Hypoattenuating periportal halo on CT in a patient population can occur in presence of a variety of diseases

Many pathologies can occur in the periportal space and manifest as fluid accumulation, visible in Computed tomography (CT) images as a circumferential region of low attenuation around the intrahepatic portal vessels, called periportal halo (PPH). This finding is associated with different types of hepatic and extra-hepatic disease in humans and remains a non-specific sign of unknown significance in veterinary literature. The aim of this study was to investigate the prevalence of PPH in a population of patients undergoing CT examination and to assess the presence of lesions related to hepatic and extra-hepatic disease in presence of PPH. CT studies including the cranial abdomen of dogs and cats performed over a 5-year period were retrospectively reviewed. The prevalence of PPH was 15% in dogs and 1% in cats. 143 animals were included and the halo was classified as mild, moderate and severe, respectively in 51%, 34% and 15% of animals. The halo distribution was generalized in 79 cases, localized along the second generation of portal branches in 63, and along the first generation only in one. Hepatic disease was present in 58/143 and extra-hepatic disease in 110/143 of the cases. Main cause of hepatic (36%) and extra-hepatic disease (68%) was neoplasia. Associations between halo grades and neoplasia revealed to be not statistically significant (p = 0.057). In 7% of animals the CT examination was otherwise unremarkable. PPH is a non-specific finding, occurring in presence of a variety of diseases in the examined patient population.

Treatment of Chronic Ankle Instability in the Military Population: A Systematic Review

Background The high incidence of ankle sprain within the military sets the stage for prevalent chronic ankle instability. The purpose of this review was to compare and evaluate chronic ankle instability treatment strategies in the military population. Methods Electronic databases were systematically searched in accordance with the Preferred Reporting Items for Systematic Reviews guidelines for English-language, human studies with a military patient population that had been diagnosed with and treated for chronic ankle instability. Exclusion criteria were animal, cadaver, and review studies and case reports. Results Eight studies met the inclusion criteria, representing 695 military service members—625 males (89.9%) and 70 females (10.1%)—and 4 treatment strategies: Broström-related procedures, modified Watson-Jones procedure, Colville’s technique, and anatomic lateral ligament reconstruction using semitendinosus tendon allograft. The percentage of satisfactory outcomes was 100% for Colville’s technique, and ranged from 73.2% to 94.7% for Broström-related procedures and 72% to 80% for the modified Watson-Jones procedure. Mean American Orthopaedic Foot and Ankle Society scores, anterior drawer displacement, talar tilt, and visual analogue scale scores were also reported. Conclusion This review demonstrates that the Bröstrom procedure has consistently satisfactory outcomes within the military population, and Colville’s technique is another promising option for this patient population but would require additional studies to support this claim. Levels of Evidence: Level IV

Time trends with response-adaptive randomization: The inevitability of inefficiency

Response-adaptive randomization, which changes the randomization ratio as a randomized clinical trial progresses, is inefficient as compared to a fixed 1:1 randomization ratio in terms of increased required sample size. It is also known that response-adaptive randomization leads to biased treatment effects if there are time trends in the accruing outcome data, for example, due to changes in the patient population being accrued, evaluation methods, or concomitant treatments. Response-adaptive-randomization analysis methods that account for potential time trends, such as time-block stratification or re-randomization, can eliminate this bias. However, as shown in this Commentary, these analysis methods cause a large additional inefficiency of response-adaptive randomization, regardless of whether a time trend actually exists.

Polypharmacy and the occurrence of potential drug–drug interactions among geriatric patients at the outpatient pharmacy department of a regional hospital in Durban, South Africa

