[National expert consensus on application of enriched platelet products in wound repair (2020 version)]

Wound biotherapy, represented by platelet concentrate derivatives, has attracted much attention. However, there are some different viewpoints due to the disunity of quality control of preparation, the ways of use, and so on. The members of the consensus writing group reviewed a large number of literatures, screened out high-quality evidence references, combined with the repeated discussion of experts in the field of wound repair to form a guiding consensus of experts, so as to guide medical personnel using enriched platelet treatment scientifically and standardly in wound repair.

Drug interactions for elderly people with mental and behavioral disorders: a systematic scoping review

OBJECTIVES

To identify drug interactions of potentially inappropriate medications and mental and behavioral disorders, according to explicit potentially inappropriate medications criteria-based tools.

METHODOLOGY

A systematic scoping review was conducted in February 2020. Study characteristics, potentially inappropriate medications, drug interactions, rationale, and therapeutic management proposed were extracted. The commercialization and potentially inappropriate medications standard as essential in Brazil and in the world were identified. Therapeutic management was proposed for the most cited potentially inappropriate medications.

RESULTS

36 tools including 151 drug interactions, in addition to 132 potentially inappropriate medications with concerns related to six mental and behavioral disorders were identified. Cognitive impairment and dementia were the most frequently disorders reported and antipsychotics, anticholinergics, and benzodiazepines were the pharmacological classes more involved in the drug interactions. Despite the tools recommended risperidone and quetiapine when the use of antipsychotics were inevitable; levodopa + carbidopa for Parkinson's disease; and short and intermediate half-life benzodiazepines; the quality of the evidence needs to be assessed. In this review, sleep hygiene; deprescription; medication review; and clinical monitoring of adverse drug reactions are strongly recommended. In addition, to consider agomelatine, bupropion, moclobemide and melatonin as potential safer options for benzodiazepines.

CONCLUSION

Knowing the clinical conditions or risk morbidities associated with the use of potentially inappropriate medications and management of these medications for safer therapeutic equivalents or non-pharmacotherapeutic alternatives are relevant for patient safety.

Triptanophobia in migraine: A case-control study on the causes and consequences of the nonuse of triptans in chronic migraine patients

Background: Triptanophobia is the excessive and inadequately justified concern about potential risks of triptans. We evaluated causes and consequences of nonuse of triptans in chronic migraine (CM) Methods: Case-control study. We included CM patients firstly referred to aheadache unit. Patients were cases or controls depending on whether they were triptan naïve, or not. We analyzed if nonuse of triptans was justified by formal contraindications or adverse events. We assessed if triptan naïve patients had higher frequency of vascular risk factors (VRF), contraceptive drugs or older age. Results: We included 941 patients, 247 (26.2%) triptan users. Triptans had been discontinued due to tolerability in 116 patients (12.3%), being 578 patients (61.4%) triptan naïve. Formal contraindications were found in 23 patients (2.4%). Frequency of VRF, contraceptive drugs or age did not differ between the groups (p > 0.1). Triptan users consumed symptomatic medications fewer days/month (13.9 vs 17.1, p < 0.001), were under prophylactic treatment more frequently (79.4% vs 34.8%, p < 0.001) and had medication overuse headache less frequently (55.1% vs. 63.0%, p = 0.03). Conclusion: Triptans were not used by three-quartersof CM patients. Nonuse of triptans was not justified by tolerability, frequency of contraindications, or frequency of VRF. Expert opinion: In the present study, we evaluated causes and consequences of the nonuse of triptans in CM sufferers. We analyzed frequency of triptan use in CM patients. We compared, between triptan users and triptan naïve patients, the presence of contraindications, frequency of vascular risk factors, and differences in management prior to the referral to a headache unit.

