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Continues wearing gloves is a crucial problem among health care workers treating patients with coronavirus (COVID-19) infection that may cause skin complications. In the present study, the skin conductance (SC), skin potential (SP) and skin susceptance (SS) were used to identify the effects of long-term wearing gloves among health care workers managing COVID-19. The experimental procedure was repeated 30 times on three subjects recruited as volunteers to wear gloves for 4 hours. The baseline of parameters SC, SP, and SS were recorded at normal conditions without wearing the glove at zero time (To). The parameters were again recorded in the cases of glove-wearing with and without zinc oxide ointment (ZnO) for the same period. Noticeable differences were found in each of SC, SP and SS for subjects who wore gloves when compared to the baseline for 4 h. Results also showed significant differences in each of SP and SS during the same period with applying ZnO comparing to wearing gloves without applying ZnO. The results show that skin hydration is significantly improved by using ZnO. However, changing gloves at least every four hours of continuous wearing is recommended.

In cases of ethylene glycol (EG) toxicity requiring hemodialysis (HD), fomepizole is dosed every four hours. HD efficiently clears EG and its toxic metabolites, and it's unclear if multiple doses (MD) of fomepizole improve patient outcomes or whether a single dose (SD) prior to initiation of HD is sufficient.We reviewed cases of EG toxicity at a toxicology referral center from 2008 to 2018. Patients treated with HD with EG levels greater than 20 mg/dL were included. Duration of dialysis, creatinine at discharge, hospital length of stay (LOS), and complications were analyzed. We compared patients who received a single dose of fomepizole prior to HD to those who received continued dosing during and after HD.Twenty-five patient encounters were identified (MD: 20; SD: 5). Initial bicarbonate (11 [SD] vs. 9 mg/dL [MD]) and pH (7.1 vs. 7.1) were similar between the groups; however, there was a trend toward a greater proportion of patients with renal dysfunction in the MD group: 11 (55%) vs. 1 (20%). HD was initiated a median interval of 5.2 h [SD] vs. 5.7 h [MD] after a dose of fomepizole. There was one death in the MD group and none in the SD group. Median creatinine on the day of discharge was 0.7 mg/dL (IQR: 0.57-3.8) in the SD group and 2.0 mg/dL (0.90-7.0) in the MD group. LOS was similar (5.8 days [95% CI 3.6-8.0] vs. 7.6 days [5.3-9.9]) (Patients with moderately severe EG toxicity (acidosis and no initial renal dysfunction) treated with a single dose of fomepizole prior to HD had similar outcomes to those receiving continued dosing of fomepizole during or after HD. This raises the possibility that a single dose of fomepizole may be sufficient if HD is initiated quickly.

Study objective and design The objective of this study was to determine the effectiveness of triamcinolone acetonide when used as a single dose as compared to the topical use of dexamethasone to control the inflammation after phacoemulsification. The study was a randomized controlled trial conducted in the Department of Ophthalmology at the District Headquarter (DHQ) Teaching Hospital, Dera Ghazi Khan, from March 1, 2018, to August 31, 2019. Materials and methods Eighty patients were included in the study. All patients were assigned to two groups of 40 patients each using the lottery method. Group A patients were treated with a 1-mg intracameral injection of triamcinolone acetonide postoperatively after phacoemulsification. Group B patients were administered 0.1% dexamethasone eye drops with a dosage of one drop every four hours for four weeks. Postoperative follow-up was planned for day one, day seven, and day 28. Results The postoperative inflammation cell values of Group A on day one, day seven, and day 28 were 1.68 ±0.84, 0.22 ±0.15, and 0.12 ±0.23, respectively, while the postoperative inflammation cell values of Group B on day one, day seven, and day 28 were 1.91 ±0.75, 0.28 ±0.15, and 0.09 ±0.20, respectively. The postoperative inflammation flare values of Group A on day one, day seven, and day 28 were 0.31 ±0.37, 0.03 ±0.44, and 0.00 ±0.22, respectively, while the postoperative inflammation flare values of Group B on day one, day seven, and day 28 were 0.25 ±0.26, 0.22 ±0.46, and 0.02 ±0.18, respectively. Conclusion The efficacy of both modes of treatments is comparable; however, triamcinolone acetonide is preferable to dexamethasone, as its intracameral injection generally results in better compliance than multiple dosages of topical eye drops of dexamethasone.

Background: The traditional treatment of soft tissue injuries consists of the RICE protocol – rest, ice, compression, and elevation, followed for up to 72 hours after a trauma. Although designed as an immediate therapy to reduce inflammation that occurs after an acute injury, the RICE protcol might not be the best way to promote healing due to limiting blood flow. Molecular hydrogen (H2) has recently been put forward as a possible adjuvant treatment in musculoskeletal medicine, yet limited data are available concerning its effectiveness as a first-aid intervention. Case report: We report here a case of an elite professional athlete who suffered a grade II ankle sprain, and who subsequently received six sessions of ankle and foot hydrotherapy (e.g. 30-min at every four hours) with super-saturated hydrogen-rich water during the first 24 hours post-injury. The pain VAS self‐completed by the patient dropped from 50 points (moderate pain) at baseline (immediately after injury) to 20 points (mild pain) at 24-h follow-up. Ankle swelling dropped by 2.8% and dorsiflexion range of movement improved by 27.9% from baseline to follow-up, respectively. Conclusions: Our case has indicated that an acute multi-session hydrotherapy with hydrogen-rich water might be a helpful treatment in terms of pain, swelling reduction and regaining range of motion after an ankle sprain.

Objective To compare effectiveness and safety of oral misoprostol (50 μg every four hours as needed), low dose vaginal misoprostol (25 to 50 μg every six hours as needed), and our established dinoprostone vaginal gel (one to two mg every six hours as needed) induction. Materials and methods Consenting women with a live term single cephalic fetus for indicated labor induction were randomized (3N = 511). Prior uterine surgery or non-reassuring fetal surveillance were exclusions. Concealed computer generated randomization was stratified and blocked. Newborns were assessed by a team unaware of group assignment. The primary outcome was time from induction at randomization to vaginal birth for initial parametric analysis. Sample size was based on mean difference of 240 minutes with α2 = 0.05 and power 95%. Non-parametric analysis was also pre-specified ranking cesareans as longest vaginal births. Results Enrollment was from April 1999 to December 2000. Demographics were similar across groups. Analysis was by intent to treat, with no loss to follow up. Mean time (±SD) to vaginal birth was 1356 (±1033) minutes for oral misoprostol, 1530 (±3249) minutes for vaginal misoprostol, and 1208 (±613) minutes for vaginal dinoprostone (P = 0.46, ANOVA). Median times to vaginal birth were 1571, 1339, and 1451 minutes respectively (P = 0.46, Kruskal-Wallis). Vaginal births occurred within 24 hours in 44.9, 53.5 and 47.7% respectively (P = 0.27, χ2). There were no significant differences in Kaplan Meier survival analyses, cesareans, adverse effects, or maternal satisfaction. The newborn who met birth asphyxia criteria received vaginal misoprostol, as did. all three other newborns with cord artery pH

