The acute vestibular syndrome: prevalence of new hearing loss and its diagnostic value

OBJECTIVES

To assess the prevalence of new hearing losses in patients with acute vestibular syndrome (AVS) and to start to evaluate its diagnostic value for the differentiation between peripheral and central causes.

DESIGN

We performed a cross-sectional prospective study in AVS patients presenting to our Emergency Department (ED) from February 2015 to November 2020. All patients received an MRI, Head-impulse test, Nystagmus test and Test of skew ('HINTS'), caloric testing and a pure-tone audiometry.

RESULTS

We assessed 71 AVS patients, 17 of whom had a central and 54 a peripheral cause of dizziness. 12.7% had an objective hearing loss. 'HINTS' had an accuracy of 78.9% to diagnose stroke, whereas 'HINTS' plus audiometry 73.2%. 'HINTS' sensitivity was 82.4% and specificity 77.8% compared to 'HINTS' plus audiometry showing a sensitivity of 82.4% and specificity of 70.4%. The four patients with stroke and minor stroke had all central 'HINTS'. 55% of the patients did not perceive their new unilateral hearing loss.

CONCLUSIONS

We found that almost one-eighth of the AVS patients had a new onset of hearing loss and only half had self-reported it. 'HINTS' plus audiometry proved to be less accurate to diagnose a central cause than 'HINTS' alone. Audiometry offered little diagnostic accuracy to detect strokes in the ED but might be useful to objectify a new hearing loss that was underestimated in the acute phase. Complete hearing loss should be considered a red flag, as three in four patients suffered from a central cause.

Gastroparesis in Adolescent Patient with Type 1 Diabetes: Severe Presentation of a Rare Pediatric Complication

Gastroparesis is a long-term complication of diabetes related to autonomic neuropathy. It is characterized clinically by delayed gastric emptying and upper gastrointestinal symptoms, including early satiety, postprandial fullness, nausea, vomiting, and abdominal pain. Gastric emptying scintigraphy is the gold standard for diagnosis as it reveals delayed gastric emptying. Therapeutic strategies include dietary modifications, improvement of glycemic control, and prokinetic drugs. Case descriptions of diabetic gastroparesis in pediatric ages are very scarce. We report the case of a 16-year-old adolescent with severe presentation of diabetic gastroparesis. She presented with recurrent episodes of nausea, vomiting and abdominal pain which led progressively to reduced oral intake and weight loss. Her past glycemic control had been quite brittle, as demonstrated by several hospitalizations due to diabetic ketoacidosis and recurrent episodes of severe hypoglycemia. After the exclusion of infectious, mechanical, metabolic, and neurological causes of vomiting, a gastric emptying scintigraphy was performed, leading to the diagnosis of gastroparesis. Treatment with metoclopramide was started with progressive relief of symptoms. To improve glycemic control, insulin therapy with an advanced hybrid, closed loop system was successfully started. Pediatricians should consider diabetic gastroparesis in children and adolescents with long-standing, poorly controlled diabetes and appropriate symptomology.

Impact of antithrombotic therapy on acute and delayed intracranial haemorrhage and evaluation of the need of short-term hospitalisation based on CT findings after mild traumatic brain injury: experience from an oral and maxillofacial surgery unit

PURPOSE

The primary aim was to compare the prevalence of acute and delayed intracranial haemorrhage (ICH) following mild traumatic brain injury (mTBI) in patients on antithrombotic medication referred to a clinic for oral and plastic maxillofacial surgery. The secondary aim was to evaluate the need for short-term hospitalisation based on initial radiological and clinical findings.

METHODS

This was an observational retrospective single-centre study of all patients on antithrombotic medication who were admitted to our department of oral and plastic maxillofacial surgery with mTBI over a 5 year period. Demographic and anamnesis data, injury characteristics, antithrombotic medication, radiological findings, treatment, and outcome were analysed. Patients were divided into the following four groups based on their antithrombotic medication: (1) single antiplatelet users, (2) vitamin K antagonist users, (3) direct oral anticoagulant users, and (4) double antithrombotic users. All patients underwent an emergency cranial CT (CT0) at admission. Based on clinical and radiological evaluation, different treatment protocols were applied. Patients with positive CT0 findings and patients with secondary neurological deterioration received a control CT (CT1) before discharge. Acute and delayed ICH and patient's outcome during hospitalisation were evaluated using descriptive statistical analysis.

RESULTS

A total of 696 patients (mean age, 71.6 years) on antithrombotic medication who presented at our department with mTBI were included in the analysis. Most injuries were caused by a ground-level fall (76.9%). Thirty-six patients (5.1%) developed an acute traumatic ICH, and 47 intracerebral lesions were detected by radiology-most of these in patients taking acetylsalicylic acid. No association was detected between ICH and antithrombotic medication (p = 0.4353). In total, 258 (37.1%) patients were admitted for 48 h in-hospital observation. The prevalence of delayed ICH was 0.1%, and the mortality rate was 0.1%. Multivariable analysis identified a Glasgow Coma Scale (GCS) of < 15, loss of consciousness, amnesia, headache, dizziness, and nausea as clinical characteristics significantly associated with an increased risk of acute ICH, whereas age, sex, and trauma mechanism were not associated with ICH prevalence. Of the 39 patients who underwent a control CT1, most had a decreasing or at least constant intracranial lesion; in three patients, intracranial bleeding increased but was not clinically relevant.

CONCLUSION

According to our experience, antithrombotic therapy does not increase the rate of ICH after mTBI. A GCS of < 15, loss of consciousness, amnesia, headache, dizziness, and nausea are indicators of higher ICH risk. A second CT scan is more effective in patients with secondary neurological deterioration. Initial CT findings were not clinically relevant and should not indicate in-hospital observation.

Prevention of postoperative stroke in pediatric moyamoya patients: a standardized perioperative care protocol

OBJECTIVE

Perioperative stroke is a major complication of revascularization surgery in patients with moyamoya. Vomiting is common after neurosurgical procedures and may result in acute changes in intracranial pressure and cerebral blood flow. The authors instituted a standardized perioperative nausea and vomiting protocol for children with moyamoya undergoing indirect bypass surgery at their institution and analyzed its association with perioperative stroke. They hypothesized that instituting a standardized perioperative nausea and vomiting protocol would be associated with reduction in the number of perioperative strokes in children with moyamoya undergoing indirect bypass surgery.

METHODS

The authors retrospectively reviewed consecutive cases of children and young adults with moyamoya who underwent indirect bypass surgery before and after implementation of a new perioperative nausea and vomiting protocol at a single institution. They compared the rate of strokes in the perioperative period (postoperative days 0 and 1) in the 31 months following implementation to 31 months prior to implementation using Fisher's exact test.

RESULTS

The median ages pre- and postimplementation were 8.5 (IQR 4-12) years and 8.3 (IQR 5-15) years, respectively. There were no significant differences between the cohorts in disease severity or other potentially confounding factors. In the 31 months prior to initiation of the perioperative nausea and vomiting protocol, there were 5 strokes in 137 surgically treated hemispheres (3.6%). After initiation of the protocol, there were no strokes in 114 surgically treated hemispheres (p = 0.065).

CONCLUSIONS

Instituting a standardized perioperative nausea and vomiting protocol was associated with reduction in perioperative strokes in children with moyamoya treated with indirect bypass surgery.

Recognising and managing migraine

Migraine is a common neurological disorder characterised by a severe, pulsating headache, sometimes accompanied with photophobia or phonophobia and nausea and/or vomiting. The symptoms of migraine can have a significant adverse effect on a person's ability to undertake normal activities. Nurses have an important role in assisting patients in identifying migraine triggers and in supporting them to manage the symptoms of migraines through lifestyle changes and pharmacological treatments. This article describes different types of migraines and some differential diagnoses and 'red flag' symptoms that could indicate a more serious condition. The author also discusses non-pharmacological and pharmacological management strategies and treatments.

Liquid and solid gastric emptying and correlation with clinical characteristics in pediatric patients with dyspepsia

BACKGROUND

There is limited data on gastric emptying in dyspeptic children. We aimed to determine solid and liquid emptying rates in dyspeptic children and correlate with clinical characteristics.

METHODS

Charts of dyspeptic children undergoing 4-hour dual-phase gastric scintigraphy were reviewed for demographics, symptoms, and comorbidities.

KEY RESULTS

In 1078 dyspeptic patients (65% females, median age 13 years) vomiting (55%), nausea (53%), and abdominal pain (52%) were the most common symptoms. The most common comorbidities were mental health (32%), neurologic (27%), and hypermobility spectrum disorders (20%). Solid and liquid emptying rates were aligned in 61.23%. Delayed solid with normal liquid emptying were noted in 2.5%, compared to delayed liquid with normal solid emptying in 26.16%. Abdominal pain had a trend for association with delayed or normal solid emptying (p = 0.06). Nausea was mostly reported with normal solid emptying (p < 0.0001) and underreported in patients <12 years with vomiting (29%). Abnormal solid emptying (rapid and delayed) was noted more frequently in children with mental health disorders (p = 0.027). Rapid liquid emptying was more common in children with genetic disorders (p = 0.032).