[National expert consensus on application of phototherapy in acute and chronic wounds (2020 version)]

In general, different kinds of light play different roles in the treatment of wound, but the different kinds of light with similar wavelengths have some similar or the same therapeutic function. The importance of phototherapy has been gradually discovered and phototherapyhas become an important means of clinical wound treatment. At present, red light is the most widely used light in wound treatment for the outstanding effects in accelerating wound healing, alleviating pain, controlling effusion volume. Through reviewing a large number of literature and screening out high-quality evidence articles, combined with the repeated discussion of experts in the field of wound repair, the expert consensus on phototherapy in acute and chronic wounds is formulated with guiding significance, which can provide scientific and standardized application guidance for light treatment in wound repair.

Practical instructions for using drugs in CT and MR cardiac imaging

The progressive increase in numbers of noninvasive cardiac imaging examinations broadens the spectrum of knowledge radiologists are expected to acquire in the management of drugs during CT coronary angiography (CTCA) and cardiac MR (CMR) to improve image quality for optimal visualization and assessment of the coronary arteries and adequate MR functional analysis. Aim of this review is to provide an overview on different class of drugs (nitrate, beta-blockers, ivabradine, anxiolytic, adenosine, dobutamine, atropine, dipyridamole and regadenoson) that can be used in CTCA and CMR, illustrating their main indications, contraindications, efficacy, mechanism of action, metabolism, safety, side effects or complications, and providing advices in their use.

Mechanical Circulatory Support to Treat Pulmonary Embolism: Venoarterial Extracorporeal Membrane Oxygenation and Right Ventricular Assist Devices

Mechanical circulatory support may help patients with massive pulmonary embolism who are not candidates for systemic thrombolysis, pulmonary embolectomy, or catheter-directed therapy, or in whom these established interventions have failed. Little published literature covers this topic, which led us to compare outcomes of patients whose massive pulmonary embolism was managed with the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) or a right ventricular assist device (RVAD). We searched the medical literature from January 1990 through September 2018 for reports of adults hospitalized for massive or high-risk pulmonary embolism complicated by hemodynamic instability, and who underwent VA-ECMO therapy or RVAD placement. Primary outcomes included weaning from mechanical circulatory support and discharge from the hospital. We found 16 reports that included 181 patients (164 VA-ECMO and 17 RVAD). All RVAD recipients were successfully weaned from support, as were 122 (74%) of the VA-ECMO patients. Sixteen (94%) of the RVAD patients were discharged from the hospital, as were 120 (73%) of the VA-ECMO patients. Of note, the 8 RVAD patients who had an Impella RP System were all weaned and discharged. For patients with massive pulmonary embolism who are not candidates for conventional interventions or whose conditions are refractory, mechanical circulatory support in the form of RVAD placement or ECMO may be considered. Larger comparative studies are needed.

[Pharmacotherapy of attention deficit hyperactivity disorder in adults]

Pharmacotherapy is a central component in the context of an overall therapeutic concept in the treatment of adults with attention deficit hyperactivity disorder (ADHD). In this concept psychosocial interventions with psychoeducation or specific psychotherapy measures also play an important role. In adults three compounds are currently approved for the pharmacological treatment of ADHD in Germany. The long-acting stimulants retarded methylphenidate preparations and lisdexamfetamine can be prescribed. Alternatively, the adrenergic uptake inhibitor atomoxetine can be used. In several meta-analyses good effectiveness and tolerance of these drugs on ADHD psychopathology has been shown. They also improve ADHD-related disorders of emotional regulation capability and disorganization in everyday life. Importantly, an improvement in everyday functionality and quality of life under medication could also be shown in several studies. In this review the evidence for pharmacotherapy of ADHD and its implementation into treatment of adult patients is presented.

Indication and Contraindication of Endoscopic Transforaminal Lumbar Decompression

BACKGROUND

The indications and contraindications to the endoscopic transforaminal approach for lumbar spinal stenosis are not well defined.

METHODS

We performed a Kaplan-Meier durability survival analysis of patients with the following types of spinal stenosis: type I, central canal; type II, lateral recess; type III, foraminal; and type IV, extraforaminal. The 304 patients comprised 140 men and 164 women, with an average age of 51.68 ± 15.78 years. The average follow-up was 45.3 years (range, 18-90 years). The primary clinical outcome measures were the Oswestry Disability Index, visual analog scale, and the modified Macnab criteria.

