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Early treatment of acute, myocardial infarction with intravenous streptkoinase
Abstracts
u CAUSTIC INGESTION AND ITS SEQUELAE IN CHILDREN. Moazam F, Talbert JL, Miller D, et al. South Med J 1987; 80:187-190. Medical records of 56 children admitted over an 1l-year period with the diagnosis of caustic ingestions were reviewed to determine esophageal disorders resulting from caustic ingestion. Patient ages ranged from ten months to five years. Diagnostic endoscopy was performed promptly and steroids and antibiotics were administered immediately and continued if esophageal burns were demonstrated. The authors found that the strength and composition of the material was the most important determinant in the depth of the esophageal injury. Strong alkali were significantly more destructive than strong acids. Ingestions containing lye, in this study, were particularly corrosive. In the presence of full thickness esophageal burns, there remained a high potential for stricture formation regardless of the form of intial therapy. Once esophageal stricture had formed, only a relatively small number responded to esophageal dilation. The authors note that multiple esophageal strictures also seldom respond to dilation. They recommend early esophageal replacement with interposition of the colon to decrease morbidity. [Jeffrey Schaider, MD] Editor’s Note: An ounce of prevention is worth a pound of cure. Poisoning prevention education begins in the pediatrician’s office; but is reinforced in the emergency department.
0 CLINICAL SUMMARY AND COURSE OF IDIOPATHIC ANAPHYLAXIS IN 73 PATIENTS. Boxer M, Greenberger PA, Patterson R. Arch Int Med 1987; 147:269-272. The authors studied 73 patients with idiopathic anaphylaxis. The natural history is as follows: 52% have infrequent reactions (defined as one episode only or mild episodes less than six times per year) requiring acute treatment, and 48% have severe or frequent lifethreatening reactions requiring therapy with maintenance antihistamines and prednisone. Of the patients with single or infrequent episodes, there is an excellent prognosis with acute treatment alone: 50% remain in remission (without therapy); 34% do not experience anaphylaxis, but do have infrequent episodes of angioedema, urticaria, or both; and 16%
577
have been asymptomatic for less than one year. Of the patients with severe or life-threatening reactions, the course is variable: 13% require maintenance prednisone above a critical dose to avoid anaphylaxis; 23% remain in remission (following a treatment period of several years); 20% do not experience anaphylaxis, but do have infrequent episodes of angioedema, urticaria, or both (following a treatment period of several years); and 43% have been asymptomatic for less than one year or are currently undergoing tapering doses of prednisone. No fatalities occurred in 224 patient-years of follow [David W. Steedle, MD] UP. Editor’s Note: Idiopathic anaphylaxis can be extremely frightening, especially since no inciting source can be found. This article emphasizes that the prognosis is favorable in most cases and that long term therapy can be effective.
0 EARLY TREATMENT OF ACUTE MYOCARDIAL INFARCTION WITH INTRAVENOUS STREPTKOINASE. Koren G, Luria MH, Weiss AT, et al. Arch Inr Med 1987; 145:237-240 Early thrombolytic therapy of acute myocardial infarction was evaluated during a threemonth follow-up period in 51 successive patients treated with intravenous streptokinase 1.7 kO.8 hours after onset of symptoms. Coronary angiography was performed four to nine days after onset of symptoms revealing a reperfusion rate of 80% in the area of infarct. During follow-up, 75% of patients developed one or more postinfarction ischemic syndrome: angina pectoris (41 Vo), abnormal exercise stress test (55%) congestive heart failure (16%), or reinfarction (10%). In the reperfusion group patients, postinfarction angina pectoris was significantly more common when the residual stenosis was 60070 or greater (p< .05). Of the 41 patients with patent, reperfused coronary arteries, 15 patients underwent PTCA or CABG intervention due to significant angina pectoris despite maximal medical therapy. The remaining 26 patients were adequately controlled medically. The authors concluded that early thrombolytic therapy of acute myocardial infarction salvages myocardium, but leaves the region at risk for further ischemia if the residual stenosis is 60% or greater. Such patients
578
The Journal of Emergency
should undergo intravenous thrombolysis early PTCA or CABG. [Dane Chapman,
with MD]
0 STAB WOUNDS TO THE EXTREMITIES: INDICATIONS FOR ANGIOGRAPHY. Hartling RP, McGahan JP, Blaisdell FW, et al. Radiology 1987; 162:465-467. In this retrospective study, 61 stab wound cases were reviewed. Documented preangiographic physical examinations performed by the chief surgical resident or trauma surgeon were reviewed from patient charts and correlated with angiographic results. Physical findings as an indication for angiography were divided into two groups: major and minor. Major physical findings included:
1. 2. 3. 4. 5.
