Mechanical hemolysis secondary to percutaneous repair of an iatrogenic Gerbode defect with the Amplatzer™ Septal Occluder

The Gerbode defect is defined as an abnormal communication between the left ventricle and the right atrium, and is etiologically classified as congenital or acquired (iatrogenic or not). The typical treatment consists of surgical repair of the shunt, but transcatheter occlusion of this condition has proven to be a safe and effective therapeutic alternative for such patients, especially for those with prior surgeries. The aim of this study was to report a case of transcatheter closure of an acquired Gerbode defect, using the Amplatzer™ Septal Occluder device, in a 58-year-old patient, with two prior mitral valve replacements, and the consequent post-procedure mechanical hemolysis.

Teatro-terapia: un approccio originale per la gestione del comportamento dirompente del bambino

Aggressive behaviours are the main problem in children with disruptive behaviour disorders. In the majority of cases an oppositional defiant disorder (ODD), often in comorbidity with ADHD, is diagnosed. In these cases the most effective intervention is the multimodal one that includes behavioural treatment for the child, counselling for parents (parent training) and teachers (teacher training) and, if needed, a pharmacological intervention. Drama therapy experiences have proved useful in various fields of medicine. It has been hypothesized that this type of intervention facilitates the development of communication skills, mutual social interaction and recognition of emotions. A group of children with ADHD-ODD comorbidity underwent a brief, intensive drama therapy intervention whose results were compared with those of a control population who received a typical treatment. The reduction in aggressive behaviour was significant and was confirmed at the follow up three months later. Drama therapy is a promising intervention, whose role should not be underestimated in the context of a multimodal approach.

Effectiveness of sarolaner in the clinical management of furuncular myiasis in dogs naturally infested with Dermatobia hominis (Diptera: Cuterebridae)

Background The human botfly, Dermatobia hominis, is a common cause of furuncular myiasis in dogs in Latin America. Lesions can be single or multiple, each harboring an individual larva, presented as an erythematous nodule that causes pruritus and pain. Typical treatment consists of sedation for removal of larvae by surgical incision or manual pressure. Medications to kill the larva before its extraction can reduce inflammation and discomfort and provide a less traumatic larval removal. Isoxazolines are broad-spectrum ectoparasiticides with larvicidal activity previously reported in the treatment of screwworm myiasis in companion animals. The aim of this study was to evaluate the effectiveness of sarolaner as part of the clinical management of furuncular myiasis in dogs caused by D. hominis larvae. Methods Ten short-haired mixed breed dogs naturally infested with D. hominis were enrolled. Clinical diagnosis was achieved by observation of skin nodules and visualization of larval motility through the lesion orifice. Sarolaner was administered at manufacturer recommended dose for fleas and ticks. Lesions were reexamined 24 h post-treatment and assessed for viability of larvae. Larvae were removed by digital compression and identified as D. hominis. Results Seventy-five D. hominis larvae were retrieved from ten dogs. No live larvae were observed, demonstrating 100% larvicidal efficacy of sarolaner. Skin lesions were healed 30 days post-treatment and new lesions were not observed. Conclusions Sarolaner seems to be effective as larvicidal treatment for dogs with furuncular myiasis, reducing discomfort caused by the presence of the larva in the skin and facilitating its safe removal. Graphical abstract

Management of Complex Treatment-resistant Psychotic Disorders

This full-color, practical handbook provides a concise, evidence-based psychopharmacological approach to the management of complex treatment-resistant psychotic disorders. Part I focuses uniquely on topics and strategies relevant to treating this challenging patient population. These approaches go beyond standard guidelines while adhering to research and clinically derived data. Part II provides a concise array of information regarding those classes of medications most commonly used when treating complex treatment-resistant psychotic disorders. Each medication guide contains sections including mechanisms of action, typical treatment response, monitoring, dosing and kinetics, medications to avoid in combination/warnings, and take-home pearls. Part III offers tips in brief appendix chapters for managing common issues ranging from loading lithium and valproic acid to the treatment of acute psychomotor agitation. An essential resource for psychiatrists, forensic clinicians, psychiatric trainees, and all mental health professionals involved with, or interested in, the treatment of challenging psychotic disorders.

