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Oral indomethacin for acute renal colic
Abstracts
voluntary and initiated through dispensing pharmacies. Objectives of the study included assessment of allergic responses, adverse events, clinical response, and characterization of patients and toxic states treated with Digibind. Data on 717 patients was collected from 487 hospitals, or an estimated 15% of all treatments that occurred during the study period. Most patients were over 70 years of age and were on maintenance dosing of digitalis for an underlying cardiovascular disorder. Of the 717 patients, 50% were reported to have a complete response to treatment, 24% a partial response, 12% no response, and 14% uncertain response. Posttreatment adverse events occurred among 215 patients; in only 52 cases were these attributed to Digibind administration. A total of 171, or 24% of patients, died within 3 weeks of treatment; none of the deaths were considered to be due to the administration of Digibind. Twenty patients experienced recrudescent toxicity which was significantly associated with administration of <50% of the total calculated antibody dose. Six patients experienced possible allergic reactions. [Merle Miller, MD] Editor’s Note: Although this study makes significant additions to the knowledge of digitalis toxicity and its treatment, limitations of this study include a retrospective, observational design, the lack of a control group, possible reporting biases, and possible conflicts of interest.
0 ORAL INDOMETHACIN FOR ACUTE RENAL COLIC. Wolfson AB, Yealy DM. Am J Emerg Med. 1991; 9:16-19. Oral indomethacin was administered to 35 patients in a preliminary prospective study of the efficacy of this agent for renal colic. Adult emergency department patients with signs and symptoms of uncomplicated renal colic who were not vomiting and had no contraindications to nonsteroidal antiinflammatory drugs were eligible for the study. A stone was documented in 25 of the 35 patients who received indomethacin. Pain intensity before and after treatment was reported using a l-to-10 scale and patients were contacted by telephone 3 to 7 days after discharge for follow-up. Eleven patients received indomethacin after oral or parenteral narcotics had failed to provide pain relief and they reported a decrease in pain from a mean of 5.8 ? 2.7 to 3.6 +- 3.8 (P < 0.02). Six patients were considered “responders,” reporting a 50% or greater decrease in pain (in 25 + 8 min). Fourteen other patients, to whom indomethacin was given as the only initial treatment, reported a decrease in mean pain scores from 7.6 ? 1.5 to 4.6 +- 4.0 (P < 0.008). Eight of 14 reported 50% or greater decrease in pain (in 40 + 11 min). One patient reported vomiting after receiving the medication. The responders (14 of 25 patients, or 56%) were discharged on oral indomethacin. At follow-up, 3 patients had taken additional doses for recurrent pain; one had returned to see a physician for pain control. The authors suggest that by initiating prostaglandins, indomethacin may interrupt the physiologic mechanism of renal colic pain; they point out the need for prospective controlled double-blind studies to confirm its efficacy. [Merle Miller MD] Editor’s Note: This study is limited by the small number of patients and does not consider the possibility of placebo effect. Nonetheless, indomethacin would be a significant addition to the treatment options for renal colic, allowing analgesia without narcotic side effects.
537
0 METERED DOSE INHALER AEROSOL CHARACTERISTICS ARE AFFECTED BY THE ENDOTRACHEAL TUBE ACTUATOR/ADAPTOR USED. Bishop MJ, Larson RP, Buschman DL. Anesthesiology. 1990;73: 1263-5. To minimize interference with ventilator mechanics and cost of equipment, delivery of aerosolized bronchodilators via endotrachael tubes (ETT) has moved from use of small-volume nebulizers to metered-dose inhalers (MDI). This has required modified MD1 actuator/adapters fit to the ETT-ventilator circuit. Three different EIT actuator/adapters were used to deliver metered doses of metaproterenol to a scattering aerosol laser spectrometer, which measured delivered particle volumes and calculated particle sizes. Comparison was made with particles from a conventional oral MDI; all systems were tested with multiple canisters of metaproterenol, to prevent skewing of data. The authors found that ETT adapters delivered only from 11% to 66% of the volume of aerosol particles in the “respiratory size range” (1 .O to 5.1 p,m) delivered by the conventional MDIU. Further, ETT actuator/adapter systems delivered virtually no particles in the > 5+m range, while conventional MDIs delivered the majority of their doses in this range. The authors note that even under ideal conditions, nonintubated patients received the majority of their MD1 dosages by absorption of large aerosol particles (greater than 5pm) from the oropharyngeal mucosa, with perhaps 20% of the drug being deposited in the lung in respiratory-sized particles. As ETI’ actuator/adaptors deliver little or no drug in these ranges, the authors conclude that current E’M actuator/adaptors may deliver markedly less drug to the patient than is delivered to the nonintubated patient with MDIs; by implication, adjustment of drug dosages (with careful monitoring) may be necessary. [W.S. Emoehazy, Jr., MD] Editor’s Note: Less isn’t always more. This study is particularly troublesome, as critically ill, intubated asthmatics or COPD sufferers are the ones who really need their bronchodilators.
