EMU Monthly – December 2016

1) Seems like an important study. A prospective study of 216 cardiogenic shock patients in 9 centers over eight countries. The bottom line? Epi caused higher mortality. Higher bio-markers elevation. Higher renal bio-marker elevation. Greater mental status changes .However, let us dissect this a little. 216 patients is kind of small. And maybe these disease and not patient oriented outcomes (except mortality of course) were all caused by these patients being sicker. They did try to control for this, and I will mention that this finding was confirmed with a multi variable logistic regression and a propensity score matched analysis. Not that I can really tell you what those are, but these statistic gymnastics both found the same thing. Oh and I forgot to tell you that nor had a higher mortality but only when combined with dobutamine or levosimendan. Again, this means to me that these were sicker patients. TBTR: Epi is killing people??

Critical Care 20(1)208

2) Delirium in the ICU isn’t pleasant- actually it isn’t pleasant anywhere, but if haloperidol fails, consider dexmedetomidine. The patients that got this drug needed less morphine, less costs, and less hospital stays. They occasionally needed atropine for sedation. Maybe, but I have a few questions. I have never found a patient that I couldn’t knock down with haloperidal. Even so, there are many other options including other anti psychotics. Dex- I have absolutely no experience with this since we haven’t got it in this country- but I understand that it does take some time to work- time I may not have when the department is being ripped apart by this bull in a china shop.  TBTR: Dexmet may be better than haloperidol for delirium. If you aren’t sure – try them both on yourself and see.

CCM 44(7)1426

 

 

 

 

 

 

3) Ever notice you give opiods and they don’t seem to work on some people? Could be they are slow metabolizers; and in this study could be because back pain is different but the relief was just “mild”. This was even when there was a morphine equivalent of 240 mg- no better than placebo. Pretty impressive, no? I do have some problems though. Morphine equivalents don’t mean very much, and indeed, many of the studies that were used for this meta analysis used tramadol, which is indeed a very week opiod. But with a better study, maybe we would see that these are not very effective. TBTR: Percocet may not be worth writing all those prescriptions you write for the kickbacks.

 (JAMA Int Med 176(7)958).

Let’s get started with some quotes.  Zsa Zsa Gabor died recently – she was the penultimate socialite – married nine times and once for only ten minutes.  While being a Hungarian immigrant with a heavy accent – she still wowed us with her quotes.

Let’s run through some

“I never hated a man enough to give him his diamonds back.”

4) Terson syndrome exists and you should know about it. It basically is acute visual loss when you inject things into the epidural space such as saline, epidural anesthesia and blood patches. They think that this is due to acute blockage of the retinal venous drainage. Good news- it gets better in most. Just be careful how fast you inject things into this space. Relevance to EM?  We have given blood patches in the ED. TBTR: Terson syndrome – know about it.

Reg Anest Pain Med 41(2)127

“I’m a marvelous housekeeper—every time I leave a man, I keep his house.”

5) I think we have mentioned this before but we will again it is a medical myth. Early repolarization is a risk factor for sudden death after controlling for every thing else. Fine, but it is also very common – do we sned all these patients to EPS? Do we put in ICDs to them? Should we be worried when we see this on an EKG in a syncope patient? No answers now. TBTR: early repol could be dangerous.

Circ Arryth Electrop 9(6)3960

“When in trouble, take a bath and wash your hair.

6) In the states they probably know about this already but the ABCDX categories are being retired. Now they will be replaced with detailed data about the risks and benefits complete with a summary and information written for health personnel and for patients. I haven’t seen this yet in practice, but it does seem like it can be confusing – especially if the clinician and the patient interpret the information differently. But it is here – so get used to it.

Clin Derm 34(3)401

Pharmcoth 34(4)389

“My husband said it was him or the cat. I miss him sometimes.

7) If you do not read anything else this month in EMU- and believe me – you shouldn’t – read this article. Double blind cross over study sponsored by the Chocolate industry – chocolate significantly increase acne in teens. They couldn’t tell us why and furthermore, maybe it isn’t all chocolate- they used dark chocolate in this study – but it has nothing to do with glycemic index – rather perhaps with falvinoids. TBTR: Choc late and pimples – be careful.

JAAD 75(1)220

“How many husbands have I had? You mean apart from my own?”