RESULTS

Of 304 study patients, 70 had type I (23.0%) stenosis, 42 type II (13.7%), 151 type III (49.7%), and 41 type IV (13.5%). Excellent outcomes were obtained in 114 patients (37.5%), good in 152 (50.0%), fair in 33 (10.9%), and poor in 5 (1.6%). Kaplan-Meier durability analysis of the clinical treatment benefit with the endoscopic transforaminal decompression surgery showed statistically significance differences (P < 0.0001) on log-rank (Mantel-Cox) χ² testing between the estimated median (50% percentile) survival times of type I (28 months), type II (53 months), type III (32 months), and type IV (66 months).

CONCLUSIONS

We recommend stratifying patients based on the underlying compressive disease and the skill level of the endoscopic spine surgeon to decide preoperatively whether more difficult central or complex foraminal stenotic lesions should be considered for alternative endoscopic approaches.

Screening for Bronchoscopic Lung Volume Reduction: Reasons for Not Receiving Interventional Treatment

BACKGROUND

Evidence for bronchoscopic lung volume reduction (BLVR) is based on phase 2 studies and small randomized controlled trials with in- and exclusion criteria defining a therapeutic window and contraindications. Little is known about the applicability in routine clinical practice.

AIM

Which percentage of patients with severe emphysema referred to a specialized treatment center for BLVR is ultimately suitable for interventional bronchoscopic treatment? What is the relevance of the different contraindications?

METHODS

Retrospective evaluation of emphysema patients referred to Asklepios Fachkliniken Munich-Gauting for BLVR between January 2014 and June 2015.

RESULTS

138 patients were referred for evaluation of BLVR. 38 patients (27.5%) underwent BLVR procedures (valves n = 18; coils n = 18; thermal vapor ablation n = 2). 100 patients (72.5%) were deemed not eligible for BLVR based on the following contraindications: 34% emphysema morphology and emphysema-related findings (severe homogeneous emphysema, extensive pleuropulmonary adhesions, postinflammatory scaring with natural volume reduction, giant bullae), 16% active smoking; 9% pulmonary function not within indication range; 8% unexpected CT findings (nodules, cancer, interstitial disease); 8% chronic ventilatory failure; 8% patient refused BLVR; 5% relevant comorbidity; 5% frequent exacerbations, 3% preserved quality of life, 4% other.

CONCLUSION

BLVR is a therapeutic option for highly selected patients. In our cohort, one in four could be treated. These data highlight the limitations of BLVR under real-life conditions.

Contraindications to immunotherapy: a global approach

BACKGROUND

Recommendations on contraindications to allergen immunotherapy (AIT) have been independently developed by National and International Societies/Academies. AIT contraindications are mainly based on case reports, case-series, or experts' opinion, while evidence-based information is limited. The aim of the present review was to describe existing guidelines on contraindications to AIT and to highlight differences between them.

MAIN BODY

An extended review of the literature regarding contraindications to AIT for respiratory allergy and venom hypersensitivity was performed. Furthermore, Societies and Academies registered in the World Allergy Organization and EAACI databases, were asked for additional information. Only AIT guidelines published under official auspicies were included. A large heterogeneity among the various recommendations on contraindications was registered. Common contraindications to most of the guidelines were: lack of adherence, pregnancy before the start of AIT, the use of beta-blockers, certain age groups, uncontrolled asthma, autoimmune diseases and malignancies.

CONCLUSION

As new data arise, revisions might soon be needed allowing AIT in the cases of patients treated with ACE inhibitors and beta-blockers, in elderly patients and in patients with concomitant autoimmune diseases and neoplasias in remission. The decision to prescribe AIT is always tailor-made, balancing risk vs benefit. Creating globally accepted guidelines would help Allergologists in their decision making.

Metformin - Postmortem fatal and non-fatal reference concentrations in femoral blood and risk factors associated with fatal intoxications

BACKGROUND & OBJECTIVES

To improve the interpretation of fatal intoxications by establishing fatal and non-fatal reference concentrations of metformin in postmortem femoral blood and to further evaluate risk factors associated with fatal metformin intoxication.

