Not Effective for Controlling Severe Acute Pain

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Intravenous Morphine at 0.1 mg/kg is Not Effective for Controlling Severe Acute Pain in the Majority of Patients Ann Emerg Med. 2005 Oct;46(4):362-7 Bijur PE, Kenny MK, Gallagher EJ. Department of Emergency Medicine, Albert Einstein College of Medicine, Bronx, NY 10461, USA. bijur@aecom.yu.edu
STUDY OBJECTIVE The objective was to quantify the analgesic effect of a dose of intravenous morphine, 0.1 mg/kg, to emergency department (ED) patients presenting in acute, severe pain.
METHODS This was a prospective convenience cohort of patients aged 21 to 65 years and presenting to an academic urban ED with acute, severe pain. Patients rated their pain intensity on a validated 11-point verbal numeric rating scale ranging from 0, "no pain," to 10, "worst possible pain," immediately before they received 0.1 mg of intravenous morphine per kilogram of body weight and 30 minutes later. The main outcome was proportion of patients whose pain decreased by less than 50% during the 30-minute interval. RESULTS Of 119 patients who received intravenous morphine at 0.1 mg/kg, the average age was 42 years (SD=11 years), 55% were female patients, 65% were Hispanic, 28% were black, and 7% were classified as other. The median numeric rating scale pain score at baseline was 10 (interquartile range 9 to 10). Sixty-seven percent (95% confidence interval 58% to 76%) of the patients receiving intravenous morphine at 0.1 mg/kg reported a less than 50% decrease in pain. No patient required an opioid antagonist at any time during or after the study period.
CONCLUSION The data suggest that a 0.1 mg/kg dose of morphine may be too low to adequately control acute severe pain.

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CDC Press Release: 1918 Pandemic Influenza Virus Declared a Select Agent The Centers for Disease Control and Prevention (CDC) published today in the Federal Register an interim rule declaring the strain of influenza responsible for the 1918 pandemic as a select agent. There are currently 41 other agents and toxins listed as select agents under the Public Health Security and Bioterrorism Preparedness and Response Act of 2002. This action follows recent work done by CDC scientists to successfully reconstruct the 1918 virus in hopes of better understanding it. The virus was reconstructed to aid public health officials in preparing for the possibility of another pandemic of influenza. It will also be helpful to biomedical scientists as they seek to understand what made the virus so harmful and to develop better antiviral drugs and influenza vaccines. "We've learned why this virus was so deadly and we know it's easily transmitted from person to person," said CDC Director Dr. Julie Gerberding. "But there is a lot we don't know so it's only logical that we take immediate steps to regulate this virus as a select agent as an added way to protect the public." Under provisions outlined in the interim rule, all entities (e.g., scientists and researchers that possess, use or transfer the 1918 strain of influenza or the eight key gene regions of the 1918 virus are required to register with the CDC. People, labs, and other facilities that work with select agents are required to ensure that they can safely handle the virus as outlined in the CDC/NIH Biosafety in Microbiological and Biomedical Laboratories, 5th edition. In addition, they are required to increase safeguards and security measures for the virus, including controlling access, screening personnel, and maintaining records to be included in a national database with records from others registered. The Act imposes criminal and civil penalties for inappropriate use of select agents and toxins. In light of this groundbreaking scientific research done to recreate the 1918 pandemic influenza virus, CDC asked a workgroup of scientists from the National Institutes for Health (NIH), the Food and Drug Administration (FDA), the Department of Defense, and the Department of Agriculture to determine if the newly created virus should be added to the select agent list. The group used four criteria to determine whether to include the 1918 strain on the select agent list - 1) the effect on human health of exposure to the agent or toxin; 2) the degree of contagiousness of the agent or toxin and the methods by which the agent or toxin is transferred to humans; 3) the availability and effectiveness of pharmacotherapies and immunizations to treat and prevent any illness resulting from infection by the agent or toxin; and 4) the needs of children and other vulnerable populations. Using these criteria, the workgroup unanimously agreed that the virus warranted select agent status.

Summary and Comment
Emergence of Fluoroquinolones as the Predominant Risk Factor for Clostridium Difficile-associated Diarrhea: A Cohort Study During an Epidemic in Quebec Clin Infect Dis. 2005 Nov 1;41(9):1254-60 Pepin J, Saheb N, Coulombe MA, Alary ME, Corriveau MP, Authier S, Leblanc M, Rivard G, Bettez M, Primeau V, Nguyen M, Jacob CE, Lanthier L. Department of Microbiology and Infectious Diseases, University of Sherbrooke, Sherbrooke, Quebec, Canada. jacques.pepin@usherbrooke.ca
BACKGROUND Since 2002, an epidemic of Clostridium difficile-associated-diarrhea (CDAD) associated with a high case-fatality rate has involved >30 hospitals in the province of Quebec, Canada. In 2003, a total of 55% of patients with CDAD at our hospital had received fluoroquinolones in the preceding 2 months. It has been suggested that massive use of proton pump inhibitors might have facilitated this epidemic.
METHODS To delineate the risk of CDAD associated with specific classes of antibiotics and whether this is modulated by concomitant use of proton pump inhibitors and other drugs altering gastric acidity or gastrointestinal motility, we conducted a retrospective cohort study of patients hospitalized in a teaching hospital in Sherbrooke, Canada, during the period of January 2003 through June 2004. We obtained data on 7421 episodes of care corresponding to 5619 individuals. Patients were observed until they either developed CDAD or died or for 60 days after discharge from the hospital. Adjusted hazard ratios (AHRs) were calculated using Cox regression.
RESULTS CDAD occurred in 293 patients. Fluoroquinolones were the antibiotics most strongly associated with CDAD (AHR, 3.44; 95% confidence interval [CI], 2.65-4.47). Almost one-fourth of all inpatients received quinolones, for which the population-attributable fraction of CDAD was 35.9%. All 3 generations of cephalosporins, macrolides, clindamycin, and intravenous beta-lactam/beta-lactamase inhibitors were intermediate-risk antibiotics, with similar AHRs (1.56-1.89). Proton pump inhibitors (AHR, 1.00, 95% CI, 0.79-1.28) were not associated with CDAD. CONCLUSIONS Administration of fluoroquinolones emerged as the most important risk factor for CDAD in Quebec during an epidemic caused by a hypervirulent strain of C. difficile.

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