Selective nonoperative management of high grade splenic trauma

The Evidence-based Telemedicine - Trauma & Acute Care Surgery (EBT-TACS) Journal Club performed a critical review of the literature and selected three up-to-date articles on the management of splenic trauma. Our focus was on high-grade splenic injuries, defined as AAST injury grade III-V. The first paper was an update of the 2003 Eastern Association for the Surgery of Trauma (EAST) practice management guidelines for nonoperative management of injury to the spleen. The second paper was an American Association for the Surgery of Trauma (AAST) 2012 plenary paper evaluating the predictive role of contrast blush on CT scan in AAST grade IV and V splenic injuries. Our last article was from Europe and investigates the effects of angioembolization of splenic artery on splenic function after high-grade splenic trauma (AAST grade III-V). The EBT-TACS Journal Club elaborated conclusions and recommendations for the management of high-grade splenic trauma.A reunião de revista Telemedicina baseada em evidências - Cirurgia do Trauma e Emergência (TBE-CiTE) realizou uma revisão crítica da literatura e selecionou três artigos atuais sobre o tratamento do trauma de baço. O foco foi em lesão de baço grave, definida pela American Association for the Surgery of Trauma (AAST) como graus III a V. O primeiro artigo foi uma atualização do protocolo de 2003 da Eastern Association for the Surgery of Trauma (EAST) para o tratamento não operatório de trauma do baço. O segundo artigo foi apresentado na plenária de 2012 da AAST avaliando o papel do extravasamento de contraste na tomografia computadorizada em pacientes com lesão grave de baço (AAST IV-V). O último artigo é europeu e investigou o efeito da angioembolização da artéria esplênica na função do baço após lesão esplênica grave (AAST III-V). A reunião de revista TBE-CiTE elaborou conclusões e recomendações para o tratamento de lesão grave do baço.24625

Women can bear a bigger burden: ante- and post-mortem evidence for reserve in the face of tau.

In this study, we aimed to assess whether women are able to withstand more tau before exhibiting verbal memory impairment. Using data from 121 amyloid-β-positive Alzheimer's Disease Neuroimaging Initiative participants, we fit a linear model with Rey Auditory Verbal Learning Test score as the response variable and tau-PET standard uptake value ratio as the predictor and took the residuals as an estimate of verbal memory reserve for each subject. Women demonstrated higher reserve (i.e. residuals), whether the Learning (t = 2.78, P = 0.006) or Delay (t = 2.14, P = 0.03) score from the Rey Auditory Verbal Learning Test was used as a measure of verbal memory ability. To validate these findings, we examined 662 National Alzheimer's Coordinating Center participants with a C2/C3 score (Consortium to Establish a Registry for Alzheimer's Disease) at autopsy. We stratified our National Alzheimer's Coordinating Center sample into Braak 1/2, Braak 3/4 and Braak 5/6 subgroups. Within each subgroup, we compared Logical Memory scores between men and women. Men had worse verbal memory scores within the Braak 1/2 (Logical Memory Immediate: β = -5.960 ± 1.517, P < 0.001, Logical Memory Delay: β = -5.703 ± 1.677, P = 0.002) and Braak 3/4 (Logical Memory Immediate: β = -2.900 ± 0.938, P = 0.002, Logical Memory Delay: β = -2.672 ± 0.955, P = 0.006) subgroups. There were no sex differences in Logical Memory performance within the Braak 5/6 subgroup (Logical Memory Immediate: β = -0.314 ± 0.328, P = 0.34, Logical Memory Delay: β = -0.195 ± 0.287, P = 0.50). Taken together, our results point to a sex-related verbal memory reserve

Study of Clinical Profile of 50 Patients with Acute Inferior Wall Myocardial Infarction

