The Chronological Evolution of Cochlear Implant Contraindications: A Comprehensive Review

Cochlear implantation has emerged as a transformative intervention in addressing profound hearing loss, offering a paradigm shift in auditory rehabilitation for individuals with restricted auditory function. Throughout its history, the understanding of contraindications for cochlear implant (CI) surgery has evolved significantly. This review comprehensively analyzes the chronological advancements in the understanding of CI contraindications, examining studies conducted from historical timelines to the present. Recent research has revealed significant developments in the field, prompting a reevaluation of established criteria and resulting in expanded indications for CI. The chronological evolution of contraindications underscores the transformative nature of the field, offering potential improvements in outcomes and enhancing the quality of life for individuals with profound hearing loss. In conclusion, this narrative review emphasizes the dynamic nature of the field, where the reevaluation of contraindications has created new opportunities and broader indications for CI. The emerging prospects, including improved outcomes and enhanced quality of life, hold promise for individuals with profound hearing loss.

Evidence-based German consensus recommendations

Whole-body electromyostimulation has proven to be a highly effective alternative to conventional resistance-type exercise training. However, due to adverse effects in the past, very extensive contraindications have been put in place for the commercial, non-medical WB-EMS market. Considering recent positive innovations e.g., federal regulation, mandatory trainer education, revised guidelines, and new scientific studies on WB-EMS application, we believe that a careful revision of the very restrictive contraindications on WB-EMS is needed. This applies all the more because many cohorts with limited options for conventional exercise have so far been excluded. During a first meeting of an evidence-based consensus process, stakeholders from various backgrounds (e.g., research, education, application) set the priorities for revising the contraindications. We decided to focus on four categories of absolute contraindications: "Arteriosclerosis, arterial circulation disorders", "Diabetes mellitus" (DM), "Tumor and cancer" (TC), "Neurologic diseases, neuronal disorders, epilepsy". Based on scientific studies, quality criteria, safety aspects and benefit/risk assessment of the category, DM and TC were moved to the relative contraindication catalogue, while arteriosclerosis/arterial circulation disorders and neurologic diseases/neuronal disorders/epilepsy were still considered as absolute contraindications. While missing evidence suggests maintaining the status of neurologic diseases/neuronal disorders as an absolute contraindication, the risk/benefit-ratio does not support the application of WB-EMS in people with arteriosclerosis/arterial circulation diseases. Despite these very cautious modifications, countries with less restrictive structures for non-medical WB-EMS should consider our approach critically before implementing the present revisions. Considering further the largely increased amount of WB-EMS trials we advice regular updates of the present contraindication list.

Perioperative Management of Paraneoplastic Necrotizing Myopathy in Thyroidectomy: A Case Report

Perioperative management of patients with myopathies can be challenging due to the increased risk of malignant hyperthermia (MH) and anesthesia-induced rhabdomyolysis (AIR). However, currently, there is no evidence regarding the optimal anesthetic management for paraneoplastic necrotizing myopathy (PNM) (total intravenous anesthetic vs. volatile anesthetics). Here, I report a case where anesthesia was administered safely using volatile anesthetics. A 63-year-old female presented with PNM associated with papillary thyroid carcinoma, necessitating urgent thyroidectomy. The patient, previously diagnosed with anti-3-hydroxy-3-methylglutaryl coenzyme A reductase (HMGCR) antibody-associated myopathy, exhibited progressive weakness and dysphagia, prompting suspicion of PNM. The patient's compromised respiratory status, attributed to tracheal compression by a large goiter, necessitated an urgent thyroidectomy. Anesthetic management considerations included the potential effect of HMGCR-M on respiratory muscles and the need for careful planning to mitigate postoperative complications. The patient underwent total thyroidectomy, left central compartment clearance, and tracheostomy. The surgery proceeded uneventfully, with meticulous monitoring and adjustment of anesthetic agents to maintain hemodynamic stability. Postoperatively, the patient recovered well, demonstrating complete resolution of neurological symptoms during a three-month follow-up. The case underscores the importance of recognizing paraneoplastic syndromes in the context of thyroid surgery and highlights potential challenges faced by anesthesiologists. Despite the lack of established safety data for anesthetic drugs in HMGCR-M necrotizing myopathy, the case demonstrates the successful use of sevoflurane and rocuronium.

Contraindicated use of modern contraceptives among mothers from a Pelotas Birth Cohort

OBJECTIVE

To describe the prevalence of contraindicated use of combined hormonal contraceptives, progesterone-only contraceptives, and intrauterine devices in mothers participating in the 2015 Pelotas Birth Cohort according to the WHO medical eligibility criteria.

METHODS

The biological mothers of children belonging to the 2015 Pelotas birth cohort who attended the 48-month follow-up were studied. The 48-month follow-up data were collected from January 1, 2019, to December 31, 2019. Contraindicated use of modern contraceptives was considered to occur when these women presented at least one of the contraindications for the use of modern contraceptives and were using these methods. The prevalence of contraindicated use was calculated according to each independent variable and their respective 95% confidence intervals (95%CI).

RESULTS

The analyzed sample consisted of 3,053 women who used any modern contraceptive method. The prevalence of contraindicated use of modern contraceptives totaled 25.9% (95%CI: 24.4-27.5). Combined hormonal contraceptives showed the highest prevalence of contraindicated use (52.1%; 95%CI: 49.3-54.8). The prevalence of contraindicated use of modern contraceptives methods was greater in women with family income between one and three minimum wages, a 25-30 kg/m2 body mass index, indication by a gynecologist for the used method, and purchasing the contraceptive method at a pharmacy. The higher the women's education, the lower the prevalence of inappropriate use of modern contraceptives.

CONCLUSION

In total, one in four women used modern contraceptives despite showing at least one contraindication. Policies regarding women's reproductive health should be strengthened.

Indications, contraindications, side effects, general assessment, and outlook for the future: An International Compression Club survey

BACKGROUND

The effectiveness of compression therapy (CT) and the best compression modality choice are questioned in many clinical stages of chronic venous disease (CVD). This work aims to obtain information on indications, contraindications, and the best treatment option for CT in different clinical scenarios of CVD.

METHOD

An online survey was made among members of the International Compression Club, experts in CT.

RESULTS

The experts apply CT in all clinical stages of CVD, even when evidence is missing. Regarding compression materials, experts use inelastic materials in the advanced stages of CVD and compression stockings in the early or chronic stages of CVD.

CONCLUSION

The authors highlight the gap between experts' practical use of CT and evidence-based medicine results. They also suggested that, given the cost of randomized clinical trials aimed at specifying specific indications for different devices, artificial intelligence could be used for large-scale practice surveys in the future.

Heart Transplantation

Heart transplantation (HTx) remains the last therapeutic resort for patients with advanced heart failure. The present work is a clinically focused review discussing current issues in heart transplantation. Several factors have been associated with the outcome of HTx, such as ABO and HLA compatibility, graft size, ischemic time, age, infections, and the cause of death, as well as imaging and laboratory tests. In 2018, UNOS changed the organ allocation policy for HTx. The aim of this change was to prioritize patients with a more severe clinical condition resulting in a reduction in mortality of people on the waiting list. Advanced heart failure and resistant angina are among the main indications of HTx, whereas active infection, peripheral vascular disease, malignancies, and increased body mass index (BMI) are important contraindications. The main complications of HTx include graft rejection, graft angiopathy, primary graft failure, infection, neoplasms, and retransplantation. Recent advances in the field of HTx include the first two porcine-to-human xenotransplantations, the inclusion of hepatitis C donors, donation after circulatory death, novel monitoring for acute cellular rejection and antibody-mediated rejection, and advances in donor heart preservation and transportation. Lastly, novel immunosuppression therapies such as daratumumab, belatacept, IL 6 directed therapy, and IgG endopeptidase have shown promising results.