Objective: to evaluate pain in children undergoing transplantation of hematopoietic stem cells. Methods: longitudinal and analytical research with children hospitalized for transplant of hematopoietic stem cells with Faces Pain Scale Revised, every four hours from hospital admission to hospital discharge analyzed with relative/absolute frequency and chi-square test. Results: nine children aged four to nine years old were evaluated, totaling 1,095 ratings 23.4% were reported with some pain score; of these, 38.9% were in hypo pharynx region; 78.8%, moderate pain. The chi-square showed significance between pain scores weeks post-transplantation and pain existence among the analyzed children. Conclusion: although the pain has not affected large proportion of children, moderate and strong pain covered around 80.0% of complaints along the hematopoietic stem cell transplantation process. Thus, it is suggested that the evaluation of pain is one of the signs to be inserted in the protocols of nursing interventions in this context of caring. Objetivo: avaliar a dor em crianças submetidas ao transplante de células-tronco hematopoéticas. Métodos: pesquisa longitudinal e analítica, com crianças internadas para transplante de células-tronco hematopoéticas, com escala Faces Pain Scale Revised, a cada quatro horas, do internamento à alta hospitalar, analisados com frequência absoluta/relativa e teste qui-quadrado. Resultados: nove crianças de quatro a nove anos de idade foram avaliadas, totalizando 1.095 avaliações, 23,4% relataram algum escore de dor; 38,9% em região hipofaríngea; 78,8%, dor moderada. O qui-quadrado mostrou significância entre escores de dor e semanas pós-transplante e existência da dor entre as crianças analisadas. Conclusão: embora a dor não tenha acometido grande proporção de crianças, as dores moderada e forte abrangeram cerca de 80,0% das queixas, ao longo do processo de transplante de células-tronco hematopoéticas. Desta forma, sugere-se que a avaliação da dor seja um dos sinais a serem inseridos nos protocolos das intervenções de enfermagem nesse contexto de cuidar.

BACKGROUND: In recent years’ medical management with misoprostol is an effective alternative to surgical evacuation. But there is a dearth of evidence to reveal the effectiveness of the different routes of misoprostol and satisfaction rate among the patients treated with these routes. AIM: This study was conducted to compare the effectiveness and patient’s satisfaction rate of vaginal versus oral misoprostol. METHODS: It was a prospective non-interventional study. One hundred women of having missed abortion confirmed by ultrasonography examination were enrolled in the trial. Fifty-eight subjects were administered 200 mcg of oral and 42 subjects received 200 mcg of vaginal misoprostol every four hours up to four doses. If complete expulsion did not occur 12 hours after the last dose, the surgical evacuation was done. RESULTS: There was no significant statistical difference between the effectiveness of treatment with vaginal (78.57%) and oral misoprostol (79.31%) (p = 0.928). The difference between Patients’ satisfaction at the time of discharge for the vaginal group (64.29%) and oral group (65.52%) was not statistically significant (P = 0.991). There was an increase in patients’ satisfaction for both groups at the follow-up session, but still, the difference was not significant (P = 0.897). CONCLUSION: This study confirms that there is no statistical difference between the effectiveness and patient satisfaction of oral and vaginal misoprostol in the treatment of missed abortion.

Background: Objective of the study was to compare the efficacy, outcome and side effects of sublingual and vaginal misoprostol for the medical management of missed miscarriage. Methods: Fifty women diagnosed as having missed miscarriage of gestational age less than 20 weeks were randomized to vaginal or sublingual route of drug administration by lottery method (random sampling) A total number of 25 cases in each of the two groups were considered. Women in Group A received 400 microgram of misoprostol sublingually every four hours for a maximum of 5 doses and those in Group B received 400 microgram of misoprostol vaginally every four hours for a maximum of 5 doses. The primary outcome measures were, complete evacuation of products of conception, mean induction to delivery time and the occurrence of side effects. Results: In complete evacuation rates between the sublingual misoprostol and the vaginal misoprostol groups there was no statistically significant difference. Mean induction to delivery time was also similar for both groups as was the total number of doses required. As far as Side effects were concerned, Diarrhea was the major frequent side effect of sublingual misoprostol seen in 32% cases against only 12% cases with vaginal misoprostol. Conclusions: The effectiveness of Sublingual misoprostol is comparable to that of vaginal misoprostol for medical management of missed miscarriage but is associated with an increased risk of side effects especially diarrhoea.

Situation16 year old girl admitted with suspected ingestion of ethylene glycol. She was treated with fomepizole and continuous renal replacement therapy (CRRT).How the Pharmacy Team ContributedEthanol was prescribed until fomepizole arrived. The volume of ethanol to be administered was calculated wrongly by the consultant due to confusion about the available strength. The Paediatric Intensive Care Unit (PICU) pharmacist intervened and the correct dosage information was given.PICU pharmacist used Toxbase to determine the correct treatment of ethylene glycol poisoning and advised on dosing regime, including adjustment due to CRRT. The pharmacist facilitated prescribing on the electronic system (added drug to system, set up administration instructions and assisted with prescribing – pharmacist was not an Independent Prescriber). This allowed medical staff to concentrate on resuscitation, monitoring cardiac function, inserting intravenous lines and obtaining access for CRRT.The PICU pharmacist and pharmacy technician co-ordinated initial supply of fomepizole. Fomepizole is usually ordered directly from the manufacturer during office hours. The patient presented in the early evening so further supply had to be obtained from a hospital hundreds of miles away after referring to the Rarely Used Medicines list. Pharmacist contacted appropriate on-call pharmacist and arranged for transfer of medicines via courier. Pharmacy technician arranged for further supply form the manufacturer the following day.Pharmacy technician arranged supply of additional dialysis fluids for CRRT due to the higher than usual administration rate.Without contribution from the pharmacy team the patient is likely to have been given the wrong dose of ethanol and fomepizole, and there would have been delay in initiation of treatment followed by an interruption, as it was wrongly assumed that it was kept as stock in the adjoining ‘adult hospital’ and subsequent supply from a local hospital would not have been sought by ward staff until original supply ran out.OutcomeEthylene glycol poisoning was confirmed on laboratory testing. Levels of ethylene glycol fell steadily over 36 hours, allowing CRRT and fomepizole to stop. Patient was discharged from PICU after 48 hours with no apparent long-lasting effects, but was referred to various specialities including renal, gastroenterology and psychology.Patient and family denied knowledge of intentional or accidental ingestion. Police investigation was inconclusive.Lessons to be LearnedLarger supplies of fomepizole are now kept in stock within Health Board. Supplies were missing from emergency cupboards when stock was needed, despite being on stock lists, necessitating courier fees to transfer stock from elsewhere. Procedures reviewed to ensure that stock is available in emergency cupboards at all times.This patient demonstrated that current (target) stock levels of fomepizole were inadequate for providing treatment during CRRT as the required doses are substantially higher (administered every four hours rather than every twelve hours) and would have lasted less than 12 hours for this average sized teenager. National Rarely Used Medicines list was updated to reflect actual stock levels and other hospitals increased their stockholding due to the realisation that existing stock was inadequate and that further supplies were hard to obtain out of working hours.

