Bed rest: outdated following traumatic solid organ injury?

INTRODUCTION

This systematic review aimed to evaluate early ambulation protocols implemented for traumatic solid organ injury.

METHODS

The electronic databases PubMed, Medline (Ovid), Embase and Cochrane Library were searched without time constraint to identify prospective and retrospective analyses, randomised controlled trials, cohort studies, and case series that investigated early ambulation in solid organ trauma.

RESULTS

Six studies met the predefined inclusion criteria and were reviewed. Three studies investigated early ambulation protocols in direct comparison with bed rest. The remaining three studies were early ambulation case series. In all studies there was no convincing evidence to suggest differences in clinical outcomes between early ambulation and bed rest protocols. In all studies early ambulation resulted in a reduced length of hospitalisation and decreased cost to national healthcare services.

CONCLUSIONS

This systematic review has found preliminary evidence that suggests bed rest has no clinical benefit in those with low-grade to mid-grade (grades 1-2) solid organ injury. Further studies are required to inform guidance to improve trauma patient outcomes.

Transient acantholytic dermatosis in a patient with prostate cancer

Transient acantholytic dermatosis (TAD) is a relatively common entity that has been also noted to occur in patients with cancer. Herein, we describe a case of transient acantholytic dermatosis occurring in a patient with a history of prostate cancer status post radiation, now being treated with combination therapy with pembrolizumab and carboplatin-pemetrexed for advanced lung adenocarcinoma. Our case emphasizes the importance of being cognizant of TAD and its associations, particularly in cancer patients.

5 Improving Diagnosis and Management of Urinary Tract Infections for Elderly Patients

Introduction

Diagnosis of urinary tract infection (UTI) in the elderly population is challenging as they commonly present with atypical signs and symptoms. Prevalence of asymptomatic bacteriuria in the elderly population is high. Hence, urine dipstick and urine culture are no longer diagnostic tests. UTI is over-diagnosed and overtreated in the elderly, resulting in poor antimicrobial stewardship. This project was carried out to assess and improve the current practices in the diagnosis and treatment of UTI in the Department of Medicine of the Elderly.

Methods

We reviewed current Scottish Intercollegiate Guidelines Network (SIGN) and National Institute for health and Care Excellence (NICE) guidelines on management of UTI and defined indications for performing urine dipstick and sending urine culture. We then collected and assessed data on all urine dipsticks performed, urine cultures sent, and use of antibiotics in treating UTI and asymptomatic bacteriuria in three Medicine of the Elderly wards in Aberdeen Royal Infirmary.

We carried out intervention by means of presenting and discussing findings of Plan-Do-Study-Act (PDSA) cycles in departmental multi-disciplinary Quality Improvement (QI) meetings followed by educational sessions.

Results

Our baseline data showed 77% of urine dipsticks were performed without clinical indication and 18% of patients had urine cultures sent without clinical indication. After presenting our initial findings and carrying out an educational intervention session, 25% of patients had urine dipstick done without clinical indication, and 0% of patients had urine cultures sent without clinical indication. However, over the course of four subsequent PDSA cycles, practices in investigation of UTI fluctuated but were overall consistently better than the initial practice with further interventions. In all PDSA cycles, no patients were treated for asymptomatic bacteriuria.

Conclusions

Multidisciplinary team involvement in discussion of this QI project findings and educational sessions proved to be an effective form of intervention for improving current practice.

1641 Bicuspid pulmonary valve - an unusual cause of dilated pulmonary artery

Introduction

Dilated pulmonary artery is a common finding with a variety of possible aetiologies. We present a case of unexplained dilated pulmonary artery that was associated with bicuspid pulmonary valve identified by CMR.

Case Presentation

A 67-year-old female underwent mitral valve repair for severe mitral regurgitation. She had presented with breathlessness, and had severe mitral regurgitation due to a myxomatous valve with bileaflet prolapse, confirmed with TOE. Echo showed: normal LV dimensions, LVEF 66%. RV size and systolic function normal. Coronary angiography was normal and pulmonary hypertension was not present on right heart catheterization.