Liver Transplantation: Contraindication and Ineligibility

Liver transplantation (LT) is a life-saving therapeutic modality for patients with various advanced liver diseases. It is crucial to identify that the patient's illness is sufficiently advanced and unlikely to improve with medical management to justify the need for transplantation. At the same time, it is crucial to identify patients with comorbidities and far advanced disease that would result in an unacceptable outcome after LT. Specific care also is required before deciding on LT in the elderly, acute on chronic liver disease, patients with comorbidities, and hepatocellular carcinoma. Transplantation needs to be timed appropriately to avoid unnecessary LT and ensure that the decision is not left too late to avoid losing the patient without a transplant. Also, important is the decision as to when not to transplant. The current review explores some of these issues of contraindications and ineligibility for LT.

Impact of Concurrent Chronic Rhinosinusitis on Complication Rates after Endonasal Endoscopic Skull Base Surgery: A Single-Center Experience

Objectives  Preoperative planning of endoscopic skull base surgery (ESBS) is essential. The safety of performing surgery before managing sinus pathologies including concurrent chronic rhinosinusitis (CRS) in patients undergoing ESBS has been questioned. The current study aimed to evaluate and compare the complication rates between patients with and without CRS undergoing ESBS. Design  This is a retrospective study. Setting  Present study was conducted at tertiary referral center. Participants  We included all patients who underwent ESBS between March 2015 and March 2021. However, patients who had surgical revision for remnant tumor, primary sinonasal tumor excision, and cerebrospinal fluid (CSF) leakage repair were excluded. The presence of concurrent CRS was determined according to the European Position Paper on Rhinosinusitis and Nasal Polyps 2020 (EPOS 2020) criteria by reviewing electronic charts about the preoperative clinical assessment and CT scan images of the paranasal sinuses. Then, the incidence rates of postoperative meningitis, CSF leakage, and surgical site infection were compared between patients with and without concurrent CRS undergoing ESBS. Main Outcome Measures  Postoperative complication rates in patients underwent ESBS with and without CRS. Results  From a total of 130 ESBS cases, 99 patients were included in this study. Among them, 24 had concurrent CRS. One patient presented with postoperative meningitis, one with CSF leakage, and two with surgical site infections. The incidence rate of postoperative meningitis, CSF leakage, and surgical site infection did not significantly differ between patients with and without concurrent CRS. Conclusion  Concurrent CRS is not a contraindication for ESBS. Moreover, simultaneous endoscopic sinus surgery can safely be performed without additional morbidity in ESBS.

Liver Transplantation in People Living with HIV: Still an Experimental Procedure or Standard of Care?

Liver transplantation (LT) is the only curative treatment for various liver diseases, including acute liver failure, end-stage liver disease, and selected unresectable liver malignancies. Combination antiretroviral therapy has improved outcomes for people living with HIV (PLWH), transforming the status of acquired immune deficiency syndrome from a fatal disease to a chronic and manageable condition. These powerful antiviral therapies have not only increased the number of HIV+ enlisted patients by improving their survival but also made the use of HIV+ organs a viable option. In this review, we summarise current knowledge on the peculiarities of liver transplantation in PLWH. In particular, we focus on the indications, contraindications, specific considerations for treatment, and outcomes of LT in PLWH. Finally, we present available preliminary data on the use of HIV+ liver allografts.

The Feasibility and Early Results of Multivessel Minimally Invasive Coronary Artery Bypass Grafting for All Comers

OBJECTIVES

Cardiovascular surgery advancements have emerged with various minimally invasive approaches for treating multivessel coronary disease to improve outcomes and minimize the burden associated with conventional cardiac surgery. We present our clinical experience and minimally invasive coronary bypass techniques through minithoracotomy, which we apply without selection to patients who have decided to have elective surgery for multivessel isolated coronary artery disease.

METHODS

It consists of 230 consecutive patients operated by the same team with this method between July 2020 and September 2022. The patients were assigned to one of the two methods preoperatively to their accompanying comorbidities and operated on either with blood cardioplegia via 5 to 7 cm left anterior minithoracotomy, with on-pump clamped technique or without pump via left anterolateral minithoracotomy.

RESULTS

Mortality was observed in two of our patients (0.9%), but myocardial infarction was not observed in our patients in the early postoperative period. None of our patients required conversion to sternotomy (0%). Five patients' needed reoperation from the same incision due to postoperative bleeding (2.2%), and atrial fibrillation developed in 17 patients in the postoperative period (7.4%). The mean number of bypasses was found to be 3.0 ± 0.9.

CONCLUSIONS

Minimally invasive coronary artery bypass surgery via minithoracotomy can be routinely reproduced safely. More long-term results and more multicenter studies are needed for more widespread acceptance of the technique.

Eligibility for the 4 Pharmacological Pillars in Heart Failure With Reduced Ejection Fraction at Discharge

Background Guidelines recommend using multiple drugs in patients with heart failure (HF) with reduced ejection fraction, but there is a paucity of real-world data on the simultaneous initiation of the 4 pharmacological pillars at discharge after a decompensation event. Methods and Results A retrospective data mart, including patients diagnosed with HF, was implemented. Consecutively admitted patients with HF with reduced ejection fraction were selected through an automated approach and categorized according to the number/type of treatments prescribed at discharge. The prevalence of contraindications and cautions for HF with reduced ejection fraction treatments was systematically assessed. Logistic regression models were fitted to assess predictors of the number of treatments (≥2 versus <2 drugs) prescribed and the risk of rehospitalization. A population of 305 patients with a first episode of HF hospitalization and a diagnosis of HF with reduced ejection fraction (ejection fraction, <40%) was selected. At discharge, 49.2% received 2 current recommended drugs, β-blockers were prescribed in 93.4%, while a renin-angiotensin system inhibitor or an angiotensin receptor-neprilysin inhibitor was prescribed in 68.2%. A mineralocorticoid receptor antagonist was prescribed in 32.5%, although none of the patients showed contraindications to mineralocorticoid receptor antagonist prescription. A sodium-glucose cotransporter 2 inhibitor could be prescribed in 71.1% of patients. On the basis of current recommendations, 46.2% could receive the 4 foundational drugs at discharge. Renal dysfunction was associated with <2 foundational drugs prescribed. After adjusting for age and renal function, use of ≥2 drugs was associated with lower risk of rehospitalization during the 30 days after discharge. Conclusions A quadruple therapy could be directly implementable at discharge, potentially providing prognostic advantages. Renal dysfunction was the main prevalent condition limiting this approach.

Evaluation of Potential Drug-Drug Interactions and Association with Adverse Drug Reactions in Predialysis Chronic Kidney Disease Patients at Indonesian National Referral Hospital

BACKGROUND

Chronic kidney disease (CKD) is often accompanied by a variety of comorbidities that require several medications thus, polypharmacy is unavoidable. One of the consequences of polypharmacy is the occurrence of potential drug-drug interactions (DDI). The aim of this study is to evaluate the profile of DDI in pre-dialysis CKD patients and to identify the possible adverse drug reactions (ADR) due to DDI.

METHODS

This cross-sectional study includes stage 3-5 pre-dialysis CKD patients at a referral hospital in Indonesia in 2019 - 2020. Data were collected from the electronic health record and the hospital's medical record. The prescriptions were analysed for potential DDI using Micromedex software and ADRs assessment through clinical symptoms and laboratory data abnormalities.

RESULTS

A total of 106 patients were included in the study, around 60 (56.6%) patients received more than six medications. There were 111 types of medications prescribed with the most frequently prescribed drug was bisoprolol (36.5%). The proportion of patients who received treatment with a potential DDI was 76% (81 patients), while the proportion of patients who experienced ADR was 28% (23 patients). The most prevalent ADRs were hyperglycaemia, hypertension, hyperkalaemia, and hypotension. Cardiovascular disease had a statistically significant relationship with ADR suspected due to DDI (p = 0.03).

CONCLUSION

A significant number of potential DDI were seen in the prescriptions of stage 3-5 pre-dialysis CKD patients at a referral hospital in Indonesia between 2019 - 2020. Cardiovascular disease was identified as the most common risk factor for ADR suspected caused by DDI.

