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Intraocular pressure elevation after pupillary dilation in open angle glaucoma
pression. When compared with diazepam, the authors conclude that lorazepam is an effective antiseizure medication with longer duration of action and significantly less cardiorespiratory depression. Preliminary data from this study indicate that lorazepam is a safe and efficacious adjunct to conventional anticonvulsant drug therapy in the management of neonatal seizures. A prospective, controlled study between two benzodiazepines is recommended by [John Neufeld, MD] the investigators. Editor’s Note: Lorazepam has an obvious advantage over diazepam in situations where ventilatory assistance for the patient is suboptimal.
EFFECTIVENESS OF q COST CULTURING FOR CHLAMYDZA TRACHOMAZ’ZS. Nettleman MD, Jones RB, Roberts SD, et al. Ann Intern Med 1986; 105:189-196. The authors evaluated the cost effectiveness of using cell culture to test for chlamydial infection in a clinic for sexually transmitted diseases. The authors divided patients into lowand high-risk groups. The high-risk group included patients with probable gonorrhea, sexual contact with persons with gonorrhea, or non gonococcal urethritis, salpingitis, or cervicitis on physical examination. Using decision analysis, the authors assigned various sensitivities of Chlamydia cell culture depending on site of culture: for example, endourethral culture in males was 90% sensitive; endocervical culture alone, 68%; and endocervical and endourethral cultures in women were 88%. Analysis and review of 9,979 patient encountered (59% men, 41% women) at the inner city clinic for sexually transmitted diseases lead the authors to conclude that the most cost-effective strategy would be to treat all patients presenting to that clinic for presumed chlamydial infection without cell culture. The second most cost-effective strategy would be to empirically treat all those at high risk (as defined) and to culture all the low-risk patients, treating those who had positive cultures. Recognizing potential problems with the indiscriminate use of tetracycline therapy, the authors favor the second approach. They state that the availability of the rapid immunofluorescent antibody tests for Chlamydia do not change the implication of this study as the sensitivity and specificity of the rapid tests do not exceed that of cell culture. [Charles McKay Jr, MD] Editor’s Note: Unfortunately, the natural history of this diseaseuntreated is not clear. It is hard to argue against symptomatic improvement sustained by routine treatment, but this will increase tetracycline resistance, and what the consequencesof that will be, is not clear.
0 A RANDOMIZED COMPARISON OF NIFEDIPINE AND SODIUM NITROPRUSSIDE IN SEVERE HYPERTENSION. Franklin C, Nightingale S, Mandani B. Chest 1986; 90:500-503. Fifteen patients with diastolic blood pressures sustained over 130 mm Hg and eye ground changes were prospectively randomized to either oral nifedipine (ten patients) or intravenous sodium nitroprusside (five patients) for treatment in a medical intensive care unit setting. They were compared with five historical controls treated with sodium nitroprusside. Patients with aortic dissection, neurologic changes, and myocardial infarction were excluded. All three groups were comparable in terms of systolic and diastolic blood pressure at admission. The length of time necessaryto lower the diastolic blood pressureto 5 120 mm Hg was 4.5h4.5 hours for nifedipine versus 14.2 f 12.6 hours for nitroprusside (P< .05). The average dose of nifedipine necessaryto reduce the blood pressurewas 20 mg (range 10 to 50 mg). There were no fatalities in either group and only one incidence of transient hypotension in a nitroprusside-treated patient. The authors state that nifedipine is a cheap and effective alternative to nitroprusside in selected patients with hypertensive emergencies. [Nicholas J. Jouriles, MD] Editor’s Note: Use of oral or sublingual nifedipine for initiating treatment of selected patients with hypertensive crisis in the emer- 0 INTRAOCULAR PRESSURE ELEVAgency department is a convenient, cheaper, and TION AFTER PUPILLARY DILATION IN efficient alternative to nitroprusside infusion. OPEN ANGLE GLAUCOMA. Shaw RB, 1986; 104:1185Close monitoring is warranted regardlessof the Lews AR. Arch Opthamol therapeutic modality. 1188.
