International consensus on (ICON) anaphylaxis

ICON: Anaphylaxis provides a unique perspective on the principal evidence-based anaphylaxis guidelines developed and published independently from 2010 through 2014 by four allergy/immunology organizations. These guidelines concur with regard to the clinical features that indicate a likely diagnosis of anaphylaxis -- a life-threatening generalized or systemic allergic or hypersensitivity reaction. They also concur about prompt initial treatment with intramuscular injection of epinephrine (adrenaline) in the mid-outer thigh, positioning the patient supine (semi-reclining if dyspneic or vomiting), calling for help, and when indicated, providing supplemental oxygen, intravenous fluid resuscitation and cardiopulmonary resuscitation, along with concomitant monitoring of vital signs and oxygenation. Additionally, they concur that H1-antihistamines, H2-antihistamines, and glucocorticoids are not initial medications of choice. For self-management of patients at risk of anaphylaxis in community settings, they recommend carrying epinephrine auto-injectors and personalized emergency action plans, as well as follow-up with a physician (ideally an allergy/immunology specialist) to help prevent anaphylaxis recurrences. ICON: Anaphylaxis describes unmet needs in anaphylaxis, noting that although epinephrine in 1 mg/mL ampules is available worldwide, other essentials, including supplemental oxygen, intravenous fluid resuscitation, and epinephrine auto-injectors are not universally available. ICON: Anaphylaxis proposes a comprehensive international research agenda that calls for additional prospective studies of anaphylaxis epidemiology, patient risk factors and co-factors, triggers, clinical criteria for diagnosis, randomized controlled trials of therapeutic interventions, and measures to prevent anaphylaxis recurrences. It also calls for facilitation of global collaborations in anaphylaxis research. In addition to confirming the alignment of major anaphylaxis guidelines, ICON: Anaphylaxis adds value by including summary tables and citing 130 key references. It is published as an information resource about anaphylaxis for worldwide use by healthcare professionals, academics, policy-makers, patients, caregivers, and the public

Polypharmacy, the Electronic Medical Record, and Adverse Drug Events

Polypharmacy, a concurrent chronic use of multiple prescribed and over-the-counter medications by the same individual, is one of the clinical problems facing primary care providers. Polypharmacy creates the potential for adverse drug-related events, especially in the elderly. The advent of electronic medical records (EMR) may help identify and respond to these potential adverse events. The purpose of this project was to investigate the relationship between the total number of medication taken by elderly, 65 years and older, and the severity of drug-drug and drug-disease interactions triggered by the EMR system. The study used a retrospective chart review of the EMRs. Three independent variables (age, gender, and number of medications) and 4 dependent variables (major drug-drug, moderate drug-drug, major drug-drug, and moderate drug-drug interactions) were analyzed among a sample of 247 individuals, ranging in age from 65 to 98 years. The total number of medications used among this sample ranged from 2 to 27 medications, with 177 (71.7%) patients using 2 to 9 medications, and 70 (28.3%) using 10 or more medications. Correlational analysis showed a positive relationship between number of medication and major drug-drug, moderate drug-drug, major drug-disease, and moderate drug-disease interactions (r = 0.240, p = 0.0001; r = .596, p = 0.0001; r = 464, p =0.0001; r = 669, p = 0.0001, respectively). However, there was no significant relationship between age and major and moderate drug-drug and drug disease interactions. The results of this study contribute to positive social change by increasing primary care providers\u27 understanding of the EMR as a tool to improve the identification and management of patients with polypharmacy