METHODS

All forensic autopsies in Sweden where metformin was detected in femoral blood 2011-2016 were identified in the National Board of Forensic Medicine databases (NFMD). The cases were classified as single substance intoxications, A (n = 22), multiple substance intoxications, B (N = 7) and postmortem controls, C (N = 13). The control group consisted of cases where metformin was detected, but the cause of death excluded the incapacitation by metformin or other substances. Strict inclusion criteria were used, and all postmortem cases were assessed by two independent reviewers. All other cases where the inclusion criteria of groups A-C where not met formed group O (N = 78). The forensic findings logged in the NFMD where linked to national registers whereby information on comorbidities, dispensed drugs and clinical data could be obtained.

RESULTS

The mean age was 66 ± 10 years in the total study population and did not differ between the groups. The proportion of men was 64% in group A, 71% in B, 77% in C and 74% in group O. The median values of metformin in group A (48.5 μg/g; range 13.0-210 μg/g) and B (21.0 μg/g; range 4.40-95.0 μg/g) were significantly (p < 0.001 and p = 0.015 respectively) higher than those of the control group C (2.30 μg/g ; range 0.70-21.0 μg/g). The median concentration of metformin in group A and B was also significantly higher than in group O (4.60 μg/g; range 0.64-54.0 μg/g) (p < 0.001 and p = 0.040 respectively). The results suggest that intoxication with metformin as a cause of death should be considered when the postmortem femoral blood level exceeds about 10 μg/g, although higher levels may be seen in postmortem in cases without incapacitation. The metformin intoxication was confirmed to be intentional in 23% (n = 5) of the single intoxications. Underlying factors identified as important for the remaining fatal metformin intoxications included living alone, any contraindication for the use of metformin, known alcohol abuse and a history of stroke or cardiovascular disease.

CONCLUSIONS

The reported post mortem femoral blood concentrations of metformin can hopefully contribute to a better interpretation of results in suspected poisonings and obscure cases. Living in a single household, history of cardiovascular disease and contraindications, predominantly alcohol abuse, were associated with fatal metformin intoxication.

[Intravenous lysis treatment in acute stroke treatment-latest situation]

CLINICAL ISSUE

Intravenous (i.v.) thrombolysis and mechanical thrombectomy are two essential pillars of acute stroke treatment in patients with vascular occlusion in the anterior circulation. The issue about using so-called bridging thrombolysis in acute stroke patients is increasingly under discussion.

RESULTS

After application of i.v. thrombolysis treatment, stroke patients who were primarily transported to a neurovascular center and underwent timely endovascular treatment, showed a lower preinterventional recanalization rate, a lower 90-day mortality but no significant difference in the clinical outcome after 3 months compared with stroke patients with mechanical thrombectomy alone. Higher rates of intracranial hemorrhage could be detected in the bridging thrombolysis group of patients.

CONCLUSION

The i.v. thrombolysis treatment is still an essential treatment concept in acute stroke management. Further studies should be carried out with respect to the application in mothership stroke patients undergoing early endovascular treatment.

[Intravenous regional anesthesia]

OBJECTIVE

Intravenous regional anesthesia.

INDICATIONS

Short duration hand operations.

CONTRAINDICATIONS

Open wounds, lengthy operations, local infections, polyneuropathy, Raynaud syndrome, allergy to local anesthetics.

TECHNIQUE

Insertion of an intravenous cannula, attachment of a double lumen cuff, Esmarch's tourniquet, injection of the local anesthetic, stepwise pumping up the tourniquet, surgery, stepwise removal of the tourniquet.

POSTOPERATIVE MANAGEMENT

Postoperative monitoring of the patient after the end of anesthesia.

RESULTS

Over a time period of 2 years (January 2017-December 2018) 90 operations of the hand were carried out with the patient under intravenous regional anesthesia (IVRA). The average age of the patients was 61 years. After surgery the patients were questioned according to the criteria of the quality of recovery‑9 score according to Myles in the German version of Eberhard et al. (2002). The tourniquet could be removed on average 29 min after surgery. No intraoperative or postoperative complications occurred. Therefore, the IVRA represents a reliable and simple form of anesthesia especially for surgery of the hand.