This study is aimed to evaluate the effect of lollipop sucking on the recovery of gastrointestinal function in children after congenital choledochal cyst excision. 58 children who had undergone congenital choledochal cyst excision were randomly divided into two groups: the controlled group and the experimental group. Children in the experimental group were allowed to suck on strawberry lollipops for 20–30 min once every four hours beginning six hours after the operation. The recovery time of bowel sounds and anal defecation was recorded and compared between experimental and control groups. Compared with the controlled group the recovery times of bowel sounds (41.75 ± 7.38 h vs. 51.43 ± 5.02; p

Introduction: Termination of missed abortion in the second trimester by suction evacuation is more traumatic than in early pregnancy. Misoprostl is effective in first and second trimester abortions. Vaginal route being superior to oral. Objectives: The study was carried out to evaluate the effectiveness and safety of vaginal Misoprostl in the management of second trimester missed abortion. Methods: This prospective study was carried out in the department of Obstretrics and Gynaecology, Dhaka Medical College Hospital from January 2004 to December 2004. A total 50 missed abortion patients were randomly selected. After required investigations Tab Misoprostol 200 ug was introduced per vagina in the posterior fornix which was repeated every four hours. The incidence of complete expulsion and side effect was examined. The patient who did not respond to Misoprostol, Oxytocin infusion was given to them after 6 hours of the last doses of Misoprostol. If the patient failed to respond, surgical evacuation was attempted. Ultrasonogram was done after 12 hours to confirm complete abortion. Results: Among the 50 cases 38 (76%) had gestation age within the range of 13?24 weeks. Twenty five (50%) cases required only Misoprostol for expulsion of product of conception with range of 1?4 doses. Eight (16%) required misoprostol with oxytocin drip & 17 (34%) required surgery even after misoprostol & oxytocin. The induction-expulsion interval of 25 (50%) cases was 11±4 in 25 women who were given Tab Misoprostol only. Forty three (86%) had no side effects & well-tolerated with the drug. Only Misoprostol is 09 JAFMC Bangladesh. Vol 10, No 1 (June) 2014 required in gestational age group of 21?24 weeks (64.3%) & 25?28 weak (66.7%). Misoprostol was successfully used in most Nulliparous women (64.7%) & Primiparous women (42.9%). Conclusion: The second trimester missed abortion termination by srgical evacuation is traumatic and complications are more. If Tab Misoprostol proves safe and effective a large number of patients will be benefited and will escape from surgical intervention and complications. DOI: http://dx.doi.org/10.3329/jafmc.v10i1.22897 Journal of Armed Forces Medical College Bangladesh Vol.10(1) 2014

Purpose Acanthamoeba keratitis is a sight-threatening infectious disease. Its effective and safe medical therapy remains highly debated. The aim of this study is to test in vitro and in vivo voriconazole as a potential antiamoebic treatment for Acanthamoeba keratitis. Methods In vitro sensitivity of Acanthamoeba polyphaga to voriconazole was assessed using a commercially available viability assay. In vivo, Sprague-Dawley male rats were injected in the left cornea stromal layer with trophozoites. Forty rats were divided into 3 groups, topically treated with 1% voriconazole eyedrop (hourly administrations for 3 days followed by every two hours for 11 days and followed every four hours for 7 days), orally treated with voriconazole (60 mg/kg/day), and control. At day 28, cornea and blood samples were collected and corneal scrapings were performed for bacterial and parasitological cultures and real-time PCR analyses. Paraffin-embedded corneas were analyzed. The plasma and corneal concentration of voriconazole was determined by high-performance liquid chromatography. Results In vitro, voriconazole inhibited Acanthamoeba polyphaga trophozoites proliferation with IC90 value of 6 μg/ml, however no cystical activity was found. Mean intracorneal concentration of voriconazole eyedrops after three days treatment was 5.6 +/- 4.4 ng / mg; after seven days treatment was 2.38 + /1.6 ng/mg; and after twenty one days treatment was 0.32 +/- 0.15 ng / mg. Clinical infection worsened in fewer rats between the 7th and the14th day post infection in the voriconazole eye drops group (1/10 rats) and the control group (9/10 rats) (p = 0.001). Conclusions Our findings support the potential use of voriconazole as anti-amoebic agents.

Postoperative flap monitoring is a key component for successful free tissue transfer. Tissue oxygen saturation measurement (TOx) with near-infrared spectrophotometry (NIRS) is a method used for this purpose. The aim of this study was to identify external variables that can affect TOx. Patients who had breast reconstruction with free flaps were monitored prospectively and intra-operative details were recorded. Flap TOx was recorded with NIRS pre-extubation, postextubation, and then every four hours for 36 hours. At each of these time points, blood oxygen saturation (SO2), amount of supplemental oxygen, and blood pressure were recorded. Thirty flaps were monitored. Initially, a significant trend over time was detected such that for every increase of 24 hours, TOx decreased on average by 2.1% (P = 0.025). However, when accounting for SO2 levels, this decrease was no longer significant (P = 0.19). An increase by 1% in SO2 produced an increase in TOx reading of 0.36 (P = 0.007). The amount of supplemental O2, systolic blood pressure, and diastolic blood pressure did not have a significant impact on TOx (P > 0.05). The TOx values were highest in the free TRAM flaps and were lower in decreasing order in the muscle-sparing TRAM, DIEP, and SIEA flaps (P > 0.05). The TOx values did not significantly correlate with vessel size, perforator number, or perforator row. Postoperative flap TOx was found to correlate with SO2 and was not significantly dependent on blood pressure, supplemental O2, or surgical variables. Careful interpretation of oximetry values is essential in decision making during postoperative flap monitoring. © 2014 Wiley Periodicals, Inc. Microsurgery 35:123–128, 2015.

Objective: To compare the efficacy and safety of intravaginal misoprostol with intracervical dinoprostone for preinduction cervical ripening. Material andMethods: It was a randomized controlled trial conducted at department of obstetrics and gynecology, JIPMER, Puducherry. Three hundred women with Bishop score of less than 6, were assigned randomly to receive either intravaginal misoprostol 25 µg every four hours for four doses, and intracervical dinoprostone gel 0.5 mg every eight hours for two doses. (one hundred women in each group). Oxytocin was initiated as per standardized protocol, if the cervix was favourable. If the cervical ripening was unsuccessful (Bishop score less than 6) after the maximum doses of drugs in both the groups, then further treatment was individualized. Efficacy and cost of the drugs were compared in both groups. Results: Primary outcome measure was change in Bishop score. Mean Bishop score change at the end of 16 hours was significantly higher in the misoprostol group, (2.57±0.59) compared to dinoprostone group (2.17±0.10, p=0.016). This finding was inspite of the fact that the dinoprostone group had higher Bishop score prior to the ripening.(3.55±0.56 vs 3.28±0.77, p=0.006). Secondary outcome measures such as mean intervention-delivery interval, oxytocin requirement, mode of delivery, maternal and neonatal outcomes were similar in both the groups. Overall mean cost of ripening agent per patient was significantly less in the misoprostol group, (22.56±93.16 rupees) compared to dinoprostone group (493.89±173.99 rupees, p less than 0.0001).Conclusion: Low dose misoprostol is as effective as dinoprostone in cervical ripening and demonstrates similar fetal and maternal safety profile.

Objectives To assess and compare the efficacy and safety of 50 μg oral misoprostol and 25 μg intravaginal misoprostol for induction of labour at term. Methods This non-blinded, randomized clinical trial included 228 pregnant women at term with obstetric or medical indications for induction of labour. Women either took 50 μg misoprostol orally (two 25 μg tablets) or had one 25 μg tablet of misoprostol inserted in the posterior vaginal fornix. In each group, misoprostol administration was repeated every four hours in the same dose until regular uterine contractions were established or to a maximum of five doses. Time to delivery and outcome data for each group were compared. Results Of the 228 women, eight (3.5%) were excluded from the analysis as they withdrew their consent after randomization. Mean induction-to-delivery interval was similar in both groups (21.22 hours in the oral group vs. 20.15 hours in the vaginal group; P = 0.58). There was no significant difference between the groups with respect to the number of women who delivered within 24 hours or who required oxytocin augmentation of labour, the mode of delivery, and neonatal outcomes ( P > 0.05). Uterine hyperstimulation occurred in two women who received misoprostol vaginally, but not in any of the women in the oral misoprostol group. Conclusion Oral misoprostol in a dose of 50 μg every four hours, to a maximum of five doses, has the potential to induce labour as safely and effectively as 25 μg misoprostol administered vaginally every four hours.