At postoperative follow up she was well and asymptomatic, with echo showing good LV systolic function, intact mitral valve repair, and normal systolic pulmonary artery pressures (36mmHg). New T wave inversion was identified across the precordial leads so a CMR was performed.

CMR showed normal LV volumes and function with no wall motion abnormality or LVH. There was no fibrosis or infarction in the late phase after Gadolinium contrast. The RV was dilated (73mm diameter at base) with normal systolic function. The main pulmonary artery was dilated at 42mm. Flow mapping showed no evidence of shunt (Qp:Qs = 1:1) and the atrial septum was intact. Pulmonary valve function was normal but the valve was bicuspid in morphology.

Discussion

Bicuspid pulmonary valve is a rare finding. In our case this was identified by CMR and was associated with a dilated pulmonary artery.

Bicuspid pulmonary valve is most commonly identified in the context of pulmonary valve stenosis. Isolated pulmonary valve stenosis is a rare finding; it is most often associated with other congenital defects like Fallot. Pulmonary stenosis has been associated with pulmonary artery aneurysm, attributed to hemodynamic changes caused by the stenotic valve. However as with bicuspid aortic valve it is recognized that the "post stenotic dilation" is part of the pathology of bicuspid valve and does not need the changed haemodynamics of a stenotic valve.

During embryogenesis neural crest cells are necessary for the normal development of the semilunar valves, the septation of the outflow tract into the aorta and pulmonary artery, and the remodeling of the aortic arch. Any defect in this migration can cause abnormalities or aneurysm of the aorta or pulmonary artery together with semilunar valve defects. A study of 3,861 donor hearts dissected at the European Homograft Bank revealed only four cases (0.1%) of bicuspid pulmonary valves.

Bicuspid pulmonary valve with normal function can be difficult to identify at echocardiography. It can be well visualized by CMR and this can be combined with an assessment of the pulmonary arteries. It should be remembered as a rarer cause of dilated pulmonary artery when other causes have been excluded.

Figure

A. Dilated MPA. B. Dilated RV. C. and D. Bicuspid pulmonary valve.

Abstract 1641 Figure. Dilated MPA. Bicuspid pulmonary valve

Gastrointestinal helminths in dog feces surrounding suburban areas of Lower Dir district, Pakistan: A public health threat

Data on environmental contamination of the parasites of zoonotic importance is scarce in Pakistan. Soil contamination with feces of dogs hide infective stages of the parasite represents a health-risk to humans. This study was aimed to assess the eggs of gastrointestinal parasites of stray dogs and household dogs in lower Dir district, Pakistan with special consideration to those that can be spread to humans. One hundred and fifty two stool specimens from (stray dogs=90 and household dogs=62) were collected. The helminth eggs were processed by direct smear method and centrifugation techniques and identified by microscopic examination. Of the total examined dogs 26.8% (n=41 /152) were found to be infected with one or more intestinal parasites. The intestinal helminths detected were Dipylidium caninum (n =18, 11.8%), followed by Toxocara canis (n =16, 10.5%), Taenia spp., (n=10, 6.57%) Ancylostoma caninum (n=6, 3.94), Toxascaris spp., Capillaria spp., and Trichuris vulpis (n=2, 1.31% each) in order of their prevalence. Pattern of infection revealed that 27 (65.8%) dogs have single, 13(31.7%) double and 1(2.43%) triple infection. The stray dogs were highly infected 34.4% (n=31) than house hold dogs 16.1% (n=10). The prevalence of infection with intestinal parasites was significantly different among these two groups (p = 0.0097). This study highlight a severe environmental contamination by frequent parasitic stages infectious to humans. There is a higher risk of zoonotic transmission from dogs which indicate an immediate need for the controlling of these parasites and educating the public to take wise action relating to the parasites and pets.

Cemented humeral stem versus press-fit humeral stem in total shoulder arthroplasty: a systematic review and meta-analysis

AIMS

The aim of this study was to evaluate the differences in revision and complication rates, functional outcomes, and radiological outcomes between cemented and press-fit humeral stems in primary anatomical total shoulder arthroplasty (TSA).

