Aim: Compare the effectiveness of administration of different doses of rectal misoprostol before cesarean section to reduce intra-and postoperative blood loss. Methods: A double-blind randomized clinical trial including 453 term pregnant woman scheduled for elective cesarean section where participants received either 200-, 400-or 600-μg misoprostol rectally before cesarean section. Study medications were administered after catheter insertion and shortly before skin incision. Primary outcome measures were intraoperative blood loss. Results: The intraoperative blood loss was higher in patients who received 200-μg misoprostol (464.6 AE 143.1 mL) than those who received 400 or 600 μg, yet, no statistical difference was found between the 400-(359.3 AE 120.9 mL) and 600-μg groups (330.8 AE 133.8 mL). The incidence of side effects as fever and chills increases with increasing the dose of misoprostol. Conclusion: Rectal administration of misoprostol for the prevention of post-partum hemorrhage and decreasing intraoperative blood loss during caesarian section is a good alternative to other uterotonics. Yet, the best dose to be used needs further research to be agreed upon.
Background Inadequately treated pain is associated with significant morbidity in older adults. We aimed to describe current pain management practices for patients with fragility pelvic fractures, a common emergency department (ED) presentation in older adults. Methods We performed a health records' review of adults ≥ 65 years old who presented to two academic EDs with nonoperative fragility pelvic fractures between 01/2014 and 09/2018. The primary outcome measures were type and timing of analgesic medications. Secondary outcome measures included ancillary service consultation, ED length of stay, admission rate and rate of return to ED at 30 days. Data were reported using descriptive statistics. ResultsWe included 411 patients. The majority were female (339, 82.5%) with mean age 83.9 (SD 8.1) years. Nearly, onethird (130, 31.6%) did not receive any analgesia for their fracture. Analgesia was initiated in 123 (29.9%) patients through paramedic and nursing medical directives; 244 (59.4%) patients received physician-initiated opioids (hydromorphone 228 (55.5%); morphine 28 (6.8%)). Only 23.1% of patients received one or more ancillary services: physiotherapy (10.5%), social work (7.3%), geriatric nurse assessment (14.1%), and homecare (3.9%). Mean ED length of stay was 11.6 (SD 7.1) h; 210 (51.1%) patients were admitted; of those discharged, 45 (22.4%) returned to the ED within 30 days. Conclusion One in three older adults presenting to the ED with nonoperative fragility pelvic fractures receive no analgesia during the course of their prehospital and ED care. Barriers to quality care must be identified and processes implemented to ensure adequate pain management for this population. Keywords Fragility pelvic fracture • Pain • Older • Emergency Department RésuméContexte La douleur insuffisamment traitée est associée à une morbidité importante chez les personnes âgées. Nous voulions décrire les pratiques actuelles de gestion de la douleur chez les patients souffrant de fractures pelviennes de fragilité, une présentation courante des services d'urgence (SU) chez les personnes âgées. Méthodes Nous avons effectué une revue des dossiers médicaux des adultes ≥ 65 ans qui se sont présentés à deux urgences universitaires avec des fractures pelviennes de fragilité non opérées entre 01/2014 et 09/2018. Les principaux critères d'évaluation étaient le type et le moment de la prise de médicaments analgésiques. Les critères d'évaluation secondairesThe results of this study have been accepted for presentation at the
The agreement between the traditionally-used ambulatory blood pressure (ABP)-load thresholds in children and recently-recommended pediatric American Heart Association (AHA)/European Society of Hypertension (ESH) ABP thresholds for diagnosing ambulatory hypertension (AH), white coat hypertension (WCH), and masked hypertension (MH) has not been evaluated.
Background Outpatient parenteral antimicrobial therapy (OPAT) with vancomycin is a common treatment modality for certain Gram-positive infections. Data regarding the safety of various models of delivery are limited. Objectives To review outcomes of a nurse-led OPAT vancomycin monitoring service. Methods This was a retrospective cohort study of consecutive patients referred to a nurse-led OPAT vancomycin clinic from December 2015 to March 2018. Patients were administered IV vancomycin in the home with active laboratory monitoring of vancomycin trough levels, renal function and complete blood count using an integrated electronic database linked with community laboratories (virtual vancomycin clinic, VVC). Monitoring was coordinated by nurses with physician approval of recommended dosing changes. Data were extracted from the electronic medical record. Demographics; clinical indication; microbial aetiology; culture source; antimicrobial regimen(s); serum creatinine and vancomycin trough values; initiation, discharge and completion dates; hospitalizations; adverse events; and outcomes were all evaluated. Results Two hundred and seventy-five patients underwent a total of 301 courses of OPAT with vancomycin; 285 courses were completed. The rate of treatment discontinuation due to adverse effects was 33/301 (11.0%), with 15/33 (45.5%) being due to renal adverse effects (15/301 [5.0%] of episodes). Two of 15 (18.2%) patients developed stage 2 acute kidney injury (AKI), and no patients had stage 3 AKI or required haemodialysis. Nine of 301 (3.0%) required readmission for treatment failure. Nursing costs associated with monitoring were $63.93 CAD/patient ($48.43 USD). Conclusions A nurse-led VVC was a safe, effective and inexpensive modality for administering outpatient vancomycin.
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