteria, 135 (28%) were initially managed at home. Of these, 115 (85.3%) were ingestions of ≤1 tablet, where 68 (59%) were witnessed and 47 (41%) were unwitnessed. One hundred twenty five (92.6%) of these patients were successfully monitored at home, with 10 (7%) ultimately referred to a healthcare facility (HCF). Symptoms of hypoglycemia, measured glucose on home meter <60 mg/dL, fluctuations in monitored glucose, or parental concern were indications for HCF referral. Of those referred, 5 (4%) developed uncomplicated, asymptomatic hypoglycemia. Two of these received octreotide, at the discretion of the treating physician. No patients developed seizures or coma. Discussion We report 135 pediatric sulfonylurea ingestions managed with initial home monitoring, the majority of which were successfully monitored at home without any reported adverse events. Ten patients “failed home monitoring,” as defined by referral to a healthcare facility. Of these, five developed hypoglycemia, though no patients developed symptoms or serious adverse events. Conclusion Our findings support home observation for children ≤5 years with small ingestions of second-generation sulfonylureas.

666 Rugby Tackle: A Cause of Delayed Onset Laryngeal Oedema

Abstract Case Presentation A 14-year-old boy presented to the emergency department with facial and neck swelling, hoarseness and dysphagia. The symptom onset was 24 hours after a rugby tackle to the neck and shoulder. Examination found significant bilateral lower facial and neck swelling. Blood results and observations were normal. Fibreoptic nasendoscopy (FNE) revealed diffuse oedema of arytenoids and soft tissue around the larynx. Computed Tomography (CT) neck with contrast demonstrated diffuse inflammatory changes in the submental and submandibular regions extending to the suprasternal notch, the aetiology for this was indeterminate. He responded to medical treatment with regular intravenous dexamethasone, intravenous antibiotics and as required, adrenaline nebulisers. He was discharged after two days and was able to return to school the following week. Discussion Laryngeal oedema is an ear, nose and throat emergency which can result in airway obstruction. It is commonly caused by bacterial infection. However, rarely other precipitants including blunt trauma are reported. This is the first case reported in the literature of delayed laryngeal oedema from a common sporting injury. It is important to recognise and consider trauma as a cause in patients with delayed laryngeal oedema, especially when no other obvious underlying cause is present. This case highlights the importance of thorough history taking to detect trauma. After ensuring a secure airway, systemic steroids are effective against trauma-induced laryngeal oedema and prophylactic antibiotics should be considered to avoid oropharyngeal contamination. FNE, CT and a minimum 24-hour observation period with specialist involvement are essential for neck trauma management.

Manual Reduction of Incarcerated Abdominal Wall Hernias. A Feasible Option during COVID-19 Pandemic: A Prospective Study.

Background Incarcerated hernia is a common surgical emergency with considerable morbidity or even mortality. Manual reduction (taxis) and elective surgery could be an alternative management approach. This study examines the role of taxis with the adjuvant use of the visual analogue scale (VAS) score in treating incarcerated hernias and thereby decreasing the emergency surgery rate, especially during the novel coronavirus disease 2019 (COVID-19) pandemic. Methods All adult patients admitted to the emergency department of our hospital with incarcerated hernias of anterior abdominal wall were prospectively submitted to hernia manual reduction. The VAS score was used as an adjuvant tool for monitoring the success of this maneuver. Patients with successful taxis and low VAS score were hospitalized for a 24-hour period of observation. On their discharge, they were scheduled for an elective hernia repair. Patients with unsuccessful taxis or with less than a 50% reduction in VAS score after successful taxis were submitted to emergency surgical repair. Age, sex, type of hernias, time until taxis, VAS scores before and after taxis, length of hospital stay, and adverse events for both groups were recorded. Results Between September 2018 and September 2020, 86 patients with incarcerated hernias were included. The types of hernias were incisional in 8 patients, umbilical in 15 patients, inguinal in 56 patients, and femoral in 7 patients. Taxis was successful in 66% of patients with a mean reduction in VAS score from 83 to 17 mm. Following successful taxis, patients were hospitalized for a 24-hour period of observation. No taxis-related complications were observed. Fifty-two patients were safely discharged from hospital and scheduled for an elective repair during the first month. Thirty-four patients were operated emergently. Five patients had successful taxis but with a reduction of posttaxis VAS score less than 50% (a mean reduction from 86 to 62 mm), while taxis failed in twenty-nine patients. Patients with emergency surgery had longer time until reduction and longer stay of hospitalization. In this group, two patients required admission to the intensive care unit while one patient died. Conclusion In this protocolized approach, taxis is a safe and feasible option for most patients with incarcerated hernias. It should be kept in our armament, especially in times when emergency surgery capabilities are under strain like the ongoing COVID-19 pandemic.

