Physiologically-based pharmacokinetic simulations of ciprofloxacin in obese and renally impaired individuals Stefan Willmann 1), Walter Schmitt 1), Heino Stass 2), Gertrud Ahr 2), Andrea N. Edginton 1) 1) Systems Biology, Bayer Technology Services GmbH, Leverkusen, Germany2) Clinical Pharmacokinetics, Bayer HealthCare AG, Wuppertal, Germany INTRODUCTION Ph
D:\documents\charlotte\stjohnambulance\training\hcptraining\journalclub\02_february2011.wpdSouth and West Yorkshire
Journal Club - February 2011
If you read any useful articles, please send the reference to firstname.lastname@example.org, preferably with a one line summary too - and then it will be included.
The aim is to send a bulletin every month, after the HCP training session. Comments and feedback welcomed. Articles are randomly included in here- inclusion does not imply agreement with thefindings or the research method - and is not an endorsement. The author accepts noresponsibility for any misleading summaries. People have always debated whether or not giving analgesia before assessingabdominal pain masks signs or not. The more compassionate of us believeanalgesia comes first - looks like we’re right and the use of opiate analgesiadoes not increase the risk of diagnostic errors. Analgesia in patients with acute abdominal pain (review) Manterola C, Vial M, Moraga J, Astudillo P http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD005660/frame.html Whilst we’re on the subject of pain, our local anaesthetics often cause pain.
Perhaps we should consider increasing the pH of our lidocaine (by addingbicarb) to reduce the pain of injection. Maybe not. Adjusting the pH of lidocaine for reducing pain on injection (Review) Cepeda MS, Tzortzopoulou A, Thackrey M, Hudcova J, Arora Gandhi P, Schumann R http://www.library.nhs.uk/Emergency/ViewResource.aspx?resID=396818 Croup season has nearly finished, but when it comes back it might be worthconsidering nebulising adrenaline (epinephrine) to help with the stridor. Thereis adrenaline in all the SJA HCP kits - for anaphylaxis, not croup. Nebulized epinephrine for croup in children (Review) Bjornson C, Russell KF, Vandermeer B, Durec T, Klassen TP, Johnson DW http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD006619/pdf_fs.html We’re probably nearly past sinusitis season too- but just as well, as it sounds likethere’s no evidence to support the use of decongestants, antihistamines or nasalirrigation for acute sinusitis in children. Decongestants, antihistamines and nasal irrigation for acute sinusitis in children (Review) http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD007909/pdf_fs.html If you’re a fan of telling people to drink lots for most medical ailments, you maylike to reconsider your evidence base. Observational studies suggest increasingfluid intake for acute respiratory infections may cause more harm than benefit. Advising patients to increase fluid intake for treating acute respiratory infections (Review) Guppy MPB, Mickan SM, Del Mar CB, Thorning S, Rack A http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD004419/frame.html Most of you already know that normal triage procedures don’t seem to work forsuspected swine flu. Hopefully we’re over the worse - but lets start reading thisreview now, and maybe we’ll have finished it by next year.
The Swine Flu Triage (SwiFT) study: development and ongoing refinement of a triage tool to provide regular information to guide immediate policy and practice for the use of critical care services during the H1N1 swine influenza pandemic KM Rowan,1* DA Harrison,1 TS Walsh,2 DF McAuley,3 GD Perkins,4 BL Taylor5 and DK Menon6 Health Technology Assessment 2010; Vol. 14: No. 55, 335–492 http://www.hta.ac.uk/fullmono/mon1455.pdf#nameddest=article05 As the Summer comes in, we might start to see a bit more asthma. Evidencesuggests that maybe suggesting patients double their inhaled dose ofcorticosteroids isn’t as helpful as maybe we thought - but needs further research. Increased versus stable doses of inhaled corticosteroids for exacerbations of chronic asthma in adults and children (Review) Quon BS, FitzGerald JM, Lemière C, Shahidi N, Ducharme FM http://www.library.nhs.uk/Emergency/ViewResource.aspx?resID=389391 There is little evidence to support anti-emetics or ginger in pregnancy, and evenless to support anything else. I think I’d go with the ginger biscuits - they tastenicer. Interventions for nausea and vomiting in early pregnancy (Review) Matthews A, Dowswell T, Haas DM, Doyle M, O’Mathúna DP http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD007575/pdf_fs.html If people survive the nausea, and their kids go on to grow up, they will soonaccompany you to a music festival. When they grow up, hopefully one of thehealthcare providers at the event will feel comfortable assessing and treatingtheir nausea or crush injury. McQueen CP: Care of children at a large outdoor music festival in the United Kingdom. Prehosp Disaster Med 2010;25(3):223–226.