Diminished or absent pulses Active bleeding or expanding Bruit or murmur Isolated neurologic deficit Hypotension.
Minor physical findings
hematoma
included:
1. Proximity to major vessel 2. Nonexpanding hematoma.
Patients with overt injuries or hemodynamic instability were taken directly to surgery without angiography. Follow-up clinical exams were performed in 47 patients one week to several years post injury. Of the 61 stab wounds, major physical findings were present in 25 (47%) patients. Arteriograms of 11 of these 25 wounds demonstrated significant vascular injuries, and patients were taken to surgery. Nine angiograms were completely normal. Four demonstrated diminished flow, extrinsic mass effects from hematoma, mild spasm, or clinically insignificant extravasation. Thirty-six (59%) of the injuries had minor physical findings. In 31 of these, angiograms were completely normal. Five showed abnormalities of mild spasm, pressure from adjacent hematoma or occlusion of peripheral vessels. The authors conclude that arteriography is unwarranted in stab wounds to the extremities if the only indications are proximity of injury or nonexpanding hematoma. [Jeffrey Schaider, MD]
Medicine
0 EFFICACY OF AMOXICILLIN WITH AND WITHOUT DECONGESTANT-ANTIHISTAMINE FOR OTITIS MEDIA WITH EFFUSION IN CHILDREN. Mandel, EM, Rockette HE, Bluestone CD, et al. N Engl J A4ed 1987; 316:432-437. This randomized, prospective study compared the efficacy of two weeks of amoxicillin with four weeks of a decongestant-antihistamine in the treatment of serous otitis media in children against amoxicillin without a decongestant-antihistamine and a control group receiving two placebos. After two and four weeks of treatment, children treated with amoxicillin had significantly better resolution. The use of a decongestant-antihistamine did not affect the result. Among subjects who had effusion at two weeks, there was a higher rate of cure at four weeks in the amoxicillin treated groups than in the control group, even though the amoxicillin was taken for only two weeks. Effusion resolution at four weeks was greater if the effusion had been present for less than eight weeks or the patient did not have an upper respiratory tract infection at the beginning of the study. The authors conclude that amoxicillin speeds serous otitis media resolution in children, whereas decongestant-antihistamines are of no benefit. [John Neufeld, MD]
0 EFFECT OF THE CONTRACEPTIVE SPONGE ON CHLAMYDIAL INFECTION, GONORRHEA, AND CANDIDIASIS. Rosenberg MJ, Rojanapithayakorn W, Feldblum PJ, et al. JAMA 1987; 257:2308-2312. To investigate the effect of nonoxynal impregnated contraceptive sponge on the incidence of chlamydia, gonococcal and Candida infection, the authors conducted a randomized, comparative clinical study for three months using the sponge in a high-risk population of prostitutes in Bangkok. All subjects were healthy, nongravid, using reliable nonbarrier contraception, keeping weekly coital logs. There were 149 women in the sponge user group, 163 in the nonuser. After six weeks, the groups were crossed over, allowing each subject to be her own control. Endocervical cultures for N. gonorrhea and vaginal fluid for chlamydia and Candida were collected weekly. Chlamydia infection was most frequent, to-
u CAUSTIC INGESTION AND ITS SEQUELAE IN CHILDREN. Moazam F, Talbert JL, Miller D, et al. South Med J 1987; 80:187-190. Medical records of 56 children admitted over an 1l-year period with the diagnosis of caustic ingestions were reviewed to determine esophageal disorders resulting from caustic ingestion. Patient ages ranged from ten months to five years. Diagnostic endoscopy was performed promptly and steroids and antibiotics were administered immediately and continued if esophageal burns were demonstrated. The authors found that the strength and composition of the material was the most important determinant in the depth of the esophageal injury. Strong alkali were significantly more destructive than strong acids. Ingestions containing lye, in this study, were particularly corrosive. In the presence of full thickness esophageal burns, there remained a high potential for stricture formation regardless of the form of intial therapy. Once esophageal stricture had formed, only a relatively small number responded to esophageal dilation. The authors note that multiple esophageal strictures also seldom respond to dilation. They recommend early esophageal replacement with interposition of the colon to decrease morbidity. [Jeffrey Schaider, MD] Editor’s Note: An ounce of prevention is worth a pound of cure. Poisoning prevention education begins in the pediatrician’s office; but is reinforced in the emergency department.