CONCLUSION AND INFERENCES

Over half of children with dyspepsia had delayed liquid gastric emptying, and one quarter had delayed liquid with normal solid emptying. Dual-phase gastric emptying studies may help target therapy in dyspeptic children. Nausea is not a reliable symptom for dyspepsia in younger children. Given the significant association of abnormal gastric emptying in children with mental health disorders, we recommend screening and treating children with dyspepsia.

GDF15 linked to maternal risk of nausea and vomiting during pregnancy

GDF15, a hormone acting on the brainstem, has been implicated in the nausea and vomiting of pregnancy, including its most severe form, hyperemesis gravidarum (HG), but a full mechanistic understanding is lacking1-4. Here we report that fetal production of GDF15 and maternal sensitivity to it both contribute substantially to the risk of HG. We confirmed that higher GDF15 levels in maternal blood are associated with vomiting in pregnancy and HG. Using mass spectrometry to detect a naturally labelled GDF15 variant, we demonstrate that the vast majority of GDF15 in the maternal plasma is derived from the feto-placental unit. By studying carriers of rare and common genetic variants, we found that low levels of GDF15 in the non-pregnant state increase the risk of developing HG. Conversely, women with β-thalassaemia, a condition in which GDF15 levels are chronically high5, report very low levels of nausea and vomiting of pregnancy. In mice, the acute food intake response to a bolus of GDF15 is influenced bi-directionally by prior levels of circulating GDF15 in a manner suggesting that this system is susceptible to desensitization. Our findings support a putative causal role for fetally derived GDF15 in the nausea and vomiting of human pregnancy, with maternal sensitivity, at least partly determined by prepregnancy exposure to the hormone, being a major influence on its severity. They also suggest mechanism-based approaches to the treatment and prevention of HG.

Treatment of postsurgical gastroparesis syndrome with Fu's subcutaneous needling: A case report

Postsurgical gastroparesis syndrome is a syndrome of significantly delayed gastric emptying in the absence of mechanical obstruction after surgery. We presented a case of 69-year-old male patient who suffered from progressive nausea, vomiting and stomach fullness, with a bloating abdomen ten days after laparoscopic radical gastrectomy for gastric cancer. Conventional treatments such as gastrointestinal decompression, gastric acid suppression therapy and intravenous nutritional support were administrated, but there were no obvious improvements in nausea, vomiting, abdominal distension of this patient. Fu's subcutaneous needling was performed once a day for three days, for a total of three treatments. After three days of Fu's subcutaneous needling intervention, he was free of symptoms of nausea, vomiting and stomach fullness. His gastric drainage volume reduced from 1000 ml per day to 10 ml per day. Upper gastrointestinal angiography showed normal peristalsis of remnant stomach. In this case report, Fu's subcutaneous needling showed a potential role of gastrointestinal motility enhancement and gastric drainage volume decrement, which provided a safe and convenient method in palliative care of postsurgical gastroparesis syndrome.

Effect of gender on presentation and outcome of renal colic

OBJECTIVES

To examine gender-related differences in the presentation, management, and outcomes of patients admitted to the emergency department ED with ureteral stones.

METHODS

Retrospective analysis of all patients admitted to the ED at our institution, found to have a ureteral stone on CT. Clinical, laboratory, imaging parameters, and outcomes were collected.

RESULTS

778 patients were admitted with ureteral stones between January 2018 and December 2020. 78% (n = 609) were males and 22% (n = 169) were females. The mean ages were 49.4 (SD 14.4) and 51.6 (SD 15.7) in males and females, respectively (p = 0.08). Female patients presented with a higher body temperature (p = 0.01), pulse rate (p < 0.0001), nausea and vomiting (p < 0.0001), elevated serum C-reactive protein (CRP) (p = 0.002) compared to males. The prevalence of elevated serum creatinine was higher in males (p < 0.0001). Alpha-blockers were recommended on discharge in 54.8% (334) of males, compared to only 29.6% (50) of females (p < 0.0001). Spontaneous stone expulsion was significantly higher in males compared to females (p = 0.01).

CONCLUSIONS

Our results demonstrate that gender does effect presentation and outcome of patients presenting with renal colic. Females were found to have elevated infectious parameters, more nausea and vomiting and a higher incidence of positive urine cultures. Males admitted to the ED were found to have significantly higher serum creatinine levels. Medical expulsive therapy (MET) with alpha-blockers was prescribed significantly less in female patients, which may have resulted in a lower spontaneous stone expulsion rate.

Impact of Sleep Disturbance on Fatigue, Nausea, and Pain: Mediating Role of Depressive Symptoms Among Youth With Disorders of Gut-Brain Interaction

OBJECTIVES

A high degree of sleep disturbance is reported among youth with disorders of gut-brain interaction (DGBIs). Given that sleep quality impacts a range of pediatric health outcomes including somatic sensations (eg, pain) and depressive mood occurs relatively frequently among youth with DGBIs, there is a dire need to disentangle the unique contributions of sleep and depressive mood on the somatic sensations experienced by youth with DGBIs. We aimed to examine whether depressive mood mediates the relations among sleep disturbance and pain intensity, nausea, and fatigue among youth with DGBIs.

METHODS

One hundred eighteen patients aged 8-17 years ( Mage = 14.05, SD = 2.88; 70.34% female), 83.05% White/non-Hispanic recruited at a pediatric neurogastroenterology clinic completed measures of sleep disturbance, nausea, fatigue, pain intensity, and depressive mood. Three mediation models examined the effect of sleep disturbance on nausea, fatigue, and pain, with depressive mood as a mediator.

RESULTS

Participants reported moderate sleep disturbance. Depressive mood partially mediated the significant, respective relations between greater sleep disturbance and more severe nausea and fatigue. Sleep disturbance was significantly associated with higher pain intensity; however, depressive mood was not a significant mediator of this relation.

CONCLUSIONS

Sleep quality is a major concern among youth with DGBIs. Low sleep quality may worsen nausea and fatigue via co-occurring increases in depressive mood symptoms. In contrast, sleep disturbance may directly increase pain, regardless of youths' depressive mood symptoms. Future research should explore these relations through prospective studies leveraging a combination of subjective and objective assessment approaches.

Anesthesia via peripheral nerve blocks during total knee replacement has no effect on postoperative inflammation in elderly patients

BACKGROUND

We have previously shown that, compared with general anesthesia (GA), the procedure of peripheral nerve blocks (PNB) facilitates faster recovery of elderly patients from total knee replacement (TKR). Here, we investigated whether the faster recovery is associated with decreased perioperative stress and inflammation and decreased incidences of postoperative complications.

METHODS

After randomization, 165 patients aged ≥65 years underwent TKR under GA or PNB. The primary outcomes were the perioperative inflammation and stress levels, based on the serum C-reactive protein and interleukin-6 levels, erythrocyte sedimentation rate, white-blood cell and neutrophil counts, and blood-sugar level. The secondary outcomes were the postoperative complications, including cardiovascular, respiratory, and hepatic or renal complications, insomnia, delirium, electrolyte disturbances, and nausea and vomiting.

RESULTS

The two groups were not significantly demographically different (p > .05). Of the cytokines related to stress and inflammation, the differences of time points were statistically significant between the two groups (p < .01), but two-way ANOVA revealed no interaction between the time points and groups. Incidences of postoperative complications were far lower in PNB group than in GA group (p = .006). Incidences of postoperative respiratory complications (p = .005) and postoperative nausea and vomiting (p = .040) were significantly lower in PNB group than in GA group. There were no significant differences in other complications between the two groups (p > .05).

CONCLUSIONS

PNB does not alleviate the stress and inflammation in elderly patients post TKR but significantly reduces the incidences of postoperative complications, especially respiratory complications, and nausea and vomiting. (ClinicalTrials.gov Identifier: NCT01871012).

Can robotic-assisted surgery support enhanced recovery programs?

Enhanced recovery after surgery (ERAS) protocols comprise a multimodal approach to optimize patient outcome and recovery. ERAS guidelines recommend minimally invasive surgery (MIS) when possible. Key components in MIS include preoperative patient education and optimization; multimodal and narcotic-sparing analgesia; prophylactic measures regarding nausea, infection, and venous thrombosis; maintenance of euvolemia; and promotion of the early activity. ERAS protocols in MIS improve outcome mainly in terms of reduced length of stay and subsequently reduced cost. In addition, ERAS protocols in MIS reduce postoperative pain and nausea, increase patient satisfaction, and might reduce the rate of postoperative complications. Robotic surgery supports ERAS through facilitating MIS in complex procedures where laparotomy is an alternative approach.

