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Prehospital thrombolytic treatment of acute myocardial infarction with anisoylated plasminogen streptokinase activator complex
mained fairly constant over the entire period. IUD use, pelvic inflammatory disease, and infertility remained constant over the 1975-1985 period despite the shift in incidence of ect0pic pregnancies. Previous tubal surgery and ectopic pregnancy did rise sharply between 1975 and 1985, with a notable increase in incidence of conservative tubesparing techniques attempted. The authors speculate that with increasing tubal sterilization, attempted salpingostomy, tubal reanastomosis, and the like, we may see a continuing rise in ectopic pregnancy.
Robin Nicholson, MD
sinusitis, nasotracheal intubation
I n c i d e n c e of sinusitis in p at i en t s wi t h n a s o t r a c h e a l intubation Hansen M, Poulsen MR, Bendixen DK, et al Br J Anaesth 61:231-232
1988
A prospective study was conducted to evaluate the incidence of sinusitis in nasotracheally intubated patients. Twelve patients intubated for mechanical ventilation, six with intracerebral hemorrhage, and six with cranial trauma were studiedl All patients had CT scans that included all sinus cavities prior to or immediately after intubation. Patients received follow-up scans on days 1, 2, and 3 following i n t u b a t i o n , w i t h air/fluid levels or opacification Considered positive findings. All patients showed signs of sinusitis on day 1 or 2; seven patients had the ipsilateral maxillary sinus infected, nine patients had polysinusitis, and in one patient the contralateral maxillary sinus was infected where a nasogastic tube was in place. All developed fever of more than 38.5 C, with frank pus produced containing either predominantly Gram-negative or Gram-positive species in seven patients. It was concluded that the incidence of sinusitis is higher than previously reported (100% versus 26%), and that sinusitis should be considered when fever occurs without a known focus in patients with nasotracheal intubation.
Duncan S a u e g M D
myogtobin, myocardial ischemia
Serum myoglobin levels in patients wi t h i s c h e m i c myocardial insult Isakov A, Shapira I, Burke M, et al Arch Intern Med 148:1762-1765
Aug 1988
The investigators studied serum myoglobin levels in 178 consecutive patients admitted for chest pain due to ischemic cardiac injury. Myocardial infarction (MI) was 18:2 February 1989
defined as typical ECG changes with elevations of cardiac enzymes (CK) of at least 1.5 times the upper limit of normal. Myoglobin levels were considerably elevated on admission in all 93 patients diagnosed with acute MI. Slight additional elevation was found at six to 12 hours. CK levels were moderately elevated on admission and had peak levels in six to 12 hours. Acute coronary insufficiency was defined as severe angina, with one or more attacks of pain at rest, lasting more than 30 minutes and without prompt reaction to sublingual drugs, together with normal CK and nonappearance of Q-waves. In 85 patients with acute coronary insufficiency, 43 had elevated serum myoglobin levels with significantly higher CK levels, although within the normal range, compared with the 42 patients with normal myoglobin levels. Four patients with acute coronary insufficiency and elevated myoglobin levels developed left ventricular failure. Serum myoglobin levels have been found to correlate with histologic infarct size and with severity, complications, and prognosis of acute MI. The authors suggest that serum myoglobin levels are an earlier and more sensitive marker for both Q-wave and non-Q-wave acute MI.