QT-tidsförlängande läkemedelsbehandling hos äldre vuxna inom hemvården

Many drugs are associated with the risk of QT prolongation and torsades de pointes (TdP). The risk increases with other risks factors for QT prolongation. Recognizing risk factors and QT prolonging drugs is critical in the management of this drug-related problem. The aim of this master’s thesis was to study the prevalence of use of QT prolonging drugs in older adults receiving home care. Additionally, the aim was to study concomitant use of QT prolonging drugs as well as clinically significant QT prolonging drug-drug interactions in the participants. The secondary objective was to study the most commonly used QT prolonging in the participants. The material used in this master’s thesis originated from a randomized controlled trial in City of Lohja, Finland, which enhanced a coordination in medication risk management for older home care clients. The analysis of the baseline data collected in fall 2015 was only deepened regarding QT prolonging drugs. The participants (n=188) were older adults (≥65 years) receiving regular home care from City of Lohja, randomized into an intervention group (n=101) and a control group (n=87). The majority of the participants were women (69%). The mean age of the participants was 83 years. Data on the participants’ drugs were collected from their medication lists. Clinically significant drug-drug interactions were identified using the SFINX database. The QTDrugs Lists of CredibleMeds were used for identifying drugs associated with QT prolongation and TdP. On average, the participants (n=188) used 2.3 drugs (SD 1.3, median 2.0) associated with QT prolongation and TdP. Of the participants, 36% (n=67) used drugs with known risk of TdP (QTDrugs List 1). The most commonly used drugs with known risk of TdP were donepezil and citalopram. The prevalence of QTDrugs List 2 drugs (possible risk of TdP) was 36% (n=67). Most of the participants (n=156, 83%) used drugs which under certain circumstances are associated with TdP (QTDrugs List 3). One fifth (21%) of the participants used concomitantly 2-3 drugs associated with QT prolongation and TdP. QT prolonging drugdrug interactions (SFINX-D interactions) were found in 3% of the participants. The drugs involved in the drug-drug interactions were donepezil, (es)citalopram and haloperidol. The prevalence of use of clinically relevant QT prolonging drugs (QTDrugs Lists 1-2) was higher in this study compared with the prevalence in outpatients in previous studies. Concomitant use of QT prolonging drugs is common in outpatients. Health care professionals need to be educated on the risks of QT prolongation, TdP and the risks of using QT prolonging drugs concomitantly. Risk assessment tools considering patient-specific risk factors could be more widely used, as they may reduce modifiable risk factors, and actual events of QT prolongation and TdP may be avoided. There is a need for systematic procedures for assessing and managing the risks of QT prolongation and TdP in the Finnish health care system.Många läkemedel är förknippade med en risk för QT-tidsförlängning och torsades de pointes (TdP). Risken ökar med andra samtidiga riskfaktorer för QT-tidsförlängning. Det är avgörande för hanteringen av detta läkemedelsrelaterade problem att kunna identifiera riskfaktorer och läkemedel som kan förlänga QT-tiden. Syftet med denna pro graduavhandling var att studera förekomsten av användning av QT-tidsförlängande läkemedel hos äldre vuxna inom hemvården. Dessutom studerades samtidig användning av QT-tidsförlängande läkemedel samt kliniskt relevanta läkemedelsinteraktioner med risk för QT-tidsförlängning hos deltagarna. Det sekundära syftet var att studera de mest använda QT-tidsförlängande läkemedlen bland deltagarna. Materialet som användes i den här pro gradu-avhandlingen härrörde sig från en randomiserad kontrollerad interventionsstudie utförd i Lojo, vilken förbättrade en samordnad riskhantering av läkemedel hos äldre hemvårdsklienter. I analysen av det material som insamlats under hösten 2015 låg fokus på QT-tidsförlängande läkemedel. Deltagarna (n=188) var äldre vuxna (≥65 år) som använde hemvårdstjänster regelbundet i Lojo, randomiserade till en interventionsgrupp (n=101) och en kontrollgrupp (n=87). Majoriteten av deltagarna var kvinnor (69 %). Deltagarnas medelålder var 83 år. Från deltagarnas läkemedelslistor samlades in uppgifter om använda läkemedel. Från databasen SFINX identifierades kliniskt relevanta läkemedelsinteraktioner. Listor över QTtidsförlängande läkemedel från CredibleMeds användes för att identifiera läkemedel associerade med QTtidsförlängning och TdP. Deltagarna (n=188) använde i genomsnitt 2,3 läkemedel associerade med QT-tidsförlängning och TdP (standardavvikelse 1,3; medianvärde 2,0). Av deltagarna använde 36 % (n=67) läkemedel med känd risk för TdP ("QTDrugs List 1"). De mest använda läkemedlen med känd risk för TdP var donepezil och citalopram. Förekomsten av läkemedel med möjlig risk för TdP ("QTDrugs List 2") var 36 % (n=67). De flesta deltagare (n=156, 83 %) använde läkemedel som under vissa omständigheter är associerade med TdP (”QTDrugs List 3”). En femtedel (21%) av deltagarna använde 2–3 QT-tidsförlängande läkemedel samtidigt. Läkemedelsinteraktioner (SFINX-D interaktioner) som kan leda till QT-tidsförlängning hittades hos 3 % av deltagarna. De läkemedel som var involverade i läkemedelsinteraktionerna var donepezil, (es)citalopram och haloperidol. Förekomsten av användning av kliniskt relevanta QT-tidsförlängande läkemedel ("QTDrugs Lists 1–2") var högre i denna studie jämfört med förekomsten hos patienter inom öppenvården från tidigare studier. Samtidig användning av flera QT-tidsförlängande läkemedel hos patienter inom öppenvården är vanlig. Hälso- och sjukvårdspersonal behöver utbildas om riskerna för QT-tidsförlängning, TdP och om riskerna av samtidig användning av QT-tidsförlängande läkemedel. Riskbedömningsverktyg som tar hänsyn till patientspecifika riskfaktorer kunde användas i en större utsträckning, eftersom användningen av dessa kan minska på modifierbara riskfaktorer och faktiska händelser av QTtidsförlängning och TdP kan undvikas. Det finns ett behov av systematiska rutiner för bedömning och hantering av risken för QT-tidsförlängning och TdP i det finska hälsovårdssystemet