8) Genital ulcers are no fun. Especially when you have chest pain, back pain a sore throat and a fever. And especially when you are a 13 year old girl who is a Virgil

 

“I think Doctor that is supposed to be a virgin”. You are so right

. In any case vaginal pain with a fever is a UTI so they gave her some antibiotics and some phenazopyridine (Pyridium or Sedural) and – well, it didn’t work. And the Urine culture was negative. So she came back, and with a vag discharge, they called this a Candida infection and she got fluconazole and clotrimazole cream and a repeat urine culture. The culture came back negative and she is getting worse. She now has a foul smelling vaginal discharge and an ulcer on an inflamed labia. HSV, GC, tric, Chlamydia- they were all negative. But one test wasn’t- this is’ of course…..

 

 

Fam Prac 65(6)400

Sorry, I know you were expecting Madonna, but she is very old these days- and not a virgin.  And not a blonde either

“My most favorite joke is that to keep a marriage, the husband should have a night out with the boys and the wife should have a night out with the boys, too.”

9 )I do not know why these criteria are recommended – they date back to 1999 and were based on a retrospective case series. Yet they are still in use and you should know them. You know someone once accused me of taking my time to introduce what I am talking about and I wonder if that is really the case. Could be- I gotta give it some thought. Could be my ADHD. Oh yes- we are speaking about knowing the difference between transient synovitis and a septic hip. And the Kocher criteria are a way to help you differentiate include- inability to weight bear (don’t both of them have that?) fever greater than 38.5, ESR>40 and WBC greater than 12000. However, note that while having three gives you a 93% chance of having septic arthritis; if they are the three latter ones- well all kids with fever can have this. Here are the references for these

ACEP Mobile article 

And

Ped Annals 45(6)E209

EM RAP looked at this many years ago-2010- when they recorded Marty Hellman at the Scientific Assembly. And he brought many studies – even prospective ones- which showed these criteria aren’t that great. Basically, septic arthritis is rare, these patients do look sick, they don’t get better with an NSAID, and their CRP is not so high. However, everyone agrees – do an US and you will have the answer most of the time, and an MRI and you will have it all of the time. TBTR: Can you figure out when it is a septic hip??

“I always said marriage should be a fifty-fifty proposition. He should be at least fifty years old, and have at least fifty-million dollars.”

10) I found this interesting but then again, I am a sick guy.

Traditional autopsy and post mortem CT scans both find stuff the others one doesn’t.  There still is a lot to be done to define what is good for what- as this study is powered enough to tell us. Of course CT isn’t good at vessels as you can’t give contrast to a dead person, but was better at boney stuff. More to come. TBTR: Autopsy – going out?

Surgery 160(1)211

 

 

 

“Diamonds are a girl’s best friend and dogs are a man’s best friend. Now you know which sex has more sense.”

 

11) This is odd but EMU is ecumenical and non discriminatory (with the exception that we are against the Gay Nazis for Peace) so if you are one of these strange guys who instead of deflating pediatric ET cuffs you just cut off the pilot balloon- just know that 2/3 of the volume is retained. IS this dangerous? Will this happen in bigger sizes of ET tubes? The article doesn’t say but I think the take home for all of us in general is do not overinflate these pilot balloons.BTW I have seen similar results with cutting off the port of a Foley. TBTR: Do not cut off the pilot balloon to deflate the cuff in an ET tube.

Int J Ped Otot Larynx 86:15

“I believe in large families. Every woman should have at least three husbands.”

12) I respect dentists although I do not like them.  Here they write that they feel NSAIDS are very effective and opioids are questionably effective. Then they give a whole bunch of reasons why you should not use opioids. Like all opinion articles and review articles –the medical academic dictum ”garbage in garbage out” may apply to the articles they used for this paper. Readers of EMU know that opioids do have a lot of questions when it comes to effectiveness, but no one doubts that NSAIDS are not really strong pain relievers. I am waiting for a mini lidocaine injector to the site of the extraction- no addiction no pain. Is this Buck Rodgers talk???

JADA 14(7)530.

“A man in love is incomplete until he has married. Then he’s finished.”

13) I am not sure why, but once we realized that anti emetics were safe in children – we went straight to Odansetron. True the Americans love their Comapazine, but it has a lot of side effects and isn’t available in many countries- like mine. What about good ole Pramin? AKA Reglan. AKA metoclopramide. They looked at kids in this study and determined that the side effects- some sedation, EPS and diarrhea – were minor and of no significance. The “problem” with this study was it was a review – and it really depends on what dosage you use.  I think you should feel safe in using it. TBTR: Metoclopramide seems to be safe in kids.