0 CLINICAL SUMMARY AND COURSE OF IDIOPATHIC ANAPHYLAXIS IN 73 PATIENTS. Boxer M, Greenberger PA, Patterson R. Arch Int Med 1987; 147:269-272. The authors studied 73 patients with idiopathic anaphylaxis. The natural history is as follows: 52% have infrequent reactions (defined as one episode only or mild episodes less than six times per year) requiring acute treatment, and 48% have severe or frequent lifethreatening reactions requiring therapy with maintenance antihistamines and prednisone. Of the patients with single or infrequent episodes, there is an excellent prognosis with acute treatment alone: 50% remain in remission (without therapy); 34% do not experience anaphylaxis, but do have infrequent episodes of angioedema, urticaria, or both; and 16%
577
have been asymptomatic for less than one year. Of the patients with severe or life-threatening reactions, the course is variable: 13% require maintenance prednisone above a critical dose to avoid anaphylaxis; 23% remain in remission (following a treatment period of several years); 20% do not experience anaphylaxis, but do have infrequent episodes of angioedema, urticaria, or both (following a treatment period of several years); and 43% have been asymptomatic for less than one year or are currently undergoing tapering doses of prednisone. No fatalities occurred in 224 patient-years of follow [David W. Steedle, MD] UP. Editor’s Note: Idiopathic anaphylaxis can be extremely frightening, especially since no inciting source can be found. This article emphasizes that the prognosis is favorable in most cases and that long term therapy can be effective.
0 EARLY TREATMENT OF ACUTE MYOCARDIAL INFARCTION WITH INTRAVENOUS STREPTKOINASE. Koren G, Luria MH, Weiss AT, et al. Arch Inr Med 1987; 145:237-240 Early thrombolytic therapy of acute myocardial infarction was evaluated during a threemonth follow-up period in 51 successive patients treated with intravenous streptokinase 1.7 kO.8 hours after onset of symptoms. Coronary angiography was performed four to nine days after onset of symptoms revealing a reperfusion rate of 80% in the area of infarct. During follow-up, 75% of patients developed one or more postinfarction ischemic syndrome: angina pectoris (41 Vo), abnormal exercise stress test (55%) congestive heart failure (16%), or reinfarction (10%). In the reperfusion group patients, postinfarction angina pectoris was significantly more common when the residual stenosis was 60070 or greater (p< .05). Of the 41 patients with patent, reperfused coronary arteries, 15 patients underwent PTCA or CABG intervention due to significant angina pectoris despite maximal medical therapy. The remaining 26 patients were adequately controlled medically. The authors concluded that early thrombolytic therapy of acute myocardial infarction salvages myocardium, but leaves the region at risk for further ischemia if the residual stenosis is 60% or greater. Such patients
578
The Journal of Emergency
should undergo intravenous thrombolysis early PTCA or CABG. [Dane Chapman,
with MD]
0 STAB WOUNDS TO THE EXTREMITIES: INDICATIONS FOR ANGIOGRAPHY. Hartling RP, McGahan JP, Blaisdell FW, et al. Radiology 1987; 162:465-467. In this retrospective study, 61 stab wound cases were reviewed. Documented preangiographic physical examinations performed by the chief surgical resident or trauma surgeon were reviewed from patient charts and correlated with angiographic results. Physical findings as an indication for angiography were divided into two groups: major and minor. Major physical findings included:
1. 2. 3. 4. 5.