Safety and efficacy of intrathecal morphine in early onset scoliosis surgery

Intrathecal morphine (IM) is a popular adjunct for pain management in spinal deformity surgery for idiopathic scoliosis. It has not been studied in patients with early onset scoliosis (EOS). We retrospectively reviewed EOS patients undergoing growth-friendly surgery who received IM or did not receive IM (non-IM). Data from initial insertion and final fusion procedures were studied. IM was not used for lengthening procedures, short procedures (<3 h), patients with significant underlying respiratory issues, paraplegia, unsuccessful access and anesthesiologist discretion. We assessed pediatric ICU (PICU) admission and IM complications (respiratory depression, pruritus and nausea/vomiting), time to first postoperative opiate, and pain scores. There were 97 patients including 97 initial insertions (26 IM and 71 non-IM) and 74 patients with final fusions (17 IM and 57 non-IM). The first dose of opioids following insertion and final fusion occurred at 16.8 ± 3.8 and 16.8 ± 3.1 h postoperatively in the IM group compared to 5.5 ± 2.8 and 8.3 ± 3.2 h in the non-IM group, respectively ( P  < 0.001). Postoperative pain scores were lower in the IM groups ( P  = 0.001). Two patients with IM developed mild respiratory depression following initial insertion ( P  = 0.01) but did not require PICU admission. The rate of respiratory depression was not different between the final fusion groups. There was no difference between pruritus and nausea/vomiting at the final fusion. Preincision IM can provide well-tolerated and effective initial postoperative analgesia in select children with EOS undergoing spinal deformity surgery.

Efficacy of a propofol bolus against placebo to prevent cough at emergence from general anesthesia with desflurane: a randomized controlled trial

PURPOSE

Emergence from anesthesia is a critical period and cough can result in adverse effects. Propofol inhibits airway reflexes and when infused it reduces cough more than inhalation anesthesia does. We evaluated the effect of a propofol bolus given at emergence on the incidence of coughing following a desflurane-based anesthesia.

METHODS

One hundred and fifty-four patients scheduled for elective surgery were prospectively randomized to propofol (0.5 mg·kg-1) or normal saline (NS) administered at the end of the surgery at 1 minimum alveolar concentration (MAC) of desflurane. A "no touch" emergence technique was used until extubation. The primary outcome was the incidence of cough at the discontinuation of desflurane (T0) and reaching a MAC adjusted for age (MACage) of 0.15. Secondary outcomes included incidence and severity of cough until five minutes postextubation (T0-T5), time to extubation, nausea and vomiting, sedation, hemodynamic variations, postoperative hypoventilation, hypoxemia, and sore throat.

RESULTS

We could not draw inferences on the incidence of cough between T0 and MACage of 0.15 because only 27/68 (40%) patients in the NS group and 13/73 (18%) patients in the propofol group regained consciousness before reaching a MACage of 0.15. There were no significant differences between the groups in coughing incidence and severity between T0 and T5 (NS group, 57/68 [84%] vs propofol group, 70/73 [96%] ). The mean time to extubation in the propofol group was prolonged by 3 min 27 sec (95% confidence interval, 1 min 7 sec to 4 min 47 sec; P < 0.001) and more vasopressors were used at emergence (P = 0.02). The incidence of respiratory complications, nausea and vomiting, agitation, and sedation were not different between groups.

CONCLUSION

In the present trial, a propofol bolus administered at emergence did not reduce the incidence of cough occurring between T0 and T5 following a desflurane-based general anesthesia compared with placebo.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT02932397); registered 13 October 2016.

Safety and efficacy of combined ropivacaine and sufentanil compared with ropivacaine for cesarean sections: A systematic review and meta-analysis

Cesarean sections are the most common operations in the United States and one of the most common worldwide. Using the lowest possible dose of anesthetic that provides painless delivery with the lowest adverse events is a major concern. We investigated the efficacy and safety of combined ropivacaine and sufentanil by pooling data from relevant studies. We searched PubMed, Web of sciences, Scopus, and Cochrane Library until the end of December 2021 and included all records with data about combined ropivacaine and sufentanil. We used Review Manager to pool data as a mean difference for continuous outcomes or risk ratio for dichotomous outcomes with a 95% confidence interval. Methodological quality was appraised using version one of the Cochrane risks of bias tool. Seven Randomized clinical trials with a total sample size of 730 women were included; the mean age of enrolled parturients ranged from 28 to 35 years. We found that combined sufentanil and ropivacaine were significantly associated with decreased risk of being aware and nervous during CS (presented by Sedation level 1) (RR: 0.05, 95%CI [0.01,0.33], P=0.002), decreased risk of shivering (RR=0.29, 95%CI [0.19,0.44], P<0.00001), nausea (RR=0.62, 95%CI [0.41, 0.92], P=0.02), and vomiting (RR=0.27, 95% CI [0.12, 0.61], P=0.002). However, combined sufentanil and ropivacaine slightly were associated with late-onset of sensory blockade (MD=0.41, 95%CI [0.13, 0.68], P=0.004) and less motor blockade of leg flexion at hip joint presented by Bromage Scale 0 (RR=7.15 95%CI [2.71, 18.86], P<0.0001). Combined ropivacaine and sufentanil were associated with a reduction in visceral pain and lower risks of hypotension, shivering, nausea, and vomiting, compared to isolated ropivacaine, with no difference regarding the incidence of bradycardia. Although Combined ropivacaine and sufentanil were associated with a higher risk of pruritus, the incidence of pruritus was reportedly proportionate with the used dose of sufentanil. However, combined ropivacaine and sufentanil may slightly delay the onset of the sensory blockade to pinprick at T10 with less motor blockade but with a smaller probability for women to be aware and nervous during CS.

Clinical characteristics and outcomes of pheochromocytoma crisis: a literature review of 200 cases

PURPOSE

Pheochromocytoma crisis is a life-threatening endocrine emergency that requires prompt diagnosis and treatment. Because of its rarity, sudden onset, and lack of internationally uniform and validated diagnostic criteria, pheochromocytoma crisis remains to be fully clarified. Therefore, we aimed to describe the clinical characteristics and outcomes of pheochromocytoma crisis through a literature review.

METHODS

We performed a systematic literature search of PubMed/MEDLINE database, Igaku-Chuo-Zasshi (Japanese database), and Google Scholar to identify case reports of pheochromocytoma crisis published until February 5, 2021. Information was extracted and analyzed from the literature that reported adequate individual patient data of pheochromocytoma crisis in English or Japanese. Cases were also termed as pheochromocytoma multisystem crisis (PMC) if patients had signs of hyperthermia, multiple organ failure, encephalopathy, and labile blood pressure.

RESULTS

In the 200 cases of pheochromocytoma crisis identified from 187 articles, the mean patient age was 43.8 ± 15.5 years. The most common symptom was headache (39.5%). The heart was the most commonly damaged organ resulting from a complication of a pheochromocytoma crisis (99.0%), followed by the lungs (44.0%) and the kidney (21.5%). PMC accounted for 19.0% of all pheochromocytoma crisis cases. After excluding 12 cases with unknown survival statuses, the mortality rate was 13.8% (26/188 cases). Multivariable logistic regression analysis revealed that nausea and vomiting were significantly associated with a higher mortality rate.

CONCLUSION

Pheochromocytoma can present with different symptomatology, affecting different organ systems. Clinicians should be aware that patients with nausea or vomiting are at a higher risk of death because of pheochromocytoma crisis.

[Hantavirus infections]

Hantaviruses are enveloped zoonotic RNA viruses hosted by rodents and responsible in the Americas for hantavirus pulmonary syndrome. In Europe, they cause hemorrhagic fever with renal syndrome and its milder form, nephropathia epidemica. The disease begins abruptly with high fever, chills, headache, back pain and abdominal pain associated with nausea and vomiting. Diagnosis is primarily made by serology. There is currently no specific medication or preventive available in Europe. Treatment is symptomatic.

Animal contact and paediatric acute febrile illness in Greater Accra Region, Ghana

Objective

To examine the association between animal contact (primarily dogs and cats) and non-malarial fever, as well as with secondary symptoms of headache, nausea, vomiting, and cough, in 687 children in Greater Accra Region, Ghana.

Design

Cross-sectional study of acute febrile illness among children aged 1-15 years old between October 2016 and August 2017.

Setting

Ledzokuku-Krowor Municipal Assembly (LEKMA) Hospital, Teshie, Greater Accra Region.

Participants

The study included children with acute fever, defined as a measured temperature of greater than 37.5°C, occurring less than seven days before the hospital visit, and afebrile children as controls.

Main outcome measures

Measured fever, self-reported fever, and secondary symptoms, each adjusting for patient household characteristics.

Results

Animal contact was neither associated with measured fever (OR = 1.04, 95% CI 0.73-1.49) nor with self-reported fever (OR = 0.97, 95% CI 0.68-1.39). Animal contact was associated with headache (OR = 3.26, 95% CI 2.23-4.77, P < .01) and nausea (OR = 3.05, 95% CI 1.99-4.68, P < .01), but not with vomiting or cough. Additional models that used alternate inclusion criteria to define non-malarial fever yielded similar results. Several bacterial zoonoses that could plausibly have been transmitted by dogs and cats were diagnosed in the study population.