Drug Safety 39(7)675

“I want a man who’s kind and understanding. Is that too much to ask of a millionaire?”

14)  A quick one here- if you have no ring cutter and the ring is stuck – you should try the two rubber band technique. The article has good pictures, and is free access. However, this does require you can advance a hemostat under the ring.

Am Roy Coll Surg Eng 98(5)300

“Personally, I know nothing about intercourse, because I have always been married.”

15) This is a case report of a STEMI equivalent that was missed- specifically the De Winter sign.  For thosetwits who do not remember what the DeWinter sign is (I am one of those twits) here it is from Chris Nickson’s excellent life in the fast lane. However truth be told- you better not miss this – it has enough ST depression – even though it may be reversible – that it should worry you.

JEM 50(6)875

“One of my theories is that men love with their eyes; women love with their ears.”

16) Ever notice that EPi has a very short expiration date? And this is important considering how much folks are paying for auto injectors these days. Well heat will affect epi but only prolonged exposure. Cold seems to preserve epi – refrigeration did help. Freezing? We do not know. Same problem here – this was a review of published studies- seems like an easy enough question to study on its own. TBTR: Put epi in the fridge- maybe.

Ann All Asthma Immuno 117(1)79

“You never really know a man until you have divorced him.”

17) Maybe. This Chinese study only had 152 patients but they reported – double blinded – that Fosfomycin did the trick in ridding males of gonorrhea. But again- the numbers were small. They were Chinese- other people may be different. TBTR: Fosfomycin for GC?

Clin Derm 34(4)482

“I have learned that not diamonds but divorce lawyers are a girl’s best friend.”

18) Yet another study showing that superficial venous thrombosis is not beingn. However , this too was  areview of the literature and because the data was so divergent, they usede a weighted mena prevelance. The problem is that this assigns weights to the events and that can only be an assumption. Really, I mean seriously – can’t we get a good study done?

J Thrombo Haemo 145(5)964

“Getting divorced just because you don’t love a man is almost as silly as getting married just because you do.”

19) Rectal foreign bodies – I know- you were just doing some gardening in the nude and fell on tomato plant- how do you get them out? I have tried obstetrical forceps in the past without success, but this article suggests – use just one and angle it right…. hard to explain without getting the article – but yet again – it is free access and comes with a picture – removing an apple – I guess they did not realize that will keep the doctor a way. TBTR: Rectal foreign bodies- how do deliver them.

Ann Roy Coll Surgeons 97(5)397

Now to finish up – we lost another beloved actress – Mary Tyler Moore. Here are some quotes from her TV series

“I’m an experienced woman; I’ve been around. Well, all right, I might not have been around, but I’ve been … nearby.”

20) Here is something for the trivia department- the amount of sodium in 0.95 Normal saline (anyone out there know why it is called normal?) is equal to a serum sodium of 154.

AJKD 68(1)11

“Take chances, make mistakes. That’s how you grow. Pain nourishes your courage. You have to fail in order to practice being brave

21)  Morphine is the falling star in MI pain but in this DOO (disease oriented outcome paper) it seems to delay the onset of action of Prasugrel. Maybe

Thromb Haem 116(7)96

Lou: Mary, where are the idiot cards?

Ted: Cue cards, Lou! Cue Cards!

Lou: Excuse me, Ted. Mary, could you please give those cue cards to this idiot?

22) As you all know (all three of you readers) that I am a huge fan of Steve Selbst’s Legal Briefs- while they appear in a pediatric journal – they do take a lot of adult cases. If you want the excitement of reading the cases themselves – get the article; but I will just summarize some important points. A lady with a psychiatric breakdown is sent to jail and gets Lamictal (lamotrigine). A few days later she gets a rash. Stevens Johnson-. Just make sure you warn people. Oh dear do not restrain patients physically and defiantly not in the prone position- this can kill people. And of you want more of the gore and stupidity that we physicians are capable of- make sure you tune into Greg Henry and Rick Bukata’s Risk Management Monthly. I am just burying this here to see if they find it. If they did – than I award them with first prize- they will be honored to provide me with a free subscription to RMM. But only if they acknowledge this within 5 days of posting. TBTR: Legal stuff

PEC 32(6)422

Rhoda: There are no men friends when you’re thirty. They’re either fiances or rejects

23) Skin infections- we see a lot of cellulitis here in the warm sweaty climate of the sub tropics. So while I was reading this article on the beach under a palm tree and sipping a pina colada while you freeze your patuchkies off. 