MP51-08 VOIDING PATTERN IN HEALTHY TERM NEWBORNS: A 24 HOURS VOLUME/FREQUENCY CHART USING ALARM BELLS

You have accessJournal of UrologyPediatric Urology IV (MP51)1 Sep 2021MP51-08 VOIDING PATTERN IN HEALTHY TERM NEWBORNS: A 24 HOURS VOLUME/FREQUENCY CHART USING ALARM BELLS Dmitry Khunovich, Alexander Tsivian, Ami Sidi, and David Ben Meir Dmitry KhunovichDmitry Khunovich More articles by this author , Alexander TsivianAlexander Tsivian More articles by this author , Ami SidiAmi Sidi More articles by this author , and David Ben MeirDavid Ben Meir More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002077.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The frequency/volume chart is an excellent screening method for the evaluation of voiding disorders in children. It is simple and practical and provides relevant information on daily voiding patterns. For the evaluation of suspected pediatric bladder dysfunction, a 4-hour observation period has been used in Sweden for more than a decade. Voiding patterns in healthy neonates are characterized by small, frequent voids of varying volumes. Their voiding frequency is 10 to 15 times per day until almost 12 months of age; some have suggested that normalization of urinary flow begins after the first year of life with decrease of urinary frequency to 8–10 times per day at the age of 2–3 years. It is often necessary to evaluate the bladder function in neonates with overt or suspected neuropathic bladder. However, there are no reference values for a 24-hour observation for this age group. To our knowledge, this study is the first evaluating the voiding pattern in newborns during a consecutive 24-hour period. Aim 1st- To obtain a more comprehensive data on the voiding patterns in newborns using 24-hour observations. The secondary end point of the study was the observation on defecation patterns. METHODS: Healthy newborns. 24-hour long observation period of voiding parameters. The diaper was equipped with an alarm bell (Malem™ Audio Alarm (MO3). The residual volume was not measured. RESULTS: 24 newborns completed the study, 11 girls and 13 boys, aged 7 to 49 hours (median, 19.5). The median birth age was 39.1 weeks (range 38.2-41.2), median weight was 3.284 kg (range 2.7-3.998). There was no correlation between age, height, or body weight and any micturition parameter. Neither were there any differences between girls and boys. The newborns voided 2 to 10 times during the 24-hour observation period with a median frequency of 6. The voided volume (VV) range was 10-39 ml (median 16 ml). The maximal VV in each infant was 12 to 53 ml (median, 26 ml). All but 1 infant voided within 24 hours of birth, the range was 1-36 hours (median 8.5). One infant voided for the 1st time 36 hours after birth without any obvious reason. Defecations were recorded in 23 infants during the 24-hour observation period with frequency of 0 to 7 (median, 3). CONCLUSIONS: This pilot study found that healthy newborns voids with a median frequency of 6 during a 24-hour observation period and not once an hour as previously suggested. 4-hour observation, evaluating infants and pre-toiled trained children, is insufficient. 24-hour observation should be used and may be effectively done using alarm bell. Source of Funding: No © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e899-e899 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Dmitry Khunovich More articles by this author Alexander Tsivian More articles by this author Ami Sidi More articles by this author David Ben Meir More articles by this author Expand All Advertisement Loading ...

Anxiety and depression among parents of children with mild head injuries.