0 FATAL OCCUPATIONAL ELECTRICAL INJURIES IN VIRGINIA. J Occup Med. 1991;33:57-62. Unintentional injury is the 4th leading cause of death in the United States; a significant number of these deaths occur at the work place. Electrical injuries account for a considerable number of injuries and fatalities. This retrospective study reviewed electrical injuries and fatalities in Virginia from 1977 to 1985. Of the 277 electrical deaths recorded, 186 were occupational electrical deaths, 179 were electric shock fatalities, and 7 were lightning fatalities. The mean yearly death rate was 0.9/100,000 workers/year; 65% died between the months of May and September. Of these accidental electrocutions, 50% resulted from power line contact (53%) and machine tool usage or repair (22%). Death rate for industryspecific groups were highest at 10/100,000 for utility workers, 5.9/100,000 for mining, and 3.9/100,000 for construction workers. Only 1.5% of the workers who died were legally intoxicated. The study concluded that major protective measures are needed to prevent occupational electrical injuries and deaths. They should include specific educational programs to workers throughout the year, with specific efforts
voluntary and initiated through dispensing pharmacies. Objectives of the study included assessment of allergic responses, adverse events, clinical response, and characterization of patients and toxic states treated with Digibind. Data on 717 patients was collected from 487 hospitals, or an estimated 15% of all treatments that occurred during the study period. Most patients were over 70 years of age and were on maintenance dosing of digitalis for an underlying cardiovascular disorder. Of the 717 patients, 50% were reported to have a complete response to treatment, 24% a partial response, 12% no response, and 14% uncertain response. Posttreatment adverse events occurred among 215 patients; in only 52 cases were these attributed to Digibind administration. A total of 171, or 24% of patients, died within 3 weeks of treatment; none of the deaths were considered to be due to the administration of Digibind. Twenty patients experienced recrudescent toxicity which was significantly associated with administration of <50% of the total calculated antibody dose. Six patients experienced possible allergic reactions. [Merle Miller, MD] Editor’s Note: Although this study makes significant additions to the knowledge of digitalis toxicity and its treatment, limitations of this study include a retrospective, observational design, the lack of a control group, possible reporting biases, and possible conflicts of interest.