MATERIALS AND METHODS

A comprehensive systematic review and meta-analysis was conducted searching for studies that included patients who underwent primary anatomical TSA for primary osteoarthritis or rheumatoid arthritis.

RESULTS

There was a total of 36 studies with 927 cemented humeral stems and 1555 press-fit stems. The revision rate was 5.4% (95% confidence interval (CI) 3.9 to 7.4) at a mean of 89 months for cemented stems, and 2.4% (95% CI 1.1 to 4.7) at a mean of 40 months for press-fit stems. A priori subgroup analysis to control for follow-up periods demonstrated similar revision rates: 2.3% (95% CI 1.1 to 4.7) for cemented stems versus 1.8% (95% CI 1.4 to 2.9) for press-fit stems. Exploratory meta-regression found that longer follow-up was a moderating variable for revision (p = 0.003).

CONCLUSION

Cement fixation had similar revision rates when compared to press-fit stems at short- to midterm follow-up. Rotator cuff pathology was a prevalent complication in both groups but is likely not related to fixation type. Overall, with comparable revision rates, possible easier revision, and decreased operative time, humeral press-fit fixation may be an optimal choice for primary anatomical TSA in patients with sufficient bone stock. Cite this article: Bone Joint J 2019;101-B:1107-1114.

The health burden of malaria and household choices regarding treatment and prevention in Pakistan

The extent of the economic burden of malaria and its imposed mechanisms are both relevant to public policy. This paper investigates the economic burden of malaria and household behaviour in relation to the treatment and prevention of the illness in Pakistan. In this regard, data were collected from a randomly selected sample of 360 households using structured questionnaires. The survey results indicate that 23.4% of household members contracted malaria during the three-month reference period. The average per person cost of malaria is estimated at 3116 Pakistani rupees (PKR) (USD 32). The estimated cost of the illness was found to be equivalent to, on average, 6.7% of monthly household income. Although high-income households face a higher financial burden due to better preventive and mitigation measures, the negative consequences hit low-income households harder due to liquidity constraints and poor access to effective treatment. We recommend that malaria control policies be integrated into development and poverty reduction programs.

Additional Diagnostic value of Mini Electrodes in an 8-mm Tip in Cavotricuspid Isthmus Ablation

Background

Eight-mm ablation catheters are widely used in cavotricuspid isthmus ablation (CTI) for treatment of right sided atrial flutter. However a high success rate, these large ablation tips comes with adisadvantage of lower resolution of fractionated signals.

Purpose

The aim of this study was to evaluate the additional diagnostic value of the electrograms recordedfrom mini electrodes (MEs) in an 8-mm ablation catheter tip during CTI.

Methods

CTI-ablation procedures were compared retrospectively in two groups, namely, group A: the Abbott Safire 8-mm tip with a 3D mapping system (n =37) and group B: the Boston Scientific MiFi IntellaTip XP 8-mm tip without a 3D mapping system (n=13). We analyzedacute procedural success, ablation characteristics and recurrence rate at one-year follow-up. Electrograms from MEs were analyzedright before the onset of the critical ablation application that resulted in acute CTI-block. We determined whether these ME electrograms had additional diagnostic value in addition to of the 8-mm tip derivedelectrogram.

Results

At the onset of the critical ablation application, the MEs had an important additional value in 3 out of 13 cases as local signals were sensed on the MEs that were not recorded by the 8-mm tip electrode. In 2cases the ME did not show local electrogramsalthough the ablationwas still effective. Acute procedural and long-term success wereobserved in all patients. No differences were found in time to bidirectional block, procedure time or fluoroscopic exposure.

Conclusion

Our data show that signals recorded from the MEs had additional diagnostic value, but only in asmall percentage of the patients. We did not observe, although omitting 3D-mapping in the ME group, any differencebetween groups with regard to procedural or ablation characteristicsduring CTI-ablation.