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Low mortality in burned patients in a pseudomonas vaccine trial
catheterization using quadripolar electrode catheters positioned in the r i g h t atrial coronary sinus and right ventricular apex. After control m e a s u r e m e n t s , tocainide was given by Imed pump at doses of 0.5, 0.75 or 1.0 mg/kg per min for 15 minutes. Plasma levels of tocainide 15 minutes after initiation of tocainide varied from 1.2 to 11.4 mg/ml. Tocainide did not cause side effects or significant changes in h e a r t rate, blood pressure, P-R interval, QRS duration or Q-T interval. There was no statistically significant change in sinus node and corrected sinus node recovery times, intraarterial conduction, effective refractory period of the atrium, A-V node refractory period, H-V interval, or the effective refractory period of the right ventricle following tocainide infusion. Tocainide is an orally active a n t i a r r h y t h m i a congener of lidocaine that, at therapeutic concentrations, has no significant detrimental electrophysiologic effects on the myocardium of patients with coronary artery disease. (Editor's note: The importance of tocainide is that it is a lidocaine congener with similar action that can be given orally.)
peritoneal fluid. Of the isolated peritoneal bacteria in all sub'ects, 70% w e r e a n a e r o b e s . The a u t h o r s conclude t h a t naerobic bacteria are involved in m a n y cases of PID, t h o u g h most of these infections are initiated by N gonorrhoeae. They suggest t h a t growth of nongonococcal bacteria creates a hostile environment for the more fragile N gonorrhoeae and t h u s ~ongonococcal bacteria supercede gonorrhea as a secondary invader. Technical difficulties in culturing N Gonorrhoeae from women with polymicrobial flora may lead to failure to identify this organism more frequently. (Editor's note: This stttcly confirms the polymicrobial nature of PID and the frequent involvement of anaerobes. Most strains o f N gonorrhoeae and most anaerobes remain sensitive to penicillins. There is no reason to change standard antibiotic therapy to clindamycin because of the involvement of anaerobes.)
~
Betsy Pepper, MD
adnexitis
Steven Koenigsknecht, MD
Early intraaortic balloon pumping for anterior myocardial infarction without shock. Leinbach RC, Gold HK, Harper RW, et al, Circulation 58:204-210, (Aug)
antiarrhythmia agents
1978.
Low mortality in burned patients in a pseudomonas vaccine trial, Jones RJ, Roe EA, Gupta JL, Lancet
Eleven patients with anterior myocardial infarction less t h a n six hours old u n d e r w e n t intraaortic balloon pumping (IABP) in an effort to control injury. Direct hemodynamic measurements excluded shock. There was no pulmonary edema. Response to therapy was judged individually by comparison to a one hour p r e t r e a t m e n t period. There was no parallel control group. Five patients (45%) responded favorably with rapid resolution of chest pain, an 84% fall in ST elevation in one hour, preservation of precardial R waves, modest development of new Q waves, and normal left ventricular ejection fractions following circulatory assist. All five patients have survived for a substantial period of time following discharge without subsequent coronary events or angina. In contrast, six patients responded poorly with no immediate resolution of ST segment elevations, more p r o m i n e n t Q waves development, much higher serum creatine phosphokinase isoenzyme values, abnormal ejection fractions with prominent disorders of ventricular regional contractions. Two of these patients died within a year from coronary events, two have a n g i n a and one is symptomatic from poor left ventricular function. Coronary angiography demonstrated a.significant correlation between response and presence or absence of complete left anterior descending coronary artery occlusion. The authors conclude the early use of IABP in p a t i e n t s with anterior myocardial infarction may interrupt injury although apparently only in patients with less t h a n total occlusion of the left anterior descending coronary artery. (Editor's note: On the other hand, the five responders may have done well anyway. I n the absence of controls, we withhold any conclusions on this study.) Solomon Hockbaum, MD
2:401-403, (Aug) 1978. Burn patients in New Delhi, India have frequent episodes of pseudomonas sepsis. In an a t t e m p t to control this infection, a polyvalent vaccine against pseudomonas was administered to patients w i t h i n 72 hours of t h e i r burns. Adults with 15% to 50% full thickness b u r n s and children with 5% to 30% full thickness b u r n s were alternately placed in vaccinated (18 pat i e n t s ) a n d u n v a c c i n a t e d groups (20 patients). The two groups were similar in age, weight, and percent burn. None of the 18 vaccinated p a t i e n t s died but 8 of the 20 unvaccinated patients died and h a d blood cultures positive for gram negative organisms - - three with pseudomonas. These data imply t h a t the vaccine induces a n early nonspecific protection a g a i n s t gram negative infection. (Editor's note: It is tempting to relate the improved survival of the vaccinated group to the vaccine. However, only three of the eight that died in the control group had cultures positive for pseudomonas. The remaining five died o f other causes.)