Sclerotherapy of lower limb veins: Indications, contraindications and treatment strategies to prevent complications - A consensus document of the International Union of Phlebology-2023

BACKGROUND

Sclerotherapy is a non-invasive procedure commonly used to treat superficial venous disease, vascular malformations and other ectatic vascular lesions. While extremely rare, sclerotherapy may be complicated by serious adverse events.

OBJECTIVES

To categorise contraindications to sclerotherapy based on the available scientific evidence.

METHODS

An international, multi-disciplinary panel of phlebologists reviewed the available scientific evidence and developed consensus where evidence was lacking or limited.

RESULTS

Absolute Contraindications to sclerotherapy where the risk of harm would outweigh any benefits include known hypersensitivity to sclerosing agents; acute venous thromboembolism (VTE); severe neurological or cardiac adverse events complicating a previous sclerotherapy treatment; severe acute systemic illness or infection; and critical limb ischaemia. Relative Contraindications to sclerotherapy where the potential benefits of the proposed treatment would outweigh the risk of harm or the risks may be mitigated by other measures include pregnancy, postpartum and breastfeeding; hypercoagulable states with risk of VTE; risk of neurological adverse events; risk of cardiac adverse events and poorly controlled chronic systemic illness. Conditions and circumstances where Warnings and Precautions should be considered before proceeding with sclerotherapy include risk of cutaneous necrosis or cosmetic complications such as pigmentation and telangiectatic matting; intake of medications such as the oral contraceptive and other exogenous oestrogens, disulfiram and minocycline; and psychosocial factors and psychiatric comorbidities that may increase the risk of adverse events or compromise optimal treatment outcomes.

CONCLUSIONS

Sclerotherapy can achieve safe clinical outcomes provided that (1) patient-related risk factors and in particular all material risks are (1a) adequately identified and the risk benefit ratio is clearly and openly discussed with treatment candidates within a reasonable timeframe prior to the actual procedure; (1b) when an individual is not a suitable candidate for the proposed intervention, conservative treatment options including the option of 'no intervention as a treatment option' are discussed; (1c) complex cases are referred for treatment in controlled and standardised settings and by practitioners with more expertise in the field; (1d) only suitable individuals with no absolute contraindications or those with relative contraindications where the benefits outweigh the risks are offered intervention; (1e) if proceeding with intervention, appropriate prophylactic measures and other risk-mitigating strategies are adopted and appropriate follow-up is organised; and (2) procedure-related risk factors are minimised by ensuring the treating physicians (2a) have adequate training in general phlebology with additional training in duplex ultrasound, procedural phlebology and in particular sclerotherapy; (2b) maintain their knowledge and competency over time and (2c) review and optimise their treatment strategies and techniques on a regular basis to keep up with the ongoing progress in medical technology and contemporary scientific evidence.

Use of contraindicated antiretroviral drugs in people with HIV/HCV coinfections receiving HCV treatment with direct-acting antivirals-Results from the EuroSIDA study

OBJECTIVES

Our objective was to determine whether antiretroviral drugs (ARVs) were used according to the European AIDS Clinical Society (EACS) guidelines for people with HIV/hepatitis C virus (HCV) coinfection treated with direct-acting antivirals (DAAs) between 30 November 2014 and 31 December 2019 in the pan-European EuroSIDA study.

METHODS

At each publication date of the EACS guidelines, plus 3 and 6 months, we calculated the number of people receiving DAAs with potential and actual ARV contraindications ('red shading' in the EACS guidelines). We used logistic regression to investigate factors associated with using contraindicated ARVs.

RESULTS

Among 1406 people starting DAAs, the median age was 51 years, 75% were male, 57% reported injected drug use as an HIV risk, and 76% were from western Europe. Of 1624 treatment episodes, 609 (37.5%) occurred while the patient was receiving ARVs with potential contraindications; among them, 38 (6.2%; 95% confidence interval [CI] 4.3-8.2) involved a contraindicated ARV (18 non-nucleoside reverse transcriptase inhibitors), 16 involved protease inhibitors, and four involved integrase strand transfer inhibitors. The adjusted odds of receiving a contraindicated ARV were higher (3.25; 95% CI 1.40-7.57) among participants from east/central east Europe (vs. south) and lower (0.22; 95% CI 0.08-0.65) for 2015-2018 guidelines (vs. 2014). In total, 29 of the 32 (90.6%) patients receiving a contraindicated ARV and 441 of the 461 (95.7%) with potential ARV contraindications experienced a sustained virological response ≥12 weeks after stopping treatment (SVR12; p = 0.55).

CONCLUSION

In this large heterogenous European cohort, more than one-third of people with HIV/HCV coinfection received DAAs with potential ARV contraindications, but few received a contraindicated ARV. Use of contraindicated ARVs declined over time, corresponding to the increased availability of ARV therapy regimens without interactions with DAA across Europe. Participants who received a contraindicated DAA and ARV combination still had a high rate of SVR12.

Reasons for Exclusion From Intravenous Thrombolysis in Acute Ischemic Stroke: Experience From a Moroccan Stroke Unit

Background and objective The rate of intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) is still low due to several absolute and relative contraindications, including admission time delay, which remains the main reason for exclusion from thrombolysis. In this study, we aimed to identify reasons for non-thrombolysis at our stroke center. Methods This retrospective study included all patients with a final diagnosis of AIS as per our stroke prospective register from 2014 to 2019. Reasons for non-thrombolysis were analyzed for all AIS and for patients admitted within 4.5 hours from symptom onset. From 2014 to 2016, a non-contrast CT scan was the unique imaging modality used to decide on performing IVT. In 2017, CT angiography was added to the imaging protocol. Results Among 3,562 patients with AIS, 3,365 (94.4%) were excluded from thrombolysis; 2,871 (80.6%) were admitted out of the IVT time window, which represents the main reason for exclusion from thrombolysis. Thrombolysis alert (TA) was triggered for 691 (19.4%) patients, and 197 patients had IVT (which represents 28.5% of TA and 5.5% of all AIS). Minor stroke and rapidly improving symptoms of stroke were also reasons for non-thrombolysis, which explain the high-average initial National Institutes of Health Stoke Scale (NIHSS) score of more than 12 in the thrombolysis group. CT angiography allows for the analysis of the supra-aortic trunks, the circle of Willis, and the collateral status. Therefore, during the period when a CT angiography scan was used, there were more IVTs for minor strokes, rapidly improving strokes, and AIS patients admitted beyond the IVT time window. Conclusions This study highlights the common reasons for exclusion from thrombolysis. Efforts should be undertaken to avoid admission time delays. Also, based on our findings, minor stroke and improving stroke no longer represent absolute contraindications for IVT in AIS.

False Contraindications for Vaccinations Result in Sub-Optimal Vaccination Coverage in Quito, Ecuador: A Cross-Sectional Study

Vaccination coverage in Ecuador has decreased since 2013, falling short of the World Health Organization's vaccination goal. There are several causes for this deficiency in coverage, one of these are lost vaccination opportunities, which are caused when a patient without contraindications postpones, or for other reasons fails to receive a recommended immunization. The objective of this study was to determine the state of knowledge regarding vaccination contraindications among the Metropolitan District of Quito health personnel to assess missed vaccination opportunities. Through this cross-sectional descriptive study, health personnel were surveyed online and asked 18 clinical scenarios which were created to evaluate their knowledge of the true contraindications of vaccination, and measure missed opportunities. A total of 273 surveys were collected; 74% belonged to the public health system, and the rest represented by private practitioners. Of those surveyed, 98.2% of health personnel had improperly denied vaccination at least once. We specifically found vaccinations were incorrectly denied more frequently in cases where the hypothetical patient presented mild or moderate fever cases. The use of corticosteroids, autoimmune diseases, and egg allergy were also incorrectly denied (89%, 71.4%, 72.9%, and 58.6%, respectively). Among the health personnel surveyed, there is an apparent lack of knowledge of the true contraindications of vaccination and differences in knowledge about contraindications according to personnel in charge of administering immunization to children. Our preliminary results suggest that lack of education related to side effects could be biasing medical professionals' decisions, causing them to unnecessarily delay or deny vaccinations, which likely contributes to explaining low overall vaccination coverage in Quito, the capital city of Ecuador.

