EMU Monthly – November 2005

1)    Nesiritide is being heavily marketed here in Israel as a treatment for CHF, but this drug has been shown to increase mortality and length of stay in the hospital when compared with nitroglycerine. While there are many articles now out on this subject, I wanted our database to include at least one (Circ 29 Mar 05)

2)    Are antiseptics better than tap water for cleansing wound? The EMJ says there is not enough evidence to say, the Annals says yes, and this article- well done for an obscure journal -reports that acute wound fluid is stimulatory to cell movement and proliferation, and therefore, the minimum to clean the wound should be done. The article also mentions that iodine salts (Betadine, Polydine) do kill host’s cells, but there is not clinical difference. ( J of the Amer Pod Med Assoc Mar/Apr 05). What I do is use saline as a spray on dirty wounds, but do the minimum on clean wounds (like a kitchen knife that was cutting a tomato) and I believe that wounds that bleed freely usually need very little cleansing. The article doesn’t discuss whether antiseptics really help lower infection rates- this seems obvious but has never been tested.

3)    Do STDs travel together? Well, Chlamydia is always a tough call and PCRs for this are becoming cheaper but still unavailable. This study makes an important statement in saying that Trich and Chlamydia/Gonorrhea do not have an association, but it suffered from retrospective design and from incorporation bias, so it is hard to tell (AJEM Mar 05). Gonorrhea should always have co treatment in my opinion for Chlamydia as well, and Syphilis should be considered as well. I have heard that Trich may hang out at Mikvas- anyone know anything on that?

4)    In the USA they do not have Tranxemic Acid (Hexacapron) an antifibrinolytic, and this stuff does work to stop bleeding in SAH, but it does not change outcome (perhaps since outcome is so bad no matter what). (EMJ 1 Apr 05) I find that using this medication helps a lot in nosebleeds and bleeding arterioles. You should be aware that Novo 7 is being heavily marketed for similar indications and it costs thousands of Dollars per dose. A study on Hexacapron in trauma is being done in Europe (The CRASH study, see Feb 05 IJEM), but Israel will not take part, as all the trauma centers have been signed up to study Novo 7 instead for the same indication (Personal Communication D. Simon, Trauma Director, Sheba)

5)    Etomidate is very expensive in Israel, although propofol is cheap, but Etomidate causes much less hypotension and respiratory depression. However, even a single dose causes blunting of the adreno cortical axis, and while it is not clear how clinically significant that is, it may be another good reason to give 100 mg of hydrocortisone for people in septic shock who have been intubated using this agent. (Chest Mar 05) I believe, as well as my peer reviewer that this drug should still be considered the first line agent in intubation, if – of course- cost is not an issue.

6)    Antipsychotics are problematic. While we reported about that increased death rate with atypical antipyschotics in the elderly with dementia (JAMA 293), the conventional ones cause more hospitalization for ventricular arrhythmias and cardiac arrest. (Arch Int Med 28 Mar 05). Since this study did not find the same with conventional ones, seems the mechanism is different in the atypicals. Atypicals also cause diabetes and weight gain

7)    It is not very specific and it will miss those microinfarcts (i.e. CK/MB negative and troponin positive), but lactate is highly sensitive for acute MI- rising in two hours. While they only looked at 718 patients of which 64 were MI s and they did not compare with myoglobin- Ian Stiel is behind the article and his work is always superlative. In some facilities- like Sheba- you get this marker automatically when you order a venous blood gas. (AEM Feb 05)

8)    Another study trashing antispasmodics- glycopyrrolate failed to treat biliary pain- it performed so poorly that the study had to be stopped early. (Ann Emerg Med Feb 05) We have previously – many years ago brought an article in the same journal that stated how poorly papaverine performed, yet they use this medication like water in Israel. NSAIDs are still the best for stones of all kinds.