I thought I would update you a little on this subject- indeed broken skin is where this all starts like in fungal infections, leg ulcers from PVD and yes- frostbite. It is not like you are going to know the causative agent – doing cultures of the skin with a needle aspiration is a waste of time and blood cultures is also (even the culture loving IDSA agrees here). It is going to be strep usually in immune competent adults and Staph also – but much less of the time. If the person is healthy and the cellulitis is not complicated (not clear what they mean here) then you needn’t worry about MRSA. Cellulitis is nearly always unilateral (but then again so is DVT) and it has dolor, calor, rubor and tumor – that is swelling, heat, erythema and pain- but then again so can DVT. Lymphatics may be inflamed as well. Lab tests- do not help. Special cases include aquatic cellulitis from bites or punctures (think Vibrio and Aeromon
as), nec fasc and animal bites. Diabetic infections also need consideration.  These need special attention because often the treatment is surgical or special antibiotics are needed.  Abscesses are always treated surgically –antibiotics generally do not help. DDX include a whole bunch of things but the things that will get you mixed up are insect bites, allergic reactions, gout and DVT- although if it is clearly cellulitis- DVT doesn’t generally go together with it.  Often there is enough damage to lymphatics, that recurrent cellulitis is a given and indeed half of the cases will have another flare-up within three years. I use high doses of Cephalexin for this but there are other possible regimens- liked Augmentin for example if you like to see you patient wobbling to the bathroom to deal with diarrhea. Prophylaxis fails in ¼ of the cases but may be worth it in patients with 3-4 episodes a year. PCN 250mg may be enough TBTR: Cellulitis- some warm thoughts.

JAMA 316(3)325

Ted[bragging] I even got cheered for cutting a ribbon at a supermarket!

Murray: That’s because they didn’t think you could do it.

24) Maybe someone out there will make this diagnosis – I won’t – but periodic fever, apthous stomatitis , pharygitis and adenitis  is called PFAPA . Mostly occurs before age five- but adults can get it too.  Prednisone will help, but it will come back real fast once it is stopped. The treatment is surgical – i.e.- ripping out the tonsils which works remarkably well, and some biological

Clin Derm 34:482

Mary: At our age, having your tonsils out can be dangerous.

Rhoda: At our age, having your hair done can be dangerous.

25) Small numbers –but admittedly a hard study to design- colloids –especially heat treated albumin may do better in large burns. The key is ”may”.

PCCM 17(6)578

Ted[badly mispronouncing German] This is Ted Baxter, saying Oof Weederzane.

Lou: Now that he’s demolished English he’s branching out.

26) NSAID bashing again? No I have grown out of that. We do know that NSAIDS are really good for prostaglandin induced pain – like renal stones.  In Suisse (that is how they call themselves- we call it Switzerland) – they hospitalize 10% of folks with stones (wow). They point out that all NSAIDS are good for this indications and compare favorably against opioids, – with the exception of indomethacin which is inferior (don’t laugh – we still have this med in our department). They note –as well should – that chronic use of NSAIDS will results in ulcers in 15- 30% of the patients and that there is a slight increase in relative risk of MI and death with diclofenac, naproxen, rofecoxib and celecoxib. None was seen in ibuprofen. This may be but it is isn’t telling. Both coxibs are known to cause increases of MIs – that is why Vioxx was taken off the market. Diclofenac has a large degree of COX -2 inhibition (but not enough to be called a Cox-2). Naproxen was a surprise. TBTR: NSAIDS back in the EMU news again.

Drugs 76:993 

Phyllis: Believe it or not, I too once had a feeling of inadequacy.

Rhoda: Oh, no. We’re not going to hear about your honeymoon again, are we?