Parents who escort their children in hospital may present emotional disorders. Personnel pressure and reduced time availability often prevent their detection, reducing the efficacy of parental support. We aimed to identify the prevalence and assess the severity of anxiety and depression among parents of children with mild head injuries who were admitted for a 24-hour observation period in a pediatric hospital, and to detect possible determinants for the severe forms of the two emotional disorders. A cohort of 163 parents participated in our survey for anxiety and depression with the Hospital Anxiety and Depression Scale (HADS). Associations of the two disorders with factors of possible prognostic significance, such as gender, age, family status, residence, education, employment, and income were studied. Multinomial logistic regression analysis, with anxiety and depression of the parents as dependent variables, was performed. More than half of parents presented clinical scores for both disorders. Female gender, distant residence, high school level education, unstable employment, and low income were determinants for severe anxiety. Depression in fathers was five times more likely to be severe than subclinical compared to mothers. Psychological support and guidance of parents who escort their children with mild head injuries are mandatory. When accredited trauma support is not available, it is the hospital personnel who must identify and support these parents.

Shock-adaptation in a three-stage anaerobic reactor treating tofu whey wastewater

Anaerobic digestion is often used to treat wastewater with high organic content. The effectiveness of anaerobic digestion is determined by organic loading rate and hydraulic retention time, as well as influenced by temperature, pH, and wastewater composition. The multi-stage reactor system is stable towards sudden changes in the influent and fluctuations in hydraulic and organic loadings. The objective of the study was to investigate the adaptability and stability of the three-stage anaerobic reactor after a hydraulic shock loading. This study used tofu whey wastewater due to its enormous generated volume, varying COD concentration, and the low pH. A three-stage anaerobic packed-bed reactor system that had operated for 26 days at a total hydraulic retention time of 3.75 days or 1.25 day per reactor (0.33 l-wastewater per hour) was used in the experiment. The reactor was filled with wastewater at 4 l/h, twelve times the usual flow rate, for one hour. During this period, the changes in pH, COD concentration, and biogas production were monitored. Compared with the performance before the shock loading, COD and pH did not show changes after the 24-hour observation period, except for the pH in the second stage. In addition, biogas and methane production in the second stage was lower than production before the shock loading, even though the total production remained constant. This suggests that the second stage acted as the buffering reactor during the shock loading.

Can a brief psychological expectancy intervention improve postoperative pain? A randomized, controlled trial in patients with breast cancer.

Pain after surgery remains a major health problem, calling for optimized treatment regimens to maximize the efficacy of pharmacological interventions. In this randomized controlled trial, we tested in a routine surgical treatment setting whether postoperative pain can be reduced by a brief preoperative intervention, ie, positive verbal suggestions in combination with sham acupuncture, designed to optimize treatment expectations. We hypothesized that the expectancy intervention as add-on to patient-controlled intravenous analgesia with morphine reduces patient-reported postoperative pain and improves satisfaction with analgesia. Ninety-six women undergoing breast cancer surgery were randomized at 2 stages: Before surgery, anesthesiologists delivered either positive or neutral verbal suggestions regarding the benefits of acupuncture needling on postoperative pain ("information condition"). Patients were then randomized to receive sham acupuncture or no sham acupuncture during postoperative care ("sham acupuncture condition"). Average pain during the 24-hour observation period after surgery as primary and satisfaction with analgesia as secondary outcome was assessed with standardized measures and analyzed with analysis of covariance accounting for morphine dose, surgery-related, and psychological parameters. Postoperative pain ratings were significantly reduced in patients who received positive treatment-related suggestions (F = 4.45, P = 0.038, main effect of information). Moreover, patients who received an intervention aimed at optimized treatment expectations reported significantly greater satisfaction with analgesia (F = 4.89, P = 0.030, interaction effect). Together, our proof-of-concept data support that optimizing treatment expectations through verbal suggestions may offer a promising approach to improve patient-reported outcomes. Future translational and clinical studies are needed to test such psychological strategies in different surgical interventions, patient groups, and pharmacological treatment regimens.