[Pharmacology of non-opioid analgesics]

Due to high prescription rates as well as the frequent use as over the counter drugs, it is of interest to consider non-opioid analgesics when evaluating the quality and appropriateness of a given overall medication. This article sums up the basic pharmacology and main adverse effects of these analgesics. Non-opioids can be further classified according to their additional mechanisms of action besides analgesia. High-dose acetylsalicylic acid, traditional nonsteroidal anti-inflammatory drugs, and coxibs exhibit antipyretic and anti-inflammatory properties. Acetaminophen and metamizole (dipyrone) are analgesics and antipyretic agents, while metamizole exhibits also spasmolytic effects. Capsaicin and intrathecal ziconotide are pure analgesics.

[ECMO treatment in acute lung failure : Who profits?]

In intensive care medicine, rapid technical developments that are often beneficial to patients are taking place. On the other hand, there are also voices that generally criticize an increasing "interventionalism". This area of tension includes other important questions regarding usefulness, quality, ethical compliance, scientific evidence, structural capacities and economy. The treatment of acute respiratory distress syndrome (ARDS) using extracorporeal membrane oxygenation (ECMO) is an example of these considerations. Although ECMO has rarely been prospectively evaluated according to scientific criteria, it is still used with an increasing tendency, not least since the documented register survival rates in ECMO patients with severe ARDS are 60%. However, the implementation of this therapy means an immense effort. The necessary centralization and certification for ECMO treatment is currently under intensive discussion. Closely related to this are considerations about which criteria represent good quality in patient care. In order to be able to guarantee high quality, a precise indication is the first step. And here indications and contraindications still need to be defined. It has not yet been sufficiently clarified which prognosis factors need to be taken into account. This article summarizes what is known about ECMO prognosis and indication criteria. In conclusion, parameters are identified that should be developed scientifically in the future.

Arthroscopic-Assisted Reduction of Tibial Plateau Fractures

Arthroscopic reduction of tibial plateau fractures have been gaining in popularity. Advantages include accurate diagnosis and treatment of joint pathology, minimally invasive soft tissue dissection, quicker recovery of joint motion, and anatomic reduction of joint surface. Success depends on accurate fracture selection. With arthroscopic-assisted reduction of tibial plateau fractures, patient set-up is similar to standard knee arthroscopy, but the C-arm is used to aid with fracture reduction and fixation. Outcomes are comparable or even improved when compared with standard procedures, and morbidity with arthroscopic reduction can often be lower with decreased rates of infection, wound complications, and thromboembolism.

[Current CO2 angiography]

BACKGROUND

Carbon dioxide (CO₂) is a very good and validated alternative to iodine-containing contrast media in diagnostic and interventional angiography. Nevertheless, its routinely use is still limited to specialized centers.

OBJECTIVE

The presentation of the current role and limitations of CO₂ in diagnostic and interventional angiography (venous and arterial).

MATERIAL AND METHODS

A comprehensive review of the literature regarding CO₂ angiography (physical features, indications, contraindications, applications) was carried out.

RESULTS

The results show that CO₂ can be used as a reliable alternative for diagnostic angiography and to support interventions in many arterial and venous vascular territories. An exception is the intra-arterial use of CO₂ above the diaphragm due to the risk of severe myocardial and cerebral complications, which represents the most important contraindication. Moreover, due to its very low viscosity, CO₂ is more effective than iodine-containing contrast media in detecting bleeding arising from small vessels.

CONCLUSION

The CO₂ angiography is a safe and effective technique and can be used as valid alternative. In several clinical cases it even offers some advantages compared to iodine-containing contrast media.

Use of hormone therapy (HT) among Swedish women with contraindications - A pharmacoepidemiological cohort study

OBJECTIVES

To assess how women in Sweden with breast cancer (BC), endometrial cancer (EC), and/or pulmonary embolism (PE) were dispensed menopausal hormone therapy (HT).

