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1661. Drotrecogin alfa (activated) should not be used in patients with severe sepsis and low risk for death Full Text available with Trip Pro

to antibiotics ▪ Early broad-spectrum antibiotics ▪ Narrowing antibiotic therapy based on microbiology and clinical data ▪ Source control ▪ Stress-dose steroids for septic shock ▪ DrotAA for patients with severe sepsis and high risk for death ▪ Target hemoglobin values of 7–9 g/dL in absence of coronary artery disease or acute hemorrhage ▪ Lung protective ventilation for ALI/ARDS ▪ Semirecumbent bed position ▪ Protocols for weaning and sedation/analgesia ▪ Avoidance of neuromuscular blockers ▪ Maintenance

2006 Critical Care - EBM Journal Club

1662. Dexamethasone in Benign Headaches

. Unfortunately, this desire to help our patients has often led us to wide-scale adoption of treatments that were used in thousands of patients before ultimately being proven unsound. Allow me to point to some historical treatments, such as steroids in septic shock, aminophylline in status asthmaticus, prophylactic lidocaine in acute MI, eye patching for corneal abrasion, the pneumatic anti-shock garment in hemorrhagic shock, forced IV fluids for ureteral stones, magnesium in acute MI, antibiotics for acute

2007 Sinai EM Journal Club

1663. The Paining, Part I (Morphine in acute abdomen)

from 98 to 65, on average, whereas the placebo group went from 99 to 97. Diagnostic discordance occurred 11 times in each group, meaning that accuracy wasn’t affected by analgesia. The dictum to avoid analgesia in abdominal pain dates to a 1921 proclamation by Sir Zachary Cope — a good example of emminence-based medicine. Maybe this warning was appropriate in the age before antibiotics and CT scanners, but we now have eleven trials in the last twenty years showing that Cope doesn’t cut

2006 Sinai EM Journal Club

1664. pegfilgrastim

, there was no difference between the two formulations of filgrastim in mortality, hospitalization rates, development of serious neutropenia, median time to recovery of absolute neutrophil count, febrile neutropenia during a cycle of chemotherapy, rate of antibiotic use, dose intensity of chemotherapy, or adverse reactions. • Four of the five RCTs reported no statistically significant difference in the number of patients having febrile neutropenia in any single treatment cycle. One RCT also reported no statistically (...) stimulating factors should be reviewed as a “class”. Of interest to the committee is the impact of filgrastim on the proportion of patients receiving intravenous antibiotics, infection-related hospitalization, infection-related mortality, complete tumor response, overall hospitalization and overall survival. 2. Because pegfilgrastim and filgrastim are of similar efficacy, and the relative cost of the two drugs depends upon the dose and length of use of filgrastim, it is recommended that funding

2004 Canadian Agency for Drugs and Technologies in Health - Common Drug Review

1665. Coartem (artemether/lumefantrine)

Coartem (artemether/lumefantrine) CENTER FOR DRUG EVALUATION AND RESEARCH APPLICATION NUMBER: 22-268 MEDICAL REVIEW(S) REVIEW OF REQUEST FOR PRIORITY REVIEW To: Edward Cox, MD, MPH Director, Office of Antimicrobial Products Through: Renata Albrecht, M.D Director, DSPTP, OAP From: Joette M. Meyer, Pharm.D. Acting Medical Team Leader, DSPTP, OAP NDA: 22-268 Submission Date: 6/27/08 Date Review Completed 7/25/08 Product: Coartem (artemether/lumefantrine) Sponsor: Novartis Pharmaceuticals

2008 FDA - Drug Approval Package

1669. Neutropenic Precautions Demystified

of antimicrobial prophylaxis and systemic growth factors? Typical strategies to prevent infection among neutropenic patients have included a protective environment, dietary constraints, and protective clothing. With the resource burden associated with maintaining protective measures, there are surprisingly few studies systematically monitoring infection rates in neutropenic patients. In the early eighties, investigators studied the effect of laminar airflow and HEPA filtration in decreasing the rates (...) ]. It is important to note that although the majority of deaths from leukemia and solid tumors are related to infection secondary to neutropenia, the majority of infections are a result of translocation of microbial flora, largely from the patient’s gastrointestinal tract [10,11]. It has been shown that suppression of the patient’s endogenous flora with prophylactic antibiotics has the best outcome, regardless of whether the patient has received standard ward care or has been treated in a protected environment

