Obidoxime in Acute Organophosphate Poisoning: 1 – Clinical Effectiveness: Eyer F, Worek F, Eyer P,...
1
the study may not represent STEMI treatment in smaller com- munity hospitals where patients may be less likely to receive re- perfusion therapy. Consequently, this study may under-report the percentage of patients who do not receive reperfusion therapy. The authors identified factors associated with lack of reperfusion therapy and advocate that contraindications to re- perfusion therapy should be better defined. Although some hos- pitals, especially those without cardiac surgical services, could benefit from better reperfusion protocols, the absolute and rela- tive contraindications to fibrinolysis are well defined. Regard- less of well- or better-defined contraindications to PCI and fibrinolysis, clinical judgment in deciding against reperfusion therapy will always play a role, as the overall health-benefit- to-risk ratio should be discussed by the clinicians and family. , INSURANCE STATUS IS A POTENT PREDICTOR OF OUTCOMES IN BOTH BLUNT AND PENETRATING TRAUMA. Greene WR, Oyetunji TA, Bowers U, et al. Am J Surg 2010;199:554–7. This retrospective study addressed the relationship between insurance status and mortality from trauma. The authors ana- lyzed mortality after trauma for patients in the National Trauma Data Bank from 2002–2006. Patients aged 65 years and older, burn patients, and those with incomplete insurance information were excluded, leaving 920,269 patients who met inclusion cri- teria. Seventy percent of the patients examined had insurance and the vast majority (86.3%) had a blunt mechanism of trauma. Overall, 69.4% of the patients were male, 62.5% were white, 17.4% were black, 13.1% were Latino, and 7% had other ethnic backgrounds. The penetrating trauma group had a higher pro- portion of minorities than the blunt trauma group. Mortality was 3.7% for all patients, but was significantly higher for pene- trating trauma patients than for blunt trauma patients (7.9% vs. 3.0%; p < 0.001). Black, Latino, and Asian-American patients had higher death rates than whites overall. The authors also found that mortality was higher for uninsured patients than for insured patients (5.3% vs. 3.2%; p < 0.001). This pattern persisted when mechanism of injury was taken into account. Mortality for insured patients with blunt trauma was 2% and with penetrating trauma was 5%, whereas mortality for unin- sured patients with blunt and penetrating trauma was 4% and 11%, respectively. The authors specifically analyzed young peo- ple (age 18–30 years) as well and found that this pattern per- sisted, indicating that insurance status plays a role in mortality independent of age and comorbidities. Based on these results, the authors conclude that insurance status strongly influences mortality in trauma. They suggest several possible explanations for this finding, including lower socioeconomic status and more lethal mechanisms of injury (such as gunshot wounds) among uninsured patients. [Ian Tate, MD Denver Health Medical Center, Denver, CO] Comment: As the authors note, this study shows that even a field as protocol-driven as trauma care suffers from worse out- comes among uninsured patients. Although its findings are im- portant and disturbing, this study only begins to explain why such a disparity exists. In particular, further analysis is needed to determine if insurance status itself affects care or is simply a marker for low socioeconomic status and poor health. , OBIDOXIME IN ACUTE ORGANOPHOSPHATE POISONING: 1 – CLINICAL EFFECTIVENESS. Eyer F, Worek F, Eyer P,et al. Clin Toxicol (Phila) 2009;47:798–806. This was an observational study examining the clinical ef- fectiveness of obidoxime in acute organophosphate poisoning. Patients for the study were identified from hospitals in Germany through a national toxicology center. Inclusion criteria were pa- tients with a history of organophosphate intake or with clinical signs and symptoms of organophosphate poisoning. Exclusion criteria were patients under age 18 years and pregnant women. Emergency physicians performed initial resuscitation and treat- ment with atropine. Obidoxime was administered with a 250- mg intravenous bolus followed by a continuous infusion of 750 mg/day, which was stopped after levels of acetylcholines- terase (AChE) steadily increased. All patient care, both in the initial resuscitation and in the intensive care unit, other than obi- doxime administration, was not controlled for. Laboratory values that were measured included: RBC-AChE in vivo, which was used to estimate synaptic AChE; RBC-AChE in vitro, which measured the ‘‘reactivatability’’ of the inhibited enzyme, obidoxime concentration, and organophosphate concentration. Thirty-four cases of organophosphate poisoning were enrolled and, despite maximal therapy, mortality was high (7/34). The authors do note that the time to mortality was prolonged with the use of obidoxime and that the use of the agent was safe in all patients, with no organ dysfunction noted in any patient who received the drug. [Colleen Foster, MD Denver Health Medical Center, Denver, CO] Comments: This was a preliminary, observational study to test the safety and efficacy of obidoxime. In this small trial the drug does seem to be safe, but it remains to be determined if it offers any benefit over the current therapy in terms of out- comes, be they biochemical or otherwise. Further prospective studies with comparison groups receiving pralidoxime will be necessary to assess this. , TACHYPNEA A POOR PREDICTOR OF PNEUMO- NIA IN CHILDREN. Shah S, Bachur R, Kim D, et al. Pediatr Infect Dis J 2010;29:406–9. Tachypnea is included in the assessment of pneumonia in pa- tients of all ages. The World Health Organization (WHO) has recommended the use of tachypnea in children as a proxy to the diagnosis of pneumonia in resource-poor settings. Previous studies report detecting more than 80% of children in the devel- oping world who require antibiotic treatment of bacterial pneu- monia using the WHO guidelines, however, the utility of using tachypnea to assess for pneumonia in a modern and readily accessible medical system is unclear. This prospective observa- tional study sought to assess the association between tachypnea and pneumonia in a single academic pediatric emergency 534 Abstracts
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Transcript of Obidoxime in Acute Organophosphate Poisoning: 1 – Clinical Effectiveness: Eyer F, Worek F, Eyer P,...