27) Diarrhea. While acute diarrhea is really fun, this article is going to focus on chronic diarrhea. Bacterial causes are rare – they just do not last that long.  However, E coli, Shigella, Salmonella, Campylobacter and some non cholera Vibrios can be causes. C DifFicle of course can hang around in patients who have taken antibiotics. Think also parasites as well as helminthes and norovirus.  Non infectious causes include celiac disease, cancer, mal absorption, lactose or carbohydrate processing disorders. , IBD, IBS and of course idiopathic (ever notice that idiopathic and idiot start out the same way?).  Think also about Sprue and Brainerd diarrhea (if you drink unpasteurized milk). Treatment and diagnosis vary and there are good charts here (no way I can copy all of them – at least not legally) and treatment can include antibiotics, and yes – loperamide if you already started antibiotics in a bacterial cause. Fecal transplants- can also help- I take one of these with breakfast every morning. TBTR: Chronic runs- how to get you patient not to paint the porcelain.

JAMA 315(24)2712

Ted: I saw you do the news, Lou. You were terrible.

Lou: I know, but that’s because I made a mistake.

Ted: What’s that, Lou?

Lou: I started drinking after the show.

28) When to stop NOACS or DOACS before surgery? The guidelines say 4-6 days for dabigitran, 3 days for rivoroxaban and 3-5 days for apixaban. This study seems to think that one day was enough for low risk bleeding, and more than two days for high risk bleeding. Don’t have to stop at all for fecal transplants!

Reg Ana Pain Med 41(2)127

Ted: You like my new jacket, Lou?

Lou: No, I don’t like your new jacket! At this moment, I don’t like your face, your voice, your fingernails, your name! Waddya say to that?

Ted[looks slightly troubled] Would you like it better in green?

29) Prolonged grief disorder is more common in ICU deaths than hospital or home deaths. Other risks include being a female, living alone, close acquaintances that did not have a chance to say good bye, ditto for patients that were incubated and those with poor communication with the medical providers. Please be sensitive to this.

ICM 42:1279

Murray: Ted has been in love ever since he was a baby and saw his reflection in the bathwater.

30) Letters: we got one from Eric Schneider (from where?) who answers our conundrum about  Pseudomonas- what is the pseudo here? Walter Migula coined the term Pseudomonas for a genus he described as, “Cells with polar organs of motility. Formation of spores occurs in some species, but it is rare.” Migula never clarified the etymology of the term. However, the description of Pseudomonas as “false unit” does not make much sense, and an alternative explanation posits that Migula “had not traced directly the Greek ancestry of the name, but had simply created the name Pseudomonas for the resemblance of the cells to those of the nanoflagellate Monas in both size and active motility.” Thank you Eric.. I was frankly surprised that Ken didn’t give this answer, but Ken checked in anyhow to thank me. I always appreciate it, Ken, BTW –where are you now?

31) Yes, in eight it was Mono – EBV can cause this – not clear why. Direct inoculation? EBV has been found on the cervix. Another name for this ulcer is a Lipschutz Ulcer (AJEM 34(7)E1)

EMU LOOKS AT: Pre Eclampsia

The essays this month really have nothing to do with pre eclampsia- rather with subjects related to this malady.  Sources for this essay are Curr Opin Nephro Hypertens 25:301 and Clinics in Derm 34:368

Hypomagnesemia

1) OK, so you used up all the magnesium in the hospital for that eclampsia patient- what about Mrs. Smith with the 0.001 magnesium level in the IM ward?  So this is what you gotta know on low mag- no hormones in the body protect your levels, most o f it is in the cells so it won’t be that easily measured and there are only two ways to get it in and out- the GI tract and the kidneys.

2) It s not like this is going to be obvious when folks are low- they have weakness- never saw that one before in an ED patient- ataxia , cramps, and maybe seizures and rhythm disturbances.

3) Let’s talk about causes- but please recognize this is supposed to be useful and not exhaustive – I absolutely refuse to include genetic causes. Dietary decencies can occur and the bone and other extracellular stores hold on to their magnesium tightly – so there will not be much replenishment from the body like there is with calcium. You can also lose mag by vomiting – but much less than  you lose with diarrhea since the  lower GI tract has a higher concentration of mag. Primary Familial hypomagnesemia –I promised and I am not backing off. We will not talk about this.

4) Pancreatitis will cause this due to saponification The use of PPIs together with a diuretic will also cause low mag through blockage of channels. Hypercalcemia will cause this – due to competition of excretion via the kidney

5) Fluids – such as volume expansion and our favorite fluid – alcohol can cause low mag. Uncontrolled DM results in more mag sent out to the urine. Lastly, hungry bone syndrome, chelation therapy and high fat diets can cause this as well.