0 ORAL INDOMETHACIN FOR ACUTE RENAL COLIC. Wolfson AB, Yealy DM. Am J Emerg Med. 1991; 9:16-19. Oral indomethacin was administered to 35 patients in a preliminary prospective study of the efficacy of this agent for renal colic. Adult emergency department patients with signs and symptoms of uncomplicated renal colic who were not vomiting and had no contraindications to nonsteroidal antiinflammatory drugs were eligible for the study. A stone was documented in 25 of the 35 patients who received indomethacin. Pain intensity before and after treatment was reported using a l-to-10 scale and patients were contacted by telephone 3 to 7 days after discharge for follow-up. Eleven patients received indomethacin after oral or parenteral narcotics had failed to provide pain relief and they reported a decrease in pain from a mean of 5.8 ? 2.7 to 3.6 +- 3.8 (P < 0.02). Six patients were considered “responders,” reporting a 50% or greater decrease in pain (in 25 + 8 min). Fourteen other patients, to whom indomethacin was given as the only initial treatment, reported a decrease in mean pain scores from 7.6 ? 1.5 to 4.6 +- 4.0 (P < 0.008). Eight of 14 reported 50% or greater decrease in pain (in 40 + 11 min). One patient reported vomiting after receiving the medication. The responders (14 of 25 patients, or 56%) were discharged on oral indomethacin. At follow-up, 3 patients had taken additional doses for recurrent pain; one had returned to see a physician for pain control. The authors suggest that by initiating prostaglandins, indomethacin may interrupt the physiologic mechanism of renal colic pain; they point out the need for prospective controlled double-blind studies to confirm its efficacy. [Merle Miller MD] Editor’s Note: This study is limited by the small number of patients and does not consider the possibility of placebo effect. Nonetheless, indomethacin would be a significant addition to the treatment options for renal colic, allowing analgesia without narcotic side effects.
537
0 METERED DOSE INHALER AEROSOL CHARACTERISTICS ARE AFFECTED BY THE ENDOTRACHEAL TUBE ACTUATOR/ADAPTOR USED. Bishop MJ, Larson RP, Buschman DL. Anesthesiology. 1990;73: 1263-5. To minimize interference with ventilator mechanics and cost of equipment, delivery of aerosolized bronchodilators via endotrachael tubes (ETT) has moved from use of small-volume nebulizers to metered-dose inhalers (MDI). This has required modified MD1 actuator/adapters fit to the ETT-ventilator circuit. Three different EIT actuator/adapters were used to deliver metered doses of metaproterenol to a scattering aerosol laser spectrometer, which measured delivered particle volumes and calculated particle sizes. Comparison was made with particles from a conventional oral MDI; all systems were tested with multiple canisters of metaproterenol, to prevent skewing of data. The authors found that ETT adapters delivered only from 11% to 66% of the volume of aerosol particles in the “respiratory size range” (1 .O to 5.1 p,m) delivered by the conventional MDIU. Further, ETT actuator/adapter systems delivered virtually no particles in the > 5+m range, while conventional MDIs delivered the majority of their doses in this range. The authors note that even under ideal conditions, nonintubated patients received the majority of their MD1 dosages by absorption of large aerosol particles (greater than 5pm) from the oropharyngeal mucosa, with perhaps 20% of the drug being deposited in the lung in respiratory-sized particles. As ETI’ actuator/adaptors deliver little or no drug in these ranges, the authors conclude that current E’M actuator/adaptors may deliver markedly less drug to the patient than is delivered to the nonintubated patient with MDIs; by implication, adjustment of drug dosages (with careful monitoring) may be necessary. [W.S. Emoehazy, Jr., MD] Editor’s Note: Less isn’t always more. This study is particularly troublesome, as critically ill, intubated asthmatics or COPD sufferers are the ones who really need their bronchodilators.
0 FATAL OCCUPATIONAL ELECTRICAL INJURIES IN VIRGINIA. J Occup Med. 1991;33:57-62. Unintentional injury is the 4th leading cause of death in the United States; a significant number of these deaths occur at the work place. Electrical injuries account for a considerable number of injuries and fatalities. This retrospective study reviewed electrical injuries and fatalities in Virginia from 1977 to 1985. Of the 277 electrical deaths recorded, 186 were occupational electrical deaths, 179 were electric shock fatalities, and 7 were lightning fatalities. The mean yearly death rate was 0.9/100,000 workers/year; 65% died between the months of May and September. Of these accidental electrocutions, 50% resulted from power line contact (53%) and machine tool usage or repair (22%). Death rate for industryspecific groups were highest at 10/100,000 for utility workers, 5.9/100,000 for mining, and 3.9/100,000 for construction workers. Only 1.5% of the workers who died were legally intoxicated. The study concluded that major protective measures are needed to prevent occupational electrical injuries and deaths. They should include specific educational programs to workers throughout the year, with specific efforts