The acoustic properties of speech are a reliable marker of changes in the central nervous system. Measures of speech timing and frequency have been used to assess impairment in clinical patient groups, including stroke, Huntington’s disease, and depression. Associations between speech properties and impaired performance have also been described in healthy individuals under periods of sleep deprivation. In the current study, we aimed to compare the time course of speech outcomes to other objective measures of alertness during 40 hours of sleep deprivation. Methods Twenty-three healthy volunteers (18 males; mean age=25.41 ± 5.73 years) underwent 40 hours of acute sleep deprivation under constant routine conditions. Speech tasks were administered every four hours, beginning three hours after scheduled waketime. The Psychomotor Vigilance Test (PVT), Karolinska Sleepiness Scale (KSS), and EEG collected during the Karolinksa Drowsiness Test (KDT) were measured bi-hourly. Objective measures of speech were derived using spectral, cepstral and timing analyses. Results Acoustic parameters displayed impairment across 40-h of sustained wakefulness. Measures of speech timing (e.g. speech rate) and frequency deteriorated significantly following 23 hours awake compared to baseline (first 16 hours awake). Impairment peaked around 31 hours of wakefulness before showing slight improvements. These findings were consistent with laboratory standard assessments of sleepiness and vigilant attention. Conclusion The time course of changes in the acoustic properties of speech are comparable to those changes observed in alertness and performance impairment across 40 h of sleep deprivation. These findings suggest the acoustic properties of speech may be a reliable indicator of alertness/drowsiness, with utility for development of objective and non-invasive systems to identify and manage sleep-related impairment in workplace settings. Support (If Any) The study was supported by the Cooperative Research Centre for Alertness, Safety and Productivity.

Junior doctors have lost a High Court test case backed by the BMA over their right to have a 30 minute break every four hours or be paid at a higher rate.1 The group of 21 doctors, led by Sarah Hallett, argued that Derby Teaching Hospitals NHS Foundation Trust breached their employment contracts by using an incorrect system to monitor rotas to check whether doctors took their breaks.2 Hallett brought the case on behalf of herself and another 20 doctors training at the trust between August 2013 and August 2014, when she was in her foundation year. She is now a paediatric trainee and deputy chair for education and training of the BMA’s Junior Doctors Committee. The junior doctors argued that Department …

Purpose/Objectives: In 2004, almost 200,000 children were hospitalized due to asthma in the United States, costing nearly $280 million.1-2 Rising health care costs have led to initiatives to improve discharge timeliness without compromising patient safety or increasing readmission rates. Typically, hospitalized asthma patients are considered medically ready for discharge when their short acting beta agonist (SABA) treatments are spaced to every four hours (Q4H) or longer. Though this was not specified in the 2007 NHLBI ASTHMA guidelines, it is common practice according …

The diet composition of the larvae of four Anacroneuria species from a Venezuelan river was studied (A. cacute, A. tachira, A. chorrera and A. paleta). Every four hours a D-net was used to obtain four samples in different sections of the channel. The gut content of the stonefly larvae was analysed, with Baetidae (Ephemeroptera) being the predominant prey for all four species. According to the electivity index, the four species have different prey choices, but they all preferred Simuliidae, and rejected Leptophlebiidae. Analysis of diet amplitude suggests that A. tachira is the most generalist and A. paleta the most specialist species, although high overlapping values indicate that all four species have very similar diets.

We studied the possible influence on the pattern of diurnal ocular tension curve by peroral hydrocortisone in 16 eyes of 16 subjects with primary open-angle glaucoma. The baseline diurnal curve was determined by Schiotz tonometry six times daily starting at 10 a.m. and repeated every four hours. The baseline curve showed a significant rise in the daytime with a fall during the night. On another day, 20 mg hydrocortisone was given perorally at 5 p.m., for a repeat 24-h measurement period. A significant rise in ocular tension over the baseline resulted in the following night-time tonometric readings, i.e. at 10 p.m. (P less than 0.01) and 2 a.m. (P less than 0.001). The results seem to strongly indicate that plasma cortico-steroid levels dictate the pattern of diurnal variation of ocular tension.

T. was reported to have a long history of aggressive, as-saultive, and unpredictable behavior, angry and irritablemoods, impulsivity, hyperactivity, enuresis, and a history ofnightmares and flashbacks. T. had experienced four priorpsychiatric hospitalizations. Prior to the current transfer,during an approximately three-month stay at a private hos-pital, T. was reported to have become increasingly aggres-sive, assaultive, and impulsive, requiring frequent as-neededmedications including intramuscular injections of lo-razepam, haloperidol, and chlorpromazine. Lorazepam andother benzodiazepines were thought to cause disinhibitionand worsened his behaviors. Upon transfer to the state chil-dren’s psychiatric hospital, T. carried diagnoses of mixedbipolar disorder, thyroid abnormalities, asthma, and possi-ble fetal alcohol syndrome.Upon transfer, T.’s medications included risperidone 3 mg,clozapine 200 mg, valproic acid 750 mg, guanfacine 4 mg, anddesmopressin 0.6 mg. His as-needed medications were chlor-promazine 50 mg every two hours, with a maximum of fourdoses daily, Benadryl 50 mg every four hours, and albuterolinhaler two puffs every four hours with a maximum of fourdoses daily. The clozapine dose had been adjusted downwardin the previous hospital due to sedation and drooling.

A 68-year-old woman who, for the first time, had a generalized tonic-clonic seizure and persisting confusional state was found to have nodular enlargement of the thyroid and a tachycardic arrhythmia. Electroencephalography (EEG) demonstrated a continuous irregular polyspike wave pattern. Total T4 concentration was elevated to 23 micrograms/dl. Consecutive Administration of 250 mg phenytoin, 4 mg clonazepam and 7.5 mg midazolam changed neither the clinical nor the EEG findings. But after general intensive care measures and high-dose thyrostatic treatment (40 mg thiamazole intravenously every four hours) the clinical and neurological status became normal. Serial EEGs over the subsequent weeks and months showed gradual disappearance of the abnormal changes with increasingly prolonged periods of normal activity.

Every four hours variations in atmospheric 214Pb concentrations were observed at Kawasaki, Japan. The monthly averaged concentration ranged from 1.3 to 4.1Bq/m3. The variation patterns within 24 hours of the atmospheric concentration of short-lived 214Pb(half-life:26.8 min)is similar to that of 212Pb(half-life:10.6h). The variation in atmospheric concentrations of 214Pb was observed to depend strongly on the local meteorological conditions in a short period. High concentrations of 214Pb tend to appear on the days with westerly wind from inland area, low wind velocity and without precipitation.

Objective: To report the case of a 6 year-old male child that presented ligneous conjunctivitis (LC) after infectious conjunctivitis, showing recurrent membranes after surgical removal; treatment with autologus fresh frozen plasma (AFFP) resulted in remission of the membranes. Methods: Ophthalmologic examination, plasminogen functional activity and plasmatic plasminogen level were measured for LC diagnosis. Surgical removal of the membranes was performed and light microscopy was applied on biopsies from both eyes. Topical treatment with corticosteroids and aminoglycosides was administered on both eyes. Bilateral recurrence was treated with the administration of a single subconjunctival injection of 0.75 ml of AFFP, continued with topical application every four hours for four weeks, tapered to every 6 hours to present. Results: The diagnosis of LC was confirmed with the 48% of plasminogen functional activity and supported with histological typical findings. Following surgical removal of membranes and topical treatment with corticosteroids, bilateral recurrence of membranes was observed after one month. Treatment with subconjunctival and topical AFFP revealed no recurrence of LC membranes after 4 years of follow-up. Conclusion: In our patient a single subconjunctival injection associated with topical administration of the AFFP impeded the recurrence of hard wood-like membranes presented in LC.

