Huron Hospital

Suzetrigine: A novel nonopioid systemic analgesicO pioids have been the mainstay of postoperative analgesia for decades.However, their side effects and potential complications, such as respiratory depression, postoperative nausea, vomiting, and ileus, have fueled the search for alternative ways to control pain.Thus, the concept of multimodal analgesia was born-a technique using a combination of different analgesic modalities, including acetaminophen, nonsteroidal anti-infl ammatories, N-methyl-D-aspartate receptor antagonists, intravenous lidocaine infusion, local anesthetic infi ltration, regional anesthesia, and peripheral nerve blocks, that can result in maximal pain relief with the minimum necessary dose of opioids to lessen their side effects.This strategy has coincided with the adoption of enhanced recovery after surgery protocols that have helped promote multimodal analgesia to minimize opioid use while permitting a more expedient recovery. 1ecently, suzetrigine, a voltage-gated sodium channel 1.8 (Na V 1.8) blocker, was approved by the US Food and Drug Administration (FDA), leading to interest in possibly adding this nonopioid analgesic to the multimodal analgesic regimen.

To determine the effect of mode of ligation and bracket material on resistance to sliding (RS) by comparing various esthetic brackets of conventionally ligated and self-ligating (SL) designs under an increasing applied moment in the second-order dimension. Eight different commercially available esthetic brackets of SL and conventional elastomeric-ligated (CL) designs were mounted on a testing apparatus to simulate canine retraction using sliding mechanics and the application of a moment on 0.019″×0.025″ stainless steel archwire. The samples examined were the CL brackets Clarity™, Inspire Ice™, SpiritMB™, and Mystique™, and the SL brackets ClaritySL™, In-OvationC™, In-OvationR™, and Smartclip™. The RS at calculated moments of 2000 g-mm and 4000 g-mm was determined and compared between the various brackets. Descriptive measures and one-way analysis of variance were used to calculate means and statistical differences among the bracket types. The CL monocrystalline bracket displayed significantly greater (P < .05) RS than all other brackets tested. Among the other brackets, the range of RS values was 145.8-191.7 g and 291.9-389.2 g at moments of 2000 g-mm and 4000 g-mm, respectfully, though these differences were not significant (P < .05). All brackets tested displayed greater levels of RS (P < .05) at 4000 g-mm than at 2000 g-mm. With the exception of the CL monocrystalline bracket, all brackets displayed comparable amounts of RS regardless of mode of ligation or bracket slot material.

Doripenem is the most recently introduced carbapenem, with a broad spectrum of antimicrobial activity. Preliminary data indicated that activity is optimized by maximizing the time that serum concentration remains above the minimum inhibitory concentration; however, limited clinical data are available to support this approach. To compare clinical outcomes before and after implementation of a hospital-wide initiative extending the duration of infusion for doripenem from 1 hour (standard) to 4 hours (prolonged). This retrospective, quasi-experimental study compared clinical outcomes associated with doripenem administered as a 1-hour infusion versus a 4-hour infusion for treatment of suspected or documented infections caused by gram-negative organisms. Outcomes were assessed for the entire cohort, as well as for the subpopulation of patients admitted to the intensive care unit. Two hundred patients were included; 106 patients received doripenem via standard infusion and 94 patients via prolonged infusion. No significant differences were noted between the treatment groups in clinical success, length of stay, or duration of treatment when the entire cohort was evaluated. In the critically ill subgroup, pneumonia, standard-infusion doripenem, and concomitant bacteremia were independent predictors of clinical failure (adjusted odds ratio [95% CI] 7.8 [2.4-25.6], 5.5 [1.6-18.7], and 7.0 [1.6-31.3], respectively). Additionally, critically ill patients who received doripenem via standard infusion were significantly more likely to experience recurrence of infection or death within 90 days. No significant differences were noted in length of stay or duration of bacteremia. The duration of infusion did not significantly impact outcomes when the entire cohort was compared; however, prolonged infusion of doripenem was associated with significantly improved clinical outcomes among critically ill patients. These findings support the use of prolonged infusion of doripenem for critically ill patients.