9)    We mentioned that not all antibiotics cause the same rate of resistance and this was an idea put for the by Burke Cunha from Winthrop Hospital in New York. The best example is the elderly antibiotic doxycycline, which has remained effective for it’s indications for years. This article speaks about this and confirms this thought (Lancet 12 Feb 05)

10)Airbags have caustic chemicals inside that can cause serious burns- even through clothing, as well as causing an irritant dermatitis. Corneal burns with this alkali substance have been documented, and copious irrigation of all burns is recommended. (AJ Clin Derm May 05) New airbags have been designed that expand slower as to cause less mechanical injuries (Plast Recon Surg Feb 05 and AJEM- how the same article got published twice, I do not know)

 

 

EMU LOOKS AT: Avian Flu and Stroke

 

A first for EMU- two essays in one month. Avian flu is a hot topic, but the best review came out in the NEJM 29 Sept 05, and many of you read it already. If you didn’t, I will summarize it below. If you did, skip forward to my summary of the AHA Scientific Statement on the update to it’s guidelines on stroke from 2003. You can find this update in the journal called Stroke, Apr 05

 

AVIAN FLU:

 

1) You need contact with a bird at this point to get this disease; it spreads poorly from person to person. Contact means handling ill birds, eating undercooked poultry, plucking or preparing birds for cooking, but not eating store bought eggs or cooked chicken.   While all deaths from this disease (there have been about 130 cases with 61 deaths) have been in the Far East, the disease has now spread to Russia, Rumania and Croatia, with one diseased imported parrot found in England. Israel has no cases as of this printing, and has agreed in priciniple with Jordan to cooperate to halt its spread (Yahoo News 24 Oct 05) The chief fear is that the virus will mutate to be able to easily infect humans.

 

2) Good luck diagnosing this disease. Most will have fever, signs of-you guessed it- influenza type syndrome with lower respiratory tract symptoms. There can be diarrhea, and abdominal pain. Almost all patients look like they have pneumonia clinically; x rays usually show some form of infiltrate. Leukopenia and lymphopenia are common. As you can see, not an easy diagnosis. As opposed to other flus, throat culture for this is better than nasal samples. Nasal cannulas and high flow masks can spread this disease.

 

3) Bad flu deteriorates to intubation within 48 hours. In vitro sensitivity exists with the new antivirals oseltamir (Tamiflu) and zanamivir. Higher than normal doses may be needed. These medications are being stockpiled. Curiously, Amantadine and rimantidine- classic antivirals that are much cheaper are ineffective. Steroids and interferon have not been studied enough.

 

STROKE UPDATE:

 

1)    Clearly for TIA and stroke MRI is the best test- even medical students picked up bleeding with a sensitivity of 95%. This might be important in the setting of microhemorrhage before starting TPA, but it isn’t clear to me that this is indeed a contraindication if the vessel is small.

2)    Lowering blood pressure is still not recommended routinely, but if you need to, candesartan (Atacand in Israel) may perform the best. They still like labetolol when the blood pressure is too high (they call that systolic greater than 220, but no evidence for this), but this drug causes seizures in dogs with cocaine induced hypertension, so??? Could it be just because of cocaine??

3)    TPA – see Leibman in IJEM, Feb 05. Some updates- aspirin does not increase bleeding after tPA. TPA- when it works, works in all subtypes of stroke, so pinpointing what type of stroke (large artery, cardioembolism, etc) is not necessary. Will more than 3 hours help? – They think it might. Doppler studies show fast reocclusion after tPa-one third reocclude. INR of up to 1.7 is not a contraindication to the use of tPa. I’d like to add these pieces of interesting but still not proven information Abciximab in a small study worked, (Stroke, same issue), and Doppler rays have been used to open up occluded arteries in a tiny study (Neuro 22 Mar 05)

4)    Anticoagulation- despite helping in MI is still not recommended in stroke.

5)    Aspirin acutely has very modest effects

6)    Volume expansion and inducing hypertension is called a therapy with promise. It seems to help in SAH.   A little to gutsy for me-yet.

7)    Neruoprotective agents- still waiting for that magic bullet!

8)    Good nutrition is stressed, but still nothing about stroke units, which is the real panacea for stroke at this point.

All the best

 

 

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