Early Identification of Patients Who Will Meet 24-Hour Fluid Output Threshold for Chest Tube Removal After Lung Resection

Improving evidence-based chest tube removal may reduce the length of stay following surgery. Presently, most chest tube removal protocols include a fluid output threshold based on a 24-hour observation period. The purpose of this study was to evaluate if, within a 24-hour time period, fluid output measurements at 6, 8, and 12 hours could predict if the total 24-hour fluid output would comply with a predetermined volume threshold considered acceptable for safe chest tube removal. Following lung resection, pleural fluid output data were prospectively recorded by a digital drainage system and analyzed retrospectively. Twenty-four-hour fluid output was calculated from every available 6-, 8-, and 12-hour measurement and compared to set 24-hour output criteria for chest tube removal (ie, 400 mL, 250 mL, and 20% of whole-body lymphatic flow). Performance of interim fluid outputs in predicting whether 24-hour fluid output criteria were satisfied was measured. From 2015 to 2018, 150 patients had digital pleural fluid drainage data suitable for analysis. Performance of interim fluid output data in identifying which patients would satisfy 24-hour output criteria ranged from 85% (95% confidence interval [CI] = 83-86) to 94% (95% CI = 93-94) for specificity, 75% (95% CI = 73-76) to 92% (95% CI = 90-93) for positive predictive value, and 6% (95% CI = 6-7) to 15% (95% CI = 14-17) for false-positive rate. Potential time saved in duration of drainage using interim fluid output data ranged from 10 to 16 hours. Pleural fluid output measured for 6-, 8-, and 12-hour durations can accurately identify patients who will meet 24-hour fluid output threshold for safe chest tube removal.

Trauma patients are safe to fly 72 hours after tube thoracostomy removal.

Current recommendations for safe air travel following traumatic pneumothorax are 2 to 3 weeks after radiographic resolution. These recommendations are based on several small observational studies and expert consensus, which cite a theoretical risk of recurrence and hypoxia because of decreased oxygen tension at altitude. We sought to systematically study the timing of chest drain removal after traumatic pneumothorax and risk of recurrence in relation to air travel. A retrospective cohort study of consecutively admitted patients who sustained a traumatic chest injury treated with tube thoracostomy over a 5-year period was undertaken. Adult patients with a postremoval expiratory chest x-ray demonstrating absence of pneumothorax and at least a 24-hour observation period before flight were eligible for study. All patients were transferred to a participating medical center for continued care. In-flight medical monitoring was available for all patients. Baseline patient characteristics, interval period from drain removal to flight, in-flight medical records, and incidence of radiographic or clinical recurrence of pneumothorax at the destination facility were recorded. Seventy-three patients who met the inclusion criteria were studied. All were male with a median age of 24 years (interquartile range [IQR], 22-26 years), injury severity score of 30 (IQR, 24-38), and chest abbreviated injury scale value of 3 (IQR, 2-4). The majority of patients sustained a penetrating injury (74%). The median duration of tube thoracostomy was 4 days (IQR, 3-6 days). The median period between thoracostomy tube removal and flight was 2.5 days (IQR, 1.5-4 days). Twenty-nine patients (40%) remained mechanically ventilated during transport. There were no reported in-flight medical emergencies for the entire cohort. There were no reported postflight radiographic or clinical recurrences during the subsequent 30 days. After a 72-hour period of observation, air travel after tube thoracostomy removal appears safe for both mechanically ventilated and nonventilated patients. Therapeutic, level IV.

External Validation of Six Pediatric Fever and Neutropenia Clinical Decision Rules.

Fever and neutropenia (FN) clinical decision rules (CDRs) are recommended to help distinguish children with cancer at high and low risk of severe infection. The aim of this study was to validate existing pediatric FN CDRs designed to stratify children with cancer at high or low risk of serious infection or medical complication. Pediatric CDRs suitable for validation were identified from a literature search. Relevant data were extracted from an existing data set of 650 retrospective FN episodes in children with cancer. The sensitivity and specificity of each of the CDR were compared with the derivation studies to assess reproducibility. Six CDRs were identified for validation: 2 were designed to predict bacteremia and 4 to predict adverse events. Five CDRs exhibited reproducibility in our cohort. A rule predicting bacteremia had the highest sensitivity (100%; 95% confidence interval (CI): 93%-100%) although poor specificity (17%), with only 15% identified as low risk. For adverse events, the highest sensitivity achieved was 84% (95% CI: 75%-90%), with specificity of 29% and 27% identified as low risk. A rule intended for application after a 24-hour period of inpatient observation yielded a sensitivity of 80% (95% CI: 73-86) and specificity of 46%, with 44% identified as low risk. Five CDRs were reproducible, although not all can be recommended for implementation because of either inadequate sensitivity or failure to identify a clinically meaningful number of low-risk patients. The 24-hour rule arguably exhibits the best balance between sensitivity and specificity in our population.