344
This is a retrospective study of 60 patients (116 eyes) with primary open-angle glaucoma to assess the frequency and severity of intraocular pressure elevation following dilation with 2.5% neosynephrine and 1% tropicamide. The patients included 28 men and 32 women. Fifty-three patients (103 eyes)were receiving some topical medication, that is, 58 eyeswere receiving miotic therapy. Eighty-three eyes were receiving timolol; 40 eyes, adrenergic; and 28 eyes, carbonic anhydrase inhibitor. The change in intraocular pressure after dilation (one hour later) ranged from - 6 to + 22 mm Hg. Intraocular pressure was elevated in 69 eyes(60%) and decreased in 34 eyes(30%). Thirty-seven eyes (32%) had a mild pressure elevation of 5 mm Hg or more; 14 eyes(12%) had moderate pressure elevation of 10 mm Hg or greater; and two eyes(2010)had pressure elevation of 20 mm Hg or more. The evidence supports that there is a potential hazard of routine dilation of eyes with open-angle glaucoma. [Nguyen Vo, MD]
0 BICARBONATE THERAPY IN SEVERE DIABETIC KETOACIDOSIS. Morris LR, Murphy MB, Kitabchi AE. Ann Intern Med
1986; 105:836-840. The use of sodium bicarbonate in the management of diabetic ketoacidosis is controversial. This prospective randomized trial was designed to determine whether bicarbonate affected the outcome of severe diabetic ketoacidosis. Twenty one patients with an initial pH of 6.9 to 7.14 were randomized to receive intravenous bicarbonate or to serveas controls. Patients with a pH lessthan 6.9 were excluded because the prevailing practice at the author’s institution is to administer bicarbonate to this subset of critically ill diabetics. Treated patients were given between 45 and 134 mEq of bicarbonate, depending on the severity of the, initial pH, over a 30-minute period. All patients received standard intravenous fluid and insulin therapy. There was no significant difference in time to reach a plasma glucose of 250 mg/dL, pH of 7.3, or bicarbonate level of 15 mEq between the two groups. It was concluded that bicarbonate administration has no effect on clinical recovery from severediabetic [R. Scott Israel, MD] ketoacidosis.
The Journal
of Emergency
Medicine
0 PROTON MAGNETIC RESONANCE IMAGING IN ISCHEMIC CEREBROVASCULAR DISEASE. Salgado ED, Furlan AJ, Medic MT, et al. Ann Neural 1986; 20:502-507.
A prospective study of 60 patients with transient ischemic attacks (TIAs) or brain infarction compared proton magnetic resonance imaging (MRI) with high-resolution computed tomography (CT). Eighty-five percent of the CT and MRI scans were done within seven days of each other, and all scans were read by the same neuroradiologist without prior knowledge of the patients’ clinical diagnosis. The authors’ findings were that MRI showed parenchymal changes in 84% of patients with TIAs compared with 42% for CT. Sensitivity of MRI was also found to be higher than that of CT for infarcts, but the differences were not as great. Difficulties found with MRI included findings that could not be correlated to the patient’s history or physical examination. In addition, 23% of patients had CT findings that were not seen on MRI. Inability to distinguish acute hemorrhagic infarcts from non-hemorrhagic ones within two days of onset further limited MRI’s usefulness in making management decisions. The authors conclude that although MRI is more sensitivethan CT in detecting ischemic cerebrovascular lesions, it provided no added advantage in the evaluation and management of patients with acute stroke. [Alan F. Chou, MD]
0 THE NECESSITY OF MANDATORY EXPLORATION OF PENETRATING ZONE II NECK INJURIES. Bishara RA, et al. Surgery
1986; 100:655-658. In this retrospective study, charts of 110 patients who underwent surgical exploration were reviewed to evaluate the necessity of surgical exploration for penetrating wounds of zone II of the neck. Zone I, defined as neck below the sternal notch; zone III, above the angle of the mandible; and zone II is in between. Structures in zone II can be readily identified at operation, and surgical exploration of this zone carries a minimal risk of morbidity. Initial resuscitation measures were taken when appropriate. Patients who were bleeding or in hypovolemic shock underwent surgical exploration immediately. Arteriography was performed selectively in patients (61oio)with stable vital signs.