Use of Thrust Cervical Spinal Manipulative Therapy for Complicated Neck Pain: A Cross-Sectional Survey of Asia-Pacific Chiropractors

Background Chiropractors often use manual thrust cervical spinal manipulative therapy (thrust-cSMT) to treat musculoskeletal neck conditions. We hypothesized <50% of surveyed Asia-Pacific chiropractors would report using thrust-cSMT given potential contraindications, and secondarily explored predictors of thrust-cSMT use. Materials and methods We designed, validated, achieved sufficient reliability, and disseminated a survey to explore thrust-cSMT use. The survey queried chiropractors' characteristics (e.g., years in practice, education level, time with patients, importance of subluxation), and use of thrust-cSMT for uncomplicated neck pain and vignettes describing vertebral artery disorders, Arnold-Chiari malformation, and anterior cervical discectomy and fusion (ACDF). We performed logistic regression for each vignette with thrust-cSMT as the dependent variable and chiropractor characteristics as covariates. Results There were 241 respondents, having 12.8±10.9 years in practice, representing >15 countries. Less than 50% of chiropractors reported the use of thrust-cSMT for each vignette, including vertebral artery insufficiency (14%) and stenosis (17%), Arnold-Chiari type I (18%) and type II (5%), C5/6 ACDF (39%) and C3-6 ACDF (27%). Regressions identified significant predictors of increased or decreased use of thrust-cSMT including time spent with new patients, focus on subluxation, degree, group practice environment, use of thrust-cSMT on a healthy patient, and hours reading scientific literature (P<.05 for each). Conclusions This study was the first to chiropractors' use of thrust-cSMT for complicated neck pain and found that most Asia-Pacific chiropractors reported avoiding this treatment in the presence of a potential treatment contraindication. The use of thrust-cSMT in complicated neck pain may be related to practice characteristics. However, further research is needed to identify specific reasons why chiropractors use or avoid thrust-cSMT.

Cannabis Use and Heart Transplantation: Disparities and Opportunities to Improve Outcomes

Heart transplantation (HT) remains the optimal therapy for many patients with advanced heart failure. Use of substances of potential abuse has historically been a contraindication to HT. Decriminalization of cannabis, increasing cannabis use, clinician biases, and lack of consensus for evaluating patients with heart failure who use cannabis all have the potential to exacerbate racial and ethnic and regional disparities in HT listing and organ allocation. Here' we review pertinent pre-HT and post-HT considerations related to cannabis use' and relative attitudes between opiates and cannabis are offered for context. We conclude with identifying unmet research needs pertaining to the use of cannabis in HT that can inform a standardized evaluation process.

Safety of Electrotherapy Treatment in Patients with Knee Osteoarthritis and Cardiac Diseases

OBJECTIVE: To assess the safety of electrotherapy applied in the knee area in patients with known atrial arrhythmias or ischemic heart disease, as it is not known whether this treatment induces or aggravates arrhythmias during or immediately after therapy. MATERIAL AND METHODS: The analytical and transversal study involved 46 patients with degenerative knee osteoarthritis (OA), with or without cardiac diseases, from the Clinical Rehabilitation Hospital inpatient center, Cluj-Napoca, Romania. All patients underwent a 10-day physical therapy program for knee OA (electrotherapy, massage and kinesiotherapy). Heart rate and the total number of ventricular and supraventricular extrasystoles were evaluated before and after treatment, by 24 h Holter ECG monitoring. RESULTS: There was no significant increase in heart rate or in the number of ventricular or supraventricular extrasystoles before or after electrotherapy treatment, regardless of the positive or negative history of arrhythmia or ischemic heart disease (all p > 0.05). Mean values during day 1 were: 35.15 (95% CI [9.60−60.75]) for ventricular ones extrasystoles and 91.7 (95% CI [51.69−131.7]) for supraventricular ones, which during day 2 were 38.09 (95% CI [3.68−72.50]), 110.48 (95% CI [48.59−172.36]), respectively. CONCLUSION: One of the most important things to consider when dealing with an OA patient is that they are most likely older than 65 years, which increases the chance of having a cardiac disease. This raises the need for viable interventions regarding the management of this disease in patients that probably have multiple comorbidities, and where pharmacological and surgical management are not possible, limited or have multiple side effects. Electrotherapy used for treating knee OA did not cause a significant increase in heart rate or number of ventricular and supraventricular extrasystoles in this category of patients.

Current Approaches in the Allocation of Liver Transplantation

In recent decades, important advances have been made in the field of liver transplantation. One of the major problems remaining in this area is the small number of donors. Thus, recent data bring multiple updates of the indications and contraindications of this therapeutic method. The main goal is to increase the number of patients who can benefit from liver transplantation, a therapeutic method that can improve life expectancy and the quality of life of patients with end-stage liver disease. Another goal in the management of these patients is represented by the optimal care of those on the waiting list during that period. A multidisciplinary team approach is necessary to obtain the best results for both the donor and the recipient.

Total ankle arthroplasty with the use of Zimmer prosthesis and a review of the results of previous research conducted in this field

The aim of this article is to describe surgical technique and early results of Total Ankle Replacement (TAR) from lateral approach using Zimmer TM prosthesis. The study uses theoretical knowledge which is the result of research conducted by other authors, and practical knowledge due to the fact that our center performs that type of operation. Arthrodesis as the current standard in the treatment of advanced degenerative ankle disease, apart from its advantages, also has many disadvantages. The relative durability and reduction of the patients' pain have been achieved at the expense of the adjacent joints. Their accelerated arthrosis is the result of compensatory loads as a consequence of change in foot biomechanics. That determined implementation of solutions that will guarantee elimination of pain in the ankle joint, preserve its motor function and improve gait, while having no negative impact on the mobility of adjacent joints.

Variation in Left Ventricular Assist Device Postdischarge Caregiver Requirements: Results From a Mixed-Methods Study With Equity Implications

BACKGROUND

Left ventricular assist device (LVAD) evaluation includes a psychosocial assessment, conducted by social workers (SWs) on the advanced heart failure multidisciplinary team. Postdischarge caregiving plans are central to psychosocial evaluation. Caregiving's relationship with LVAD outcomes is mixed, and testing patients' social resources may disadvantage those from historically undertreated groups. We describe variation in policies defining adequate caregiving plans post-LVAD implant and possible impacts on patients from marginalized groups.

METHODS

This was a 2-phase sequential mixed-methods study: (1) phase 1, survey of US-based LVAD SWs, describing assessment structure and policies guiding candidacy outcomes; and (2) phase 2, individual interviews with SWs to further describe how caregiving plan adequacy impacts LVAD candidacy.

RESULTS

Sixty-seven SWs returned surveys (rr=47%) from unique programs. Caregiving plan inadequacy (n=30) was the most common psychosocial dealbreaker. When asked what duration of caregiving is required, 23% indicated ≥3 months, 27% 4 to 12 weeks, and 30% <4 weeks. Two reported no duration requirement, 6 stated an indefinite 24/7 commitment was necessary. Across 22 interviews, SWs mirrored that caregiving plans were the most common psychosocial contraindication. How caregiving is operationalized varied. Participants voiced a tension between extended caregiving improving outcomes and the sense that some people of color, women, or low socioeconomic status patients struggle to meet stringent requirements.

CONCLUSIONS

Policies regarding adequate duration of 24/7 caregiving vary, but inadequate caregiving plans are the most common psychosocial contraindication. Participants worry about patients' ability to meet restrictive requirements, particularly from historically undertreated groups. This highlights a need to operationalize quality caregiving, standardize assessment, and support medically appropriate patients with strained social resources.