Mark H Murphy, MD
anisoylated plasminogen streptokinase activator complex; thrombotytic therapy, acute myocardial infarction
Prehospital t h r o m b o l y t i c t r e a t m e n t of a c u t e myocardial infarction with anisoylated pl asm i nogen s t r e p t o k i n a s e act i vator complex Bossaert LL, Demey HE, Colemont LJ, et al Crit Care Med 16:823-830 Sep 1988
Many factors are known to delay the administration of thrombolytic agents. This study tried to expedite this process by using a group of trained general practitioners who responded to all potential acute myocardial infarction patients in their homes. After diagnosis of acute myocardial infarction of less than two hours since onset of pain, a medical ICU team was dispatched to the scene. They repeated the evaluation and included a trial of isosorbide dinitrate and nifedipine, noting their effects on symptoms and 12-lead ECG. Inclusion and exclusion criteria were similar to those used in prior studies. Patients meeting these criteria received anisoylated plasminogen streptokinase activator complex (APSAC) 30 units IV over three to five minutes. Analgesics, antiarrhythmics, and other drugs were used when required. All patients then were admitted to the coronary care unit and placed on full-dose heparin. Cardiac catheterization was performed on all patients on day 2 or 3, or before if clinically indicated. Further intervention by percutaneous transluminal coronary angioplasty or coronary artery bypass graft was dictated by the patient's anatomy and clinical course. Of
Annalsof EmergencyMedicine
223/163
ABSTRACTS
the 58 patients with suspected acute myocardial infarction, 13 met all the criteria and were given APSAC at home. The sensitivity of the initial screening by the general practitioner was 84%. Successful thrombolysis and coronary reperfusion was achieved in 77% of patients. The mean time gained by home treatment compared with waiting for coronary care unit admission was 46 + 14 minutes. There were no bleeding complications or allergic reactions. None of the patients treated with APSAC at home died in the hospital or during the subsequent fivemonth follow-up. This study did not have a large enough sample size to demonstrate significant differences in mortality and morbidity between treatment groups. It did confirm the findings of other studies that prehospital administration of thrombolytic agents is safe, feasible, and efficacious. It was the authors' belief that this can only be achieved when well-defined inclusion/exclusion criteria are met. Tim Hutchinson, MD
hypotension, postural
P r e v a l e n c e of postural hypotension in elderly patients in a long-term health c a r e facility Aronow W, Lee N, Sales F, et al Am J Cardiol 62:336 Aug t988
Orthostatic blood pressure change is often used to help assess a patient's intravascular volume status. Many factors other than dehydration produce postural hypotension. This paper describes the overall prevalence of postural hypotension in the elderly population. The study measured orthostatic blood pressures in 476 patients in long-term health care facilities with ages ranging from 62 to 101 (mean age, 82). The only requirement to be eligible for the study was that the patient not be bedridden. Postural hypotension was defined as a drop in systolic blood pressure of more than 20 m m Hg along with a drop in diastolic blood pressure of more than 10 m m Hg after assuming a standing or sitting (patients who were chairbound) position for two minutes. Of the 476 patients, 39 (8%) were found to have postural hypotension. Patients receiving cardiovascular or psychotropic drugs were found to have a 13% prevalence of postural hypotension compared with 3% in patients not taking these drugs. Symptoms associated with assuming an upright position were not significantly different between those patients having postural hypotension and those who did not. The prevalence of postural hypotension was the same among men and women (8%). When using orthostatic blood pressures clinically, one must be aware of the high prevalence of postural hypotension in the elderly and that it may not be indicative of a dehydrated state. Brien Duncan, MD
164/224
amoxicillin, Candid& dermatitis
Amoxicillin and diaper d e r m a t i t i s Honig P, Gribetz B, Leyden J, et al J Am Acad Dermatol 19:275-279
Aug 1988
The development of Candida dermatitis in infants may be related to the quantity of Candida albicans in the stool. Factors that lead to an increased quantity of C albicans in the stool may contribute to an increased risk for the development of Candida diaper dermatitis. This study tried to determine if oral amoxicillin is one such factor. Eighty-seven infants (children 2 to 24 months old) being treated with oral amoxicillin for otitis media were studied. Only 57 patients returned for follow-up. Candida cultures were taken from the oral mucosa, anterior nares, rectum, perineum, inguinal fold, and buttocks area prior to beginning amoxicillin and at the time of the two-week ear check. Infants were excluded from the study if they had diaper dermatitis one month earlier or were on antibiotics or oral or topical steroids two months prior to the study. There was a twofold increase in the percentage of positive cultures before and after treatment in the rectal (10.5% to 22.8%) and the inguinal fold (5.3% to 10.5%) cultures. Patients who developed candidal rashes during the study had significant increases in the number of candidal organisms recovered from these same sites. The authors conclude that amoxicillin increases the risk for developing candidal diaper rashes. Brien Duncan, MD
malaria, prevention
C o m p a r i s o n of m osqui to nets, proguanil hydrochloride, and p l a c e b o to prevent malaria Nesill CG, Watkins WM, Carter JY, et al Br Med J 297:401-403 Aug 1988
This study was undertaken to compare mosquito nets, proguanil hydrochloride, and placebo in prevention of malaria. One hundred ninety students ages 6 to 18 at a boarding school in Kenya participated in a comparative trial of malaria prophylaxis. Initially, treatment with a combination of amodiaquine 25 mg/kg over three days plus doxycycline 100 mg twice daily for five days cleared their blood of Plasmodiurn falciparum. The students then were randomly divided into the following three groups matched for age and sex: those who slept under mosquito nets, those who received placebo tablets, and those who received proguanil hydrochloride tablets. Malaria was diagnosed when asexual P falciparum were seen on blood films'and was treated with pyrimethamine sulphadoxine.