Barry Brenner, PhD, MD pseudomonas infections, burns Coma in the Wernicke-Korsakoff syndrome. Wallis WE, Willoughby E, Baker P, Lancet 2:400-401, (Aug) 1978. Four patients in coma with Wernicke-Korsakoff syndrome, an unusual cause of coma, are described. Three of the four went into coma after being fed without vitamin or t h i a m i n e supplements. Upon i n s t i t u t i o n of v i t a m i n s and t h i a m i n e , m e n t a l function improved markedly from 0.5 to 72 hours. Wernicke-Korsakoff syndrome deserves wider recognition as a cause of coma. Alcoholics with unknown causes of coma should be treated empirically with intravenous t h i a m i n e a n d vitamins. (Editor's note: Despite initial improvement after the institution o f vitamin therapy, three of the four patients died of thiamine deficiency - clearly a case o f iatrogenic mortality due to lack of meticulouscare.) Barry Brenner, PbD, MD
myocardial infarction, assisted circulation Human electropharmacology of tocainide, a lido¢aine congener. Horowitz LN, Josephson ME, Farshidi A, Am J Cardiol 42:276-280, (Aug) 1978. A prospective study documents electrophysiologic changes with therapeutic blood levels of tocainide. Ten patients with documented coronary artery" disease u n d e r w e n t right .heart
8:7 (July) 1979
Wernicke-Korsakoff syndrome, coma
JACEP
295/79
peritoneal fluid. Of the isolated peritoneal bacteria in all sub'ects, 70% w e r e a n a e r o b e s . The a u t h o r s conclude t h a t naerobic bacteria are involved in m a n y cases of PID, t h o u g h most of these infections are initiated by N gonorrhoeae. They suggest t h a t growth of nongonococcal bacteria creates a hostile environment for the more fragile N gonorrhoeae and t h u s ~ongonococcal bacteria supercede gonorrhea as a secondary invader. Technical difficulties in culturing N Gonorrhoeae from women with polymicrobial flora may lead to failure to identify this organism more frequently. (Editor's note: This stttcly confirms the polymicrobial nature of PID and the frequent involvement of anaerobes. Most strains o f N gonorrhoeae and most anaerobes remain sensitive to penicillins. There is no reason to change standard antibiotic therapy to clindamycin because of the involvement of anaerobes.)
~
Betsy Pepper, MD
adnexitis
Steven Koenigsknecht, MD
Early intraaortic balloon pumping for anterior myocardial infarction without shock. Leinbach RC, Gold HK, Harper RW, et al, Circulation 58:204-210, (Aug)
antiarrhythmia agents
1978.
Low mortality in burned patients in a pseudomonas vaccine trial, Jones RJ, Roe EA, Gupta JL, Lancet
Eleven patients with anterior myocardial infarction less t h a n six hours old u n d e r w e n t intraaortic balloon pumping (IABP) in an effort to control injury. Direct hemodynamic measurements excluded shock. There was no pulmonary edema. Response to therapy was judged individually by comparison to a one hour p r e t r e a t m e n t period. There was no parallel control group. Five patients (45%) responded favorably with rapid resolution of chest pain, an 84% fall in ST elevation in one hour, preservation of precardial R waves, modest development of new Q waves, and normal left ventricular ejection fractions following circulatory assist. All five patients have survived for a substantial period of time following discharge without subsequent coronary events or angina. In contrast, six patients responded poorly with no immediate resolution of ST segment elevations, more p r o m i n e n t Q waves development, much higher serum creatine phosphokinase isoenzyme values, abnormal ejection fractions with prominent disorders of ventricular regional contractions. Two of these patients died within a year from coronary events, two have a n g i n a and one is symptomatic from poor left ventricular function. Coronary angiography demonstrated a.significant correlation between response and presence or absence of complete left anterior descending coronary artery occlusion. The authors conclude the early use of IABP in p a t i e n t s with anterior myocardial infarction may interrupt injury although apparently only in patients with less t h a n total occlusion of the left anterior descending coronary artery. (Editor's note: On the other hand, the five responders may have done well anyway. I n the absence of controls, we withhold any conclusions on this study.) Solomon Hockbaum, MD
2:401-403, (Aug) 1978. Burn patients in New Delhi, India have frequent episodes of pseudomonas sepsis. In an a t t e m p t to control this infection, a polyvalent vaccine against pseudomonas was administered to patients w i t h i n 72 hours of t h e i r burns. Adults with 15% to 50% full thickness b u r n s and children with 5% to 30% full thickness b u r n s were alternately placed in vaccinated (18 pat i e n t s ) a n d u n v a c c i n a t e d groups (20 patients). The two groups were similar in age, weight, and percent burn. None of the 18 vaccinated p a t i e n t s died but 8 of the 20 unvaccinated patients died and h a d blood cultures positive for gram negative organisms - - three with pseudomonas. These data imply t h a t the vaccine induces a n early nonspecific protection a g a i n s t gram negative infection. (Editor's note: It is tempting to relate the improved survival of the vaccinated group to the vaccine. However, only three of the eight that died in the control group had cultures positive for pseudomonas. The remaining five died o f other causes.)
Barry Brenner, PhD, MD pseudomonas infections, burns Coma in the Wernicke-Korsakoff syndrome. Wallis WE, Willoughby E, Baker P, Lancet 2:400-401, (Aug) 1978. Four patients in coma with Wernicke-Korsakoff syndrome, an unusual cause of coma, are described. Three of the four went into coma after being fed without vitamin or t h i a m i n e supplements. Upon i n s t i t u t i o n of v i t a m i n s and t h i a m i n e , m e n t a l function improved markedly from 0.5 to 72 hours. Wernicke-Korsakoff syndrome deserves wider recognition as a cause of coma. Alcoholics with unknown causes of coma should be treated empirically with intravenous t h i a m i n e a n d vitamins. (Editor's note: Despite initial improvement after the institution o f vitamin therapy, three of the four patients died of thiamine deficiency - clearly a case o f iatrogenic mortality due to lack of meticulouscare.) Barry Brenner, PbD, MD
myocardial infarction, assisted circulation Human electropharmacology of tocainide, a lido¢aine congener. Horowitz LN, Josephson ME, Farshidi A, Am J Cardiol 42:276-280, (Aug) 1978. A prospective study documents electrophysiologic changes with therapeutic blood levels of tocainide. Ten patients with documented coronary artery" disease u n d e r w e n t right .heart
8:7 (July) 1979
Wernicke-Korsakoff syndrome, coma
JACEP
295/79