STUDY DESIGN

A retrospective study of Swedish women aged 40 years or more on 31 December 2005 (n = 2,863,643), followed through to December 2011. The study analysed three mandatory national healthcare registries: the Swedish Prescribed Drug Register, the National Inpatient Register and the Cancer Register. New users were defined as having a first dispensation after at least a 9-month break, and thus were possible to identify from April 2006. New users with at least one of the diagnoses BC, EC or PE before the first dispensation were classified as having a relative or absolute contraindication for HT.

MAIN OUTCOME MEASURES

The relative risks of having HT dispensed after being diagnosed with BC, EC and/or PE.

RESULTS

In total, 171,714 women had at least one of the diagnoses BC, EC or PE. The relative risk of having hormone therapy dispensed (current and new users) after being diagnosed with any of the diagnoses was significantly lower (PE, IRR 0.11, 95% CI 0.10-0.12;/ BC, IRR 0.12, 95% CI 0.11-0.13; EC, IRR 0.43, CI 0.40-0.46) than for women without these diagnoses.

CONCLUSIONS

One in about 250 women started treatment with HT after being diagnosed with BC, PE or EC. Swedish prescribers seem to be well aware of the recommendations for HT use in women with contraindications. A few women, however, are prescribed HT despite having BC, EC or PE, possibly after careful evaluation of the risks and benefits and giving informed consent. Women with a history of PE were prescribed transdermal HT to a larger extent than women in general, in line with results from observational studies.

[National experts consensus on application of silver-containing dressings in wound therapy (2018 version)]

New silver-containing dressings developed in recent years have brought new and powerful means for the prevention and treatment of wound infection, which promote development and progress of wound therapy. There are many kinds of silver-containing dressings, however, misunderstanding and even misapplication exist in how to choose and use these dressings. Based on literature evidence, we propose this national expert consensus on clinical application of silver-containing dressings, particularly in terms of kinds and mechanisms, indications, contraindications, rational selections in different wounds, and cautions in the clinical application of silver-containing dressings. This consensus would be helpful for medical and nursing personnel to use silver-containing dressings in wound repair field in clinic correctly and professionally.

[National experts consensus on application of silver-containing dressings in wound therapy (2018 version)]

New silver-containing dressings developed in recent years have brought new and powerful means for the prevention and treatment of wound infection, which promote development and progress of wound therapy. There are many kinds of silver-containing dressings, however, misunderstanding and even misapplication exist in how to choose and use these dressings. Based on literature evidence, we propose this national expert consensus on clinical application of silver-containing dressings, particularly in terms of kinds and mechanisms, indications, contraindications, rational selections in different wounds, and cautions in the clinical application of silver-containing dressings. This consensus would be helpful for medical and nursing personnels to use silver-containing dressings in wound repair field in clinic correctly and professionally.

Reintroducing OPV in Israel on the journey to global polio eradication - Estimation at a low rate of contraindicated population

INTRODUCTION

The 2013 reemergence of wild poliovirus in Israel led to the reinstatement of a routine OPV vaccination. Fearing VAPP in immunocompromised, the MOH regulated contraindications for vaccination candidates and household contacts. In this study we estimate the size of the contraindicated population to OPV vaccination.

METHOD

We studied vaccination candidates aged 2-9 and 14-23 months and probable household contacts. Using the rate of contraindications extracted for each study group from a medical records database, a statistical model was built to estimate the probability of contraindications in candidates.

RESULTS

3.9% of the 2-9-month-old study group and 4% of the 14-23-month-old group had contraindications by either self or household contacts.

CONCLUSION

A statistical model can provide an estimation of the contraindicated population and can be used in the future when devising vaccination campaigns. In contrast to concerns raised by the MOH, our findings show a smaller than anticipated contraindicated population.

Survey of Kidney Biopsy Clinical Practice and Training in the United States

BACKGROUND AND OBJECTIVES

Practicing clinical nephrologists are performing fewer diagnostic kidney biopsies. Requiring biopsy procedural competence for graduating nephrology fellows is controversial.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

An anonymous, on-line survey of all Walter Reed training program graduates (n=82; 1985-2017) and all United States nephrology program directors (n=149; August to October of 2017), regarding kidney biopsy practice and training, was undertaken.