Management of traumatic hyoid bone fractures: A case series

Purpose: Hyoid bone fractures are uncommon, reported mainly in cases of hanging. There is a paucity of reports involving other mechanisms, and only a handful of case reports are available to guide the management of these fractures, especially within the emergency department setting. This study focused on identifying optimal initial airway management and subsequent treatment of patients with hyoid fractures. Methods: Patients presenting to an adult major trauma referral centre between January 2007 and July 2014 with a diagnosis of hyoid bone fracture were identified. Patient records were reviewed retrospectively. Results: Of the 19 patients identified, 16 cases were secondary to blunt force trauma. Motor vehicle crashes accounted for eight of the 19 cases. All patients with major trauma were intubated as part of their initial airway management, while 50% of the minor trauma patients were intubated. Only one patient underwent surgical repair of the hyoid bone. Most patients experienced excellent outcomes with no hyoid fracture-related complications. Conclusion: Early intubation for suspected hyoid fractures is advised for those with a penetrating mechanism of injury, clinical features of airway compromise, and severe associated injuries. Conservative, nonsurgical management of hyoid fractures remains the mainstay of management. A minimum 24-hour period of observation for patients who are not managed with endotracheal intubation is advised.

Physicians' attentional performance following a 24-hour observation period: do we need to regulate sleep prior to work?

BackgroundThe tradition of physicians working while sleep deprived is increasingly criticised. Medical regulatory bodies have restricted resident physician duty-hours, not addressing the greater population of physicians. We aimed to assess...

Results of a Prospective Observational Study on Mountaineering Emergencies in Western Alps: Mind Your Head.

Brustia, Raffaele, Giulia Enrione, Bruna Catuzzo, Luca Cavoretto, Massimo Pesenti Compagnoni, Enrico Visetti, Emmanuel Cauchy, Stefanie Ziegler, and Guido Giardini. Results of a prospective observational study on mountaineering emergencies in Western Alps: mind your head. High Alt Med Biol. 17:116-121, 2016.- In the northern Italian district Valle d'Aosta district during winter and summer season the population can increase up to 170% of the resident population. A prospective monocentric observational registry was held to obtain a precise picture of seasonal mountain-related medical and traumatic major events. From 1st January 2012 to 31st December 2013 all patients admitted to the Aosta Regional Hospital Emergency Room for any event occurred above 2500 m were screened: all those affected by High Altitude Illness, Acute Illness in High Altitude, Trauma, or Cold disease were prospectively included. Activity incidence rate is expressed as the occurrence of mountain-related events per 1000 hours of mountain activity. Event Incidence rate is expressed as the occurrence of new cases per 1000 hours of mountain activity. Two hundred two patients were included during the study period. Trauma (65.1% vs. 24.6%, p < 0.001) and head commotive injury (48.1% vs. 15.1%, p < 0.001) were more frequent during winter compared to the summer season. High altitude illness (36.9% vs. 9.3%, p < 0.001) and cold pathologies (15.1% vs. 0.1%, p < 0.001) occurred more frequently in summer than in winter. Patients (51.4%) were immediately discharged from emergency room, 8.4% after a 24-hour observation period, and 30.6% required hospitalization. During summer, the event risk is 0.013 per person and 1000 hours of mountain activity, while in winter, event risk amounts to 0.005 per person and 1000 hours of mountain activity. High altitude medical events or trauma represent <1% of pathologies observed in the emergency room department of a mountain district in the western Alps. Head commotive injury is the most observed mountain-related event in high altitude, in winter and during ski practice. High altitude illness and cold injuries are observed more frequently in summer, during trekking or climbing activities.