- Email: [email protected]
Paraben allergy
,errnination of lead III Q w a v e s
significance.
!iiieln~;:`4~7143M97iA~a~ ~;7~S, HelfantRH:Arch In tern Tl~erelative clinical significance of lead IlI Q waves and the ct o£ inspiration has received added impetus after the finding elseo waves have predictive value for coronary artery disease ~d asynergy- The effect of deep inspiration on Q waves in leads i][ SBd a V F in 31 patients was studied and correlated with the ~Aings at cardiac catheterization. It was found t h a t phasic resY~-*~oncan alter Q-wave duration significantly in leads II[ and pll'tt~ V ¢ regardless of the presence or absence of mgmficant asoo~ted coronary artery disease and asynergy, and is therefore :i~n0 clinical value in making these diagnoses. (Editor's note. IVllen the clinical condition suggests myocardial disease, the ~ergency physician must act on this possibility with or without supporting electrocardiogram evidence.) Robert Rothstein. MD ,
.
electrocardiography Urticaria ~ an updated review. Monroe EW, Jones HE, Arch Dermatol 113:80-90, (Jan) 1977. In a review of the recent literature on the subject of urticaria, the mechanisms thus far delineated in its production are, in general, immunological, including direct IgE hypersensitivity ,nd complement cascade activation. However, o t h e r nonimmunological factors have been found to have an influence, ie, certain drugs and other chemicals t h a t can liberate histamine directly from m a s t cell g r a n u l e s (eg, m o r p h i n e , c o d e i n e , d.tubocurarine, antibiotics, and quinine). The various causes of urticaria include drugs, foods, inhalant allergens, infections, insect and arthropod bites, permtrants and contactants, internal disease (ie, connective-tissue vascular), psychogenic factors, genetic abnormalities, and physical agents t h a t may lead to dermographism (ie, cold urticaria, h e a t urticaria, and solar urticaria). It is stressed t h a t certain compounds such as aspirin and penicillin are quite ubiquitous in t h e i r ' p r e s e n c e in many foods and combination drugs. Thus, a careful, detailed history is essential in trying to establish the causative agent in urticaria. Treatment primarily consists of eliminating the cause if found, and secondarily eliminating the symptoms with any of a variety of antihistamines. It is noted t h a t several recent studies have confirmed the superiority of hydroxyzine HC1 to the other commonly used antihistamines. (Editor's note: There is much argument over whether short term steroids are of benefit in addition to antihistamines and adrenalin. It is my experience that it reduces significantly the number of returning visits to an emergency department, and therefore I am in favor of its use.)
Geoffrey Korn, MD
laboratory studies demonstrated elevation of liver enzymes with prolonged prothrombin time. Symptoms resolved with a week of intravenous fluid therapy and parenteral vitamin K. Her course was c h a r a c t e r i s t i c and c o n f i r m s t h e major complication of acetaminophen overdosage - - liver damage. Nausea and vomiting ensue within a few hours after ingestion, associated with epigastric pain and liver tenderness. Jaundice and fulminant hepatic failure may occur by the third to fifth day. Mortality rates are low. The degree of liver dysfunction correlates with blood acetaminophen levels. Centrilobular necrosis is the main histologic feature; recovering patients do not progress to cirrhosis. The a g e n t r e s p o n s i b l e s e e m s to be a m e t a b o l i t e of' ficetaminophen, Treatment of overdosage includes induction of emesis and supportive measures. Activated charcoal is effective only if taken within the first hour. Dialysis is ineffective. Propranolol reduces mortality. Recently, cysteamine has been used with some success, although its efficacy in a double-blind study is unproved and side effects significant. The authors do not recommend its use. (Editor's note: Acetaminophen ~s being widely advertised [Datril, Tylenol] so we may anticipate an increased number of cases of overdose in the emergency department. It is important to remember that this overdose does not produce lethargy so that the patient will be taken seriously and treated promptly and aggressively despite his alertness.) Jacek Franaszek, MD
pulmonary embolism, clinical features
Paraben allergy. Nagel JE, Fuscaldo JT, Fireman P, JAMA 237:1594-1595, (Apr) 1977. A hydrocortisone p r e p a r a t i o n containing m e t h y l p a r a b e n and propylparaben provoked bronchospasm and pruritis when given intravenously to an asthmatic patient, whereas another hydrocortisone preparation without paraben preservative did not. Direct and passive transfer (Prausnitz-Kustner) skin tests for iramediate hypersensitivity to parabens were positive. Parabens, frequently employed as bacteriostatic agents, are capable of producing immunologically mediated, immediate systemic hypersensitivity reactions. (Editor's note: Parabens are found in many foods as well as parenterally administered antibiotics, corticosteriods, local anesthetics, vitamins, radiopharmaceuticals, antihypertensives, diuretics, insulin, heparin and chemotherapeutic agents. They are usually f o u n d as preservatives in multidose packages. Physicians should be as alert to package labeling as the food shopper.) Robert Rothstein, MD
parabens, hypersensitivity
urticaria The controversy of treatment of asymptomatic bacteriuria in n o n - p r e g n a n t w o m e n - - R e s o l v e d . Gleckman R, J Urol 116:776-777, (Dec) 1976. A review of the literature from several longitudinal studies shows that asymptomatic bacteriuria in n o n p r e g n a n t women with no u n d e r l y i n g r e n a l pathology (stones or o b s t r u c t i v e uropathy) is a benign condition. Several i n v e s t i g a t o r s have shown that u n t r e a t e d asymptomatic bacteriuria does not increase the likelihood of renal disease, hypertension, or symptomatic bacteriuria. There is now no longer an unresolved conflict, ie, whether to treat or not, rather, the assurance t h a t no treatment is required for this entity. (Editor's note: I f the patient is in the emergency department, the chances are the bacteriuria has not been asymptomatic.) Geoffrey Korn, ME)
bacteriuria Hepatotoxicity in acetaminophen poisoning. Ferguson DR, Snyder SK, Cameron AJ, Mayo C/in Proc 52:246=,
248, (Apr) 1977.