Conclusion

These findings suggest the need for future studies to evaluate animal contact as a risk factor for bacterial zoonoses that may serve as an etiological driver of acute febrile illness.

Funding

no external funding.

Evaluation of the Efficacy and Adverse Reactions of Mirena Combined with Hysteroscopic Surgery When Treating AUB: Based on a Retrospective Cohort Study

Objective

A case-control study was performed to explore the efficacy and adverse reactions of Mirena combined with hysteroscopy when treating AUB.

Methods

108 patients with perimenopausal AUB treated in our hospital from June 2019 to December 2021 were enrolled, and their clinical data were collected and analyzed retrospectively. According to the mode of treatment, the patients were assigned into control group (54 cases) and study group (54 cases). The therapeutic effects were compared. Visual analog score (VAS) was adopted to evaluate the degree of incision pain, Barthel index score was adopted to evaluate the ability of daily living, quality of life scale was adopted to investigate the quality of life before and after treatment, and the changes of sex hormone levels, endometrial thickness, and menstruation were detected before and after treatment. The incidence of adverse reactions was calculated.

Results

In terms of the therapeutic effects, 46 cases were cured, 6 cases were effective, and 2 cases were ineffective in the study group, and the effective rate was 96.30%; in the control group, 32 cases were cured, 10 cases were effective, and 12 cases were ineffective, and the effective rate was 77.78%; the effective rate of the study group was higher than that of the control group (P < 0.05). In terms of VAS score, the VAS score decreased after treatment, and the VAS score in the study group was significantly lower than that in the control group at 1 week, 2 weeks, 1 month, and 3 months after treatment. With regard to the Barthel index scores after treatment, the Barthel index scores increased, and the Barthel index scores of the study group at 1 week, 2 weeks, 1 month, and 3 months after treatment were higher compared to the control group (P < 0.05). In terms of the Barthel index scores after treatment, the Barthel index scores increased, and the Barthel index scores of the study group at 1 week, 2 weeks, 1 month, and 3 months after treatment were higher compared to the control group (P < 0.05). Compared with those before treatment, the levels of FSH, LH, and E2 in both groups decreased remarkably (all P < 0.05). In terms of the changes of endometrium and menstruation, the endometrial thickness, menstrual time, and menstrual volume were significantly improved after treatment (P < 0.05). After treatment, the endometrial thickness, menstrual time, and menstrual volume in the study group were better than those in the control group (P < 0.05). With regard to the scores of qualities of life, the scores of qualities of life decreased after treatment. Compared between the two groups, the scores of physiological function, psychological function, social function, and health self-cognition in the study group were lower compared to the control group. Regarding the incidence of adverse reactions, in the study group, there were 1 case of breast pain, 2 cases of vaginal bleeding, and no dizziness and nausea, and the incidence of adverse reaction was 5.56%; In the control group, there were 1 case of dizziness, 2 cases of breast pain, 4 cases of nausea, and 3 cases of vaginal bleeding, and the incidence of adverse reactions in the study group was 18.52%. The incidence of adverse reactions in the study group was lower compared to the control group (P < 0.05).

Conclusion

Hysteroscopy combined with Mirena when treating perimenopausal AUB can remarkably enhance the related symptoms, regulate the level of sex hormones, and remarkably reduce the amount of menstrual bleeding. The curative effect is better than hysteroscopy combined with dydrogesterone tablets, which is worth popularizing in clinic.

Adductor Canal Blocks With Bupivacaine and Magnesium After Same-day Discharge Total Knee Arthroplasty Improve Postoperative Pain Relief and Decrease Opioid Consumption: A Prospective Randomized Controlled Trial

OBJECTIVES

Adequate pain management is a critical component of facilitating same-day discharge for total knee arthroplasty (TKA). Adductor canal blocks (ACB) have been shown to be an effective technique for managing pain after TKA. The objective of this study was to investigate the impact of adding magnesium to local anesthetic in ACB on postoperative pain, opioid consumption, nausea, and overall patient satisfaction.

MATERIALS AND METHODS

A sample of 119 adults undergoing elective unilateral TKA were included. Patients were randomly assigned to receive ACB with magnesium and bupivacaine (n=56) or with bupivacaine only (n=63). Primary outcomes were total opioid consumption in the first 48 hours after surgery and pain scores. Secondary outcomes were the incidence of nausea in the first 48 hours after surgery and total overall satisfaction.

RESULTS

Opioid consumption decreased significantly in the Mg group compared with the no-Mg group over the first 24 hours (33.2±3.0 vs. 21.3±2.4, P=0.003), the second 24 hours (35.4±2.7 vs. 27.3±2.3, P=0.026), and the first 48 hours total after surgery (68.6±5.1 vs. 48.6±4.3, P=0.004). Pain scores were reduced in the Mg group (24 h: 5.1±2.3 vs. 3.5±2.0, P=0.000; 48 h: 5.1±1.6 vs. 3.9±1.6, P=0.000). Secondary outcomes showed no difference in the incidence of nausea over the first 48 hours and overall satisfaction.

CONCLUSION

The addition of magnesium to local anesthetic in ACB decreases pain scores and opioid consumption, without increasing nausea, when compared with ACB with local anesthetic alone.

Clinical role and safety of tapentadol in patients with cancer: A single-center experience

OBJECTIVE

To evaluate real-world data on the use of tapentadol (TAP) in cancer patients.

DESIGN

Single-center retrospective study.

SETTING

Curative/palliative.

PATIENTS, PARTICIPANTS

Patients who started TAP between October 2014 and December 2018 at our institution.

MAIN OUTCOME MEASURE(S)

The primary outcome was the reason for TAP initiation. Secondary outcomes included prescription duration, TAP cessation rate, reason for cessation, and adverse events (AEs). Since the palliative care team (PCT) tended to prescribe to cancer patients with intractable pain more often than patients in usual care, and also tended to prescribe opioids based on their characteristics, we decided to compare patients with and without PCT intervention.

RESULTS

There were 175 patients who first received TAP during the study period, of whom 81 patients (46.3 percent) were male. The median age was 60 years. TAP was prescribed for opioid-naive patients in 45 (26 percent) cases and opioid switch in 130 (74 percent) cases. When comparing the PCT group (n = 121) and the non-PCT group (n = 54) using univariate analysis, the PCT group had a higher opioid switch rate (81.8 percent vs 57.4 percent, p < .001), higher proportion of patients with neuropathic pain (NP) (65.3 percent vs 16.7 percent, p < .001), and a higher proportion of patients with a history of nausea (41.3 percent vs 18.5 percent, p < .01). The cessation rate due to AEs was 8 percent overall.

CONCLUSIONS

Palliative care physicians prescribed TAP for patients with NP or a history of nausea. Opioid-naive patients were preferred by oncologists. TAP has good tolerability in both groups, with a low dropout rate due to AEs.

Serological Detection of Helicobacter pylori Infection in Pregnant Women Related to ABO Blood Group

Helicobacter pylori was known as a pathogen related to peptic ulcers and gastric carcinoma. Some researches confirmed that the infected pregnant women with H. pylori have poor pregnancy outcomes so that its effects extended to other systems other than gastrointestinal tracts. This study aimed to evaluate H. pylori infection in pregnant women who had morning sickness (nausea and vomiting) related to the ABO blood group. In total, 202 pregnant women within the age range of 15-45 years with severe nausea and vomiting attended the outpatient and specialized clinic. The seroprevalence of H. pylori was 62% in pregnant women, especially at the age group of 20-24 years with 32.5% of the cases who had epigastric pain, nausea, vomiting, flatulence, and burning of the stomach, the majority of which related to O⁺ (33.3%), followed by A⁺ and B⁺ (25.39%) blood groups. Most infected pregnant women with H. pylori were during the first (41.26%) and second trimesters (34.12%), especially in multigravida (68.25%) cases. This study found that hyperemesis (severe nausea and vomiting), dyspepsia, and other gastrointestinal symptoms during pregnancy were related to the infection with H. pylori; therefore, it is a risk factor for complications in pregnancy and its poor outcomes, especially in developing countries, such as Iraq. These results can be minimized by improving the socioeconomic and sanitation conditions. H. pylori infection in pregnancy is considered a health problem and should be treated before and during pregnancy. Further investigations are required in this regard and researchers are recommended to conduct studies on the RBC antigens to recognize the pathophysiology related to H. pylori infection.

