Migraine in the Emergency Department: A Prospective Multinational Study of Patient Characteristics, Management, and Outcomes

<b><i>Background and Aim:</i></b> Migraine headache is commonly diagnosed in emergency departments (ED). There is relatively little real-world information about the epidemiology, investigation, management, adherence to therapeutic guidelines and disposition of patients treated in ED with a final diagnosis of migraine. The primary aim of the current study is to get a snapshot of assessment and management patterns of acute migraine presentations to the different settings of EDs with a view to raise awareness. <b><i>Methods:</i></b> This is a planned sub-study of a prospective study conducted in 67 health services in 10 countries including Australia, New Zealand, Southeast Asia, Europe, and the UK investigating the epidemiology and outcome of adult patients presenting to ED with nontraumatic headache. Outcomes of interest for this study are demographics, clinical features (including severity), patterns of investigation, treatment, disposition, and outcome of patients diagnosed as having migraine as their final ED diagnosis. <b><i>Results:</i></b> The cohort comprises 1,101 patients with a mean age of 39 years (SD ± 13.5; 73.7% [811]) were female. Most patients had had migraine diagnosed previously (77.7%). Neuroimaging was performed in 25.9% with a very low diagnostic yield or significant findings (0.07%). Treatment of mild migraine was in accordance with current guidelines, but few patients with moderate or severe symptoms received recommended treatment. Paracetamol (46.3%) and nonsteroidal anti-inflammatory drugs (42.7%) were the most commonly prescribed agents. Metoclopramide (22.8%), ondansetron (19.2%), chlorpromazine (12.8%), and prochlorperazine (12.8%) were also used. <b><i>Conclusions:</i></b> This study suggests that therapeutic practices are not congruent with current guidelines, especially for patients with severe symptoms. Efforts to improve and sustain compliance with existing management best practices are required.

Integrated Transcriptomic Analysis Reveals a Distinctive Role of YAP1 in Extramedullary Invasion and Therapeutic Sensitivity of Multiple Myeloma

Multiple myeloma (MM) is the second most common hematologic malignancy. There are no standard therapeutic guidelines for extramedullary invasion (EM). We performed a retrospective integrated transcriptomic analysis based on GEO, TCGA, and Oncomine datasets with a total of over 2,500 cases enrolled. GSVA analysis was performed on GSE24080. The external validation cohorts include GSE9782, GSE2658, MMRF-COMPASS, and Oncomine. The data of MGUS to relapsed MM were acquired from GSE6477, GSE5900, and Oncomine. The data of EM were acquired from GSE39683 and GSE66291. Single-cell level transcriptome data of MM and EM were acquired from GSE106218. GSVA analysis revealed that 559 cases could be divided into 2 groups based on the expression of oncogenic pathways with prognostic significances. Group 1 with a specific phenotype of YAP1-MYC+ exhibited an unpromising prognosis. The univariate analysis revealed YAP1 as a tumor suppressor in MM. The activity of DNA repair, glycolysis, and oxidative phosphorylation was significantly higher in YAP1-MYC+ MM, which is in concordance with EM myeloma cells based on single-cell analysis. Furthermore, we discovered that YAP1-MYC+ MM patients exhibited an improved response for IMiD treatment. Collectively, YAP1-MYC+MM patients might suffer a worse prognosis and stronger propensity for EM progression.

Spiritual Emergency

Mindfulness meditation has been proven efficient in treating many physical and psychological disorders. Mindfulness meditation techniques are also subjected to specific indications and contraindications. Scanning of gross body, thoughts, emotions, and memories are the essential components of any form of meditation. During those scannings, some unwanted memories and some unusual experiences are very much apparent. There are many energy points in the gross human body, which are correspondent to the endocrine system of the human body, known as Kundalini or Chakra. During meditation, those chakras are stimulated, and hidden energy is exploded; increased psychomotor activities manifest in the behaviors of the person. This behavioral manifestation is called a spiritual emergency. Professionals often confused this behavioral manifestation with psychotic illness. A spiritual emergency requires specific therapeutic management. Against this backdrop, this chapter attempts a review of research articles on spiritual emergencies and therapeutic guidelines to handle them in clinical settings.

Calming the Storm: A review of corticosteroid use in severely ill COVID-19 patients on mechanical ventilation

The importance of corticosteroids in the therapy of COVID-19 has been controversial. However, as the world develops a better understanding regarding the pathophysiology of COVID-19, we are realizing that suppressing the host immune response may reduce lung inflammation preventing further complications. In addition, more high-quality randomized controlled trials, meta-analysis, and review articles are being published discussing the role of corticosteroids. Majority of these studies concluded that corticosteroids are beneficial for hospitalized severely ill COVID-19 patients requiring supplemental oxygen. To date, therapeutic guidelines for COVID-19 patients recommend dexamethasone or other alternative corticosteroids, including methylprednisolone, hydrocortisone, or prednisone, as a treatment choice for severely ill COVID-19 patients. This review will discuss the pharmacology, mechanism of action, pharmacodynamics, pharmacokinetics, and benefits of corticosteroids in COVID-19 patients, and review current published clinical evidence on corticosteroids. Keywords: Corticosteroids, COVID-19, ARDS