INTRODUCTION: Myocardial infarction is the term used when the myocardium is necrosed due to ischemia. It may be transmural or subendocardial. Patients with ischaemic heart disease fall into two large groups. Patients with stable angina and patients with acute coronary syndromes (ACS). ACS group in turn is composed of patients with acute myocardial infarction with ST elevation (STEMI), those with unstable angina (UA) and non ST segment elevation MI (NSTEMI). Inferior wall infarction has got some special features like association with right ventricular infarction and bradyarrhythmias especially sinus bradycardia and second degree AV block. Right Ventricular infarction is different from that of the left ventricle in the acute presentation, therapy and long term prognosis. The early recognition of RVI is important, because the time of onset of its haemodynamic consequence is unpredictable and these may be prevented by the administration of intravenous fluid load. The description of RVI appeared more than 60 years ago. But it was considered unimportant until Cohn and Co-workers in 1974 published their classic report on RVI as a distinct clinical entity. The reported incidence is between 25 – 50% of IWMI. Involvement of RV is related to atherosclerotic occlusion of the right coronary artery and is associated with involvement of postero-inferior wall and posterior portion of the septum. Clinically RVI can be suspected when a patient with IWMI presents with elevated JVP, positive Kussmaul’s sign, hypotension, right sided third or fourth heart sounds, tender hepatomegaly, oliguria, rarely tricuspid regurgitation and clear chest. Electrocardiogram was generally believed to be unhelpful in identifying RVI, until Erhardt and co-workers described the value of a right precordial lead in patients with autopsy proved RVI. A 1 mm ST elevation in this lead is 93% sensitive and 95% specific. The change is transient. In one series, 48% of the patients had resolution of ECG changes within 10 hours of the onset of symptoms. AIM OF THE STUDY: To study the clinical profile of 50 serial cases of Acute Inferior Wall Myocardial Infarction with Right Ventricular Infarction and to analyse the age and sex distribution, symptomatology, clinical features, complications and outcome. MATERIALS AND METHODS: This study was conducted during December 2006 to July 2007 period. 50 consecutive patients admitted to the coronary care unit with a diagnosis of acute inferior wall infarction were included in the study. All patients included in the study were subjected to ECG examination of V3R and V4R in addition to the conventional 12 leads. In addition, all patients were subjected to ECG examination of extended leads V7 to V9. Rhythm strips were taken in patients with arrhythmias. ECGs were examined at the time of admission, second day and on the day of discharge. Only those cases with hyperacute inferior wall infarction were included in the study. Patients with slope elevation of ST segment in leads, II, III and aVF were taken as having hyperacute inferior wall infarction. Right ventricular infarction was diagnosed if there was ST elevation equal to or more than 1 mm in V4R. Posterior wall myocardial infarction was diagnosed if there was ST segment elevation equal to or more than 1 mm in extended leads V7 to V9,with tall ‘R’, ST segment depression, upright ‘T’ in leads V1,V2. All patients were assessed clinically and electrocardiographically with special emphasis on presenting complaints, risk factors, vital signs, arrhythmias and mortality. Patients were followed up till discharge. Patients who presented after 24 hrs of onset of chest pain were excluded, as the ST changes in right ventricular infarction may be transient. Patients with history of chronic lung disease, previous MI, rheumatic heart disease, pericardial disease or LBBB were excluded because diagnosis of right ventricular infarction is not possible in these cases when ECG is used as the criteria. RESULTS: The observations in 50 patients with acute inferior wall myocardial infarction is presented in this section in descriptive and tabular form. Cases were divided in to groups of 5 years difference for comparing age and sex incidence. Peak incidence was found in 2 groups, one group with mean age 42 and another with mean age 62. The lowest age was 31 years who was a male. The patient with highest age was a female of 82 years. 41 patients were male and 9 were female. CONCLUSION: 1. The incidence of Acute Inferior Wall Myocardial Infarction is much higher in males than in females, the difference being less as age advances. 2. In males, there is a distinct increase in the incidence after age of 40 years in this study. 3. Typical retrosternal chest pain lasting for more than 30 minutes associated with sweating was seen in almost all patients. 4. Smoking was the most prevalent risk factor (56%). 5. The onset of symptoms in majority of the patients (60%) was between 6 am – 12 noon. 6. The incidence of Right ventricular infarction in this study was 38%. 7. Syncope or presyncope was a prominent symptom in patients with right ventricular infarction. 8. Triad of raised JVP, Hypotension and clear lung fields were seen in 15 patients (30%). 9. All cases of inferior wall infarction should have right-sided leads during ECG examination and this should be done as early as possible. 10. If diagnosis of RVMI is correctly made and treated early, the prognosis is usually good. 11. Incidence of true posterior wall myocardial infarction in this study was 16%. 12. Mortality is higher in patients with right ventricular infarction when compared with those without this complication

The Department of Anaesthesia, UCT 1920-2000 : a history

Bibliography: leaves 307-312

Meta-Analysis of Genomewide Association Studies Reveals Genetic Variants for Hip Bone Geometry