OBJETIVO: Avaliar a eficácia de substâncias consideradas estimulantes da cicatrização, como o mel puro e o soro autólogo a 20% na cicatrização do epitélio corneal de coelhos. MÉTODOS: Foi realizada a remoção do epitélio corneal de dois grupos de coelhos que receberam a instilação de solução de mel puro (G1) ou soro autólogo (G2) a cada 4 horas. O olho contralateral foi usado como controle e submetido ao mesmo procedimento de remoção do epitélio, recebendo a instilação de BSS®. A área de desepitelização corneal foi avaliada 12, 24 e 48 horas após a indução do defeito epitelial. RESULTADOS: Os grupos estudados foram estatisticamente semelhantes: mel (48 horas) e controle (48 horas) p

Aims To study the elimination of ephedrines with reference to the International Olympic Committee (IOC) doping control cut-off levels, following multiple dosing of over-the-counter decongestant preparations. Methods A double-blind study was performed in which 16 healthy male volunteers were administered either pseudoephedrine or phenylpropanolamine in maximal recommended therapeutic doses over a 36-h period. Urine was collected every two hours between 08:00 and 24:00 h and at 04:00 h throughout the testing period of three days. Urine drug levels were quantified using high performance liquid chromatography. Side-effects were assessed, including heart rate and blood pressure, every four hours between 08:00 and 20:00 h. Results Mean (95% CI) total phenylpropanolamine and pseudoephedrine eliminated unchanged was 75 (88, 61) and 81 (92, 71)%, respectively. Maximum urine concentrations of phenylpropanolamine and pseudoephedrine were 112.1 (164.2, 59.9) and 148.5 (215.0, 82.1) mg.l−1, respectively. A peak in drug urine concentration occurred four hours following the final dose. There were no adverse cardiovascular effects and only mild CNS stimulation was evident. Conclusions Following therapeutic, multiple dosing, drug levels remain above the IOC cut-off levels for a minimum of 6 h and 16 h following final doses of phenylpropanolamine and pseudoephedrine, respectively. Athletes require informed advice on this from their healthcare professionals.

The introduction of fentanyl transdermal patches has led to concern and confusion regarding the management of pain control in the dying phase. Data were collected retrospectively from 94 dying patients. Two groups were identified-patients treated with fentanyl transdermal patch who remained on the patch in the dying phase and patients on oral morphine who converted to a 24-hour subcutaneous infusion of diamorphine via a syringe driver in the dying phase. Both the fentanyl group and the diamorphine group had good pain control in the last 48 hours of life. During the last 48 hours of life, the proportion of patients with controlled pain was statistically significant in favor of the fentanyl group in 2 of the 12 observations undertaken, in particular whether the fentanyl transdermal patch should be continued or discontinued. Patients in the fentanyl group received fewer "as required" opioid doses compared to patients in the diamorphine group, although the difference was statistically significant only for the last day of life. This study showed that pain control was not compromised in the dying phase with continued use of the fentanyl patch.

Objective To compare the efficacy and patient acceptability of 50 μg of sublingual misoprostol with 100 μg of oral misoprostol in the induction of labour at term. Design Non-blinded randomised comparative trial. Setting Tertiary level UK Hospital. Sample Two hundred and fifty women at term with indications for labour induction. Methods Fifty micrograms of sublingual misoprostol or 100 μg of oral misoprostol was administered every four hours after random allocation, to a maximum of five doses. Main outcome measures Number of patients delivering vaginally within 24 hours of the induction, mode of delivery, neonatal outcomes and patient acceptability. Results There was no significant difference in the number of women delivering vaginally within 24 hours of the induction in the sublingual group as compared with the oral group (62.8%vs 59%, RR 1.1, 95% CI 0.6–2.1), or in the mean induction to delivery time (21.8 vs 24.1 h, mean difference 2.3 h 95% CI −2.2 to +6.7). There was no difference in the uterine hyperstimulation rates (1.6% in both groups), operative delivery rates or neonatal outcomes. In the sublingual group, 92.6% found the induction acceptable with 15.8% finding the tablets with an unpleasant taste, while in the oral group it was 96.9% and 4%, respectively. More patients in the oral group thought that they would consider the same method of induction again as compared with the sublingual group (58.6%vs 40%, RR 1.4, 95% CI 1.04–1.9). Conclusion Fifty micrograms of sublingual misoprostol every four hours has the same efficacy and safety profile as compared with 100 μg orally, but the oral route might be preferred by women.

This research measured several vegetations that were planted in Bumi Serpong Damai, South Tangerang to absorb dust pollutions produced by vehicles. The locations for monitoring were divided based on traffic levels: high, medium and low. We measured the pollution based on two approaches i.e. measuring every four hours and a daily measurement. Based on our monitoring, each species will have different feedbacks to dust pollution at various traffic conditions. We found that species of Heliconia was able to absorb the dust at the top for high traffic condition, whereas Kaca Piring is effective for medium traffic. Our findings revealed that monitoring dust should be frequent at least four hours/day, and selection of species for reducing dust pollution should consider the leave structure.

Protocol BT-23, a Phase II study, was performed to determine the efficacy and safety of combination Antineoplaston A10 and Antineoplaston AS2-1 (ANP) in children with an optic pathway glioma (OPG). Sixteen patients (12 males, 4 females) ages 1 to 16 years (median age 4.5 years) were treated. The patients received ANP, by intravenous infusion, six times daily (i.e., every four hours). The length of treatment extended from a minimum of 4.1 weeks to a maximum of 210.0 weeks. The median dosage of A10 was 8.07 g/kg/d while for AS2-1 itwas 0.39 g/kg/d.Patients’ best response to ANP was determined: 12.5% of this patient population achieved a complete response, 18.8% achieved a partial response, and 31.3% maintained stable disease. The median overall survival was 78.5 months (95% CI: 37.6-92.3) while median progression-free survival was 45.4 months (95% CI: 7.1-71.4). ANPwas associated with a12% incidence of Grade 3 and a12% incidence of Grade 4 adverse drug experiences (ADEs). There were no Grade 5 ADEs. Grade 3 ADEs included somnolence and elevated SGOT; Grade 4 ADEsincluded hypernatremia and hypokalemia. Long-term quality of life was excellent with no chronic toxicity identified. Children with an OPG respond very well to ANP with good efficacy and toxicity profiles.

Objective Patient-controlled analgesia (PCA) is employed successfully on surgical wards. Continuous monitoring is important for the safety of the patient and the efficiency of this form of pain therapy. In the study we evaluated the regularity and completeness of monitoring data which had been collected by the nursing staff on the surgical wards. Methods Data on pain intensity, vital signs, and side effects were collected. Additionally, in the case of epidural analgesia, sensory and motor function were tested. In the first four hours after starting the PCA-pump, the nursing staff was instructed to document this data hourly (phase I), followed by a two hour interval until 8 am the next day (phase II). In general, monitoring was continued every four hours up to the discontinuation of the PCA; whereas in our study only forty hours (10 measurements) were included (phase III). Documentation protocols of 637 patients were evaluated and tested for the completeness of the data. Results In phase I, the data of 128 patients (20%) were complete. In 173 patients (27%) less than 50% of the data were documented. During phase II, only in 98 patients (15%) the data collection was complete. In 237 patients (37%) less than 50% of the measurements were determined. In phase III, in 205 patients (32%) all measurements, and in 104 patients (16%) less than 50% of the measurements were documented. Conclusion Complications during PCA become manifest mainly during the first hours after starting the PCA-pump. Especially during these phases, documentation was found to be quite poor. This underlines the importance of an intense cooperation between acute-pain service and nursing staff with periodical training of the staff.