Postoperative care in finger replantation. Our case-load and review of the literature

OBJECTIVE: Technical success of a finger replantation depends on several factors such as surgical procedure, type of injury, number of segments amputated, amputation level and individual patient factors. Among early complications that can occur in this type of surgery the onset of venous or arterial thrombosis is the most dreaded. Local irrigating solutions, oral and intravenous anticoagulants, thrombolytic agents, plasma expanders, vasodilating, and antiaggregant drugs are routinely used in patients undergoing microvascular procedures, but currently there is only a non-standardized practice based on anecdotal personal experience. MATERIALS AND METHODS: The aim of our study is to review selected literature relating to perioperative therapy in microsurgical digital replantation. We also report our case-load of 16 patients with finger avulsion describing our particular protocol for postoperative anticoagulation and restoration of fluid and electrolyte balance. RESULTS: Following our daily pharmacological protocol, the postoperative course of the replanted fingers was uneventful. The survival rate for finger replantations performed was 100% (n = 16) with no need for surgical revisions. CONCLUSIONS: The association Dextran-40/Heparin/fluids in the proposed standardized pro-weight pharmacological protocol is an optimal postoperative prophylactic/therapeutic plan to reduce the incidence of endovascular thrombosis after replantation, so ensuring high rate of success in microvascular surgery

Application of Smartphone Technology in the Management and Treatment of Mental Illnesses

Abstract: Background: Mental illness continues to be a significant Public Health problem and the innovative use of technology to improve the treatment of mental illnesses holds great public health relevance. Over the past decade telecommunications technology has been used to increase access to and improve the quality of mental health care. There is current evidence that the use of landline and cellular telephones, computer-assisted therapy, and videoconferencing can be effective in improving treatment outcomes. Smartphones, as the newest development in communications technology, offer a new opportunity to improve mental health care through their versatile nature to perform a variety of functions. Methods: A critical literature review was performed to examine the potential of smartphones to increase access to mental health care, reduce barriers to care, and improve patient treatment outcomes. The review was performed by searching several electronic databases using a combination of keywords related to smartphones and mental health interventions using mobile devices. Literature concerning the use of cell phones, handheld computers, and smartphones to improve access to mental health care and improve treatment outcomes was identified.Results: The majority of studies identified were feasibility and pilot studies on patients with a variety of diagnosed mental illnesses using cell phones and PDAs. Authors report that most study participants, with some exceptions, were capable of using a mobile device and found them acceptable to use. Few studies extensively measured treatment outcomes and instead reported preliminary results and presented case illustrations. Studies which used smartphones successfully used them collect data on patients and deliver multimedia interventions. Discussion: The current literature offers encouraging evidence for the use of smartphones to improve mental health care but also reflects the lack of research conducted using smartphones. Studies which examine care provider use of smartphones to improve care is encouraging but has limited generalizability to mental health care. The feasibility of patient use of smartphones is also encouraging, but questions remain about feasibility in some sub-populations, particularly schizophrenia patients. Pilot testing of mobile devices and applications can greatly increase the feasibility of using smartphones in mental health care. Patients who are unfamiliar with smartphones will likely need initial training and support in their use. Conclusion: The literature identified several ways in which smartphones can increase access to care, reduce barriers, and improve treatment outcomes. Study results were encouraging but scientifically weak. Future studies are needed replicating results of studies using cell phones and PDAs on smartphones. Larger and higher quality studies are needed to examine the feasibility, efficacy, and cost-effectiveness of smartphones to deliver multiple component interventions that improve access to mental health care and improve treatment outcomes

Impact of the SGLT2 inhibitor empagliflozin on urinary supersaturations in kidney stone formers (SWEETSTONE trial): protocol for a randomised, double-blind, placebo-controlled cross-over trial.