2008 Clinical Correlations

1670. Grand Rounds: Regulation of Mammalian Iron Metabolism Reveals a Link to Inflammation

are phagocytosed by macrophages which provides 20-30 mg of iron/day. Iron entry into plasma is regulated through hepcidin. Hepcidin is a small 25 amino acid protein, which is a member of the defensins family of antimicrobial peptides. It is secreted primarily by hepatocytes. Hepcidin synthesis is increased in periods of inflammation, and decreased in hypoxia and anemia. In mice and humans, deletion of the hepcidin gene, HAMP, results in iron overload, and over-expression of HAMP causes anemia, indicating

2008 Clinical Correlations

1671. Grand Rounds: Pseudomonas aeruginosa Pathogenesis-Studies of an Opportunist

quorum sensing signals. Other bacterial virulence factors, such as flagella that enable movement, are also downregulated during chronic persistence, limiting immune detection and host clearance of Pseudomonas . Understanding the pathogenesis of this organism in acute and chronic forms of infection has important clinical implications. Bacteria are increasingly becoming more resistant to our antibiotic armamentarium, especially Pseudomonas , necessitating newer agents designed to target vulnerable

2007 Clinical Correlations

1672. Grand Rounds: Bacterial Meningitis

observations have led to the use corticosteroids in bacterial meningitis, with the thinking that they could attenuate the breach of the blood-brain barrier. In a large clinical trial in the Netherlands, adjunctive dexamethasone reduced mortality and morbidity, but the overall effect appeared limited to those with S. pneumoniae disease and those with Glasgow Coma Scale of <11. Current recommendations for empiric treatment of bacterial meningitis require bactericidal antibiotics. For immunocompetent adults (...) with suspected bacterial meningitis, the recommendations are Ceftriaxone plus Vancomycin (+Ampicillin if age >60 since Listeria is considered in this age group); however, if corticosteroids are given then Rifampin is recommended in place of Vancomycin, because dexamethasone inhibits the penetration of vancomycin, but not rifampin, into the CSF. In immune deficient or neurosurgical patients, double coverage of gram-negative organisms is necessary. In summary: 1. An LP and initiation of antibiotics should

2008 Clinical Correlations

1673. Grand Rounds: 10 Moveable Objects

of medical education. Another problem with graduate medical education addressed by Dr. Wiese includes how to more effectively determine patient caps. He suggests basing caps on a modified APACHE score as opposed to hard numbers. He also referred to “Patient Emeritus Services,” whereby patients hospitalized for long-term are grouped according to need, i.e. antibiotic administration, and are managed by Nurse Practitioners rather than housestaff in order to unburden resident teams and improve

2008 Clinical Correlations

1674. What Is Sezary Syndrome?

therapy. Her rash progressed to a diffuse pruritic erythema covering the vast majority of her body, including palms and soles. (erythroderma). She was noted to have Sezary cells on peripheral smear and diagnosed with Sezary syndrome. She was now admitted to TH with fevers likely secondary to cellulitis on her lower extremities, the site of significant skin breakdown. The patient is improving on treatment with IV antibiotics and interferon alpha. (image courtesy of ) Teaching Points: 1. What is Mycosis

2006 Clinical Correlations

1675. Some say tomato, some say nationwide outbreak of Samonellosis

. Given that the disease is self-limited, antibiotic treatment is usually not indicated unless the patient is severely ill, immunocompromised, or at either end of the age spectrum. Any patients who present to their physician’s office with diarrhea and stomach cramps and who report a history of fresh tomato consumption should have stool cultures sent. All specimens positive for clinical Salmonella isolates should be forwarded to the NYC DOHMH. Share: | | Sites We Follow: Useful Links: Questions