Background Polypharmacy is the administration of an excessive number of medicines and a significant irrational medicine use practice. Little is known about this practice in South Africa. This study aimed to determine the level of polypharmacy and potential drug–drug interactions amongst the geriatric patient population in a facility in South Africa. Method A cross-sectional retrospective prescription chart review for 250 geriatric patients was conducted at the outpatient pharmacy department of a regional hospital. Variables extracted included demographic information, diagnosis, type of prescriber contact, and polypharmacy. Potential drug–drug interactions were determined with web-based multi-drug interaction checkers. Results The average (SD) number of diagnosed clinical problems was 3.54 ± 1.26, with hypertension, diabetes mellitus, and heart disease occurring most frequently. The level of polypharmacy was high with patients receiving an average (SD) of 12.13 ± 4.25 prescribed medicines from 3032 prescribed medicines. The level of polypharmacy was highest within the age categories, 60–64, and 70–74 years of age, respectively. The level of potential drug–drug interactions was also high with an average (SD) of 10.30 ± 7.48 from 2570 potential drug interactions. The majority of these interactions were moderate (72.5%) and pharmacodynamic (73.2%) by nature of the clinical severity of action and mechanism of action, respectively. Polypharmacy and type of prescriber contact were statistically significant contributors to the occurrence of potential drug–drug interactions, (F (2, 249) = 68.057, p < 0.05). However, in a multivariate analysis of variables to determine the strength of the association, polypharmacy was determined to be the strongest contributor to the occurrence of potential drug–drug interactions (p < 0.05) when compared with the type of prescriber contact (p value = 0.467). Therefore, irrespective of the type of prescriber contact, polypharmacy increases the potential for drug interactions among the sampled patient population. Conclusion A comprehensive consideration of disease management guidelines, patient factors, and rational medicine review could be measurable strategies towards improving medicine use. This would also limit the occurrence of significant drug interactions among the geriatric patient population. A national study is required to determine if differences occur across hospitals and regions.

Surgical Stabilization of Rib Fractures Improves Outcomes in the Geriatric Patient Population

Introduction Rib fractures in the ≥65-year-old population have been shown to strongly influence mortality and pneumonia rates. There is a growing body of evidence demonstrating improvements in the geriatric patient’s survival statistics and respiratory performances after surgical stabilization of rib fractures (SSRF). We have observed a strong survival and complication avoidance trend in geriatric patients who undergo SSRF. The purpose of our study was to evaluate the outcomes of geriatric patients with rib fractures treated with SSRF compared to those who only receive conservative therapies. Methods We performed a retrospective review of our trauma registry analyzing outcomes of patients ≥65 years with rib fractures. Patients admitted from 2015 to 2019 receiving SSRF (RP group) were compared to a nonoperative controls (NO group) admitted during the same time. Bilateral fractures were excluded. Independent variables analyzed = ISS, mortalities, hospital days, ICU days, pleural space complications, and readmissions. Follow-up was 60 days after discharge. Group comparison was performed using Kolmogorov-Smirnov, Shapiro-Wilk, and Mann-Whitney U tests. Results 257 patients were analyzed: 172 in the NO group with mean age of 75 (65-10) and 85 in the RP group with mean age of 74 (65-96). Mean ISS = 13 (1-38) for the NO group and 20 (9-59) for the RP group ( P < .001). Mean hospital days = 8 (1-39) and 15 (3-49) in NO and RP groups, respectively. Mean ICU days = 10 (1-32) and 8 (1-11) in NO and RP groups, respectively. Deaths, pneumonia, readmissions, and pleural effusions in the NO group were statistically significant ( P < .01). Analysis of complications revealed 4 RP patients (4.7%) with respiratory complications out to 60 days and 65 NO patients (37.8%) ( P < .001). Conclusions Surgical stabilization of rib fractures appears to be associated with a survival advantage and an avoidance of respiratory-related complications in the ≥65-year-old patient population.

Crotalidae Polyvalent Immune Fab and Cost-Effective Management of Hospital Admissions for Snakebites

Background Venomous snakebites are a common clinical scenario in the Southeastern United States. CroFab® (Crotalidae Polyvalent Immune Fab (Ovine), BTG, Wales, UK) antivenom is indicated in cases involving pit vipers and is known to be expensive. The treatment protocol for snakebites is based on clinically subjective measures triggering the application, or escalation of, antivenom administration. The purpose of this study is to characterize the use of CroFab at our institution and to evaluate the impact of its use regarding cost and overall outcomes. We suspect that it is often used but potentially less often needed. We hypothesized that CroFab use was associated with increased length of stay (LOS) without an observed difference in patient outcomes. Materials and Methods A retrospective chart review of snakebite patients at our level-1 trauma center from 2000 to 2016 was performed. Snakebite location, snake species, number of vials of CroFab administered, hospital LOS, intensive care unit (ICU) LOS, and complications were identified for each patient. Patients were divided into CroFab (C) and no CroFab (NC) groups. Results One hundred ninety patients with venomous snakebites were included. 53.7% of patients received CroFab. There was no difference in the complication rate of C versus NC groups, ( P = .1118). CroFab use was associated with longer hospital LOS ( P < .0001) and ICU LOS ( P < .0001). Discussion CroFab use was associated with increased LOS in our patient population. There was no difference in observed outcomes between the C and NC groups. These findings imply that CroFab is potentially over-used in our patient population.