Strategies for the treatment of acute benzodiazepine toxicity in a clinical setting: the role of antidotes

INTRODUCTION

Although not a potentially life-threatening poisoning, benzodiazepine (BZD) intoxication may be life-threatening in special situations/populations or those with background diseases.

AREAS COVERED

The aim of this review is to evaluate all possible treatment options available in the literature for the management of benzodiazepine poisoning with special attention to antidote administration. We conducted a literature search using PubMed, Google Scholar, EMBASE, and Cochrane central register from 1 January 1980 to 10 November 2021 using keywords 'benzodiazepine,' 'poisoning,' 'toxicity,' 'intoxication,' and 'treatment.'

EXPERT OPINION

Careful patient selection, ideally by a clinical toxicologist, may decrease the complications of flumazenil and add to its efficacy. The cost-to-benefit ratio should be considered in every single patient who is a candidate for flumazenil administration. In case a decision has been made to administer flumazenil, careful consideration of the possible contraindications is essential. We recommend slow administration of low doses of flumazenil (0.1 mg/minute) to avoid complications or withhold the administration with development of first signs of adverse effects. The main treatment of benzodiazepine toxicity is conservative with administration of activated charcoal, monitoring of the vital signs, prevention of aspiration and development of deep vein thrombosis due to prolonged immobilization, and respiratory support.

Effects of Drugs and Chemotherapeutic Agents on Dental Implant Osseointegration: Narrative Review

BACKGROUND

Dental implants have been one of the most popular treatments for rehabilitating individuals with single missing teeth or fully edentulous jaws since their introduction. As more implant patients are well-aged and take several medications due to various systemic conditions, clinicians should be mindful of possible drug implications on bone remodeling and osseointegration.

OBJECTIVE

The present study aims to study and review some desirable and some unwelcomed implications of medicine on osseointegration.

METHODS

A broad search for proper relevant studies were conducted in four databases, including Web of Science, Pubmed, Scopus, and Google Scholar.

RESULTS

Some commonly prescribed medicines such as nonsteroidal anti-inflammatory drugs (NSAIDs), glucocorticoids, proton pump inhibitors (PPIs), selective serotonin reuptake inhibitors (SSRIs), anticoagulants, metformin, and chemotherapeutic agents may jeopardize osseointegration. On the contrary, some therapeutic agents such as anabolic, anti-catabolic, or dual anabolic and anti-catabolic agents may enhance osseointegration and increase the treatment's success rate.

CONCLUSION

Systemic medications that enhance osseointegration include mineralization promoters and bone resorption inhibitors. On the other hand, medications often given to the elderly with systemic problems might interfere with osseointegration, leading to implant failure. However, to validate the provided research, more human studies with a higher level of evidence are required.

Workup and Clinical Assessment for Allergen Immunotherapy Candidates

Allergen Immunotherapy (AIT) is a well-established, efficient, and safe way to treat respiratory and insect-venom allergies. After determining the diagnosis of the clinically relevant culprit allergen, AIT can be prescribed. However, not all patients are eligible for AIT, since some diseases/conditions represent contraindications to AIT use, as described in several guidelines. Allergists are often preoccupied on whether an extensive workup should be ordered in apparently healthy AIT candidates in order to detect contra-indicated diseases and conditions. These preoccupations often arise from clinical, ethical and legal issues. The aim of this article is to suggest an approach to the workup and assessment of the presence of any underlying diseases/conditions in patients with no case history before the start of AIT. Notably, there is a lack of published studies on the appropriate evaluation of AIT candidates, with no globally accepted guidelines. It appears that Allergists are mostly deciding based on their AIT training, as well as their clinical experience. Guidance is based mainly on experts’ opinions; the suggested preliminary workup can be divided into mandatory and optional testing. The evaluation for possible underlying neoplastic, autoimmune, and cardiovascular diseases, primary and acquired immunodeficiencies and pregnancy, might be helpful but only in subjects for whom the history and clinical examination raise suspicion of these conditions. A workup without any reasonable correlation with potential contraindications is useless. In conclusion, the evaluation of each individual candidate for possible medical conditions should be determined on a case-by-case basis.

Direct Oral Anticoagulants Versus Warfarin in the Treatment of Cerebral Venous Thrombosis (ACTION-CVT): A Multicenter International Study

BACKGROUND

A small randomized controlled trial suggested that dabigatran may be as effective as warfarin in the treatment of cerebral venous thrombosis (CVT). We aimed to compare direct oral anticoagulants (DOACs) to warfarin in a real-world CVT cohort.

METHODS

This multicenter international retrospective study (United States, Europe, New Zealand) included consecutive patients with CVT treated with oral anticoagulation from January 2015 to December 2020. We abstracted demographics and CVT risk factors, hypercoagulable labs, baseline imaging data, and clinical and radiological outcomes from medical records. We used adjusted inverse probability of treatment weighted Cox-regression models to compare recurrent cerebral or systemic venous thrombosis, death, and major hemorrhage in patients treated with warfarin versus DOACs. We performed adjusted inverse probability of treatment weighted logistic regression to compare recanalization rates on follow-up imaging across the 2 treatments groups.

RESULTS

Among 1025 CVT patients across 27 centers, 845 patients met our inclusion criteria. Mean age was 44.8 years, 64.7% were women; 33.0% received DOAC only, 51.8% received warfarin only, and 15.1% received both treatments at different times. During a median follow-up of 345 (interquartile range, 140-720) days, there were 5.68 recurrent venous thrombosis, 3.77 major hemorrhages, and 1.84 deaths per 100 patient-years. Among 525 patients who met recanalization analysis inclusion criteria, 36.6% had complete, 48.2% had partial, and 15.2% had no recanalization. When compared with warfarin, DOAC treatment was associated with similar risk of recurrent venous thrombosis (aHR, 0.94 [95% CI, 0.51-1.73]; P=0.84), death (aHR, 0.78 [95% CI, 0.22-2.76]; P=0.70), and rate of partial/complete recanalization (aOR, 0.92 [95% CI, 0.48-1.73]; P=0.79), but a lower risk of major hemorrhage (aHR, 0.35 [95% CI, 0.15-0.82]; P=0.02).

CONCLUSIONS

In patients with CVT, treatment with DOACs was associated with similar clinical and radiographic outcomes and favorable safety profile when compared with warfarin treatment. Our findings need confirmation by large prospective or randomized studies.

Current trends in candidate selection, contraindications, and indications for lung transplantation

Lung transplantation is an established treatment option that can improve quality of life and prolong survival for select patients diagnosed with end-stage lung disease. Given the gaps in organ donation and failures to make effective use of available organs, careful selection of candidates for lung transplant remains one of the most important considerations of the transplant community. Toward this end, we briefly reviewed recent trends in pretransplant evaluation, candidate selection, organ allocation, and organ preservation techniques. Since the latest consensus statement regarding appropriate selection of lung transplant candidates, many advances in the science and practice of lung transplantation have emerged and influenced our perspective of ‘contraindications’ to transplant. These advances have made it increasingly possible to pursue lung transplant in patients with risk factors for decreased survival—namely, older recipient age, increased body mass index, previous chest surgery, poorer nutritional status, and presence of chronic infection, cardiovascular disease, or extrapulmonary comorbid conditions. Therefore, we reviewed the updated evidence demonstrating the prognostic impact of these risk factors in lung transplant recipients. Lastly, we reviewed the salient evidence for current trends in disease-specific indications for lung transplantation, such as chronic obstructive pulmonary disease, idiopathic pulmonary fibrosis, cystic fibrosis, emphysema due to alpha-1 antitrypsin deficiency, and pulmonary arterial hypertension, among other less common end-stage diseases. Overall, lung transplant remains an exciting field with considerable hope for patients as they experience remarkable improvements in quality of life and survival in the modern era.