http://pdm.medicine.wisc.edu/Volume_25/issue_3/mcqueen.pdf If you’re lucky, and your child is poorly at a festival - maybe their nursery friendswill successfully have learnt first aid. A pilot study suggests that children asyoung as 4-5 years old can successfully learn first aid. Effects of first aid training in the kindergarten - a pilot study Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2011, 19:13 doi:10.1186/1757-7241-19-13 Once the kids know first aid, maybe their parents will want to learn first aid - andsome evidence suggests that even just watching a 60 second video will helppeople to learn first aid. Simply Watching a CPR Video Might Save Lives By Ellin Holohan Health Day Reporter for MSN http://health.msn.com/health-topics/first-aid/articlepage.aspx?cp-documentid=100270425 If people do decide to use YouTube to learn first aid, lets hope they choose theleast popular videos - as these are the videos most likely to be correct. The mostpopular videos viewed are unlikely to be accurate, although YouTube is apotentially useful source for learning CPR.
YouTube as a source of information on cardiopulmonary resuscitation K. Murugiah et al. / Resuscitation 82 (2011) 332–334 We’ve all suspected that you can’t learn CPR by yourself. This study suggeststhat self directed CPR study helps, but quality of CPR is diminished. Traditionalteaching methods yield the best CPR technique.
A randomized controlled trial comparing traditional training in cardiopulmonary resuscitation (CPR) to selfdirected CPR learning in first year medical students: The two person CPR study But now mobile phones can take your pulse, and call the ambulance for you,they’ll surely soon be doing CPR too - so it doesn’t matter if technique is bad.
Call me a techno-phobe, but I think I’d still rather a Healthcare Professional reviewedme.
New mobile can check pulse, send ambulance http://www.independent.co.uk/life-style/health-and-families/new-mobile-can-check-pulse-send-ambulance-2218713.html And yes, being a techno-phobe means that I would rather a human performedCPR on me, than a mechanical device. Luckily, the evidence suggests thatneither method of delivering chest compressions is superior. Mechanical versus manual chest compressions for cardiac arrest (Review) http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD007260/frame.html Luckily rescuers are no more likely to tire with the new 30:2 ratio than they arethe old 15:2. More compressions are inadequate with 30:2 - another reason toencourage excellent CPR during training. Performer fatigue and CPR quality comparing 30:2 to 15:2 compression to ventilation ratios in older bystanders: A randomized Christian Vaillancourta,b, , Ines Midzicb, Monica Taljaardb, Brian Chisamorec Still, if people are tiring, they can have a break whilst they do some rescuebreaths. In some people (children) compression only CPR is less effective thanconventional CPR.
Ogawa T et al. Outcomes of chest compression only CPR versus conventional CPR conducted by lay people in patients with out of hospital cardiopulmonary arrest witnessed by bystanders: Nationwide population based observational study. http://emergency-medicine.jwatch.org/cgi/content/full/2011/304/1?q=etoc_jwem# Surprisingly, the centre of the chest technique for deciding where to start chestcompressions is more variable than the inter-nipple technique. Structurescompressed in both positions vary - but the effect of this is as yet unknown.
Logic would suggest compressing the left ventricle (as in inter-nipple technique)has greater efficacy than compressing the arch of the aorta (as in centre of chesttechnique)- lets wait for some evidence. Basic life support providers’ assessment of centre of the chest and internipple line for hand position and their underlying Partial pressure of end tidal carbon dioxide may be helpful in working out aprognosis after an arrest. The lifepak 15 can measure end tidal carbon dioxide -maybe we’d better start saving some pennies (or pounds). The dynamic pattern of end-tidal carbon dioxide during cardiopulmonary resuscitation: difference between asphyxial cardiac arrest and ventricular fibrillation/pulseless ventricular tachycardia cardiac arrest.