[Assessment of the state of the small intestine microbiota in children on a long-term dairy-free diet]

An overview of recent outcomes of studies indicates an imbalance in the diet of children. Quantitative and qualitative malnutrition of children is the basis of a number of childhood diseases. The aim of the research was to study the prevalence of small intestine bacterial overgrowth syndrome (SIBO) in children on a long-term dairy-free diet. Material and methods. 40 children aged 7-11 years following a long-term dairy-free diet (average 3 years and 5 months, from 0.5 to 6.3 years) were examined (main group). 30 children who did not follow restrictive diets were consisted control group. In all children, SIBO was determined using a hydrogen breath test with a load of lactulose using a digital analyzer of exhaled hydrogen. Results. The proportion of children with intolerance to dairy products was 32.5%: 10.0% with allergy to cow's milk proteins, and 22.5% with lactose intolerance. 27.5% children followed a dairy-free diet according to an unjustified prescription by physician. 30.0% of children did not consume dairy products because of their unwillingness. 10.0% of children did not consume dairy products due to the unwillingness of their parents. An imbalance in the microbiota of the small intestine during the hydrogen breath test with lactulose loading was detected in 55.0% of children following a long-term dairy-free diet. 22.5% of children complained of recurrent abdominal pain, diarrhea was determined in 10.0%, constipation - in 7.5%, nausea - in 10.0%. In the control group, the SIBO during the hydrogen breath test with lactulose loading was found in 20.0%. Periodic abdominal pain was determined in 10.0%, nausea - in 6.7%, diarrhea - in 10.0%, constipation - in 3.3% children. Conclusion. Thus, among children of primary school age who follow a long-term dairyfree diet, SIBO is significantly more often recorded relative to children who are on a traditional type of diet.

Aetiological diagnosis of hyponatraemia in non-critical patients on total parenteral nutrition: A prospective multicentre study

BACKGROUND

In patients receiving total parenteral nutrition (TPN), the frequency of hyponatraemia is high. However, the causes of hyponatraemia in TPN have not been elucidated, although diagnosis is required for appropriate therapy. The aim of this study is to describe the aetiology of hyponatraemia in non-critical hospitalised patients receiving TPN.

METHODS

Prospective multicentre study in 19 Spanish hospitals. Non-critically hyponatraemic patients receiving TPN and presenting hyponatraemia over a 9-month period were studied. Data collected included sex, age, previous comorbidities, and serum sodium levels (SNa) before and following TPN initiation. Parameters for study of hyponatraemia were also included: clinical volaemia, the presence of pain, nausea, gastrointestinal losses, diuretic use, oedema, renal function, plasma and urine osmolality, urinary electrolytes, cortisolaemia, and thyroid stimulating hormone.

RESULTS

162 patients were included, 53.7% males, age 66.4 (SD13.8) years. Volume status was evaluated in 142 (88%): 21 (14.8%) were hypovolaemic, 96 (67.6%) euvolaemic and 25 (17.6%) hypervolaemic. In 111/142 patients the analytical assessment of hyponatraemia was completed. Hypovolaemic hyponatraemia was secondary to GI losses in 10/111 (9%), and to diuretics in 3/111 (2.7%). Euvolaemic hyponatraemia was due to Syndrome of Inappropriate Antidiuretic Hormone secretion (SIADH) in 47/111 (42.4%), and to physiological stimuli of Arginine Vasopressin (AVP) secretion in 28/111 (25.2%). Hypervolaemic hyponatraemia was induced by heart failure in 19/111 (17.1%), cirrhosis of the liver in 4/111 (3.6%).

CONCLUSIONS

SIADH was the most frequent cause of hyponatraemia in patients receiving TPN. The second most frequent cause was physiological stimuli of AVP secretion induced by pain/nausea.

Increasing nausea and vomiting of pregnancy is associated with sex-dependent differences in early childhood growth: the GUSTO mother-offspring cohort study

BACKGROUND

Nausea and vomiting of pregnancy (NVP) is common and underlying mechanisms are poorly understood. Longer-term offspring outcomes are also not well documented. This study aimed to determine if NVP, even in milder forms, is associated with adverse pregnancy and childhood growth outcomes.

METHODS

In the GUSTO prospective mother-offspring cohort, women with singleton pregnancies (n = 1172) recruited in first trimester responded to interviewer-administered questions at 26-28 weeks' gestation about earlier episodes of NVP since becoming pregnant. Pregnancy outcomes were obtained from medical records. Offspring height and weight measured at 15 time-points between birth to 72 months (m) were standardised for age and sex.

RESULTS

58.5% (n = 686) reported mild-moderate vomiting (mNVP), 10.5% (n = 123) severe vomiting (sNVP) and 5.7% (n = 67) severe vomiting with hospitalisation (shNVP). There was no difference in odds of gestational diabetes, hypertensive disorders of pregnancy, labour induction or caesarean section after adjustment for covariates. sNVP was associated with late preterm delivery [34+ 0-36+ 6 weeks', adjusted OR = 3.04 (95% CI 1.39,6.68)], without increased odds of neonatal unit admission. Compared with no NVP, boys born to mothers with sNVP were longer at birth [adjusted β = 0.38 standard deviations (SDs) (95% CI 0.02,0.73)], remained taller [0.64 SDs (0.23,1.04) at 72 m] and heavier [0.57 SDs (0.05,1.08) at 60 m] without differences in BMI. Conversely, girls born to mothers with shNVP were lighter from 48 m [- 0.52 SDs (- 1.00, - 0.03)] onwards with lower BMI [- 0.61 SDs (- 1.12,-0.09)]. Conditional growth modelling revealed significant sex-divergence in weight-gain at birth-3 m, 6-9 m and 4-5 years.

CONCLUSIONS

Severe NVP was associated with late preterm delivery, and both mild-moderate and severe NVP associated with sex-dependent differences in early childhood growth. Boys whose mothers had NVP were taller and heavier from birth with faster growth in the first year, whereas, girls had poorer weight gain and were lighter by 48 m. As even milder severities of NVP could have long-term impact on offspring growth, further research is needed to determine mechanisms involved and implications on future health.

TRIAL REGISTRATION

Clinicaltrials.gov identifier NCT01174875 .

Migraine (Shaqeeqa) and its management in Unani medicine

Out of many disease conditions suffered by mankind since ancient ages, Migraine holds a significant position. It is derived from the word "hemi-crania" and is a type of primary headache. This disease is mentioned in the ancient scriptures dating back to the Mesopotamian era. It has been documented by Hippocrates (460-377 BC) in his treatise, further explored and explained on the basis of cause and location by Galen (131-201 AD). Later its etiopathogenesis clinical features and management was described by Al-Razi (850-923 AD), an eminent Unani physician. Migraine is a disease majorly affecting one side of the head and characterized by recurrent attacks of pulsating headache, mostly associated with nausea, vomiting, photophobia and phonophobia, with or without an aura. It is triggered by noise and light, based on the brightness, intensity, wavelengths or type of light that is being emitted. According to Unani physicians, the word Shaqeeqa is derived from Arabic word 'Shiq', meaning 'a part' or 'a side', hence the name Shaqeeqa. They describe it as a type of headache (Suda) in which pain occurs only in one side of head, and the causative factors for it are the morbid matters and morbid vapours (Bukharat e Radiya) arising from morbid humours which are either excessive in amount, too hot or too cold. It often results due to abnormal substantial temperament (Su-e-Mizaj Maddi) giving two variants acute (Shaqeeqa haar) and chronic (Shaqeeqa barid). The treatment mainly consists of elimination of morbid matter which is accumulated in the body, and strengthening the brain using brain tonics (Muqawwiyat-e-Dimagh).

Women's perspectives on the management and consequences of hyperemesis gravidarum - a descriptive interview study

OBJECTIVE

Hyperemesis gravidarum (HG) affects 0.3-3% of pregnant women and is a leading cause of hospitalization in early pregnancy. The aim of the study was to investigate women's treatment and management of HG, as well as the consequences of HG on women's daily life.

DESIGN AND SETTING

A cross-sectional study based on a structured telephone interview and an online questionnaire. Participants were recruited by social media and by the Norwegian patient's organization for HG.

SUBJECTS

Norwegian women that experienced HG.

MAIN OUTCOME MEASURE

Women's perspectives on management and consequences of HG.

RESULTS

The study included 107 women. Maternal morbidity was profound; about 3/4 of participants were hospitalized due to HG, and the majority showed clinical signs of dehydration (79%), ketonuria (75%), and >5% weight loss (84%). Antiemetics were used by >90% and frequently prescribed "as needed". Metoclopramide (71%) and meclozine (51%) were most commonly used. Participants described HG as having severe psychosocial consequences and profound impact on daily activities. Almost two out of five reported thoughts of elective abortion, and 8 women had at least one elective pregnancy termination due to HG. Overall, 20 women (19%) changed GPs due to dissatisfaction with HG management.

CONCLUSION

Despite the high psychosocial burden and major impact on daily activities, many women with HG reported a lack of support from healthcare professionals and suboptimal management. Greater awareness and knowledge among healthcare professionals is needed to improve care for women with HG. Key Points There is a paucity of studies on management and the consequences of HG on women's daily lives and psychosocial burden. We found that: • Many women described HG as one of their worst life experiences with profound morbidity. • Many women reported suboptimal management of HG and lack of support from healthcare professionals. • Greater understanding of patient perspectives among healthcare professionals is important to improve care and management for HG patients.