Vitamin D deficiency is highly prevalent among patients with chronic kidney disease (CKD). The benefits and harms of vitamin D supplementation (ergocalciferol or cholecalciferol) were assessed in patients with nondialysis-dependent CKD, dialysis-dependent CKD, and renal transplant recipients. MEDLINE (1966 to September 2009), SCOPUS (September 2009), and nephrology conference proceedings were searched for relevant observational and randomized controlled trials (RCTs). Treatment effects were summarized as mean differences (MDs) with 95% confidence intervals (CIs) using a random effects model. Separate analyses were conducted for observational studies and RCTs. Twenty-two studies (17 observational and 5 RCTs) were included. There was a significant improvement in 25-hydroxyvitamin D (MD 24.1 ng/ml, 95% CI 19.6 to 28.6) and an associated decline in parathyroid hormone (PTH) levels (MD -41.7 pg/ml, 95% CI -55.8 to -27.7) among observational studies. PTH reduction was higher in dialysis patients. Among RCTs, there was a significant improvement in 25-hydroxyvitamin D (MD 14 ng/ml, 95% CI 5.6 to 22.4) and an associated decline in PTH levels (MD -31.5 pg/ml, 95% CI -57 to -6.1). A low incidence of hypercalcemia and hyperphosphatemia was reported with vitamin D supplementation. Cardiovascular and skeletal effects of vitamin D supplementation have not been studied. Included studies were mostly of low to moderate quality. Available evidence from low-to-moderate quality observational studies and fewer RCTs suggests that vitamin D supplementation improves biochemical endpoints. However, whether such improvements translate into clinically significant outcomes is yet to be determined.

Community-acquired pneumonia (CAP) affects 5-10 million adults annually in the United States with approximately 1.1 million hospitalizations. Current guidelines recommend fluoroquinolones as monotherapy for treatment of CAP in general medical wards and doxycycline monotherapy for outpatient therapy only. Fluoroquinolones are expensive and development of bacterial resistance to them has become a concern. Therefore, we studied whether doxycycline is as efficacious as levofloxacin in treatment of CAP in general medical wards. In this prospective double-blinded trial, non-pregnant adults with clinical and radiological evidence of pneumonia requiring hospitalization were enrolled. Patients who were septic, hypoxic requiring intubations, nursing home residents, diagnosed with severe hepatic or renal dysfunction, recently hospitalized or immunocompromised were excluded from the study. Subjects were randomly assigned to either i.v. levofloxacin 500 mg daily or doxycycline 100 mg twice daily. After discharge, patients were followed for 2 months. There were 30 patients in the levofloxacin group and 35 patients in the doxycycline group. Groups were comparable in both clinical and laboratory profiles. Additionally, efficacy of treatment was not significantly different between the two groups (P = 0.844). Length of stay was 5.7 +/- 2.05 days in the levofloxacin group and 4.0 +/- 1.82 days in the doxycycline group (P < 0.0012). Failure rate was similar in both groups (P = 0.893). Total antibiotic cost was $122.07 +/- 15.84 for levofloxacin and $64.98 +/- 24.4 for doxycycline (P < 0.0001). Our study supports doxycycline as an effective and economical alternative therapy for levofloxacin in the empirical treatment of CAP in general medical wards.

This study examined the effect of translatoric spinal manipulation (TSM) on cervical pain and cervical active motion restriction when applied to upper thoracic (T1-T4) segments. Active cervical rotation range of motion was measured re- and post-intervention with a cervical inclinometer (CROM), and cervical pain status was monitored before and after manipulation with a Faces Pain Scale. Study participants included a sample of convenience that included 32 patients referred to physical therapy with complaints of pain in the mid-cervical region and restricted active cervical rotation. Twenty-two patients were randomly assigned to the experimental group and ten were assigned to the control group. Pre- and post-intervention cervical range of motion and pain scale measurements were taken by a physical therapist assistant who was blinded to group assignment. The experimental group received TSM to hypomobile upper thoracic segments. The control group received no intervention. Paired t-tests were used to analyze within-group changes in cervical rotation and pain, and a 2-way repeated-measure ANOVA was used to analyze between-group differences in cervical rotation and pain. Significance was accepted at p=0.05. Significant changes that exceeded the MDC95 were detected for cervical rotation both within group and between groups with the TSM group demonstrating increased mean (SD) in right rotation of 8.23° (7.41°) and le rotation of 7.09° (5.83°). Pain levels perceived during post-intervention cervical rotation showed significant improvement during right rotation for patients experiencing pain during bilateral rotation only (p=.05). This study supports the hypothesis that spinal manipulation applied to the upper thoracic spine (T1-T4 motion segments) significantly increases cervical rotation ROM and may reduce cervical pain at end range rotation for patients experiencing pain during bilateral cervical rotation.

Acanthosis nigricans was observed 3 months after single lung transplantation in a 51-year-old African American woman with idiopathic pulmonary fibrosis. The patient had no endocrinological abnormalities and was not taking any medications known to cause acanthosis nigricans; extensive investigation did not reveal an underlying malignant process. Because acanthosis nigricans may occur as a paraneoplastic phenomenon, it is important to rule out an underlying malignancy. This is especially important in solid-organ transplant recipients receiving chronic immunosuppressive therapy.