Lah et al. Critical Care 2011, 15:R13http://ccforum.com/content/15/1/R13 All this has probably made you wonder what kind of people would voluntarily dolots of CPR. A study investigating this shows that most emergency medicalpersonnel are “resilient and stable”. And a few other things :s :s . Personality traits of emergency physicians and paramedics Emerg Med J 2011;28:141e146. doi:10.1136/emj.2009.083311 141 21.You will probably be slightly concerned, but not surprised to know that first year medical students are not the people to be around if you collapse and need CPR- in this study, four out of ten pairs of students did not even start chestcompressions in a non breathing casualty- despite some of them havingreceived CPR training. One wonders if the six pairs who did are the “resilient andstable” ones, who go on to become emergency medical personnel. Use of an automated external defibrillator: A prospective observational study of first year Lets speedily move on to trauma. Most of you will probably not be surprised tolearn that there is evidence to suggest speed cameras reduce the number ofroad traffic injuries and deaths - so we’ll probably be seeing more speedcameras about. Speed cameras for the prevention of road traffic injuries and deaths (Review) Wilson C, Willis C, Hendrikz JK, Le Brocque R, Bellamy N http://www.library.nhs.uk/Emergency/ViewResource.aspx?resID=238947 If you’ve forgotten how to logically assess trauma patients, this quick ATLSsummary may be a useful refresher - for tidy in hospital management. 2009; Volume 7 : Issue 2, Article Number: 990355 http://www.jephc.com/full_article.cfm?content_id=528 When some of you may have sighed in relief when removal of motorcyclehelmets was taken off the advanced first aider syllabus, you obviously realisedtheir helmet was protective - and these are the group of patients with lowerincidence of c-spine injuries - so perhaps the ones we need to worry about less. Crompton J, et al "Motorcycle helmets associated with lower risk of cervical spine injury: debunking the myth" J Am Coll Surg 2011; DOI:10.1016/j.jamcollsurg.2010.09.032 Review article accessed online at: http://www.medpagetoday.com/Neurology/HeadTrauma/24780 If you’re not sure how to immobilise all these potential c-spine injuries, thecollege of emergency medicine has just released some summary guidance. Asexpected, they say anyone deemed at high risk should have their neckimmobilised, and it should stay immobilised until it has been clinically cleared-with imaging if necessary. Any patient with anatomical abnormalities should havetheir neck immobilised in a position of comfort, and the use of a collar is notcompulsory. College of Emergency Medicine Clinical Effectiveness Committee Guideline on the management of alert, adult patients with potential cervical spine injury http://www.library.nhs.uk/Emergency/ViewResource.aspx?resID=400268 And if you’ve just got a potential pelvis injury, and want to know how to use aSAM splint, there is a useful summary article, describing how to roll the patientonto a SAM pelvic splint. If you look at the manufacturer’s instructions for use,they differ- but do seem more logical. Pre-hospital Expedition Medicine Series – Pelvic Injury http://www.expeditionmedicine.co.uk/blog/category/pre-hospital-care/ (http://www.sammedical.com/sam_sling.html) Those of you who know me, know I hate “tin foil blankets” with a passion.
Evidence suggests if we’re going to use hypothermia blankets, the “Blizzard blanket” is superior. Anyone know a UK provider? While we’re at it, hand warmers aren’t very good at warming up IV fluids - sosave them for your freezing cold hands. Wilderness and Environmental Medicine, 21, 373–378 (2010) Selected Abstracts From the 2010 Annual Scientific Meeting The Utilization of Chemical “Hard Warmers” and Multiple Insulation Methods for Warming of Normal Saline in Cold Environment A Comparison of Survival Blankets in Cool Ambient Temperature http://download.journals.elsevierhealth.com/pdfs/journals/1080-6032/PIIS1080603210002607.pdf If all this has made you want to look for further resources, but you’re not surewhere to start - have a look at this very useful review article. It suggests that“The Internet for Medics” site (http://www.vts.intute.ac.uk/tutorial/medicine) mightbe a helpful site. Searching for learning and teaching resources and evidence Those of you who have wondered if it’s safe to reduce a shoulder dislocationpre-hospitally, may be pleased to know that non medical personnel manage torelocate dislocations safely. Transfer to hospital is probably still a safer plan. Safety and Efficacy of Attempts to Reduce Shoulder Dislocations by Non-medical Personnel in the Wilderness Setting Wilderness & Environmental Medicine, 21, 357–361 (2010) If you want to be really ahead of the news, then this article has been publishedonline before publication in the BMJ. We always knew laughter was the bestmedicine - but it even helps heal wounds. Researchers at the University ofLeeds suggest laughter gets the diaphragm moving, and moves blood aroundthe body.
http://www.leeds.ac.uk/news/article/1559/laughter_really_is_the_best_medicine_for_leg_ulcers We all know that high concentration oxygen is bad for patients with COPD. Thispaper talks you through the research, critically appraising the initial researchpaper. Titrated oxygen is the way to deliver oxygen - and any med gassestrained HCPs should make sure they fully understand how to titrate oxygen. Randomised controlled trial: effect of high flow oxygen in COPD Is high flow or titrated oxygen better for patients in a pre-hospital setting? http://student.bmj.com/student/view-article.html?id=sbmj.d96
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This is a concise book with a concise summary ofproblems you might encounter on expeditions and similarthings. It covers heat illness, altitude medicine and cold weather -along with practical considerations like how to cross a riversafely.
If you’re interested in exploring, whether it’s the peakdistrict or Norway, this book might be a useful summary! Expedition and Wilderness Medicine Online, Sean Hudson and Caroline Knox http://expeditionmedicine.wordpress.com/2008/05/08/buy-the-expedition-and-wildern email@example.com
LOS GRANDES FALLOS DE LA JURISPRUDENCIA ARGENTINA EN MATERIA DE DERECHO DE LOS CONTRATOS. Mariela Molina I. PRINCIPIOS CONTRACTUALES A/ Buena Fe 1.- El principio general: CNCom. Sala B 28/04/98 “Finvercon S A c. Pierro, Claudia” LL 1998 – C- 624, DJ 1998 – 2- 1220, Lexis Nº 30001344 Conforme con los principios generales que regulan los contratos, es deb