EFFECTIVENESS OF q COST CULTURING FOR CHLAMYDZA TRACHOMAZ’ZS. Nettleman MD, Jones RB, Roberts SD, et al. Ann Intern Med 1986; 105:189-196. The authors evaluated the cost effectiveness of using cell culture to test for chlamydial infection in a clinic for sexually transmitted diseases. The authors divided patients into lowand high-risk groups. The high-risk group included patients with probable gonorrhea, sexual contact with persons with gonorrhea, or non gonococcal urethritis, salpingitis, or cervicitis on physical examination. Using decision analysis, the authors assigned various sensitivities of Chlamydia cell culture depending on site of culture: for example, endourethral culture in males was 90% sensitive; endocervical culture alone, 68%; and endocervical and endourethral cultures in women were 88%. Analysis and review of 9,979 patient encountered (59% men, 41% women) at the inner city clinic for sexually transmitted diseases lead the authors to conclude that the most cost-effective strategy would be to treat all patients presenting to that clinic for presumed chlamydial infection without cell culture. The second most cost-effective strategy would be to empirically treat all those at high risk (as defined) and to culture all the low-risk patients, treating those who had positive cultures. Recognizing potential problems with the indiscriminate use of tetracycline therapy, the authors favor the second approach. They state that the availability of the rapid immunofluorescent antibody tests for Chlamydia do not change the implication of this study as the sensitivity and specificity of the rapid tests do not exceed that of cell culture. [Charles McKay Jr, MD] Editor’s Note: Unfortunately, the natural history of this diseaseuntreated is not clear. It is hard to argue against symptomatic improvement sustained by routine treatment, but this will increase tetracycline resistance, and what the consequencesof that will be, is not clear.
0 A RANDOMIZED COMPARISON OF NIFEDIPINE AND SODIUM NITROPRUSSIDE IN SEVERE HYPERTENSION. Franklin C, Nightingale S, Mandani B. Chest 1986; 90:500-503. Fifteen patients with diastolic blood pressures sustained over 130 mm Hg and eye ground changes were prospectively randomized to either oral nifedipine (ten patients) or intravenous sodium nitroprusside (five patients) for treatment in a medical intensive care unit setting. They were compared with five historical controls treated with sodium nitroprusside. Patients with aortic dissection, neurologic changes, and myocardial infarction were excluded. All three groups were comparable in terms of systolic and diastolic blood pressure at admission. The length of time necessaryto lower the diastolic blood pressureto 5 120 mm Hg was 4.5h4.5 hours for nifedipine versus 14.2 f 12.6 hours for nitroprusside (P< .05). The average dose of nifedipine necessaryto reduce the blood pressurewas 20 mg (range 10 to 50 mg). There were no fatalities in either group and only one incidence of transient hypotension in a nitroprusside-treated patient. The authors state that nifedipine is a cheap and effective alternative to nitroprusside in selected patients with hypertensive emergencies. [Nicholas J. Jouriles, MD] Editor’s Note: Use of oral or sublingual nifedipine for initiating treatment of selected patients with hypertensive crisis in the emer- 0 INTRAOCULAR PRESSURE ELEVAgency department is a convenient, cheaper, and TION AFTER PUPILLARY DILATION IN efficient alternative to nitroprusside infusion. OPEN ANGLE GLAUCOMA. Shaw RB, 1986; 104:1185Close monitoring is warranted regardlessof the Lews AR. Arch Opthamol therapeutic modality. 1188.