Effectiveness of Sarolaner in the Clinical Management of Furuncular Myiasis in Dogs Naturally Infested with Dermatobia Hominis (Diptera: Cuterebridae)

Background – The human botfly, Dermatobia hominis is a common cause of furuncular myiasis in dogs in Latin America. Lesions can be single or multiple, each harboring an individual larva, presented as an erythematous nodule that causes pruritus and pain. Typical treatment consists of sedation for removal of larvae by surgical incision or manual pressure. Medications to kill the larva before its extraction can reduce inflammation and discomfort, and provide a less traumatic larval removal. Isoxazolines are broad-spectrum ectoparasiticides with larvicidal activity previously reported in the treatment of screwworm myiasis in companion animals. The aim of this study was evaluate the effectiveness of sarolaner as part of the clinical management of furuncular myiasis in dogs caused by D. hominis larvae. Methods and materials – Ten short-haired mixed breed dogs naturally infested. Clinical diagnosis was achieved by observation of skin nodules and visualization of larval motility through the lesion orifice. Sarolaner was administered at manufacturer recommended dose for fleas and ticks. Lesions were reexamined 24 hours post-treatment and assessed for viability of larvae. Larvae were removed by digital compression and identified as D. hominis.Results – Seventy-five D. hominis larvae were retrieved from 10 dogs. No live larvae were observed, demonstrating 100% larvicidal efficacy of sarolaner. Skin lesions were healed 30 days post-treatment and new lesions were not observed.Conclusions – Sarolaner seems to be effective as larvicidal treatment for dogs with furuncular myiasis, reducing discomfort caused by the presence of the larva in the skin and facilitating its safe removal.

Numerical and Experimental Assessment of a Novel Anchored for Intramedullary Telescopic Nails Used in Osteogenesis Imperfecta Fractures

Osteogenesis Imperfecta (IO) is a bone disease mainly characterized by the low bone density that produces common fractures in children around 0–7 years. The use of metal implants is a typical treatment of this disease. The intramedullary telescopic nail (ITN) was inspired by the progressive growth in the long bones such as the femur or humerus during children’s aging. This work shows an experimental assessment of the ITN’s, focusing on their fixation; the proposed improvements in the design of the intramedullary nail studied include the separation of the element into two parts for telescopic enlargement, minimal invasive fixation through the distal anchorage, and the double auto-drilled end for fixation on the distal and proximal section of the bone. The samples were manufactured in 316 L steel and mounted on specialized jaws to replicate the implants’ boundary conditions. The experimental test was repeated three times to report the intramedullary telescopic nail’s behavior at three lengths. The results show that the device supports only 79.06 N when not at extension length. However, if the device is extended 150% it will support 46.87 N which suggests that intramedullary telescopic nails can only increase by 25% of their original length before they fail.

P634 Trajectories of oral budesonide use in Crohn’s disease cohort of Tuscan patients

Background Crohn’s disease (CD) is an immune-mediated inflammatory chronic disorder of the gastrointestinal tract. The therapeutic approach includes firstly oral budesonide (OB), followed by immunomodulatory drugs and biologics. The aim of the present study was to identify and characterize adherence trajectories of OB in CD patients and related patterns. Methods In this retrospective cohort study, data was retrieved from administrative healthcare databases in Tuscany, an Italian region. Patients were included if they had a first record of a diagnosis of ICD-9 or disease exemption or a first record of dispensation of OB as CD patient, in the period from 6/1/2011 to 6/30/2016 (index date, ID). Patients < 18 years old at ID or with history of data before ID < 5 years or follow-up of data after ID < 3 years were excluded. Patients with autoimmune hepatitis, cancer and no dispensation of OB were excluded from CD cohort. We considered as covariates sex, age, and number of concomitant drugs during the month before ID. We estimated adherence to OB monthly through the Medication Possession Ratio and computed trajectory of adherence treatment with a procedure consists into 3 steps: 1) computation of 24 statistical measures; 2) factor analysis; 3) cluster analysis. We described the adherence in the clusters. Results 3333 patients were included CD cohort, among them 1262 were excluded for no dispensation of OB. 2071 were patients included the computation of trajectory of OB use. Trajectories’ curves showed three difference clusters of adherences to OB, which identify two main subgroups of OB users: 925, 603 and 543 were the patients in each cluster. Cluster 1 is represented by a curve of adherence that rapidly decreased to 20–30% of adherence within 5 months. Instead, cluster 2 and 3 described patterns of a short therapy timing, with discontinuation within about 4 months, likely referring to an acute treatment of CD, typical treatment approach used in mild to moderate CD. Statistically significance differences were evidenced between covariates across the clusters. Conclusion Trajectories’ curves showed three difference clusters of adherences, which identify two main subgroups of OB users. Further analyses need to characterize the identified clusters in order to evaluate possible inappropriate use of drug (cluster 1) and potential switch to other therapies (cluster 2 and 3). Finally, these results could clarify drug use in patients with CD and provide new insights in order to improve management of patients by clinicians.