Measles vaccination of special risk groups

Measles is an important vaccine preventable disease with significant morbidity and mortality. Although measles vaccine is a safe and effective vaccine available worldwide for more than 50 years, still immunization efforts have not successfully reached the WHO goal of 95% vaccination coverage. Hesitancy is especially increased amongst parents of children with chronic conditions. Contraindications for measles-containing vaccines are well defined and include history of anaphylactic reactions to neomycin, history of severe allergic reaction to previous vaccination, pregnancy, and severe immunosuppression. Concurrently, precautions for measles-containing vaccines include amongst other, history of thrombocytopenia or thrombocytopenic purpura and personal or family history of seizures of any etiology. This article aims to address misconceptions on measles vaccine safety and review data on adverse events among special groups of subjects at increased risk following measles immunization.

Contraindications differ widely among Beta Blockers and Ought to be Cited for an Individual Drug, Not for the Entire Class

Beta-blockers (BBs) have significant side effects that contribute to low adherence and persistence. Therefore, the optimal choice of BB is a vital mode to prevent BB's side effects, leading to an increase in compliance, which can improve the outcomes in BBs' evidence-based indications such as acute myocardial infarction, heart failure, etc. The paper aims to suggest an improved method of reporting contraindications for BBs. We used a search of the following indexing databases: SCOPUS and PubMed, and web search engine Google Scholar to identify guidelines on arterial hypertension (HTN). HTN guidelines published during the last two decades were analyzed (from 2000 to 2020). Some of the contraindications (e.g., bradycardia, acute heart failure) are true for every BB. However, some contraindications do not belong to the whole BB class. For example, propranolol and carvedilol are contraindicated in chronic obstructive lung disease, but nebivolol and bisoprolol are not. To our knowledge, there is a lack of guidelines citing contraindications for individual BBs because they vary a lot within the class of BBs. We suggest that contraindications specific for some BBs (i.e., not for the whole class) ought to be listed with the exact name(s) of the individual BBs. In this way, we may decrease the number of wrong choices among BBs and consequently increase drug adherence (which is currently worse for the class of BBs than for most of the other antihypertensive drugs). It is an approach to improve both primary medical education and guidelines.

Is a Mask That Covers the Mouth and Nose Free from Undesirable Side Effects in Everyday Use and Free of Potential Hazards?

Many countries introduced the requirement to wear masks in public spaces for containing SARS-CoV-2 making it commonplace in 2020. Up until now, there has been no comprehensive investigation as to the adverse health effects masks can cause. The aim was to find, test, evaluate and compile scientifically proven related side effects of wearing masks. For a quantitative evaluation, 44 mostly experimental studies were referenced, and for a substantive evaluation, 65 publications were found. The literature revealed relevant adverse effects of masks in numerous disciplines. In this paper, we refer to the psychological and physical deterioration as well as multiple symptoms described because of their consistent, recurrent and uniform presentation from different disciplines as a Mask-Induced Exhaustion Syndrome (MIES). We objectified evaluation evidenced changes in respiratory physiology of mask wearers with significant correlation of O2 drop and fatigue (p < 0.05), a clustered co-occurrence of respiratory impairment and O2 drop (67%), N95 mask and CO2 rise (82%), N95 mask and O2 drop (72%), N95 mask and headache (60%), respiratory impairment and temperature rise (88%), but also temperature rise and moisture (100%) under the masks. Extended mask-wearing by the general population could lead to relevant effects and consequences in many medical fields.

Adverse effects of modeling substances in Cali, Colombia

Introducción

El deseo de mejorar la apariencia física mediante métodos sencillos y económicos, ha generado la aplicación indiscriminada de sustancias modelantes y, con ello, el surgimiento de la alogenosis iatrogénica, enfermedad cada vez más prevalente en Latinoamérica.

Objetivo

Describir las características epidemiológicas y los efectos adversos de las sustancias modelantes en un grupo de pacientes de Cali, Colombia.

Materiales y métodos

Se hizo una revisión retrospectiva de las historias clínicas de los pacientes que acudieron a consulta por complicaciones producidas por sustancias modelantes durante un sexenio.

Resultados

Se incluyeron 1.322 pacientes, 95,5% de ellos mujeres. Las edades oscilaron entre los 19 y los 83 años, con una media de 39 años. El sitio anatómico de infiltración con sustancias modelantes con mayor frecuencia de efectos adversos, fueron los glúteos. La asimetría y el aumento del volumen en el sitio infiltrado fueron los signos más comunes, en tanto que el dolor, las alteraciones del ánimo y la depresión o la ansiedad fueron los síntomas más percibidos. El 33,6% de los pacientes desconocía la sustancia aplicada y el 28,1% refirió haberse aplicado biopolímeros. La mayoría de estos procedimientos estuvo a cargo de personal sin la debida formación.

Conclusiones

Estos pacientes requieren la atención de equipos multidisciplinarios para establecer alternativas de tratamiento que mejoren su calidad de vida. Además, se necesitan la regulación de los establecimientos, y las medidas de vigilancia, inspección y control en la importación y el uso de estas sustancias.

A Case Report Examining a Contraindication for Mechanical Thrombectomy in the Setting of a Large Vessel Occlusion and a Concurrent Contralateral Intracranial Hemorrhage

An acute ischemic stroke occurring contralateral to a hemorrhagic stroke is an uncommon occurrence that presents unique challenges. Hemorrhages have classically been described as a contraindication for mechanical thrombectomy. However, the natural course of a large vessel occlusion with or without decompressive hemicraniectomy is associated with significant morbidity and mortality. This paper investigates the origin of the contraindication for mechanical thrombectomy, the natural history of large vessel occlusion, risks of craniectomy, and risks of mechanical thrombectomy. Given the likelihood of poor outcomes without intervention, mechanical thrombectomy could be considered in select individuals, but future studies into the natural course of contralateral ischemic and hemorrhagic strokes would better guide management.

Off-label use of intravenous thrombolysis for acute ischemic stroke: a critical appraisal of randomized and real-world evidence

Intravenous thrombolysis (IVT) represents the only systemic reperfusion therapy able to reverse neurological deficit in patients with acute ischemic stroke (AIS). Despite its effectiveness in patients with or without large vessel occlusion, it can be offered only to a minority of them, because of the short therapeutic window and additional contraindications derived from stringent but arbitrary inclusion and exclusion criteria used in landmark randomized controlled clinical trials. Many absolute or relative contraindications lead to disparities between the official drug label and guidelines or expert recommendations. Based on recent advances in neuroimaging and evidence from cohort studies, off-label use of IVT is increasingly incorporated into the daily practice of many stroke centers. They relate to extension of therapeutic time windows, and expansion of indications in co-existing conditions originally listed in exclusion criteria, such as use of alternative thrombolytic agents, pre-treatment with antiplatelets, anticoagulants or low molecular weight heparins. In this narrative review, we summarize recent randomized and real-world data on the safety and efficacy of off-label use of IVT for AIS. We also make some practical recommendations to stroke physicians regarding the off-label use of thrombolytic agents in complex and uncommon presentations of AIS or other conditions mimicking acute cerebral ischemia. Finally, we provide guidance on the risks and benefits of IVT in numerous AIS subgroups, where equipoise exists and guidelines and treatment practices vary.

Laser Photobiomodulation (PBM)-A Possible New Frontier for the Treatment of Oral Cancer: A Review of In Vitro and In Vivo Studies

The treatment of oral squamous cell carcinoma (OSCC) is particularly complex due to its aggressive behavior, location, the patient’s age, and its spread at diagnosis. In recent years, photobiomodulation (PBM) has been introduced in different medical fields; however, its application, in patients suffering from OSCC for palliative support or to induce analgesia, has been hotly debated due to the possibility that the cell growth stimuli induced by PBM could lead to a worsening of the lesions. The aim of this study is to review the literature to observe the available data investigating the effect of PBM on cancer cells in vitro and in vivo. A review was conducted on the PubMed and Scopus databases. A total of twelve studies met the inclusion criteria and were therefore included for quality assessment and data extraction. The analysis showed that the clinical use of PBM is still only partially understood and is, therefore, controversial. Some authors stated that it could be contraindicated for clinical use in patients suffering from SCC, while others noted that it could have beneficial effects. According to the data that emerged from this review, it is possible to hypothesize that there are possibilities for PBM to play a beneficial role in treating cancer patients, but further evidence about its clinical efficacy and the identification of protocols and correct dosages is still needed.