Four mature sedentary geldings were used in a 4×4 Latin square designed experiment to evaluate the effects of supplemental molybdenum (Mo) on copper (Cu) balance. Four diets were formulated to contain 0 (control), 5, 10 and 20 ppm of supplemental Mo and were fed for a 21-day adjustment period followed by a 72-hour fecal and urine collection. Diets consisted of a pelleted concentrate based on corn, soybean meal and cotton seed hulls fed in a 50:50 ratio of concentrate to native prairie grass hay. All diets were formulated to be isonitrogenous and isocaloric with similar concentrations of Cu. Urine was collected every four hours for 72 hours and multiple fecal grab samples were taken every two hours post feeding. On the third collection day, blood samples were drawn at the time of feeding, each hour for five hours post feeding, and eight hours post feeding for serum Cu analysis. Balance data were analyzed using a general linear model procedure with horse, period and treatment as main effects. Serum Cu data were analyzed using the general linear model procedure with horse, treatment and period as main effects and time as the repeated variable. The intake of Cu was similar among all diets fed. There was no difference (p>.05) in serum Cu concentrations over time or between treatments due to supplemental Mo. Urinary and fecal excretion of Cu did not differ (p>.05) between diets. Consequently, the balance of Cu was similar among diets consumed. Excretion of Mo in the urine was higher (p

Molting process of E. sinensis juveniles in laboratory and the habitat, illumination and temperature in relation to molting in an earthen pond were studied during July to August, 1993. Intermolt cycle of crabs is divided into five stages (Stage A, B, C, D, E). For individuals with body-weight of 0. 5 - 2g, stage A lasted about 2h, stage B about 15h, and stage E about 3 -- 6h. The number of cast integuments per m_2 from weed-growing bottom was significantly greater than that from weedless bottom. Experiment shows that all the crabs molted normally at water depth of less than 2. 0m. Diel variations in molting every four hours were observed, indicating that massive molting occurred at 07: 00 - 11: 00. Analysis of covariance (water temperature as covariate) suggests that the number of cast integuments every four hours in daytime (07: 00 - 19: 00) was significantly higher than that at night (19: 00 - 07: 00) (F(1.30) = 13. 4,P = 0. 0009); the changes in diel water temperature (28 - 35℃ ) did not affect molting (F(7.11) = 1. 99, P = 0. 1467). Studies also show that crabs initiate molting at water temperature of about 14℃ and molt normally until 35℃.

Atmospheric concentrations of radon (Rn-222) gas and its short-lived progenies Po-218, Pb-214, and Po-214 were continuously monitored every four hours at the ground level in Jeddah city, Kingdom of Saudi Arabia. The measurements were performed three times every week, starting from November 2014 to October 2015. A method of electrostatic precipitation of positively charged Po-218 and Po-214 by a positive voltage was applied for determining Rn-222 gas concentration. The short-lived Rn-222 progeny concentration was determined by using a filter holder connected with the alpha-spectrometric technique. The meteorological parameters (relative air humidity, air temperature, and wind speed) were determined during the measurements of Rn-222 and its progeny concentrations. Rn-222 gas as well as its short-lived progeny concentration display a daily and seasonal variation with high values in the night and early morning hours as compared to low values at noon and in the afternoon. The observed monthly atmospheric concentrations showed a seasonal trend with the highest values in the autumn/winter season and the lowest values in the spring/summer season. Moreover, and in parallel with alpha-spectrometric measurements, a single filter-holder was used to collect air samples. The deposited activities of Pb-214 and the long-lived Rn-222 daughter Pb-210 on the filter were measured with the gamma spectrometric technique. The measured activity concentrations of Pb-214 by both techniques were found to be relatively equal largely. The highest mean seasonally activity concentrations of Pb-210 were observed in the autumn/winter season while the lowest mean were observed in the spring/summer season. The mean residence time (MRT) of aerosol particles in the atmospheric air could be estimated from the activity ratios of Pb-210/Pb-214.

To evaluate the effect of pFSH dose on the in vivo embryo production of Dorper ewes in the semi-arid northeast of Brazil, 40 sheep females were distributed into two groups of 20 animals that received intravaginal CIDR for 14 days, and two days before device removal, they received one of the following treatments: in the FSH200 group, the ewes received 200 mg of pFSH; and in the FSH128 group, the ewes received a total of 128 mg in decreasing doses every 12 h. Beginning 12 h after the conclusion of the treatments, estrus detection was performed every four hours using two Dorper rams of proven fertility. The ewes were mated at estrus onset and 24 hours later. Seven days after intravaginal device removal, the superovulatory response was evaluated, and embryo collection was performed using the laparotomy method. The recovered flushings were subjected to embryo searches under a stereomicroscope and classified according to their qualities. Analyses of variance (ANOVAs) and LSD tests were used to compare the different parameters. The data expressed as percentages were analysed by chi-square test. The ovulation rate was higher in the FSH200 group, which had 16.3 ± 0.3 corpora lutea (CL), than in the FSH128 group, which had 11.3 ± 0.3 CL (P0.05), demonstrating that pFSH dose reduction promoted a greater production of freezable and transferable embryos in Dorper ewes subjected to MOET.

A randomized, placebo-controlled, double-blind clinical trial was conducted to compare the use of regularly dosed po morphine and on-demand in morphine in 47 patients undergoing total hip arthroplasty. Patients were randomized to receive either 20 mg (initial dose) of regularly dosed morphine (every four hours po) plus breakthrough pain medication on-demand consisting of both 10 mg morphine po and placebo im, or an equivalent regularly dosed oral placebo (every four hours) with breakthrough pain medication consisting of oral placebo and 5-10 mg morphine im. Subsequent to each request for breakthrough pain medication, the next regularly dosed oral solution was increased by 5 mg (or equivalent volume of placebo) to a maximum of 40 mg po Q4H. Time-averaged pain scores were lower on both postoperative day 1 and 2 in the group receiving regularly dosed morphine po (P < 0.05). Fewer patients requested breakthrough pain medication on both days in the oral morphine group. The incidence of nausea and vomiting, and of decreased respiratory rates were similar in both groups. Regularly dosed oral morphine is inexpensive and should be compared to other methods of opioid delivery.

Methods Healthy males from the University of Oxford (n = 12, age 24 ± 2) underwent twenty hours of normobaric hypoxia in purpose-built hypoxia chambers. The partial pressure of oxygen during end tidal expiration (PETO2) was kept between 50 and 60 mmHg, whilst keeping peripheral oxygen saturation (SaO2) above 80%. Cardiac function was measured using magnetic resonance imaging (MRI) and echocardiography. High-energy phosphate metabolism was measured as the ratio of phosphocreatine to ATP (PCr/ATP) by 31Phosphorus magnetic resonance spectroscopy (MRS) before and after twenty hours of hypoxia. Additionally, four subjects had blood taken for biochemical analysis every four hours.