~5
A Woman overdosed on acetaminophen and presented to the emergency d e p a r t m e n t w i t h e p i g a s t r i c pain, vomiting, and ~eakness. Physical examination revealed liver tenderness and
J~.~) 6.8 (Aug) 1977
Porphyria-like c u t a n e o u s changes induced by tetracycline hydrochloride photosensitization. Epstein JH, Tuffanelli DL, Seibert JS, et al, Arch Dermatol 112:661-
666, (May) 1976. Five patients with porphyria-like cutaneous changes on the dorsum of the hands were studied. Each had a history of long term tetracycline HC1 use for acne vulgaris plus a history of repeated prolonged sun exposure. The lesions appeared as fragile denuded areas and e r y t h e m a t o u s blisters, identical clinically, light microscopically, electromicroscopically and via immunoflourescence study to those cutaneous lesions found in porphyria. Urinary and fecal prophyrin values were all normal. Most druginduced phototoxic reactions are rather acute in onset, varying from several minutes to several hours after sun exposure following administration of a drug, whereas the photoreactions observed in this study occurred only after prolonged tetracycline HC1 use plus prolonged sun exposure. The mechanism of this delayed phototoxic reaction is yet to be delineated. (Editor's note: In the emergency department the patient usually reports his rash, but forgets his tetracycline ingestion. Being aware of this syndrome may allow the emergency physician to hey correctly into the definitive historical questions.) Geoffrey Korn, MD
tetracycline, photosensitization
386/63
significance.
!iiieln~;:`4~7143M97iA~a~ ~;7~S, HelfantRH:Arch In tern Tl~erelative clinical significance of lead IlI Q waves and the ct o£ inspiration has received added impetus after the finding elseo waves have predictive value for coronary artery disease ~d asynergy- The effect of deep inspiration on Q waves in leads i][ SBd a V F in 31 patients was studied and correlated with the ~Aings at cardiac catheterization. It was found t h a t phasic resY~-*~oncan alter Q-wave duration significantly in leads II[ and pll'tt~ V ¢ regardless of the presence or absence of mgmficant asoo~ted coronary artery disease and asynergy, and is therefore :i~n0 clinical value in making these diagnoses. (Editor's note. IVllen the clinical condition suggests myocardial disease, the ~ergency physician must act on this possibility with or without supporting electrocardiogram evidence.) Robert Rothstein. MD ,
.
electrocardiography Urticaria ~ an updated review. Monroe EW, Jones HE, Arch Dermatol 113:80-90, (Jan) 1977. In a review of the recent literature on the subject of urticaria, the mechanisms thus far delineated in its production are, in general, immunological, including direct IgE hypersensitivity ,nd complement cascade activation. However, o t h e r nonimmunological factors have been found to have an influence, ie, certain drugs and other chemicals t h a t can liberate histamine directly from m a s t cell g r a n u l e s (eg, m o r p h i n e , c o d e i n e , d.tubocurarine, antibiotics, and quinine). The various causes of urticaria include drugs, foods, inhalant allergens, infections, insect and arthropod bites, permtrants and contactants, internal disease (ie, connective-tissue vascular), psychogenic factors, genetic abnormalities, and physical agents t h a t may lead to dermographism (ie, cold urticaria, h e a t urticaria, and solar urticaria). It is stressed t h a t certain compounds such as aspirin and penicillin are quite ubiquitous in t h e i r ' p r e s e n c e in many foods and combination drugs. Thus, a careful, detailed history is essential in trying to establish the causative agent in urticaria. Treatment primarily consists of eliminating the cause if found, and secondarily eliminating the symptoms with any of a variety of antihistamines. It is noted t h a t several recent studies have confirmed the superiority of hydroxyzine HC1 to the other commonly used antihistamines. (Editor's note: There is much argument over whether short term steroids are of benefit in addition to antihistamines and adrenalin. It is my experience that it reduces significantly the number of returning visits to an emergency department, and therefore I am in favor of its use.)