Temporary and permanent unfitness of occupational divers. Brest Cohort 2002-2019 from the French National Network for Occupational Disease Vigilance and Prevention (RNV3P)

BACKGROUND

In France, the monitoring of professional divers is regulated. Several learned societies (French Occupational Medicine Society, French Hyperbaric Medicine Society and French Maritime Medicine Society) have issued follow-up recommendations for professional divers, including medical follow-up. Medical decisions could be temporary unfitness for diving, temporary fitness with monitoring, a restriction of fitness, or permanent unfitness. The aim of study was to point out the causes of unfitness in our centre.

MATERIALS AND METHODS

The divers' files were selected from the French National Network for Occupational Disease Vigilance and Prevention (RNV3P). Only files with a special medical decision were selected, between 2002 and 2019.

RESULTS

Three hundred and ninety-six professional divers are followed-up in our centre and 1371 medical decisions were delivered. There were 29 (7.3%) divers with a special medical decision, during 42 (3.1%) medical visit. Twelve (3.0%) had a permanent unfitness. The leading cause of unfitness was pulmonary diseases: emphysema (3), chronic obstructive pulmonary disorder (2), asthma (2). Sixteen (4.0%) divers had temporary unfitness. The leading causes were cardiovascular (4 times) and neurological (6 times). Twelve (3.0%) divers had had at least one decompression sickness.

CONCLUSIONS

Judgments of permanent unfitness for diving were rare (3.0% of divers), but were because of life-threatening disease. Medical follow-up of occupational divers was justified to decrease the risk of fatal event during occupational dives.

Prehospital Use of Ketamine in Mountain Rescue: A Survey of Emergency Physicians of a Single-Center Alpine Helicopter-Based Emergency Service

INTRODUCTION

Although ketamine use in emergency medicine is widespread, studies investigating prehospital use are scarce. Our goal was to assess the self-reported modalities of ketamine use, knowledge of contraindications, and occurrence of adverse events associated with its use by physicians through a prospective online survey.

METHODS

The survey was administered to physicians working for Air-Glaciers, a Swiss alpine helicopter-based emergency service, and was available between September 24 and November 23, 2018. We enrolled 39 participants (participation rate of 87%) in our study and collected data regarding their characteristics, methods of ketamine use, knowledge of contraindications, and encountered side effects linked to the administration of ketamine. We also included a clinical scenario to investigate an analgesic strategy.

RESULTS

Ketamine was considered safe and judged irreplaceable by most physicians. The main reason for ketamine use was acute analgesia during painful procedures, such as manipulation of femur fractures. The doses of ketamine administered with or without fentanyl ranged from 0.2 to 0.7 mg·kg^-1 intravenously. Most physicians reported using fentanyl and midazolam along with ketamine. The median dose of midazolam was 2 (interquartile range 1-2) mg for a 70-kg adult. Monitoring and oxygen administration were used infrequently. Hallucinations were the most common adverse events. Knowledge of ketamine contraindications was poor.

CONCLUSIONS

Ketamine use was reported by mountain rescue physicians to be safe and useful for acute analgesia. Most physicians use fentanyl and midazolam along with ketamine. Adverse neuropsychiatric events were rare. Knowledge regarding contraindications to the administration of ketamine should be improved.

Stroke prevention and guideline adherent antithrombotic treatment in elderly patients with atrial fibrillation: A real-world experience

Patients aged ≥75 years with the diagnosis of atrial fibrillation (AF) are at a higher risk of stroke and, according to recent recommendations, should receive oral anticoagulant (OAC) therapy. This study aimed to assess the recommended prophylactic antithrombotic therapy among patients with AF aged ≥ 75 years and its compliance with current guidelines. We also aimed to identify predisposing factors associated with the administration of non-vitamin K antagonist oral anticoagulants (NOACs) in elderly patients with AF.This was a retrospective, single-center observational study. Patients with AF aged ≥75 years hospitalized at a reference cardiology center from 2014 to 2017 were included in the analysis.Among the 1236 eligible patients (43.4% male; mean age, 82 years), OACs were recommended in 90.1% of cases. Of these, 59.8% of patients used NOACs and 40.2% used vitamin K antagonists. Additionally, 3.3% of patients received antiplatelet (AP) therapy and 2.5% were administered low molecular weight heparin. Only 4.5% of patients did not receive any anticoagulant treatment. The majority (89.9%) of patients received relevant prophylactic antithrombotic therapy according to current guidelines; only 1.4% were overtreated and 8.7% were undertreated. The significant predictors of NOAC therapy among patients treated with anticoagulants were non-permanent AF (odds ratio [OR] = 1.68, 95% confidence interval [CI] = 1.30-2.18, P = .0001), age-by 5 years (OR = 1.33, 95% CI = 1.16-1.52, P = .0001), and glomerular filtration rate-by 5 units (OR = 1.06, 95% CI = 1.02-1.10, P = .0066).A high percentage of AF patients aged ≥75 years receive OACs, mainly NOACs. Most patients are treated according to the current guidelines; under treatment is primarily observed in patients receiving AP therapy. Non-permanent AF, age, and preservation of renal function are significant predictors of NOAC use.

Case report of successful peripheral veno-arterial extracorporeal membrane oxygenation in a patient with chronic type B aortic dissection

A case report of successful application of peripheral veno-arterial extracorporeal membrane oxygenation in a patient with chronic type B aortic dissection and myocardial stunning to bridge to recovery was presented. Good outcomes from the application of peripheral veno-arterial extracorporeal membrane oxygenation in aortic dissection have rarely been reported, and the considerations of starting veno-arterial extracorporeal membrane oxygenation in this situation were seldom discussed. The orthodox that peripheral veno-arterial extracorporeal membrane oxygenation is an absolute contraindication for initiation of peripheral veno-arterial extracorporeal membrane oxygenation should be challenged. With proper planning and real-time transesophageal echocardiography-guided cannulation, peripheral veno-arterial extracorporeal membrane oxygenation is possibly beneficial. The considerations and echocardiography-guided techniques would be discussed in this report.

Iodinated contrast media and their effect on thyroid function - Routines and practices among diagnostic imaging departments in Norway

INTRODUCTION

In order to minimise adverse effects or patient injuries related to the effect of iodinated contrast media (ICM) on the thyroid, international guidelines and research recommend developing routines for identification and management of patients at risk of developing a thyroid dysfunction. This study aimed to investigate thyroid-related ICM administration practices among diagnostic imaging departments in Norway.

METHODS

The cross-sectional survey included 24 hospitals and 75 respondents with a 69% response rate. The survey covered practices for assessment and management of at-risk patients and the participants' perceived rationale for the routines.

RESULTS

The use of written checklists as recommended by international guidelines was quite modest (15%) and the respondents preferred various methods to identify risk and contraindications. Only 20% reported checking for any scheduled thyroid-scintigraphy and/or radioactive-iodine therapy. 42% indicated that they did not have thyroid-related ICM routines, and the main perceived reason was lack of knowledge on the topic. Radiographers and radiologists expressed uncertainty about each other's roles and routines.

CONCLUSION

This study revealed the need of optimisation of routines regarding ICM administration to patients at risk for thyroid dysfunction.