A 44 year-old woman took six mercuric bichloride tablets (3.0 gm.) and entered the hospital with nausea and abdominal cramps three hours later. Her blood pressure was 86/60. Five hours after the ingestion of the poison, BAL treatment was begun and she was given 2 cc. every four hours for six days, and then 1 cc, every 12 hours for five days. During the first 42 hours the patient had diarrhea, vomited and suffered abdominal cramps. Fifty cc. of urine were passed in the first 24 hours, then none for five days. The urinary output rose slowly for six days to 935 cc. and then fell to an average of 120 cc. until death. The NPN on the second day was 53 mg. per cent rising to 450 on the 28th day. On the 29th day she died, clearances of inulin, creatinine and PAH were infinitesimal on six occasions. [Abbreviations: BAL, British antilewisite or dimercaprol; NPN, nonprotein nitrogen (normal, 22—29mg per cent); PAH, para-aminohippurate.]

The diurnal expression of performance in a six-point alley-T-maze was studied in C57BI/6 Ola mice. Besides the error rate, the latency time for leaving the start box as well as the number of alleys entered per min were determined. From 08.00 hrs on, a group of 10 animals was investigated every four hours. Each group received one trial per day. Home cage activity was continously monitored over a 14-day period. The results revealed the development of a circadian rhythm of maze performance in the course of training, which became significant as from the 4th day. The best maze performance was observed in the middle of the dark phase, from 23.07 to 03.15 hrs. No indication of a direct relationship between home cage and ambulatory activity in the maze could be found.

A prospective double-blind study was designed to assess the efficacy of antibiotic prophylaxis in lung surgery. It included 114 patients undergoing lung surgery for primary or secondary malignant tumours randomly assigned to two groups. Group A patients (n = 59) were given cefamandole intravenously every four hours, three times, starting from induction of anaesthesia. The dose was determined according to the patient's weight: 1.5 g for patients weighing less than 60 kg, 2.5 g for those weighing between 60 and 80 kg, and 3 g for those above 80 kg. Group B patients (n = 55) were given a placebo at the same times. Nineteen other patients were excluded because either the tumour was found to be infected, or the patient had to be mechanically ventilated postoperatively, or an exploratory thoracotomy only was carried out, or they were allergic to beta-lactam antibiotics. The efficacy of antibiotic prophylaxis was assessed by recording the incidence of postoperative infections, the length of the patient's stay in hospital, and the need to use an antibiotic treatment. Patients, their sputum and wound were examined every day, and their temperature recorded. The white blood cell count and chest X-ray was carried out every day for the first week. All the drain and catheter tips were cultured, as well as sputum and blood (every three days). In case of infection, samples were obtained and cultured. Both groups of patients were similar with regard to age, risk factors (smoking habit, diabetes mellitus), and type of surgery (segmentectomy, lobectomy, pneumonectomy). There were 9 postoperative infections in group A, and 22 in group B (p = 0.003).(ABSTRACT TRUNCATED AT 250 WORDS)

Study objective: To determine the safety and efficacy of a 48-hour IV N -acetylcysteine (IV NAC) treatment protocol for acute acetaminophen overdose. Design: Nonrandomized trial open to all eligible patients. Setting: Multicenter; hospitals included moderate- and high-volume private, university, and municipal hospitals in urban and suburban settings. Type of participants: Two hundred twenty-three patients were entered. Of these, 179 met inclusion criteria: acute acetaminophen overdose, plasma acetaminophen concentration above the treatment nomogram line, treatment with IV NAC according to the protocol, and sufficient data to determine outcome. Interventions: IV NAC treatment consisted of a loading dose of 140 mg/ kg followed by 12 doses of 70 mg/kg every four hours. Measurements and main results: Patients were grouped for analysis according to risk group based on the initial plasma acetaminophen concentration. Hepatotoxicity (aspartate aminotransferase or alanine aminotransferase of more than 1,000 IU/L) developed in 10% (five of 50) of patients at "probable risk" when IV NAC was started within ten hours of acetaminophen ingestion and in 27.1% (23 of 85) when therapy was begun after ten to 24 hours. Among "high-risk" patients first treated 16 to 24 hours after overdose, hepatotoxicity occurred in 57.9% (11 of 19). There were two deaths (two of 179, 1.1%). Adverse reactions resulting from NAC occurred in 32 of 223 cases (14.3%), consisting in 29 of 32 patients (91% of reactions) of transient, patchy, skin erythema or mild urticaria during the loading dose that did not require discontinuation of therapy. Conclusion: This 48-hour IV NAC protocol is safe and effective antidotal therapy for acetaminophen overdose. Based on available data, it is equal to 72-hour oral and 20-hour IV treatment protocols when started early and superior to the 20-hour IV regimen when treatment is delayed. Further study will be required to determine its relative efficacy in the high-risk patient treated very late.

The objectives of this study were to evaluate rectal temperature as a diagnostic tool in postpartum dairy cows and to compare body temperature and white blood cell counts in cows that remained healthy with those that became ill. Fifty Holstein dairy cows had complete physical examinations every four hours and a complete blood count once daily for the first 10 days after calving. Illness was defined as a rectal temperature of at least 104.5°F (40.3°C) in the absence of other clinical signs, or a clinical sign of illness other than increased temperature. Fifteen cows were diagnosed with illness and 35 remained healthy throughout the 10-day study period. No difference between mean rectal temperatures of cows that became ill and cows that remained healthy was found. Among cows that remained healthy, 23 (66%) had a rectal temperature of at least 103.1°F (39.5°C) at least once, 17 (49%) had a rectal temperature of at least 103.5°F (39.7°C) at least once and six (17%) had a rectal temperature of at least 104°F (40°C) at least once during the study period. Over the first three days after calving, mean total white blood cell counts and neutrophil counts were higher in healthy cows than in cows that became ill. Because rectal temperatures were frequently elevated in healthy postpartum cows, it was concluded that rectal temperature has low specificity for diagnosing illness in postpartum dairy cows in the absence of other clinical signs., The Bovine Practitioner, Vol. 42, No. 1 (2008 Spring)

Background. The initially tested dose of zidovudine for the treatment of patients with advanced disease caused by the human immunodeficiency virus type 1 (HIV) was 1500 mg. Although this dose is effective, it is associated with substantial toxicity. Methods. To evaluate the efficacy and safety of a reduced dose, we conducted a randomized controlled trial in 524 subjects who had had a first episode of Pneumocystis carinii pneumonia. The subjects were assigned to receive zidovudine in either a dose of 250 mg taken orally every four hours (the standard-treatment group, n = 262) or a dose of 200 mg taken orally every four hours for four weeks and thereafter 100 mg taken every four hours (the low-dose group, n = 262). Results. The median length of follow-up was 25.6 months. At 18 months the estimated survival rates were 52 percent for the standard-treatment group and 63 percent for the low-dose group (P = 0.012 by the log-rank test). At 24 months the estimated survival rates were 27 percent for the st...