Hip geometry is an important predictor of fracture. We performed a meta-analysis of GWAS studies in adults to identify genetic variants that are associated with proximal femur geometry phenotypes. We analyzed four phenotypes: (i) femoral neck length; (ii) neck-shaft angle; (iii) femoral neck width, and (iv) femoral neck section modulus, estimated from DXA scans using algorithms of hip structure analysis. In the Discovery stage, 10 cohort studies were included in the fixed-effect meta-analysis, with up to 18,719 men and women ages 16 to 93 years. Association analyses were performed with ∼2.5 million polymorphisms under an additive model adjusted for age, body mass index, and height. Replication analyses of meta-GWAS significant loci (at adjusted genomewide significance [GWS], threshold p ≤ 2.6 × 10 –8 ) were performed in seven additional cohorts in silico. We looked up SNPs associated in our analysis, for association with height, bone mineral density (BMD), and fracture. In meta-analysis (combined Discovery and Replication stages), GWS associations were found at 5p15 (IRX1 and ADAMTS16); 5q35 near FGFR4; at 12p11 (in CCDC91); 11q13 (near LRP5 and PPP6R3 (rs7102273)). Several hip geometry signals overlapped with BMD, including LRP5 (chr. 11). Chr. 11 SNP rs7102273 was associated with any-type fracture (p = 7.5 × 10 –5 ). We used bone transcriptome data and discovered several significant eQTLs, including rs7102273 and PPP6R3 expression (p = 0.0007), and rs6556301 (intergenic, chr.5 near FGFR4) and PDLIM7 expression (p = 0.005). In conclusion, we found associations between several genes and hip geometry measures that explained 12% to 22% of heritability at different sites. The results provide a defined set of genes related to biological pathways relevant to BMD and etiology of bone fragility

“I was worried if I don’t have a broken leg they might not take it seriously”: Experiences of men accessing ambulance services for mental health and/or alcohol and other drug problems

Abstract Background A large proportion of ambulance callouts are for men with mental health and/or alcohol and other drug (AOD) problems, but little is known about their experiences of care. This study aimed to describe men's experiences of ambulance care for mental health and/or AOD problems, and factors that influence their care. Methods Interviews were undertaken with 30 men who used an ambulance service for mental health and/or AOD problems in Australia. Interviews were analysed using the Framework approach to thematic analysis. Results Three interconnected themes were abstracted from the data: (a) professionalism and compassion, (b) communication and (c) handover to emergency department staff. Positive experiences often involved paramedics communicating effectively and conveying compassion throughout the episode of care. Conversely, negative experiences often involved a perceived lack of professionalism, and poor communication, especially at handover to emergency department staff. Conclusion Increased training and organizational measures may be needed to enhance paramedics' communication when providing care to men with mental health and/or AOD problems

The Colonial Medical Officer and colonial identity: Kenya, Uganda and Tanzania before World War Two.

The Colonial Medical Service was the branch of the Colonial Service responsible for healthcare provision in the British overseas territories. This work profiles Colonial Medical Officers serving in Kenya, Uganda and Tanzania from the beginnings of British colonial rule to the start of World War Two. On the basis of a large prosopographical database, the composition and experiences of this governmental cadre are profiled and analysed

The American College of Rheumatology Preliminary Diagnostic Criteria for Fibromyalgia and Measurement of Symptom Severity

Objective To develop simple, practical criteria for clinical diagnosis of fibromyalgia that are suitable for use in primary and specialty care and that do not require a tender point examination, and to provide a severity scale for characteristic fibromyalgia symptoms. Methods We performed a multicenter study of 829 previously diagnosed fibromyalgia patients and controls using physician physical and interview examinations, including a widespread pain index (WPI), a measure of the number of painful body regions. Random forest and recursive partitioning analyses were used to guide the development of a case definition of fibromyalgia, to develop criteria, and to construct a symptom severity (SS) scale. Results Approximately 25% of fibromyalgia patients did not satisfy the American College of Rheumatology (ACR) 1990 classification criteria at the time of the study. The most important diagnostic variables were WPI and categorical scales for cognitive symptoms, unrefreshed sleep, fatigue, and number of somatic symptoms. The categorical scales were summed to create an SS scale. We combined the SS scale and the WPI to recommend a new case definition of fibromyalgia: (WPI ≥7 AND SS ≥5) OR (WPI 3–6 AND SS ≥9). Conclusion This simple clinical case definition of fibromyalgia correctly classifies 88.1% of cases classified by the ACR classification criteria, and does not require a physical or tender point examination. The SS scale enables assessment of fibromyalgia symptom severity in persons with current or previous fibromyalgia, and in those to whom the criteria have not been applied. It will be especially useful in the longitudinal evaluation of patients with marked symptom variability.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/75772/1/20140_ftp.pd