Exploring the Unmet Need in Acute Ischemic Stroke Patients Not Treated With Intravenous Alteplase: The Get With The Guidelines‐Stroke Registry

BACKGROUND Early administration of intravenous tissue plasminogen activator (IV alteplase) improves functional outcomes in patients with acute ischemic stroke, yet many patients are not treated with IV alteplase. There is a need to understand the reasons for nontreatment and the short‐ and long‐term outcomes in this patient population. METHODS We analyzed patients ≥65 years old with a primary diagnosis of acute ischemic stroke presenting within 24 hours of time last known well (LKW) but not treated with IV alteplase from 1630 Get With The Guidelines‐Stroke hospitals in the United States between January 2016 and December 2016. We report clinical characteristics, reasons for withholding treatment, in‐hospital mortality, and 90‐day and 1‐year outcomes including costs, stratified by time from LKW to presentation (≤4.5, >4.5–6, and >6–24 hours). RESULTS Of 39 760 patients (median age 80 [25th–75th quartiles: 73–87], 56.7% female), 19 391 (48.8%) presented within 4.5 hours of LKW. In those with documented reasons for withholding IV alteplase, the most common reasons were rapid improvement of symptoms (3985/14 782, 27.0%) and mild symptoms (3791/14 782, 25.6%). In 1100 out of 1174 (93.7%) patients presenting in the >3.0‐ to 4.5‐hour time window, the most common reason for not treating was a delay in patient arrival. The most common discharge location for those presenting ≤4.5 hours since LKW was home (8660/19 391, 44.7%). The 90‐day mortality and readmission rates were 18.9% and 23.0% in those presenting ≤4.5 hours since LKW, 19.0% and 22.2% in those presenting between 4.5 and 6 hours, and 19.1% and 23.2% in those presenting between 6 and 24 hours. Median 90‐day total in‐hospital costs remained relatively high at $9471 (Q25–Q75: $5622–$21 356) in patients presenting ≤4.5 hours since LKW. CONCLUSIONS Patients within the Get With The Guidelines‐Stroke registry not treated with IV alteplase have a high risk of readmission and mortality and have high total in‐hospital and postdischarge costs. This study may inform future efforts to address the unmet need to improve the scope of IV alteplase delivery along with other aspects of acute ischemic stroke care and, consequently, outcomes in this patient population.

Prophylactic Enoxaparin in Critically Ill Trauma Patients: Evaluation of the Initial Dose

Background: Trauma patients are at increased risk of developing venous thromboembolism given alterations in the coagulation cascade. Chemoprophylaxis with standard dosing of enoxaparin 30 mg subcutaneously twice daily has evolved to incorporate the use of anti-factor Xa (AFXa) trough level monitoring given concerns for decreased enoxaparin bioavailability in this patient population. Current available evidence suggests low rates of goal AFXa trough level achievement with standard enoxaparin dosing. Our study aims to identify the incidence of critically ill trauma patients that did not achieve goal AFXa trough levels and attempts to identify predictors that may influence the lack of achievement of goal levels. Methods: This was a retrospective, cohort analysis performed at a single academic medical center. Adult patients 18 years or older admitted to the surgical intensive care unit secondary to trauma who were initiated on standard prophylactic enoxaparin and had at least 1 AFXa trough level representative of steady state were included. Patient demographics and clinical data were collected, and descriptive statistics were utilized. All statistical tests were 2-tailed and a P < .05 was considered significant. Variables with a P < .10 on univariable analysis were included in a multivariable logistic regression analysis. Results: A majority of our patient population did not achieve goal AFXa trough levels while receiving standard doses of prophylactic enoxaparin (82.4% [108/131]). Sub-target AFXa levels were associated with higher creatinine clearance values. Positive predictors of obtaining target AFXa levels included automobile versus pedestrian mechanism of injury and requiring an enoxaparin dose escalation to at least 40 mg twice daily. Conclusions: Our study found low rates of achievement of goal AFXa trough levels in critically ill trauma patients receiving standard prophylactic enoxaparin dosing. Certain variables were identified as negative and positive predictors for achievement of goal AFXa trough levels, although the biologic plausibility of these predictors is questionable and requires further investigation.