Alhashemi JA, Alotaibi QA, Mashaat MS, Kaid TM, Mujallid RH, Kaki AM. Department of Anesthesia & Critical Care, King Abdulaziz University, King Abdulaziz University Hospital, Jeddah 21418, Saudi Arabia. jalhashemi@kau.edu.sa PURPOSE: To compare the effects of iv acetaminophen with those of oral ibuprofen with respect to postoperative pain control and morphine requirements in patients receiving morphine patient-controlled iv analgesia (PCIA) after Cesarean delivery. METHODS: Forty-five term patients scheduled for Cesarean delivery were randomized to receive acetaminophen 1 g iv every six hours plus oral placebo (group A) or ibuprofen 400 mg po every six hours plus iv placebo (group I); the first dose of study drug was given 30 min preoperatively. Postoperatively, all patients received PCIA for 48 hr using morphine bolus dose 2 mg iv, lockout interval ten minutes, and no basal infusion. Visual analogue scale (VAS; 0 to 10) at rest and morphine requirements were recorded every hour for four hours then every four hours for a total of 48 hr postoperatively. Patient satisfaction was recorded on a ten-point scale (from 1 to 10) 48 hr postoperatively. RESULTS: Visual analogue scale scores decreased similarly in both groups over time, however, there were no differences between groups at any time during the study period (estimated marginal means: 1.4 +/- SEM 0.2 vs 1.9 +/- SEM 0.2 for groups A and I, respectively, P = 0.124). Cumulative doses of postoperative morphine were 98 +/- 37 vs 93 +/- 33 mg for groups A and I, respectively (P = 0.628). Patient satisfaction with analgesia was high in both groups (9 +/- 1 vs 9 +/- 1, P = 0.93). CONCLUSION: Intravenous acetaminophen is a reasonable alternative to oral ibuprofen as an adjunct to morphine patient-controlled analgesia after Cesarean delivery. PMID: 17142654 [PubMed - indexed for MEDLINE]

Decompensated congestive heart failure (CHF) is a clinical syndrome often characterized by elevated left ventricular fi lling pressures (LVEDP). Therapy for decompensated CHF aims at normalizing fi lling pressures and thereby improves both symptoms and outcomes. However, therapy guided by direct measurements of fi lling pressure is not practical in most patients, focusing attention on non-invasive surrogate measures of LVEDP for tailoring of heart failure therapy.Natiruretic peptide levels (NP) are closely correlated with LVEDP, which is consistently elevated in decompensated heart failure. In the absence of acute mitral regurgitation and fl ash pulmonary edema, and in the presence of volume overload, NP levels are a useful indication of pulmonary capillary wedge pressure (PCWP). In a study by Kazenegra et al, patients admitted for decompensated CHF had BNP levels and hemodynamic measurements taken every 2 hours for the fi rst 24 hours and every four hours for the next 24-48 hours. PCWP showed a decrease from 33 to 25 mmHg over the fi rst 24 hours, while BNP levels decreased from 1472 to 670 pg/ml. However, no change in BNP was noted in patients with end-stage heart failure, even as wedge pressures dropped

The effects of equipotent doses of racemic albuterol and levalbuterol on heart rate (HR) in intensive care patients with and without baseline tachycardia were studied. Patients were included if they were hemodynamically stable and required bronchodilator therapy every four hours; patients were excluded if they were maintained on a beta-blocker. Four hours after the most recent bronchodilator treatment, each patient was randomized to receive at least two consecutive doses of albuterol 2.5 mg or levalbuterol 1.25 mg four hours apart via nebulization. HR was recorded at the end of the second dose and 5, 10, 15, 30, 60, 90, 120, 180, and 240 minutes after treatment. Twenty intensive care patients, including 10 with baseline tachycardia and 10 without baseline tachycardia, were enrolled. In patients with baseline tachycardia, the mean largest HR increase was 1.4 beats/min (1.3%) with albuterol and 2.0 beats/min (2.1%) with levalbuterol (both increases were not significant). In patients without baseline tachycardia, the mean largest HR increase was 4.4 beats/min (6.7%) with albuterol (p = 0.04) and 3.6 beats/min (5.0%) with levalbuterol (p = 0.03). Short-term use of nebulized albuterol and levalbuterol was associated with similar changes in HR in intensive care patients with or without baseline tachycardia.

Respiratory tract secretions (RTS), the sound created by poorly-cleared mucous in the hypopharynx or bronchial tree, can be alarming for dying patients, relatives and staff. Increased knowledge into the etiology of RTS and its response to treatment is needed to improve future management. We studied retrospectively the data from 202 patients who died on a 30-bed specialist palliative care unit during a one-year period. These patients were observed every four hours during the dying phase. RTS was treated with hyoscine hydrobromide. Ninety-nine patients (49%) developed RTS. The median time from onset of RTS till death was 16 hours. Fifty-nine patients could have their treatment response assessed. Of these, 30.5% responded within four hours, 33.9% after four hours, and 35.5% died with RTS. Increasing the dose for nonresponders had no significant effect. Significant risk factors for developing RTS were found to be prolonged dying phase, primary lung cancer and male gender.

Sodium bicarbonate is well recognised in the treatment of tricyclic overdose. But its use in the treatment of massive β blocker (propanol) overdose has not been previously reported. A 24 year old woman presented to the accident and emergency department with a history of overdose, taking 92 propanolol LA 80 mg, 45 paroxetine 30 mg, and 28 diazepam 5 mg tablets, two hours before admission. NPIS advised us to give activated charcoal every four hours and monitor vital signs closely …

Ritodrine and other β adrenergic agonists relax uterine smooth muscle and have been widely used to manage preterm labour. The effect of these drugs on birth weight and perinatal mortality remains controversial. Several side effects, including maternal pulmonary oedema, have been described. A 34 year old woman with primary infertility for 10 years had in vitro fertilisation, resulting in a twin pregnancy. She was normally fit and well with no history of cardiac disease. At 24 weeks of pregnancy she developed intermittent vaginal bleeding and was admitted to hospital. Initial assessment showed no evidence of uterine activity, but later the same day she developed contractions and the cervix was found to be 2 cm dilated, although the membranes were intact. Preterm labour was diagnosed and a ritodrine infusion was started at a dose of 200 μg/min, given in 500 ml of normal saline every four hours. She was also given dexamethasone (two 12 mg doses) and thyrotrophin releasing hormone (400 μg eight hourly over 48 hours) to improve fetal lung maturation and reduce the risk of hyaline membrane disease. Over the next 24 hours the contractions became less frequent and although she had a resting tachycardia, her chest was clinically clear. During the next day the contractions became more frequent and she was given ritodrine in 500 ml of normal saline every four hours. The contractions continued and on the fourth day she became increasingly breathless with a tachycardia of 135 beats/min, bilateral basal crackles, and some peripheral oedema. Pulmonary oedema was diagnosed clinically and she responded to oxygen and a bolus of intravenous frusemide. The ritodrine infusion was stopped and twins were delivered a few hours later. Thirty minutes after delivery she became acutely breathless and started coughing up pink frothy sputum. She had severe tachycardia with chest crepitations …

Patients ‘at risk’ of developing pressure ulcers should be repositioned at least every six hours and those considered ‘at high risk’ should have their position changed at least every four hours, according to new guidance. The updated guidance on preventing and managing pressure ulcers, produced by the National Institute for Health and Care Excellence (NICE), stresses the importance of risk assessment, adjusting patients’ positions, and the use of high-specification foam mattresses. Challenges specific to heel pressure ulcers are highlighted, as are the need for individualised care plans and the importance of training staff in pressure ulcer prevention. The guidance comes as NHS-wide targets are being finalised concerning minimising the proportion of patients with pressure ulcers in category two, three and four. These targets are expected to be introduced next year in the NHS Outcomes Framework. Four nurses, including Mark Collier, were among the 13 healthcare professionals who advised NICE on the guidelines. Mr Collier, a nurse consultant in tissue viability at United Lincolnshire Hospitals NHS Trust, said: ‘Risk assessments should be carried out on admission and at regular intervals. That is crucial. Assessments should be with validated tools such as the Waterlow tool. There should be ongoing assessments, especially when there are early signs of damage, such as discolouring or tissue hardening.’