Annals of EmergencyMedicine
18:2 February 1989
Robin Nicholson, MD
sinusitis, nasotracheal intubation
I n c i d e n c e of sinusitis in p at i en t s wi t h n a s o t r a c h e a l intubation Hansen M, Poulsen MR, Bendixen DK, et al Br J Anaesth 61:231-232
1988
A prospective study was conducted to evaluate the incidence of sinusitis in nasotracheally intubated patients. Twelve patients intubated for mechanical ventilation, six with intracerebral hemorrhage, and six with cranial trauma were studiedl All patients had CT scans that included all sinus cavities prior to or immediately after intubation. Patients received follow-up scans on days 1, 2, and 3 following i n t u b a t i o n , w i t h air/fluid levels or opacification Considered positive findings. All patients showed signs of sinusitis on day 1 or 2; seven patients had the ipsilateral maxillary sinus infected, nine patients had polysinusitis, and in one patient the contralateral maxillary sinus was infected where a nasogastic tube was in place. All developed fever of more than 38.5 C, with frank pus produced containing either predominantly Gram-negative or Gram-positive species in seven patients. It was concluded that the incidence of sinusitis is higher than previously reported (100% versus 26%), and that sinusitis should be considered when fever occurs without a known focus in patients with nasotracheal intubation.
Duncan S a u e g M D
myogtobin, myocardial ischemia
Serum myoglobin levels in patients wi t h i s c h e m i c myocardial insult Isakov A, Shapira I, Burke M, et al Arch Intern Med 148:1762-1765
Aug 1988
The investigators studied serum myoglobin levels in 178 consecutive patients admitted for chest pain due to ischemic cardiac injury. Myocardial infarction (MI) was 18:2 February 1989
defined as typical ECG changes with elevations of cardiac enzymes (CK) of at least 1.5 times the upper limit of normal. Myoglobin levels were considerably elevated on admission in all 93 patients diagnosed with acute MI. Slight additional elevation was found at six to 12 hours. CK levels were moderately elevated on admission and had peak levels in six to 12 hours. Acute coronary insufficiency was defined as severe angina, with one or more attacks of pain at rest, lasting more than 30 minutes and without prompt reaction to sublingual drugs, together with normal CK and nonappearance of Q-waves. In 85 patients with acute coronary insufficiency, 43 had elevated serum myoglobin levels with significantly higher CK levels, although within the normal range, compared with the 42 patients with normal myoglobin levels. Four patients with acute coronary insufficiency and elevated myoglobin levels developed left ventricular failure. Serum myoglobin levels have been found to correlate with histologic infarct size and with severity, complications, and prognosis of acute MI. The authors suggest that serum myoglobin levels are an earlier and more sensitive marker for both Q-wave and non-Q-wave acute MI.
Mark H Murphy, MD
anisoylated plasminogen streptokinase activator complex; thrombotytic therapy, acute myocardial infarction
Prehospital t h r o m b o l y t i c t r e a t m e n t of a c u t e myocardial infarction with anisoylated pl asm i nogen s t r e p t o k i n a s e act i vator complex Bossaert LL, Demey HE, Colemont LJ, et al Crit Care Med 16:823-830 Sep 1988
Many factors are known to delay the administration of thrombolytic agents. This study tried to expedite this process by using a group of trained general practitioners who responded to all potential acute myocardial infarction patients in their homes. After diagnosis of acute myocardial infarction of less than two hours since onset of pain, a medical ICU team was dispatched to the scene. They repeated the evaluation and included a trial of isosorbide dinitrate and nifedipine, noting their effects on symptoms and 12-lead ECG. Inclusion and exclusion criteria were similar to those used in prior studies. Patients meeting these criteria received anisoylated plasminogen streptokinase activator complex (APSAC) 30 units IV over three to five minutes. Analgesics, antiarrhythmics, and other drugs were used when required. All patients then were admitted to the coronary care unit and placed on full-dose heparin. Cardiac catheterization was performed on all patients on day 2 or 3, or before if clinically indicated. Further intervention by percutaneous transluminal coronary angioplasty or coronary artery bypass graft was dictated by the patient's anatomy and clinical course. Of
Annalsof EmergencyMedicine
223/163
ABSTRACTS