8-Way Randomized Controlled Trial of Doxylamine, Pyridoxine and Dicyclomine for Nausea and Vomiting during Pregnancy: Restoration of Unpublished Information

Objectives

We report information about an unpublished 1970s study (“8-way” Bendectin Study) that aimed to evaluate the relative therapeutic efficacy of doxylamine, pyridoxine, and dicyclomine in the management of nausea and vomiting during pregnancy. We are publishing the trial's findings according to the restoring invisible and abandoned trials (RIAT) initiative because the trial was never published.

Design

Double blinded, multi-centred, randomized placebo-controlled study.

Setting

14 clinics in the United States.

Participants

2308 patients in the first 12 weeks of pregnancy with complaints of nausea or vomiting were enrolled.

Interventions

Each patient was randomized to one of eight arms: placebo, doxylamine/pyridoxine/dicylcomine, doxylamine/pyridoxine, dicylomine/pyridoxine, doxylamine, dicyclomine/pyridoxine, pyridoxine and dicyclomine. Each patient was instructed to take 2 tablets at bedtime and 1 additional tablet in the afternoon or morning if needed, for 7 nights.

Outcomes

Reported outcomes included the number of hours of nausea reported by patients, the frequency of vomiting reported by patients and the overall efficacy of medication as judged by physicians.

Results

Data from 1599 (69% of those randomized) participants were analyzed. Based on the available summary data of physician evaluation of symptoms and ignoring missing data and data integrity issues, the proportion of participants who were “evaluated moderate or excellent” was greater in each of the seven active treatment groups when compared with placebo (57%): doxylamine/pyridoxine/dicylcomine (14% absolute difference versus placebo; 95% CI: 4 to 24), doxylamine/pyridoxine (21; 95% CI 11 to 30), dicylomine/pyridoxine (21; 95% CI 11 to 30), doxylamine (20; 95% CI 10 to 29), dicyclomine/pyridoxine (4; 95% CI -6 to 14), pyridoxine (9; 95% CI -1 to 19) and dicyclomine (4; 95% CI -6 to 14). Based on incomplete information, the most common adverse events were apparently drowsiness and fatigue. There is a high risk of bias in these previously unpublished results given the high attrition rate in a 7 day trial, the lack of prespecified outcomes or analyses, and the exclusion of some data because of questionable data integrity.

Conclusion

The available information about this “8-way Bendectin” trial indicates it should not be used to support the efficacy of doxylamine, pyridoxine or dicyclomine for the treatment of nausea and vomiting during pregnancy because of a high risk of bias.

Trial registration

Not registered.

Hyperemesis gravidarum and the risk of emotional distress during and after pregnancy

Hyperemesis gravidarum (HG) is a pregnancy condition characterised by severe nausea and vomiting. Previous studies have shown an association between HG and depressive symptoms during pregnancy, but little is known about the risk of maternal psychological distress following an HG pregnancy. The objective of the current study was therefore to assess the association between HG and emotional distress during and after pregnancy. This was a population-based pregnancy cohort study using data from the Norwegian Mother and Child Cohort Study. A total of 851/92,947 (0.9%) had HG. Emotional distress was measured by the Hopkins Symptom Checklist (SCL-5) in gestational weeks 17 and 32 and 6 and 18 months postpartum. The generalised estimating equations model was estimated for assessing time trends in emotional distress. Adjustments were made for previous HG, lifetime history of depression, maternal age, parity, BMI, smoking before pregnancy, physical activity, length of education, and pelvic girdle pain. Women with HG had higher odds for emotional distress than women without HG at the 17th (p < 0.001) and 32nd gestational weeks (p = 0.001) in addition to 6 months postpartum (p = 0.005) but not 18 months postpartum (p = 0.430). Adjusted odds for emotional distress varied significantly over time for women with and without HG (p = 0.035). Women with HG were more likely to report emotional distress compared to women without HG during pregnancy and 6 months postpartum, but the difference between the groups disappeared 18 months after birth. The results suggest that the increased risk of developing emotional distress may primarily be a consequence of HG.

Atypical symptoms in patients with cervical spondylosis might be the result of stimulation on the dura mater and spinal cord

Patients with cervical spondylosis often present with some atypical symptoms such as vertigo, headache, palpitation, nausea, abdominal discomfort, tinnitus and blurred vision and hypomnesia. Although there are a few hypotheses about the etiology of those symptoms, none of them have provided evidence convincing enough to explain the clinical, pathological and anatomic manifestation of those symptoms. One of the more acceptable explanations is that those symptoms are the results of stimulation of the sympathetic nerves in the posterior longitudinal ligament. The clinical fact that dissection of the posterior longitudinal ligament significantly alleviates the severity of those symptoms seems like an evidence for the validity of this hypothesis. However, recent clinical studies showed that laminoplasty, which has no effect on the posterior longitudinal ligament, can achieve the similar effect. In this paper, we hypothesize that stimulation of the dura mater and spinal cord might be the cause of atypical symptoms in patients with cervical spondylosis.

Phenotypic features of chronic migraine

BACKGROUND

Chronic migraine is a disabling, under-recognized, and undertreated disorder that increases health burdens. The aim of this study was to evaluate phenotypic features and the relevance of accompanying symptoms of migraine attacks in chronic migraine.

METHOD

This study was conducted as part of an ongoing Turkish Headache Database Study investigating the clinical characteristics and outcomes of headache syndromes in the Turkish population. The electronic database was examined retrospectively, and 835 patients with chronic migraine were included.

RESULTS

Patient group consisted of 710 women and 125 men (85 and 15 %, respectively). Mean patient age was 36.8 ± 13.5 years, median value of migraine onset was 60 months (18-120), median headache frequency was 25 days per month (16-30), median of attack duration was 12 h (4-24), and median of intensity was eight (7-9). Increasing headache days per month were inversely related with the presence of nausea, vomiting, phonophobia, and photophobia. Longer duration of headache (months) and higher visual analog scale (VAS) for headache intensity were associated with all accompanying symptoms. Phonophobia, nausea, photophobia, and vomiting were the most frequent accompanying symptoms (experienced by 80.2, 77.6, 71.2, and 40.9 % of patients, respectively). Osmophobia was also frequent in chronic migraine patients (53.4 %) and was closely associated with other accompanying symptoms. Vertigo and dizziness were observed less frequently, and they were not associated with accompanying symptoms.

CONCLUSION

Phenotype of chronic migraine may be associated with the course of chronification. Duration of illness and attack intensity were closely related with the presence of accompanying symptoms, although headache frequency was found to be inversely related to the presence of accompanying symptoms. Osmophobia was also a frequent symptom and was closely related with other accompanied symptoms, unlike vertigo and dizziness. Inclusion of osmophobia into the diagnostic criteria might improve accurate diagnosis of chronic migraine.

Blinded Patient Preference for Morphine Compared to Placebo in the Setting of Chronic Refractory Breathlessness--An Exploratory Study

CONTEXT

Patients' preference for morphine therapy has received little attention in the setting of chronic refractory breathlessness. However, this is one important factor in considering longer term therapy.

OBJECTIVES

The aim of this secondary analysis was to explore blinded patient preference of morphine compared to placebo for this indication and to define any predictors of preference.

METHODS

Data were pooled from three randomized, double-blind, crossover, placebo-controlled studies of morphine (four days each) in chronic refractory breathlessness. Blinded patient preferences were chosen at the end of each study. A multivariable regression model was used to establish patient predictors of preference.

RESULTS

Sixty-five participants provided sufficient data (60 men; median age 74 years; heart failure 55%, chronic obstructive pulmonary disease 45%; median Eastern Cooperative Oncology Group performance status 2). Forty-three percent of participants preferred morphine (32% placebo and 25% no preference). Morphine preference and younger age were strongly associated: odds ratio = 0.85, 95% confidence interval 0.78-0.93; P < 0.001). There was also an inverse association between morphine preference and sedation (odds ratio = 0.77, 95% confidence interval 0.60-0.99; P < 0.05). An inverse association was also seen between nausea and morphine preference in the univariate model only (P < 0.05). No association was seen between morphine preference and breathlessness intensity, either at baseline or change from baseline.

CONCLUSION

Participants preferred morphine over placebo for the relief of chronic refractory breathlessness. Morphine offers clinically important improvement, but net benefit can be easily outweighed by side effects, reducing net benefits. Side effects require aggressive management to allow more patients to realize benefits.

Euglycemic Diabetic Ketoacidosis Due to Gastroparesis, A Local Experience

Euglycemic Diabetic Ketoacidosis is an uncommon occurrence. It is caused by an interaction of existing and worsening acidosis due to nausea and vomiting by a precipitating illness. In this case, a Type I Diabetic patient initially presented with Diabetic Ketoacidosis (DKA) that eventually evolved into Euglycemic Ketoacidosis brought about by continuous nausea and vomiting. The case presented the complexity involved with Type I Diabetes in regards to glucose and energy metabolism and highlights the need for vigilance in monitoring acid/base balance in all diabetic patients who are ill and present with normal blood glucose level.