Diminished or absent pulses Active bleeding or expanding Bruit or murmur Isolated neurologic deficit Hypotension.
Minor physical findings
hematoma
included:
1. Proximity to major vessel 2. Nonexpanding hematoma.
Patients with overt injuries or hemodynamic instability were taken directly to surgery without angiography. Follow-up clinical exams were performed in 47 patients one week to several years post injury. Of the 61 stab wounds, major physical findings were present in 25 (47%) patients. Arteriograms of 11 of these 25 wounds demonstrated significant vascular injuries, and patients were taken to surgery. Nine angiograms were completely normal. Four demonstrated diminished flow, extrinsic mass effects from hematoma, mild spasm, or clinically insignificant extravasation. Thirty-six (59%) of the injuries had minor physical findings. In 31 of these, angiograms were completely normal. Five showed abnormalities of mild spasm, pressure from adjacent hematoma or occlusion of peripheral vessels. The authors conclude that arteriography is unwarranted in stab wounds to the extremities if the only indications are proximity of injury or nonexpanding hematoma. [Jeffrey Schaider, MD]
Medicine
0 EFFICACY OF AMOXICILLIN WITH AND WITHOUT DECONGESTANT-ANTIHISTAMINE FOR OTITIS MEDIA WITH EFFUSION IN CHILDREN. Mandel, EM, Rockette HE, Bluestone CD, et al. N Engl J A4ed 1987; 316:432-437. This randomized, prospective study compared the efficacy of two weeks of amoxicillin with four weeks of a decongestant-antihistamine in the treatment of serous otitis media in children against amoxicillin without a decongestant-antihistamine and a control group receiving two placebos. After two and four weeks of treatment, children treated with amoxicillin had significantly better resolution. The use of a decongestant-antihistamine did not affect the result. Among subjects who had effusion at two weeks, there was a higher rate of cure at four weeks in the amoxicillin treated groups than in the control group, even though the amoxicillin was taken for only two weeks. Effusion resolution at four weeks was greater if the effusion had been present for less than eight weeks or the patient did not have an upper respiratory tract infection at the beginning of the study. The authors conclude that amoxicillin speeds serous otitis media resolution in children, whereas decongestant-antihistamines are of no benefit. [John Neufeld, MD]
0 EFFECT OF THE CONTRACEPTIVE SPONGE ON CHLAMYDIAL INFECTION, GONORRHEA, AND CANDIDIASIS. Rosenberg MJ, Rojanapithayakorn W, Feldblum PJ, et al. JAMA 1987; 257:2308-2312. To investigate the effect of nonoxynal impregnated contraceptive sponge on the incidence of chlamydia, gonococcal and Candida infection, the authors conducted a randomized, comparative clinical study for three months using the sponge in a high-risk population of prostitutes in Bangkok. All subjects were healthy, nongravid, using reliable nonbarrier contraception, keeping weekly coital logs. There were 149 women in the sponge user group, 163 in the nonuser. After six weeks, the groups were crossed over, allowing each subject to be her own control. Endocervical cultures for N. gonorrhea and vaginal fluid for chlamydia and Candida were collected weekly. Chlamydia infection was most frequent, to-