RESULTS

Walter Reed graduates' response and completion rates were 71% and 98%, respectively. The majority felt adequately trained in native kidney biopsy (83%), transplant biopsy (82%), and tissue interpretation (78%), with no difference for ≤10 versus >10 practice years. Thirty-five percent continued to perform biopsies (13% did ≥10 native biopsies/year); 93% referred at least some biopsies. The most common barriers to performing biopsy were logistics (81%) and time (74%). Program director response and completion rates were 60% and 77%. Seventy-two percent cited ≥1 barrier to fellow competence. The most common barriers were logistics (45%), time (45%), and likelihood that biopsy would not be performed postgraduation (41%). Fifty-one percent indicated that fellows should not be required to demonstrate minimal procedural competence in biopsy, although 97% agreed that fellows should demonstrate competence in knowing/managing indications, contraindications, and complications. Program directors citing ≥1 barrier or whose fellows did <50 native biopsies/year in total were more likely to think that procedural competence should not be required versus those citing no barriers (P=0.02), or whose fellows performed ≥50 biopsies (P<0.01).

CONCLUSIONS

Almost two-thirds of graduate respondents from a single military training program no longer perform biopsy, and 51% of responding nephrology program directors indicated that biopsy procedural competence should not be required. These findings should inform discussion of kidney biopsy curriculum requirements.

Proximal Interphalangeal Joint Fusion: Indications and Techniques

This article is an in-depth analysis of proximal interphalangeal joint arthrodesis indications and surgical techniques. There are a wide variety of indications for proximal interphalangeal joint arthrodesis with relatively few contraindications. Moreover, although there is a limited surgical approach, there is a wide breadth of modalities in which to obtain the arthrodesis, of which several are listed here. Proximal interphalangeal joint arthrodesis has been shown to have excellent outcomes and a high success rate.

Outcomes indicators and a risk classification system for spinal manipulation under anesthesia: a narrative review and proposal

Over a period of decades chiropractors have utilized spinal manipulation under anesthesia (SMUA) to treat chronic back and neck pain. As an advanced form of manual therapy, SMUA is reserved for the patient whose condition has proven refractory to office-based manipulation and other modes of conservative care. Historically, the protocols and guidelines put forth by chiropractic MUA proponents have served as the clinical compass for directing MUA practice. With many authors and MUA advocates having focused primarily on anticipated benefit, the published literature contains no resource dedicated to treatment precautions and contraindications. Also absent from current relevant literature is acknowledgement or guidance on the preliminary evidence that may predict poor clinical outcomes with SMUA. This review considers risk and unfavorable outcomes indicators in therapeutic decision making for spinal manipulation under anesthesia. A new risk classification system is proposed that identifies patient safety and quality of care interests for a procedure that remains without higher-level research evidence. A scale which categorizes risk and outcome potential for SMUA is offered for the chiropractic clinician, which aims to elevate the standard of care and improve patient selection through the incorporation of specific indices from existing medical literature.

Comparison of the safety information on drug labels in three developed countries: The USA, UK and Canada

The safety information on drug labels of a company marketing the same drugs in different countries is sometimes different. The aim of the present study is to understand the differences in the volume and content of safety information on the drug labels from the same manufacturers in three developed countries: the United States of America (USA), the United Kingdom (UK) and Canada. This study involved the calculation of the proportion of total safety information (PSI) and of contraindications (PCI) in comparison to all information on the label and the percentage of boxed warnings (PBW) among the 100 labels studied from each country. The PSI on the labels of different countries is different with USA labels bearing lesser value PSI and UK labels bearing higher value PSI. The qualitative information provided on these drug labels from each country in 'contraindications' sections, 'boxed/serious warnings' and 'overdosage' sections presented differences in the information provided on most of the labels. We have found distinct differences between the safety information available on drug labels in terms of volume and content. We conclude that the safety information for the same products should be standardised across all countries.