534 Abstracts
the study may not represent STEMI treatment in smaller com-munity hospitals where patients may be less likely to receive re-perfusion therapy. Consequently, this study may under-reportthe percentage of patients who do not receive reperfusiontherapy. The authors identified factors associated with lack ofreperfusion therapy and advocate that contraindications to re-perfusion therapy should be better defined. Although some hos-pitals, especially those without cardiac surgical services, couldbenefit from better reperfusion protocols, the absolute and rela-tive contraindications to fibrinolysis are well defined. Regard-less of well- or better-defined contraindications to PCI andfibrinolysis, clinical judgment in deciding against reperfusiontherapy will always play a role, as the overall health-benefit-to-risk ratio should be discussed by the clinicians and family.
, INSURANCE STATUS IS A POTENT PREDICTOROFOUTCOMES IN BOTH BLUNT AND PENETRATINGTRAUMA. Greene WR, Oyetunji TA, Bowers U, et al. Am JSurg 2010;199:554–7.
This retrospective study addressed the relationship betweeninsurance status and mortality from trauma. The authors ana-lyzed mortality after trauma for patients in the National TraumaData Bank from 2002–2006. Patients aged 65 years and older,burn patients, and those with incomplete insurance informationwere excluded, leaving 920,269 patients who met inclusion cri-teria. Seventy percent of the patients examined had insuranceand the vast majority (86.3%) had a blunt mechanism of trauma.Overall, 69.4% of the patients were male, 62.5% were white,17.4% were black, 13.1% were Latino, and 7% had other ethnicbackgrounds. The penetrating trauma group had a higher pro-portion of minorities than the blunt trauma group. Mortalitywas 3.7% for all patients, but was significantly higher for pene-trating trauma patients than for blunt trauma patients (7.9% vs.3.0%; p < 0.001). Black, Latino, and Asian-American patientshad higher death rates than whites overall. The authors alsofound that mortality was higher for uninsured patients than forinsured patients (5.3% vs. 3.2%; p < 0.001). This patternpersisted when mechanism of injury was taken into account.Mortality for insured patients with blunt trauma was 2% andwith penetrating trauma was 5%, whereas mortality for unin-sured patients with blunt and penetrating trauma was 4% and11%, respectively. The authors specifically analyzed young peo-ple (age 18–30 years) as well and found that this pattern per-sisted, indicating that insurance status plays a role in mortalityindependent of age and comorbidities. Based on these results,the authors conclude that insurance status strongly influencesmortality in trauma. They suggest several possible explanationsfor this finding, including lower socioeconomic status and morelethal mechanisms of injury (such as gunshot wounds) amonguninsured patients.
[Ian Tate, MD
Denver Health Medical Center, Denver, CO]
Comment: As the authors note, this study shows that evena field as protocol-driven as trauma care suffers from worse out-comes among uninsured patients. Although its findings are im-portant and disturbing, this study only begins to explain why
such a disparity exists. In particular, further analysis is neededto determine if insurance status itself affects care or is simplya marker for low socioeconomic status and poor health.
, OBIDOXIME IN ACUTE ORGANOPHOSPHATEPOISONING: 1 – CLINICAL EFFECTIVENESS. Eyer F,Worek F, Eyer P, et al. Clin Toxicol (Phila) 2009;47:798–806.
This was an observational study examining the clinical ef-fectiveness of obidoxime in acute organophosphate poisoning.Patients for the study were identified from hospitals in Germanythrough a national toxicology center. Inclusion criteria were pa-tients with a history of organophosphate intake or with clinicalsigns and symptoms of organophosphate poisoning. Exclusioncriteria were patients under age 18 years and pregnant women.Emergency physicians performed initial resuscitation and treat-ment with atropine. Obidoxime was administered with a 250-mg intravenous bolus followed by a continuous infusion of750 mg/day, which was stopped after levels of acetylcholines-terase (AChE) steadily increased. All patient care, both in theinitial resuscitation and in the intensive care unit, other than obi-doxime administration, was not controlled for. Laboratoryvalues that were measured included: RBC-AChE in vivo, whichwas used to estimate synaptic AChE; RBC-AChE in vitro,which measured the ‘‘reactivatability’’ of the inhibited enzyme,obidoxime concentration, and organophosphate concentration.Thirty-four cases of organophosphate poisoning were enrolledand, despite maximal therapy, mortality was high (7/34). Theauthors do note that the time to mortality was prolonged withthe use of obidoxime and that the use of the agent was safe inall patients, with no organ dysfunction noted in any patientwho received the drug.
[Colleen Foster, MD
Denver Health Medical Center, Denver, CO]
Comments: This was a preliminary, observational study totest the safety and efficacy of obidoxime. In this small trialthe drug does seem to be safe, but it remains to be determinedif it offers any benefit over the current therapy in terms of out-comes, be they biochemical or otherwise. Further prospectivestudies with comparison groups receiving pralidoxime will benecessary to assess this.
, TACHYPNEA A POOR PREDICTOR OF PNEUMO-NIA IN CHILDREN. Shah S, Bachur R, Kim D, et al. PediatrInfect Dis J 2010;29:406–9.
Tachypnea is included in the assessment of pneumonia in pa-tients of all ages. The World Health Organization (WHO) hasrecommended the use of tachypnea in children as a proxy tothe diagnosis of pneumonia in resource-poor settings. Previousstudies report detecting more than 80% of children in the devel-oping world who require antibiotic treatment of bacterial pneu-monia using the WHO guidelines, however, the utility of usingtachypnea to assess for pneumonia in a modern and readilyaccessible medical system is unclear. This prospective observa-tional study sought to assess the association between tachypneaand pneumonia in a single academic pediatric emergency
