The endotracheal use of emergency drugs

The endotracheal route for medication is useful in emergency situations. Epinephrine, atropine, and naloxone have proved to be effective when administered by this route. Experience with lidocaine is largely anecdotal, but the available information and the drug's chemical properties indicate that endotracheal lidocaine may be considered if necessary. Drugs that should not be given by the endotracheal route include bretylium, diazepam, calcium salts, isoproterenol, norepinephrine, and sodium bicarbonate.     

Beta-adrenergic receptor blocking drugs in hypertension. With special reference to their use as initial therapy

Beta-adrenergic receptor blocking agents have been receiving attention as first-line agents for the treatment of hypertension. However, a number of significant side effects of these drugs have been brought to light. The most important of these--increases in "atherogenic" lipid concentrations--may place treated persons at risk of coronary artery disease and myocardial infarction. Other side effects, including bronchospasm, heart failure, cold extremities, reduced insulin secretion and central nervous system effects, may preclude their use in many patients. However, because several major trials have shown that controlling blood pressure reduces the incidence of coronary heart disease and stroke, the use of antihypertensive therapy is likely to increase and to continue for longer periods. The physician must prescribe an agent with the fewest and most minor side effects. Alternatives to beta-blocking drugs, such as the alpha-receptor blocking agent prazosin, should be considered and evaluated because of the limiting side effect profile of beta blockers.     

Informed choice and the widespread use of antiinflammatory drugs

OBJECTIVE: To examine whether the current widespread use of antiinflammatory drugs may reflect a lack of informed choice (i.e., unawareness of adverse effects or potential treatment alternatives) among older patients with knee osteoarthritis (OA). METHODS: Consecutive patients with symptomatic knee OA (n = 100) completed a questionnaire to assess their awareness of drug toxicity. Patients also completed an Adaptive Conjoint Analysis task so that the influence of providing an additional treatment alternative on patient preferences for nonselective nonsteroidal antiinflammatory drugs (NSAIDs) and cyclooxygenase-2 (COX-2) inhibitors could be assessed. RESULTS: Fifty-four percent of the patients surveyed were unaware of any adverse effects related to NSAIDs and 80% were unaware of any toxicity related to COX-2 inhibitors. When given a choice between NSAIDs and COX-2 inhibitors, 57% of patients preferred COX-2 inhibitors over NSAIDs. When presented with a third less effective, but safer alternative, 100% of patients switched preferences to the safer, albeit less effective, option. CONCLUSIONS: Our findings suggest that the widespread use of NSAIDs may reflect lack of informed choice among older patients with OA.     

The use of antiepileptic drugs.

The use of antiepileptic drugs has become increasingly effective through several factors: new techniques that allow better diagnosis of the seizure disorder and its underlying cause; the development of new medications and increased knowledge of old ones; and the widespread use of antiepileptic drug-level determinations. The choice of a drug depends heavily on an accurate diagnosis of seizure type, which may determine the response to the medication. Because of better diagnostic criteria and intensive monitoring procedures, the correct seizure disorder can be more easily diagnosed and, therefore, the proper medication selected. Minimal efficacious and toxic blood concentrations have now been identified for most antiepileptic drugs. Several, including primidone, carbamazepine, methsuximide, and mephenytoin, have pharmacologically active metabolites that affect both the toxicity and efficacy of the prescribed drug and can now be measured in the plasma. The most effective use of the antiepileptic drugs depends on a combination of reliable blood level measurements, clinical observation, and knowledge of their pharmacokinetics and biotransformation.     

Systemic hypertension as a treatable risk factor for cerebrovascular disease

It has long been established that hypertension is the major risk factor for stroke. Three Italian studies have been reviewed in order to examine different aspects of the problem. In the first study, the role played by the systolic, diastolic and systodiastolic components of hypertension in causing atherosclerotic damage of extracerebral and intracerebral arteries was examined. At the extracranial level, a significant correlation between systolic hypertension and atherosclerotic lesions was evident. The second study evaluated the risk of major stroke, myocardial infarction and death in patients with transient ischemic attacks and reversible ischemic neurologic deficits. Possible prognostic predictors of these events were thoroughly considered: Cumulative survival with the multivariate Kaplan-Meier analysis was significantly lower in hypertensive than in normotensive subjects, particularly for cerebral deaths and for all deaths. The third study was aimed at assessing the risk factors for transient ischemic attacks and stroke in young adults. Again, hypertension emerged as a fundamental risk factor, significantly more frequent in the subgroup of older patients than in the younger subgroup.     

抗高血压药物的选择

国内外几个重要的高血压治疗指南(指南)将利尿剂、β-受体阻滞剂、钙通道阻滞剂(CCB)、血管紧张素转换酶抑制剂(ACEI)、血管紧张素Ⅱ受体拮抗剂(ARB)以及α-受体阻滞剂作为一线抗高血压药物。六大类抗高血压药物的广泛应用，使高血压治疗及控制状况得到改观，大大降低了全球心血管病发生和死亡的危险。但目前如何正确选择及合理使用抗高血压药物，更大程度地使高血压患者从抗高血压药物治疗中获益，是我们今后面临的重要任务之一。     

New drugs for the treatment of hypertension.