Intraoperative Rupture of an Intracranial, Extradural Hydatid Cyst: Case Report and Treatment Options

A 23-year-old woman was presented to the Emergency Unit with intracranial hypertension syndrome and blindness in her left eye which had started recently. A cranial native computed tomography scan and a magnetic resonance imaging (MRI) with contrast examinations revealed a giant intracranial cystic lesion, extending into the left frontal lobe, which was compressing the optic chiasm and eroding the internal plate of the left frontal bone. Surgical craniotomy was performed for evacuation and decompression, but during the craniotomy the cyst ruptured. After assessing the degree of erosion of the internal bone plate, we concluded that the primary origin of the cyst was intraosseous. With the dura mater being intact, abundant lavage with H2O2 was applied and the bone flap was replaced after rigorous bone scraping. Imaging control at six and twelve months identified no recurrence of the cyst. In the literature, hydatid cysts located in the skull bone are very rare and most of them rupture intraoperatively. Given their extremely low incidence in developed countries, any neurosurgeons’ experience with such pathology is limited and in some cases surgery cannot be delayed. In the case of intracerebral hydatid cysts, a neurosurgeon usually has only one shot at surgery, so simple and quick-to-access therapeutic guidelines must be developed in order to inform the choice of surgical technique. We conclude that the most successful surgical approach could be double concentric craniotomy. This surgical technique is used in intracerebral tumors, which also have an important bone invasion.

In Vitro Activity of 22 Antibiotics against Achromobacter Isolates from People with Cystic Fibrosis. Are There New Therapeutic Options?

Bacteria belonging to the genus Achromobacter are increasingly isolated from respiratory samples of people with cystic fibrosis (PWCF). The management of this multidrug-resistant genus is challenging and characterised by a lack of international recommendations, therapeutic guidelines and data concerning antibiotic susceptibility, especially concerning the newer antibiotics. The objective of this study was to describe the antibiotic susceptibility of Achromobacter isolates from PWCF, including susceptibility to new antibiotics. The minimum inhibitory concentrations (MICs) of 22 antibiotics were determined for a panel of 23 Achromobacter isolates from 19 respiratory samples of PWCF. Two microdilution MIC plates were used: EUMDROXF® plate (Sensititre) and Micronaut-S Pseudomonas MIC® plate (Merlin) and completed by a third method if necessary (E-test® or UMIC®). Among usual antimicrobial agents, the most active was imipenem (70% susceptibility). Trimethoprim-sulfamethoxazole, piperacillin and tigecycline (65%, 56% and 52% susceptibility, respectively) were still useful for the treatment of Achromobacter infections. Among new therapeutic options, β-lactams combined with a β-lactamase-inhibitor did not bring benefits compared to β-lactam alone. On the other hand, cefiderocol appeared as a promising therapeutic alternative for managing Achromobacter infections in PWCF. This study provides the first results on the susceptibility of clinical Achromobacter isolates concerning new antibiotics. More microbiological and clinical data are required to establish the optimal treatment of Achromobacter infections.

Surgical antimicrobial prophylaxis in open reduction internal fixation procedures at a metropolitan hospital in Australia: a retrospective audit

Background Open reduction internal fixation (ORIF) of closed fractures is a required indication for surgical antimicrobial prophylaxis (SAP). Guidelines contain recommendations on how best to prescribe SAP, however, adherence to SAP guidelines remains suboptimal. The Australian Therapeutic Guidelines: Antibiotic v16 (updated April 2019) advocates for single dose prophylaxis for ORIF procedures. There is a paucity of information on how SAP is prescribed for ORIF of closed fractures in Australian hospitals. The aim of this study was to identify prescribing practice and to evaluate guideline adherence pre- and post-guideline update. Methods A retrospective audit was conducted for patients undergoing an ORIF of closed fractures at a metropolitan teaching hospital in a 6-month period during 2018 (pre-guideline update) and 2019 (post-guideline update). Data were collected on prescribing practice (perioperative antibiotics prescribed, dose, time and route of administration and duration of prophylaxis) and compared to SAP recommendations in Therapeutic Guidelines: Antibiotic v15 (2018) and v16 (2019). Descriptive statistics and Chi square tests were used to report categorical variables. Binary logistic regression was used to identify factors associated with guideline adherence. A p-value < 0.05 was deemed statistically significant. Results Data were collected for a total of 390 patients (n = 185, 2018; n = 205, 2019). Cefazolin was the most commonly prescribed antibiotic as per guideline recommendations, with variable, yet appropriate doses observed across the two audit periods. While 78.3% of patients received SAP for the correct duration in 2018, only 20.4% of patients received single dose prophylaxis in 2019. Overall adherence to guidelines was 63.2% in the 2018, and 18.0% in the 2019 audit periods respectively. Patient age was significantly associated with an increase in overall guideline adherence, while lower limb fractures, an American Society of Anesthesiologists (ASA) score of 3 and emergency admissions were associated with decreased overall adherence to SAP guidelines. Conclusion Adherence to guidelines was greater with v15 (2018) compared with v16 (2019). Patient factors, including limb fracture site and ASA score, had little impact on guideline adherence. Further research is required to understand what influences guideline adherence in the orthopaedic setting.