the 58 patients with suspected acute myocardial infarction, 13 met all the criteria and were given APSAC at home. The sensitivity of the initial screening by the general practitioner was 84%. Successful thrombolysis and coronary reperfusion was achieved in 77% of patients. The mean time gained by home treatment compared with waiting for coronary care unit admission was 46 + 14 minutes. There were no bleeding complications or allergic reactions. None of the patients treated with APSAC at home died in the hospital or during the subsequent fivemonth follow-up. This study did not have a large enough sample size to demonstrate significant differences in mortality and morbidity between treatment groups. It did confirm the findings of other studies that prehospital administration of thrombolytic agents is safe, feasible, and efficacious. It was the authors' belief that this can only be achieved when well-defined inclusion/exclusion criteria are met. Tim Hutchinson, MD
hypotension, postural
P r e v a l e n c e of postural hypotension in elderly patients in a long-term health c a r e facility Aronow W, Lee N, Sales F, et al Am J Cardiol 62:336 Aug t988
Orthostatic blood pressure change is often used to help assess a patient's intravascular volume status. Many factors other than dehydration produce postural hypotension. This paper describes the overall prevalence of postural hypotension in the elderly population. The study measured orthostatic blood pressures in 476 patients in long-term health care facilities with ages ranging from 62 to 101 (mean age, 82). The only requirement to be eligible for the study was that the patient not be bedridden. Postural hypotension was defined as a drop in systolic blood pressure of more than 20 m m Hg along with a drop in diastolic blood pressure of more than 10 m m Hg after assuming a standing or sitting (patients who were chairbound) position for two minutes. Of the 476 patients, 39 (8%) were found to have postural hypotension. Patients receiving cardiovascular or psychotropic drugs were found to have a 13% prevalence of postural hypotension compared with 3% in patients not taking these drugs. Symptoms associated with assuming an upright position were not significantly different between those patients having postural hypotension and those who did not. The prevalence of postural hypotension was the same among men and women (8%). When using orthostatic blood pressures clinically, one must be aware of the high prevalence of postural hypotension in the elderly and that it may not be indicative of a dehydrated state. Brien Duncan, MD
164/224
amoxicillin, Candid& dermatitis
Amoxicillin and diaper d e r m a t i t i s Honig P, Gribetz B, Leyden J, et al J Am Acad Dermatol 19:275-279
Aug 1988
The development of Candida dermatitis in infants may be related to the quantity of Candida albicans in the stool. Factors that lead to an increased quantity of C albicans in the stool may contribute to an increased risk for the development of Candida diaper dermatitis. This study tried to determine if oral amoxicillin is one such factor. Eighty-seven infants (children 2 to 24 months old) being treated with oral amoxicillin for otitis media were studied. Only 57 patients returned for follow-up. Candida cultures were taken from the oral mucosa, anterior nares, rectum, perineum, inguinal fold, and buttocks area prior to beginning amoxicillin and at the time of the two-week ear check. Infants were excluded from the study if they had diaper dermatitis one month earlier or were on antibiotics or oral or topical steroids two months prior to the study. There was a twofold increase in the percentage of positive cultures before and after treatment in the rectal (10.5% to 22.8%) and the inguinal fold (5.3% to 10.5%) cultures. Patients who developed candidal rashes during the study had significant increases in the number of candidal organisms recovered from these same sites. The authors conclude that amoxicillin increases the risk for developing candidal diaper rashes. Brien Duncan, MD
malaria, prevention
C o m p a r i s o n of m osqui to nets, proguanil hydrochloride, and p l a c e b o to prevent malaria Nesill CG, Watkins WM, Carter JY, et al Br Med J 297:401-403 Aug 1988
This study was undertaken to compare mosquito nets, proguanil hydrochloride, and placebo in prevention of malaria. One hundred ninety students ages 6 to 18 at a boarding school in Kenya participated in a comparative trial of malaria prophylaxis. Initially, treatment with a combination of amodiaquine 25 mg/kg over three days plus doxycycline 100 mg twice daily for five days cleared their blood of Plasmodiurn falciparum. The students then were randomly divided into the following three groups matched for age and sex: those who slept under mosquito nets, those who received placebo tablets, and those who received proguanil hydrochloride tablets. Malaria was diagnosed when asexual P falciparum were seen on blood films'and was treated with pyrimethamine sulphadoxine.
Annals of EmergencyMedicine
18:2 February 1989