Geoffrey Korn, MD
laboratory studies demonstrated elevation of liver enzymes with prolonged prothrombin time. Symptoms resolved with a week of intravenous fluid therapy and parenteral vitamin K. Her course was c h a r a c t e r i s t i c and c o n f i r m s t h e major complication of acetaminophen overdosage - - liver damage. Nausea and vomiting ensue within a few hours after ingestion, associated with epigastric pain and liver tenderness. Jaundice and fulminant hepatic failure may occur by the third to fifth day. Mortality rates are low. The degree of liver dysfunction correlates with blood acetaminophen levels. Centrilobular necrosis is the main histologic feature; recovering patients do not progress to cirrhosis. The a g e n t r e s p o n s i b l e s e e m s to be a m e t a b o l i t e of' ficetaminophen, Treatment of overdosage includes induction of emesis and supportive measures. Activated charcoal is effective only if taken within the first hour. Dialysis is ineffective. Propranolol reduces mortality. Recently, cysteamine has been used with some success, although its efficacy in a double-blind study is unproved and side effects significant. The authors do not recommend its use. (Editor's note: Acetaminophen ~s being widely advertised [Datril, Tylenol] so we may anticipate an increased number of cases of overdose in the emergency department. It is important to remember that this overdose does not produce lethargy so that the patient will be taken seriously and treated promptly and aggressively despite his alertness.) Jacek Franaszek, MD
pulmonary embolism, clinical features
Paraben allergy. Nagel JE, Fuscaldo JT, Fireman P, JAMA 237:1594-1595, (Apr) 1977. A hydrocortisone p r e p a r a t i o n containing m e t h y l p a r a b e n and propylparaben provoked bronchospasm and pruritis when given intravenously to an asthmatic patient, whereas another hydrocortisone preparation without paraben preservative did not. Direct and passive transfer (Prausnitz-Kustner) skin tests for iramediate hypersensitivity to parabens were positive. Parabens, frequently employed as bacteriostatic agents, are capable of producing immunologically mediated, immediate systemic hypersensitivity reactions. (Editor's note: Parabens are found in many foods as well as parenterally administered antibiotics, corticosteriods, local anesthetics, vitamins, radiopharmaceuticals, antihypertensives, diuretics, insulin, heparin and chemotherapeutic agents. They are usually f o u n d as preservatives in multidose packages. Physicians should be as alert to package labeling as the food shopper.) Robert Rothstein, MD
parabens, hypersensitivity
urticaria The controversy of treatment of asymptomatic bacteriuria in n o n - p r e g n a n t w o m e n - - R e s o l v e d . Gleckman R, J Urol 116:776-777, (Dec) 1976. A review of the literature from several longitudinal studies shows that asymptomatic bacteriuria in n o n p r e g n a n t women with no u n d e r l y i n g r e n a l pathology (stones or o b s t r u c t i v e uropathy) is a benign condition. Several i n v e s t i g a t o r s have shown that u n t r e a t e d asymptomatic bacteriuria does not increase the likelihood of renal disease, hypertension, or symptomatic bacteriuria. There is now no longer an unresolved conflict, ie, whether to treat or not, rather, the assurance t h a t no treatment is required for this entity. (Editor's note: I f the patient is in the emergency department, the chances are the bacteriuria has not been asymptomatic.) Geoffrey Korn, ME)
bacteriuria Hepatotoxicity in acetaminophen poisoning. Ferguson DR, Snyder SK, Cameron AJ, Mayo C/in Proc 52:246=,
248, (Apr) 1977.
~5
A Woman overdosed on acetaminophen and presented to the emergency d e p a r t m e n t w i t h e p i g a s t r i c pain, vomiting, and ~eakness. Physical examination revealed liver tenderness and
J~.~) 6.8 (Aug) 1977
Porphyria-like c u t a n e o u s changes induced by tetracycline hydrochloride photosensitization. Epstein JH, Tuffanelli DL, Seibert JS, et al, Arch Dermatol 112:661-
666, (May) 1976. Five patients with porphyria-like cutaneous changes on the dorsum of the hands were studied. Each had a history of long term tetracycline HC1 use for acne vulgaris plus a history of repeated prolonged sun exposure. The lesions appeared as fragile denuded areas and e r y t h e m a t o u s blisters, identical clinically, light microscopically, electromicroscopically and via immunoflourescence study to those cutaneous lesions found in porphyria. Urinary and fecal prophyrin values were all normal. Most druginduced phototoxic reactions are rather acute in onset, varying from several minutes to several hours after sun exposure following administration of a drug, whereas the photoreactions observed in this study occurred only after prolonged tetracycline HC1 use plus prolonged sun exposure. The mechanism of this delayed phototoxic reaction is yet to be delineated. (Editor's note: In the emergency department the patient usually reports his rash, but forgets his tetracycline ingestion. Being aware of this syndrome may allow the emergency physician to hey correctly into the definitive historical questions.) Geoffrey Korn, MD
tetracycline, photosensitization
386/63