Despite the many outstanding favorable results achieved in the treatment of hypertension, several unmet goals of antihypertensive therapy remain, such as better blood pressure control, greater protection against the organ damage associated with hypertension, better tolerability, and ultimately a more effective prevention of cardiovascular disease. These unmet goals are the reasons why new antihypertensive drugs are synthesized and tested in the clinical practice. This paper briefly mentions the goals of new antihypertensive agents and examines the main pharmacological and clinical features of new classes of antihypertensive drugs, such as angiotensin II receptor blockers, central agents, vasopeptidase inhibitors, and endothelin antagonists. The results of experimental and clinical studies with these new drugs are reviewed, emphasizing some advantages and potential disadvantages of these drugs compared with traditional antihypertensive drugs.     

Blood pressure control and physician management of hypertension in hospital hypertension units in Spain

Goal blood pressure (BP) was defined by the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-VI) and the World Health Organization-International Society of Hypertension (WHO/ISH) as <140 mm Hg systolic and <90 mm Hg diastolic for the general and <130 mm Hg systolic and <85 mm Hg diastolic for special high-risk populations. However, there are few reports that address BP control among special subgroups of hypertensives by reference to targeted BP. We therefore conducted a study to evaluate BP control of 4049 hypertensives in 47 hospital-based hypertension units in Spain. Overall, 42% of patients achieved goal BP (<140 mm Hg systolic and <90 mm Hg diastolic). Only 13% of diabetic patients and 17% of those with renal disease achieved the BP goal (<130 mm Hg systolic and <85 mm Hg diastolic), and only 10% and 12%, respectively, achieved the even more rigorous goal (<130 mm Hg systolic and <80 mm Hg diastolic). Likewise, only 18% of patients in JNC-VI risk group C and 17% of WHO/ISH high-risk patients attained a goal BP <130 mm Hg systolic and <85 mm Hg diastolic. BP control (<125 mm Hg systolic and <75 mm Hg diastolic) was extremely low (2%) in patients with proteinuria >1 g/d. Poorer BP control was observed among patients at high risk, with diabetes, renal disease, or obesity, than in lower-risk groups. BP control was lower for systolic than for diastolic BP. In >50% of uncontrolled patients, no measures were taken by doctors to optimize pharmacologic treatment, and approximately one-third of patients were still using drug monotherapy. Control of BP, particularly of systolic BP, is still far from optimal in hospital-based hypertension units. Patients at high risk, with diabetes or proteinuria, warrant focused attention. Moreover, a more aggressive behavior of doctors treating uncontrolled hypertension is needed.     

The emergency management of moray eel bites.

As human encounters with hazardous marine life increase, emergency physicians are more frequently confronted with the management of resultant injuries. We present three cases involving hand injuries inflected by moray eels. Each was managed with local wound care and subsequent outpatient treatment with either oral ciprofloxacin or cefuroxime. One patient had mild residual hand dysfunction, and no patient developed wound infection. To better assess the bacteriology of such injuries, oral cultures were taken from captive moray eels and surrounding aquarium water. Culture and sensitivity analyses showed Vibrio and Pseudomonas to be the predominant species, both sensitive to ciprofloxacin, cefuroxime, tetracycline, and trimethoprim-sulfamethoxazole. We conclude that moray eel bites can be managed successfully with aggressive, local wound care and antibiotic coverage that targets Vibrio and Pseudomonas species.     

Biologic drugs as analgesics for the management of osteoarthritis

BackgroundBiologic drugs are novel therapeutic agents with demonstrated effectiveness in the management of a variety of chronic inflammatory disorders. Unmet needs in the treatment of chronic pain have led physicians to utilize a similar approach to patients suffering from conditions not characterized by systemic inflammation such as osteoarthritis (OA). The aim of this review is to discuss the current knowledge on the use of commonly used biologic agents [i.e., anti-tumor necrosis factor alpha (anti-TNF alpha) and anti-nerve growth factor (anti-NGF)] for the management of OA.MethodsA narrative literature review of studies investigating the use of biologic agents for the management of osteoarthritis was conducted. We searched MEDLINE and EMBASE for English language publications. A hand-search of reference lists of relevant studies was also performed.ResultsCurrent evidence does not support TNF-alpha inhibition for the management of OA, although a selected subgroup of these patients with a marked inflammatory profile may benefit from this therapy. Anti-NGF therapy has been shown to reduce pain and improve function compared to placebo and non-steroidal anti-inflammatory drugs in OA but concerns remain regarding the safety of such treatment. The discrepant results observed in RCTs of biologic agents may be related to heterogeneity, small sample sizes, and differences in the mode of administration of these drugs.ConclusionAnti-NGF therapy is efficacious for pain in patients with hip and knee OA. Despite the fact that current data suggests that anti-cytokine treatments have limited efficacy in patients with chronic osteoarthritic pain, larger and better designed studies in more selected populations are justified to determine whether such therapeutic approaches can improve outcomes in this disabling condition where our medical treatment armamentarium is relatively poor.