6) If you are still confused as to if the source is GI or renal – do a 24 hour urine and check FEMg (UmgX Pcr/(0.7XPmg) xUcr  and times it all by 100%. <2% is GI;>2% is renal.

Our second essay concerns skin infections in pregnancy. As you all know pregnancy is a rampant, sexually transmitted condition which is fortunately self limited. The incidence favors females at the present, but this may change.

There may be one person in the world who doesn’t know who this is- so here is a picture of her in the past: 

1)Let’s start out with the real enemy – the Herpes Zoster virus- the cause of chicken pox which as we all know can be reactivated later in life. Zoster- the reactivated form is not dangerous and requires no antivirals or immunoglobulin for treatment. The fetus is protected by maternal antibodies. This rule is to be disregarded if the virus is disseminated, or in the eye.

2) Now if Mom has never had the chicken pox, but had a significant exposure, then there is danger to the fetus. What is an exposure? Either face to face contacts with a patient suffering from this disease for more than five minutes, living in a house with someone with this disease, or staying in the same room for more than 15 minutes with them. Here you would give passive immunization (immunoglobulin) which in the US is given by injection to the muscle and in Europe- IV. Will it prevent disease in Mom? Yes, in most cases. Will it prevent disease in Junior? Maybe. Maybe there will be a milder disease. We just do not know.

3) Moms who actually get the disease have a harder course – especially in the third trimester. That means higher rates of pneumonia, hepatitis and encephalitis. Uncomplicated case of the pox- used Acyclovir five times a day by mouth. Pneumonia requires IV therapy. Danger to Junior? Only 25% of cases pass on to the fetus, and of those, 1-2% result in congenital Varicella syndrome. What is that? Read on.

4) Congenital Varicella Syndrome is limb problems, eye problems, and in one third – microcephaly, Mortality is 30% in the first few months, but if they make it through, prognosis is good, Give infants acyclovir as well.

5) Infants with Varicella do generally well although the infection may have started when they were still inside.

6) So what about the really young ones- under a month. These kids have a stormy course – without therapy they have a 30% mortality, With therapy – that falls to 10%. If Mom has is in labor – they should try to stop the labor and give immunoglobulin if possible. There is no evidence to say we need to give acyclovir to newborns that were exposed but not showing signs of infection.

7) Condylomata have been in the news lately. This is a virus and can cause what folks call genital warts. They are also the cause of cervical cancer.  In pregnancy they can grow massively. Even better they can get transmitted to kiddies’ anus, genitals, eyes and mouth during delivery. These warts can also trap bacteria leading to infection of the amniotic fluid.  C section may be the answer to the first problem – although it has never been proven. Surgical therapy is the best here and that includes laser and cryo therapy. Podophyllum is toxic for mom and teratogenic for baby.

8) Every doctor has seen a pregnant lady with a yeast infection. Indeed – 50% of pregnant ladies have this problem. These are due to the changes in hormones and pH during pregnancy which favors the fungus. You can use the topical antifungal agents (the “azoles”) but response is slower, and recurrence is more common so you may need a one to two week course of therapy. Note candida albicans yeast infections may be resistant and need amphoteracin B vaginal suppositories which we do not have in Israel. They recommend oral therapy only in severe cases- not clear to me why – after all, problems in offspring have only been seen in high doses for long periods of time – the one time dose that is commonly used poses no problems. We are speaking of course about the pill called fluconazole.

9) Lyme disease – we won’t speak about it – since the incidence is lower in pregnancy and it isn’t to common outside of the USA. They can keep their spirochetes to themselves. What is relevant is that the cyclines- like tetra and doxy – are contra indicated in pregnancy despite being wonderful agents for acne and pneumonia – and Lyme disease too.  They can affect Mom- causing fatty necrosis of the liver.

10) Scabies is yucky and can occur in pregnancy. This mite is best treated with Permethrin. Lindane is not given in pregnancy. This and yeast infections do not cause any adverse pregnancy outcomes but are very annoying. Ivermectin works well, and if you haven’t heard of this medication in Israel (still not approved here) it is still very effective against other yucky bug- lice. However at very high doses – it is teratogenic- but we do not use these dosages generally.

11) We did not get into rubella here since most people are screened for that.

Speak Your Mind

*