INTRODUCTION Kidney stones are a global healthcare problem. Given high recurrence rates and the morbidity associated with symptomatic stone disease, effective medical prophylaxis is clearly an unmet need. Explanatory analyses of randomised controlled trials with sodium/glucose cotransporter isoform 2 inhibitors indicated a 30%-50% reduced rate of stone events in patients with diabetes. Underlying mechanisms remain unclear. We aim to determine the effect of empagliflozin on urinary supersaturations in non-diabetic kidney stone formers to evaluate their therapeutic potential for recurrence prevention. We will provide first clinical trial evidence on whether urinary supersaturations are affected by empagliflozin in kidney stone formers. METHODS AND ANALYSIS The SWEETSTONE trial is a randomised, double-blind, placebo-controlled, cross-over, exploratory study to assess the impact of empagliflozin on urinary supersaturations of calcium oxalate, calcium phosphate and uric acid in kidney stone formers. We plan to include 46 non-diabetic adults (18-74 years) with ≥1 past kidney stone event and stone composition with ≥80% of calcium or ≥80% of uric acid. Patients with secondary causes of kidney stones or chronic kidney disease will be excluded. Eligible individuals will be randomised in equal proportions to receive either a 14-day treatment with 25 mg empagliflozin followed after the 2-6 weeks wash out period by a 14-day treatment with a matching placebo or the reverse procedure. Secondary outcomes will include electrolyte concentrations, renal function, mineral metabolism and glycaemic parameters, urinary volume and safety.Results will be presented as effect measures (95% CIs) with p values and hypothesis testing for primary outcomes (significance level 0.02). ETHICS AND DISSEMINATION The SWEETSTONE trial was approved by the Swiss ethics committee and Swissmedic. First results are expected in the fourth quarter of 2022. TRIAL REGISTRATION NUMBER NCT04911660; Pre-results

COVID-19 and Thrombotic or Thromboembolic Disease: Implications for Prevention, Antithrombotic Therapy, and Follow-up

Coronavirus disease 2019 (COVID-19), a viral respiratory illness caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), may predispose patients to thrombotic disease, both in the venous and arterial circulations, due to excessive inflammation, platelet activation, endothelial dysfunction, and stasis. In addition, many patients receiving antithrombotic therapy for thrombotic disease may develop COVID-19, which can have implications for choice, dosing, and laboratory monitoring of antithrombotic therapy. Moreover, during a time with much focus on COVID-19, it is critical to consider how to optimize the available technology to care for patients without COVID-19 who have thrombotic disease. Herein, we review the current understanding of the pathogenesis, epidemiology, management and outcomes of patients with COVID-19 who develop venous or arterial thrombosis, and of those with preexisting thrombotic disease who develop COVID-19, or those who need prevention or care for their thrombotic disease during the COVID-19 pandemic.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/155446/1/Bikdeli-2020-COVID-19 and Thrombotic or Thromb.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/155446/3/DeepBluepermissions_agreement-CCBYandCCBY-NC_ORCID_Barnes.docxhttps://deepblue.lib.umich.edu/bitstream/2027.42/155446/4/license_rdf.rdfDescription of Bikdeli-2020-COVID-19 and Thrombotic or Thromb.pdf : ArticleDescription of DeepBluepermissions_agreement-CCBYandCCBY-NC_ORCID_Barnes.docx : Deep Blue sharing agreemen

COVID-19 and Thrombotic or Thromboembolic Disease: Implications for Prevention, Antithrombotic Therapy, and Follow-Up: JACC State-of-the-Art Review

© 2020 American College of Cardiology Foundation Coronavirus disease-2019 (COVID-19), a viral respiratory illness caused by the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), may predispose patients to thrombotic disease, both in the venous and arterial circulations, because of excessive inflammation, platelet activation, endothelial dysfunction, and stasis. In addition, many patients receiving antithrombotic therapy for thrombotic disease may develop COVID-19, which can have implications for choice, dosing, and laboratory monitoring of antithrombotic therapy. Moreover, during a time with much focus on COVID-19, it is critical to consider how to optimize the available technology to care for patients without COVID-19 who have thrombotic disease. Herein, the authors review the current understanding of the pathogenesis, epidemiology, management, and outcomes of patients with COVID-19 who develop venous or arterial thrombosis, of those with pre-existing thrombotic disease who develop COVID-19, or those who need prevention or care for their thrombotic disease during the COVID-19 pandemic