Relationship among nausea, anxiety, and orthostatic symptoms in pediatric patients with chronic unexplained nausea

This study evaluated the relationship among nausea, anxiety, and orthostatic symptoms in pediatric patients with chronic unexplained nausea. We enrolled 48 patients (36 females) aged 15 ± 2 years. Patients completed the Nausea Profile, State-Trait Anxiety Inventory for Children and underwent 70° head upright tilt testing (HUT) to assess for orthostatic intolerance (OI) and measure heart rate variability (HRV). We found nausea to be significantly associated with trait anxiety, including total nausea score (r = 0.71, p < 0.01) and 3 subscales: somatic (r = 0.64, p < 0.01), gastrointestinal (r = 0.48, p = 0.01), and emotional (r = 0.74, p < 0.01). Nausea was positively associated with state anxiety, total nausea (r = 0.55, p < 0.01), somatic (r = 0.48, p < .01), gastrointestinal (r = .30, p < .05), and emotional (r = .64, p < .01) subscales. Within 10 min of HUT, 27 patients tested normal and 21 demonstrated OI. After 45 min of HUT, only 13 patients (27%) remained normal. Nausea reported on the Nausea Profile before HUT was associated with OI measured at 10 min of tilt (nausea total r = 0.35, p < 0.05; nausea emotional subscale r = 0.40, p < 0.01) and lower HRV at 10 min of HUT (F = 6.39, p = 0.01). We conclude that nausea is associated with both anxiety symptoms and OI. The finding of decreased HRV suggests an underlying problem in autonomic nervous system function in children and adolescents with chronic unexplained nausea.

Depression, anxiety, stress and hyperemesis gravidarum: temporal and case controlled correlates

OBJECTIVE

To evaluate the temporal and case-controlled correlations of anxiety, depression and stress with hyperemesis gravidarum.

STUDY DESIGN

We performed a longitudinal cohort study of women with hyperemesis gravidarum using the Depression, Anxiety and Stress Scale (DASS-21) to evaluate psychological distress at hospitalization and in the third trimester of pregnancy (from 28 weeks gestation). Third pregnancy trimester controls were recruited from routine antenatal clinic attendees who were matched to gestational age at the second DASS-21 assessment in the HG cohort.

RESULTS

The prevalences of nausea and vomiting, depression, anxiety and stress caseness in newly hospitalised hyperemesis gravidarum women were 100% and 100%, 19%, 69% and 21% which by the third trimester had fallen to 15.7% and 9.9%, 4%, 19% and 3% and in third trimester controls were 15.9% and 14.2%, 14%, 61% and 20% respectively. Within the hyperemesis gravidarum cohort, nausea, vomiting depression, anxiety and stress reduced significantly by an absolute 84.3% (95% CI 76.2%-89.8%), 90.1% (82.8%-94.2%), 14.9% (7.2%-23.0%), 49.6% (38.6%-58.7%) and 18.2% (10.4%-26.4%) respectively between hospitalization for hyperemesis gravidarum and at the third trimester. In the third trimester, when comparing the hyperemesis gravidarum cohort to controls, the risk of nausea or vomiting was similar but depression, anxiety and stress were significantly lower: adjusted odds ratio AOR 0.10 (95% CI 0.03-0.5), 0.11 (0.05-0.23) and 0.08 (0.02-0.33) respectively.

CONCLUSION

Our study revealed a reassuring pattern of a strong rebound from depression, anxiety and stress in women with hyperemesis gravidarum such that by the third pregnancy trimester the level of psychological distress was even lower than in controls. This observation imply that much of the psychological distress in acute hyperemesis gravidarum is self-limiting and probably in the causal pathway of hyperemesis gravidarum. Care in women with hyperemesis gravidarum should focus on the relief of nausea and vomiting.

Naproxen with or without an antiemetic for acute migraine headaches in adults

BACKGROUND

Migraine is a common, disabling condition and a burden for the individual, health services, and society. Many sufferers choose not to, or are unable to, seek professional help and rely on over-the-counter analgesics. Naproxen is a non-steroidal anti-inflammatory drug (NSAID); its efficacy in acute migraine has not been established by systematic reviews. Co-therapy with an antiemetic should help to reduce the nausea and vomiting commonly associated with migraine headaches.

OBJECTIVES

To determine the efficacy and tolerability of naproxen, alone or in combination with an antiemetic, compared with placebo and other active interventions in the treatment of acute migraine headaches in adults.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library, MEDLINE, EMBASE, and the Oxford Pain Relief Database, together with two online databases (www.gsk-clinicalstudyregister.com and www.clinicaltrials.gov) and reference lists, for studies to 22 May 2013.

SELECTION CRITERIA

We included randomised, double-blind, placebo- or active-controlled studies, with at least 10 participants per treatment arm, using naproxen alone or with an antiemetic to treat a migraine headache episode.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. We used numbers of participants achieving each outcome to calculate risk ratios and numbers needed to treat (NNT) or harm (NNH) compared with placebo or a different active treatment.

MAIN RESULTS

We included six studies using naproxen 275 mg, 500 mg, or 825 mg to treat attacks of moderate or severe pain intensity. Overall, 1241 participants took naproxen (275 mg to 825 mg), 229 took sumatriptan 50 mg, 173 took naratriptan 2.5 mg, and 1092 took placebo. No studies combined naproxen with an antiemetic. Studies using naproxen 275 mg provided no useable data for analysis.Naproxen (500 mg and 825 mg) was better than placebo for pain-free response and headache relief. At two hours, the NNT for pain-free response was 11 (17% response with naproxen, 8% with placebo; risk ratio 2.0 (95% CI 1.6 to 2.6), moderate quality) and for headache relief was 6.0 (45% response with naproxen, 29% with placebo; risk ratio 1.6 (1.4 to 1.8), moderate quality). The NNT for sustained pain-free response during the 24 hours post dose was 19 (12% response with naproxen, 6.7% with placebo), and for sustained headache relief during the 24 hours post dose was 8.3 (30% response with naproxen, 18% with placebo). Analysing only the lower dose of 500 mg of naproxen did not significantly change the results. Adverse events, which were mostly mild or moderate in severity and rarely led to withdrawal, were more common with naproxen than with placebo when the 500 mg and 825 mg doses were considered together, but not when the 500 mg dose was analysed alone.There were insufficient data for analysis of naproxen compared with sumatriptan, and no data suitable for analysis of naproxen compared with naratriptan.

AUTHORS' CONCLUSIONS

Naproxen is statistically superior to placebo in the treatment of acute migraine, but the NNT of 11 for pain-free response at two hours suggests that it is not a clinically useful treatment. Cochrane reviews examining other commonly used analgesics for acute migraine have reported better (lower) NNT results for the same outcome. Naproxen is not clinically useful as a stand-alone analgesic in acute migraine, as it is effective in fewer than 2 people in 10.

Pre-bout standing body sway differs between adult boxers who do and do not report post-bout motion sickness

Background

Motion sickness is characterized by subjective symptoms that include dizziness and nausea. Studies have shown that subjective symptoms of motion sickness are preceded by differences in standing body sway between those who experience the symptoms and those who are not. Boxers often report dizziness and nausea immediately after bouts. We predicted that pre-bout standing body sway would differ between boxers who experienced post-bout motion sickness and those who did not.

Methodology/Principal Findings

We collected data on standing body sway before bouts. During measurement of body sway participants performed two visual tasks. In addition, we varied stance width (the distance between the heels). Postural testing was conducted separately before and after participants' regular warm-up routines. After bouts, we collected self-reports of motion sickness incidence and symptoms. Results revealed that standing body sway was greater after warm-up than before warm-up, and that wider stance width was associated with reduced sway. Eight of 15 amateur boxers reported motion sickness after a bout. Two statistically significant interactions revealed that standing body sway before bouts differed between participants who reported post-bout motion sickness and those who did not.

Conclusions/Significance

The results suggest that susceptibility to motion sickness in boxers may be manifested in characteristic patterns of body sway. It may be possible to use pre-bout data on postural sway to predict susceptibility to post-bout motion sickness.

[Prospective study of the clinical features of cluster headache]

INTRODUCTION

Although cluster headache (CH) is one of the most severe human pain syndromes, its symptoms and therapeutic possibilities may be suboptimally recognised in current medical practice in Hungary.

AIM

To present the clinical characteristics of CH based on a prospective study of patients attending the Headache Service of the Department of Neurology, Semmelweis University.

METHODS

We collected information about the symptoms, diagnosis and previous treatment of CH patients by filling in a 108-item questionnaire during outpatient visits.