Pain among patients with substance use disorders and non-pharmacological options: An integrative review

Background: An increased incidence of chronic pain is growing worldwide. Typical treatment of chronic pain often involves a medication regimen. Opioids are the most highly prescribed class of medications for chronic pain by providers. The liberal use of opioids to help relieve chronic pain has led to other undesirable effects such as addiction, morbidity and mortality.Methods: A literature search was conducted using the key search concepts: pain AND physical therapy AND substance use. Results: A total of 5 articles met inclusion criteria out of 331 articles considered.Conclusions: The focus on alternative approaches to treatment of chronic pain/back pain for the SUD population is limited in the literature. Training for non-pharmacological options is needed for the NP and other practitioners to treat chronic back pain in the SUD population.

Stellate ganglion block used to treat reversible cerebral vasoconstriction syndrome

BackgroundWe present a case report of a patient who developed severe reversible cerebral vasoconstriction syndrome, which was worsening despite typical interventional and supportive care. We administered a stellate ganglion block (SGB) and monitored the vasospasm with transcranial Doppler measurements.Case reportA 25-year-old woman was admitted with recurrent headaches and neurological symptoms, which angiography showed to be caused by diffuse, multifocal, segmental narrowing of the cerebral arteries leading to severe ischemia in multiple regions. Typical treatment was initiated with arterial verapamil followed by supportive critical care, including nimodipine, intravenous fluids, permissive hypertension, and analgesia. Vasospasm was monitored daily via transcranial Doppler ultrasound (TCD). After symptoms and monitoring suggested worsening vasospasm, an SGB was administered under ultrasound guidance. Block success was confirmed via pupillometry, and repeat TCD showed improved flow through the cerebral vasculature. Improvement in vascular flow was accompanied by a gradual reduction in acute neurological symptoms, with the patient reporting no headaches the following morning.ConclusionsFor patients with reversible cerebral vasoconstriction syndrome who develop severe signs or symptoms despite typical treatment, sympathetic blockade may be a possible rescue therapy. This may extend to other causes of severe vasospasm as well, and further study is needed to determine if the SGB should be included in routine or rescue therapy.

HIGH-FREQUENCY CHEST WALL COMPRESSION (HFCWC)

ABSTRACT: In healthy individuals, clearance of secretions from the respiratory tract is accomplished primarily through ciliary action. In young children the number of alveoli within the respiratory tract is also lesser and shorter and organisms may move quickly down the respiratory tract triggering more extensive involvement. Postural drainage and percussion are usually taught to family members so that the therapy may be continued at home when needed in cases of chronic disease. Since this highly labour-intensive activity requires the daily intervention of a trained caregiver, it may lead to poor compliance with the recommended treatment plan. The air-pulse generator rapidly inflates and deflates the vest, compressing and releasing the chest wall up to 20 times per second. The vibratory forces of these devices are thought to lower mucus viscosity. High-frequency airway clearance (HFCWC) assist devices generate either positive or negative trans-respiratory pressure excursions. The typical treatment lasts 20-30 minutes, and consists of short periods of compression at different frequencies, separated by coughing. The use of HFCWO compared to CPT also produced a significant improvement in blood inflammation parameter. Key Words: respiratory tract, High-frequency airway clearance (HFCWC), short periods of compression.