Management of Active Surveillance-Eligible Prostate Cancer during Pretransplantation Workup of Patients with Kidney Failure: A Simulation Study

BACKGROUND AND OBJECTIVES

The general rule that every active malignancy is an absolute contraindication for kidney transplantation is challenged by kidney failure patients diagnosed with active surveillance-eligible prostate cancer during pretransplantation workup. Interdisciplinary treatment teams therefore often face the challenge of balancing the benefits of early kidney transplantation and the risk of metastatic progression. Hence, we compared the quality-adjusted life expectancy of different management strategies in kidney failure patients diagnosed with active surveillance-eligible prostate cancer during pretransplantation workup.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

A discrete event simulation model was developed on the basis of a systematic literature search, clinical guidelines, and expert opinion. After model validation and calibration, we simulated four management strategies in a hypothetical cohort of 100,000 patients: Definitive treatment (surgery or radiation therapy) and listing after a waiting period of 2 years, definitive treatment and immediate listing, active surveillance and listing after a waiting period of 2 years, and active surveillance and immediate listing. Individual patient results (quality-adjusted life years; QALYs) were aggregated into strategy-specific means (± SEs).

RESULTS

Active surveillance and immediate listing yielded the highest amount of quality-adjusted life expectancy (6.97 ± 0.01 QALYs) followed by definitive treatment and immediate listing (6.75 ± 0.01 QALYs). These two strategies involving immediate listing not only outperformed those incorporating a waiting period of 2 years (definitive treatment: 6.32 ± 0.01 QALYs; active surveillance: 6.59 ± 0.01 QALYs) but also yielded a higher proportion of successfully performed transplantations (72% and 74% versus 56% and 59%), with less time on hemodialysis on average (4.02 and 3.81 years versus 4.80 and 4.65 years).

CONCLUSIONS

Among kidney failure patients diagnosed with active surveillance-eligible prostate cancer during pretransplantation workup, the active surveillance and immediate listing strategy outperformed the alternative management strategies from a quality of life expectancy perspective, followed by definitive treatment and immediate listing.

Safety of the current drug treatments for vitiligo

Introduction: Vitiligo is an acquired depigmenting skin disorder adversely affecting the patient's quality of life. Despite the presence of several treatment modalities, ranging from medical to physical to surgical options, none is curative. Each modality has its own drawbacks and side effects. Thus, the treatment modality needs to be tailored for each individual patient taking into consideration the disease characteristics and also its efficacy and safety to obtain a favorable risk-benefit ratio.Areas covered: This review highlights the different treatment modalities utilized in vitiligo up until 4 November 2019 along with their adverse effects and contraindications, if any.Expert opinion: All the medications have their own adverse effects and contraindications. We have included the most commonly used topical corticosteroids, which may result in striae, cutaneous atrophy, and tachyphylaxis, to the recently introduced biologics, which may induce hypersensitivity reactions, systemic toxicities, and even malignancies. However, more long-term studies are needed to assess the safety of these medications, especially the newer ones, to provide a safe and effective treatment for this disorder.

Trends of r-tPA (Recombinant Tissue-Type Plasminogen Activator) Treatment and Treatment-Influencing Factors in Acute Ischemic Stroke

Background and Purpose- Frequencies of treatment with r-tPA (recombinant tissue-type plasminogen activator) are increasing over the past 15 years. However, published data on the influence of various demographic and clinical factors on r-tPA treatment as well as estimates of future trajectories are limited. We evaluated time trends and future trajectories of r-tPA treatment in patients with acute stroke and the influence of various factors on r-tPA treatment by analyzing data of 103 970 patients enrolled in the Austrian Stroke Unit Registry from 2006 to 2018, of which 18 953 were treated with r-tPA. Methods- Time trends of r-tPA-treatment were investigated in predefined subgroups (minor/major stroke, age, anterior/posterior circulation stroke); limited exponential time series models were calculated to estimate future trends of r-tPA-treatment. Logistic regression models were calculated to estimate the influence of clinical variables on r-tPA-treatment. Results- Overall, r-tPA treatment frequencies increased from 9.9% in 2006 to 21.8% in 2018. We observed a particular increase in patients >80 years, patients presenting with a National Institutes of Health Stroke Scale Score of 2 to 3, patients with posterior circulation stroke, patients with wake-up stroke, and patients without atrial fibrillation. Forecast of overall r-tPA frequencies predicted a further but flattened increase up to 24% by 2025. Logistic regression of time-dependent associations of clinical variables with r-tPA-treatment revealed increasing odds of r-tPA-treatment in patients with a posterior circulation stroke and decreasing odds of r-tPA-treatment in patients with atrial fibrillation. Conclusions- We observed a positive development of r-tPA-treatment frequencies mirroring increasing confidence with intravenous thrombolysis in clinical practice; however, decreasing odds of r-tPA-treatment over time in patients with atrial fibrillation deserve particular attention.

Do drug-related safety warnings have the expected impact on drug therapy? A systematic review

PURPOSE

The need for drug-related safety warnings is undisputed, and their impact should also be evaluated. This systematic review investigates and assesses the impact of safety warnings on drug therapy.

METHODS

Studies published in English between January 1998 and December 2018 were searched in EMBASE and MEDLINE, complemented by manual search. Randomised controlled trials, cohort studies with a before/after component, and case-control studies were included, selected to predefined criteria, and assessed for their reporting and methodological quality.

RESULTS

Out of 7454 references identified, 72 studies were included. A total of 28/72 (39%) studies described the impact of safety warnings on drug therapy as being effective, whereas 12/72 (17%) studies did not. Further, 26/72 (36%) studies described a partial implementation of the warnings (one part of the warning had an impact on drug therapy and another did not). Unintended effects were investigated in 6/72 (8%) studies. While 34 (47%) studies examined safety warnings on psychotropic drugs using an interrupted time series (ITS) design (53%), a before/after (26%), and a time series design (21%), 38 (53%) studied other substances using an ITS design (34%), a before/after (40%), and a time series design (26%). The proportion of an effective impact on drug therapy was lower in the "psychotropic drugs" group (23%) than in the "others" group (53%).

CONCLUSION

Drug-related safety warnings induce intended and unintended effects. The included studies are of broadly varying methodological quality. To better compare their effectiveness, studies should be conducted using standardised procedures.

Are prescribers not aware of cardiovascular contraindications for diclofenac? A claims data analysis

OBJECTIVES

To compare diclofenac use before and after implementation of European risk minimization measures in 2013, focusing on diclofenac initiators and prevalence of congestive heart failure (NYHA class II-IV), ischaemic heart disease, peripheral arterial disease and cerebrovascular disease (new contraindications) in these patients in Germany.

METHODS

We included adults with health insurance coverage on 1 January 2011 (cohort 2011) or 1 January 2014 (cohort 2014) and during a 1-year pre-observation period. We defined diclofenac initiators as persons filling a prescription of systemic diclofenac in 2011 (cohort 2011) or 2014 (cohort 2014) and without such a prescription during the respective pre-observation period.

RESULTS

Each cohort comprised >10 million persons. Between 2011 and 2014, the age-standardized proportion of persons initiating diclofenac decreased by 29% (from 8.2% to 5.8%) amongst female patients and by 26% (from 8.5% to 6.3%) amongst male patients; in the subgroup of persons with new contraindications, this proportion decreased by 33% (from 9.8% to 6.6%) amongst female patients and by 31% (from 10.0% to 6.7%) amongst male patients. Amongst diclofenac initiators, the proportion of those with new contraindications did not change between 2011 (12.0%) and 2014 (11.8%).

CONCLUSION

The overall decline of about 30% in diclofenac initiation between 2011 and 2014 was largely independent of the presence or absence of new contraindications. The proportion of diclofenac initiators with a new contraindication remained at a high level (more than one in ten patients), demonstrating the need for research at the prescriber level (e.g. interventional studies) and further measures to improve patient safety.

Hepatic Microwave Ablation in Challenging Locations

In recent years, there has been increased utilization of microwave ablation (MWA) in the treatment of soft tissue tumors. MWA has several theoretical advantages over radiofrequency ablation (RFA) by achieving a more rapid and sustained heating of tissues, increased efficacy in tissues with poor thermal conductivity, and less susceptibility to heat sink effect. While its greater power output has led to appropriate caution when applying this energy to soft tissue tumors, many commonly held beliefs regarding contraindications to MWA are unsupported by data and have been passed along based on experience with RFA. The goal of this article is to review the use of MWA in challenging clinical situations along with the existing evidence for its use.