RESULTS

In the 5-year period between 2004 and 2008 we obtained data from 78 CH patients (57 males and 21 females; mean age: 44.6 +/- 14.6 years). The male:female ratio did not change in subgroups based on disease onset (calendar years). Ninety-three percent considered CH the most severe pain state of their life. The pain was strictly unilateral, affecting the territory of the 1st trigeminal division in all patients. The attacks were accompanied by signs of ipsilateral cranial parasympathetic activation (lactimation 83%, conjunctival injection 67%, rhinorrhea 56%, nasal congestion 43%); less frequently, signs of sympathetic dysfunction (ptosis 48%, miosis 7%) were also present. Two patients had attacks showing the typical localisation, severity and time course of CH attacks, but not accompanied by autonomic phenomena. A considerable part of the patients also observed symptoms that are usually ascribed to migraine (nausea 41%, vomiting 18%, photophobia 68%, phonophobia 58%). This may have been instrumental in the fact that, regardless of the characteristic clinical symptoms, the diagnosis of CH took 10 years on average. At the time of their examination 63% of patients were not using adequate abortive medications and 59% did not have an adequate prophylactic measure.

DISCUSSION

Cluster headache is characterised by attacks of devastating pain that warrant an early diagnosis and adequate treatment. Our study underlines that information about the diagnosis and therapy of CH should be emphasized on occasions of neurology specialty training and continuing medical education.

Radiology case of the month. Nausea, vomiting, and diarrhea in a patient with hepatitis C and acquired immunodeficiency syndrome (AIDS). Diffuse, severe gastric-wall thickening, consistent with edema

The patient is a 42-year-old male with a past medical history of HIV/AIDS (his most recent CD4 count, four months before admission, was 19) and hepatitis C who presented to the Emergency Department complaining of one week of persistent nausea, vomiting, and diarrhea. His admit labs were as follows: hemoglobin of 11.8, hematocrit of 35, total protein of 6.0, albumin of 1.6, total bilirubin of 2.3, aspartate aminotransferase (AST) of 141, alkaline phosphatase (ALP) of 146, and alanine aminotransferase (ALT) of 31. Computed tomography (CT) images of the abdomen and pelvis with contrast were obtained (Figures 1 - 4).

Symptom clusters in patients with advanced cancer: a reanalysis comparing different statistical methods

CONTEXT

The clinical relevance of symptom cluster research remains questionable if inconsistencies, partially attributable to the varying statistical analyses used, exist.

OBJECTIVES

To investigate whether symptom clusters identified were consistent using three different statistical methods and to observe the temporal pattern of clusters. A secondary objective was to compare symptom clustering in responders and nonresponders to radiotherapy over time.

METHODS

Reanalysis of an existing data set compiled from 1296 patients with advanced cancer was performed using hierarchical cluster analysis (HCA) and exploratory factor analysis (EFA) to extract symptom clusters at baseline, 1-, 2-, 4-, 8-, and 12-week follow-up time points. Findings were compared with results obtained using principal component analysis (PCA) in our previously published study. The original sample was further divided into two subgroups: responders and nonresponders. The symptom clusters present in each subgroup were examined using PCA, HCA, and EFA at the same time points as mentioned above.

RESULTS

The symptom cluster findings of HCA and PCA correlated more frequently with each other than either did with the results of EFA. Complete consensus in all three statistical methods was never reached at any assessment time point in the present study. Increasingly diverging patterns of symptom cluster development over time were observed in the responder vs. nonresponder subgroups. Symptom pairs comprising anxiety and depression or fatigue and drowsiness consistently presented in the same cluster despite the shifting of other symptoms in the cluster over time.

CONCLUSION

The presence and composition of symptom clusters identified varied depending on which statistical analysis method was used. A key step in achieving consistency in symptom cluster research involves the utilization of a common analytical method.

Therapeutic applications for subcutaneous triptans in the acute treatment of migraine

BACKGROUND

The features of migraine attacks and the contexts in which migraine attacks occur vary from attack to attack and from patient to patient. Current treatment strategies, which are dominated by the use of oral forms of migraine medication, do not address this patient-to-patient and attack-to-attack heterogeneity. While current therapies, and, in particular, oral triptan tablets can be effective for many types of migraine attacks that a patient can experience, they may not be the optimum treatment for every migraine in every patient.

SCOPE

This clinical review of subcutaneous sumatriptan discusses its characteristics, efficacy, and tolerability and considers its place in clinical practice. The review focuses particularly on several specific clinical settings in which subcutaneous sumatriptan might be a more appropriate therapeutic choice than the oral triptan tablet.

FINDINGS

Of the triptan formulations, subcutaneous sumatriptan is the most rapidly absorbed and demonstrates a favorable pharmacokinetic profile. Data from randomized, double-blind, clinical trials and studies of patients' perceptions and preferences suggest that subcutaneous sumatriptan can be particularly useful to help restore normal work functioning, for migraine attacks that cannot be treated early in their course, for migraine attacks associated with gastrointestinal symptoms, such as nausea or vomiting, and for difficult-to-treat migraines, including early-morning migraine and menstrual migraine. The majority of patients (9 in 10) trying subcutaneous sumatriptan indicated that they will use it again. Patients not fully satisfied with previous triptan therapy reported enhanced satisfaction with, and confidence in, treatment after trying subcutaneous sumatriptan.

CONCLUSIONS

By virtue of their availability as multiple compounds and in multiple formulations including oral, intranasal, and injectable forms, triptans can be used to customize migraine therapy to the individual patient and the individual migraine attack. Due to its route of delivery and favorable pharmacokinetic profile, subcutaneous triptans may represent an attractive alternative for specific clinical settings. Subcutaneous sumatriptan can play a key role in maximizing likelihood of pain-free response and rapid return to normal daily activities and, as such, should be considered an important part of the treatment armamentarium for migraine.

[Acute respiratory failure after metoclopramide for methemoglobinemia - a rare and potentially life-threatening side effect]

HISTORY AND CLINICAL FINDINGS

A 85-year-old patient, initially treated for aspiration pneumonia on the intensive care unit acutely complained again of nausea which was immediately treated by an i. v. bolus of metoclopramide (MCP). Without another incident of aspiration she subsequently developed acutely massive dyspnoea, increasing cyanosis and somnolence.

INVESTIGATION

On physical exam the patient showed tachycardia, dyspnoea and progressive somnolence. Laboratory investigation showed no significant abnormalities other than improving inflammatory markers. Computer tomography of the chest as well as bronchoscopy also revealed no pathologies. Blood gas analysis (BGA) however showed a massive increase in methemoglobinemia from 0.5 % just prior to MCP injection to 53.1 % after MCP injection; simultaneously the pO2 decreased from 74 auf 54 mmHg and the pCO2 from 37.7 to 34.1 mmHg.

TREATMENT AND COURSE

Instant therapy with toluidine blue led to a dramatic improvement of the patient's symptoms as well as a rapid normalisation of the pathological BGA. Soon after the patient could be dismissed.

CONCLUSION

The development of a severe and acute methemoglobinemia following the administration of MCP is described in this case report. Rapidly evolving dyspnoea following administration of MCP should instantly lead to the consideration of acute methemoglobinemia as differential diagnosis. Rapid diagnosis by blood gas analysis and instant therapy by toloudine blue (TB) can effectively prevent a potentially lethal course. The pathogenesis, clinical presentation, diagnosis and therapy for methemoglobinemia are discussed.

Symptom clusters in advanced cancer

CONTEXT

Patients with advanced cancer often experience multiple concurrent symptoms. Few studies have explored symptom clusters (SCs) in this population.

OBJECTIVES

The aim of the present study was to explore SCs in advanced cancer, evaluate the characteristics associated with various clusters, and determine their relationship to survival.

METHODS

This study included patients in the palliative care program of the Hospital Universitario La Paz from 2003 to 2005. The Edmonton Symptom Assessment System and a supplement including 13 other symptoms were used to detect symptoms. Principal component analysis was performed to determine symptom relationships and compare SCs with associated parameters.

RESULTS

In total, 406 patients were included, 61% men and 39% women. The median age was 66.4 (range 18-95). The most common primaries were gastrointestinal (35%), lung (25%), genitourinary (8%), breast (5%), and head and neck (5%) carcinomas. The following clusters were identified: confusion (cognitive impairment, agitation, urinary incontinence), neuropsychological (anxiety, depression, and insomnia), anorexia-cachexia (anorexia, weight loss, and tiredness), and gastrointestinal (nausea and vomiting). The presence of these SCs was influenced by primary cancer site, gender, age, and performance status. Survival was related to the number of SCs present in a given patient: zero SC, 52 days; one SC, 38 days; two SCs, 23 days; and three to four SCs, 19 days; P < 0.001.

CONCLUSION

Different SCs can be identified in patients with advanced cancer. These SCs are influenced by primary cancer site, gender, age, and Eastern Cooperative Oncology Group performance status, and they can have prognostic value.

Therapeutic choices for nausea and vomiting of pregnancy: a critical review of a systematic review

With 80% of pregnant women suffering from some degree of "morning sickness," or nausea and vomiting of pregnancy (NVP), symptom management is a major challenge. A recent Cochrane systematic review of randomized controlled trials concluded that, to date, there is no strong evidence of effectiveness for practically any therapeutic agent used for management of NVP. Because of fears of teratogenicity and litigation, RCTs are rarely conducted in pregnancy. In the absence of the best possible evidence from RCTs, well planned and executed prospective observational studies should be used as the best available evidence to guide clinical practice.