John P. Gaughan

Comparison of atriocaval shunting with perihepatic packing versus perihepatic packing alone for retrohepatic vena cava injuries in a swine model

BACKGROUND Retrohepatic vena cava (RVC) injuries are technically challenging and often lethal. Atriocaval shunting has been promoted as a modality to control haemorrhage from these injuries, but evidence from controlled studies supporting its benefit is lacking. We hypothesised that addition of an atriocaval shunt to perihepatic packing would improve outcomes in our penetrating RVC injury swine model. METHODS After a survivable atriocaval shunting model was refined in 4 swine without an injury, 13 additional female Yorkshire swine were randomised into either perihepatic packing and atriocaval shunt (PPAS, n=7) or perihepatic packing alone (PP, n=6) treatment arms prior to creating a standardised, 1.5 cm stab wound to the RVC. Haemodynamic parameters, intravenous fluid, and blood loss were recorded until mortality or euthanisation after 4h. Statistical tests used to test differences include the Wilcoxon rank sums test, Fisher exact test and analysis of covariance. A p-value ≤0.05 was considered statistically significant. RESULTS Immediately before and after RVC injury, no difference in temperature, cardiac output, heart rate, mean arterial pressure or mean pulmonary artery pressure was detected (all p>0.05) between the two groups. While the RVC injury did affect measures parameters in PPAS swine over time, haemodynamic compromise and blood loss were not significantly greater in PPAS than PP swine. Survival time was significantly different with all PPAS swine dying within 2h (mean survival duration 39 (SD 58)min) while all 6 PP swine survived the entire 4h study period. CONCLUSIONS While perihepatic packing alone slowed haemorrhage to survivable rates during the 4h study period, atriocaval shunt placement led to rapid physiologic decline and death in our standardised, penetrating RVC model.

Epidemiology of intravenous fluid use for headache treatment: Findings from the National Hospital Ambulatory Medical Care Survey

Background: Headache is one of the most common reasons for patients to seek care in emergency departments. While the administration of intravenous fluids is frequently recommended for emergency department patients with migraine, the epidemiology of the use of this intervention is unknown. Objectives: To describe the epidemiology of intravenous fluid use in emergency department patients with headache. Methods: This retrospective study utilized the 2011 US National Hospital Ambulatory Medical Survey, a multi‐stage weighted survey providing nationally representative estimates of ED visits. Patients with chief complaints of non‐traumatic headache or migraine headache were included. We determined the frequency of intravenous fluid administration among patients presenting with headache, and among specific subgroups including those with migraine headache. Results: There were 1251 sample cases representing 5,981,000 visits for a chief complaint of headache. Intravenous fluids were administered at 40% (95% CI 35–44%) of these visits. Among the 222 migraine cases, 47% (95% CI 39–56%) received fluids. Fluids were commonly administered regardless of pain severity, and fluid administration was not significantly associated with pain severity among patients diagnosed with migraine (p = 0.39). After adjusting for patient characteristics, ED visit duration remained greater for patients receiving fluids than for those who did not among both patients with a headache complaint and among those with a diagnosis of migraine headache. Conclusions: Despite a lack of efficacy data, patients treated in United States EDs for headache frequently receive IV fluids. Studies are needed to determine the efficacy of this basic treatment intervention.

LACK OF AN ASSOCIATION BETWEEN BMI AND TSH IN TREATED HYPOTHYROID PATIENTS AND EUTHYROID CONTROLS

OBJECTIVE The standard treatment for primary hypothyroidism is replacement with levothyroxine to achieve a thyroid-stimulating hormone (TSH) level within the normal range, (0.45-4.5 mIU/L), which is known to prevent complications including weight gain. While the normal TSH range includes the 95% confidence intervals, it is not known if there is an association between weight and TSH within this interval in treated hypothyroid patients. METHODS We conducted a retrospective analysis of patients treated within the Cooper Health System from January 1 to August 31, 2014. A sample of 245 treated hypothyroid patients and 162 euthyroid controls were studied. Data collected included age, sex, race/ethnicity, height, weight, levothyroxine dose, and diabetes and smoking history. RESULTS Hypothyroid and control groups were similar in height, weight, body mass index (BMI), and the number of patients with diabetes. There were more females, Caucasians, and nonsmokers in the hypothyroid group. The average TSH was slightly higher in the treated hypothyroid patients versus nonhypothyroid controls (median 1.87 vs. 1.55, P<.01). There was no significant relationship between TSH and BMI in the treated hypothyroid patients or the euthyroid controls. CONCLUSION Since no significant relationship was found between BMI and TSH in treated hypothyroidism, there may be no weight reduction benefit gained by adjusting TSH to the lower end of normal range. Patients should be counseled that properly treated hypothyroidism is unlikely to contribute to weight gain. Other treatments such as nutrition and exercise counseling should be offered instead.

Intravenous Fluid for the Treatment of Emergency Department Patients With Migraine Headache: A Randomized Controlled Trial

Study objective The objective of this pilot study is to assess the feasibility and necessity of performing a large‐scale trial to measure the effect of intravenous fluid therapy on migraine headache pain. Methods This was a single‐center, pilot randomized controlled trial. We randomized adult emergency department migraine headache patients to receive 1 L of normal saline solution during 1 hour (fluid group) or saline solution at 10 mL/hour for 1 hour (control group). All patients received intravenous prochlorperazine and diphenhydramine at the start of fluid administration. Participants and outcome assessors were blinded; nurses administering the intervention were not. Outcomes were assessed at 60 and 120 minutes, and 48 hours. The primary outcome was the difference in the verbal pain rating (on a scale of 0 to 10) between 0 and 60 minutes. Key secondary outcomes included additional clinical endpoints, the rate of protocol completion, and the effectiveness of blinding. Results Fifty patients consented to participate; one withdrew, leaving 25 patients randomized to the fluid group and 24 in the no fluid group. The mean improvement in 0‐ to 60‐minute pain score was 4.5 (95% confidence interval 3.7 to 5.3) in the fluid group and 4.9 (95% confidence interval 3.5 to 6.2) in the control group. Primary outcome data were collected for 49 of 50 enrolled patients, and only one participant correctly identified the group assignment. Conclusion This pilot study showed no statistically significant treatment effect from fluid administration, but does not exclude the possibility of a clinically important treatment effect. The study protocol and approach to blinding are both feasible and effective.