2008 Clinical Correlations

1676. Clinical Pharmacy Corner: Sulfonamide Allergy and Cross-Reactivity

. We must remain informed but know that may more life-years will be saved with these medications than will be lost from adverse effects. I think the nature of the reaction is important. A reaction like anaphylaxis, urticaria and shortness of breath with Sulfur antibiotic is more worrisome. Mild reactions are not an absolute contraindications to topical use of agents such as dorzolamide or brinzolamide which do not carry risk of mortality. Comments are closed. Sites We Follow: Useful Links

2007 Clinical Correlations

1677. Case Presentation: Acute Rheumatic Fever

, and diffuse myalgias. There was no associated cough. Three days later, he visited his primary care physician at an outside facility and was prescribed penicillin 500 mg twice daily for presumed streptococcal pharyngitis. Five days later, he presented to the emergency room of an outside hospital and stopped his antibiotics after a throat culture there was negative for beta-hemolytic strep. The following morning, the patient awoke in the middle of the night with severe left-sided chest pain and presented (...) 5 days after the initial TTE showed improved left ventricular wall motion, and the patient was discharged home with instructions to receive monthly intramuscular injections of penicillin G benzathine 1.2 million units for five to ten years. Prior to his discharge, contact with his outside primary care physician confirmed that his initial culture prior to starting antibiotics was positive for group A beta-hemolytic streptococcus. Discussion: Acute rheumatic fever (ARF) is a delayed, non

2008 Clinical Correlations

1678. New Drugs VIII ? Telithromycin (Ketek®), Ezetimibe (Ezetrol®), Topical Pimecrolimus (Elidel®), and Tacrolimus (Protopic®)

) Approved indications: Community-acquired pneumonia (mild to moderate) (CAP), acute bacterial exacerbation of chronic bronchitis (AECB), and tonsillitis/pharyngitis (patients intolerant to beta-lactam antibiotics). Mechanism of action: Telithromycin is a synthetic derivative of erythromycin, with a mechanism of action and spectrum of antibiotic sensitivity and resistance similar to other macrolide antibiotics. Pharmacokinetics: Telithromycin is 60% bioavailable by mouth and widely distributed throughout

2004 Therapeutics Letter

1679. Levofloxacin for acute bacterial sinusitis

and signs suggesting bacterial, as opposed to viral sinusitis include purulent nasal discharge in combination with facial pain and maxillary toothache, facial swelling and tenderness. Most diagnoses are based on history and physical examination as opposed to laboratory cultures and sinus xrays, which are considered unreliable. Drug (Product Monograph) Category: Levofloxacin is a fluoroquinolone class, broad-spectrum antibacterial agent. It is the L- isomer of the racemate, ofloxacin. Mechanism of Action (...) for 5 days (short-course therapy). Methodology of Systematic Review Research Question: In double blind randomized controlled trials (DB RCTs), does levofloxacin (normal or short-course of therapy) provide a significant therapeutic advantage in terms of mortality or morbidity when compared to other fluoroquinolones or other classes of antibacterial agents in the treatment of adult patients ≥ 18 years of age with acute bacterial sinusitis? Assessment principles: Double blind randomized controlled

2008 Therapeutics Letter

1680. Moxifloxacin for acute bacterial sinusitis

and signs suggesting bacterial, as opposed to viral sinusitis include purulent nasal discharge in combination with facial pain and maxillary toothache, facial swelling and tenderness. Most diagnoses are based on history and physical examination as opposed to laboratory cultures and sinus xrays, which are considered unreliable. Drug (quoted from Product Monograph) Category: Moxifloxacin is a fluoroquinolone class, broad-spectrum antibacterial agent. Mechanism of Action: moxifloxacin exerts its action (...) moxifloxacin provide a significant therapeutic advantage in terms of mortality or morbidity when compared to other fluoroquinolones or other classes of antibacterial agents in the treatment of adult patients ≥ 18 years of age with acute bacterial sinusitis? Assessment principles: Double blind randomized controlled trials comparing moxifloxacin to other fluoroquinolones or other classes of antibacterial agents in adult patients with acute bacterial sinusitis will be critically appraised. Therapeutic impact

2008 Therapeutics Letter

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