344
This is a retrospective study of 60 patients (116 eyes) with primary open-angle glaucoma to assess the frequency and severity of intraocular pressure elevation following dilation with 2.5% neosynephrine and 1% tropicamide. The patients included 28 men and 32 women. Fifty-three patients (103 eyes)were receiving some topical medication, that is, 58 eyeswere receiving miotic therapy. Eighty-three eyes were receiving timolol; 40 eyes, adrenergic; and 28 eyes, carbonic anhydrase inhibitor. The change in intraocular pressure after dilation (one hour later) ranged from - 6 to + 22 mm Hg. Intraocular pressure was elevated in 69 eyes(60%) and decreased in 34 eyes(30%). Thirty-seven eyes (32%) had a mild pressure elevation of 5 mm Hg or more; 14 eyes(12%) had moderate pressure elevation of 10 mm Hg or greater; and two eyes(2010)had pressure elevation of 20 mm Hg or more. The evidence supports that there is a potential hazard of routine dilation of eyes with open-angle glaucoma. [Nguyen Vo, MD]
0 BICARBONATE THERAPY IN SEVERE DIABETIC KETOACIDOSIS. Morris LR, Murphy MB, Kitabchi AE. Ann Intern Med
1986; 105:836-840. The use of sodium bicarbonate in the management of diabetic ketoacidosis is controversial. This prospective randomized trial was designed to determine whether bicarbonate affected the outcome of severe diabetic ketoacidosis. Twenty one patients with an initial pH of 6.9 to 7.14 were randomized to receive intravenous bicarbonate or to serveas controls. Patients with a pH lessthan 6.9 were excluded because the prevailing practice at the author’s institution is to administer bicarbonate to this subset of critically ill diabetics. Treated patients were given between 45 and 134 mEq of bicarbonate, depending on the severity of the, initial pH, over a 30-minute period. All patients received standard intravenous fluid and insulin therapy. There was no significant difference in time to reach a plasma glucose of 250 mg/dL, pH of 7.3, or bicarbonate level of 15 mEq between the two groups. It was concluded that bicarbonate administration has no effect on clinical recovery from severediabetic [R. Scott Israel, MD] ketoacidosis.
The Journal
of Emergency
Medicine
0 PROTON MAGNETIC RESONANCE IMAGING IN ISCHEMIC CEREBROVASCULAR DISEASE. Salgado ED, Furlan AJ, Medic MT, et al. Ann Neural 1986; 20:502-507.
A prospective study of 60 patients with transient ischemic attacks (TIAs) or brain infarction compared proton magnetic resonance imaging (MRI) with high-resolution computed tomography (CT). Eighty-five percent of the CT and MRI scans were done within seven days of each other, and all scans were read by the same neuroradiologist without prior knowledge of the patients’ clinical diagnosis. The authors’ findings were that MRI showed parenchymal changes in 84% of patients with TIAs compared with 42% for CT. Sensitivity of MRI was also found to be higher than that of CT for infarcts, but the differences were not as great. Difficulties found with MRI included findings that could not be correlated to the patient’s history or physical examination. In addition, 23% of patients had CT findings that were not seen on MRI. Inability to distinguish acute hemorrhagic infarcts from non-hemorrhagic ones within two days of onset further limited MRI’s usefulness in making management decisions. The authors conclude that although MRI is more sensitivethan CT in detecting ischemic cerebrovascular lesions, it provided no added advantage in the evaluation and management of patients with acute stroke. [Alan F. Chou, MD]
0 THE NECESSITY OF MANDATORY EXPLORATION OF PENETRATING ZONE II NECK INJURIES. Bishara RA, et al. Surgery
1986; 100:655-658. In this retrospective study, charts of 110 patients who underwent surgical exploration were reviewed to evaluate the necessity of surgical exploration for penetrating wounds of zone II of the neck. Zone I, defined as neck below the sternal notch; zone III, above the angle of the mandible; and zone II is in between. Structures in zone II can be readily identified at operation, and surgical exploration of this zone carries a minimal risk of morbidity. Initial resuscitation measures were taken when appropriate. Patients who were bleeding or in hypovolemic shock underwent surgical exploration immediately. Arteriography was performed selectively in patients (61oio)with stable vital signs.