In this issue:
  
OxyContin Use/Abuse Grows Quickly

Advanced Trauma Life Support (ATLS): Suggestions for Improvement?

Study: Tinnitus May Be Linked to Eyes

Low-Dose Aspirin to Reduce Risk of Pregnancy Complications?

Activated Protein C Enlisted in Battle against Sepsis

Tidbits of Trivia

Web Sites of Possible Interest

Quotable Quotes

ERDOCS e-mail group (listserv)

How to get in touch with us; questions; sponsorship

OxyContin Use/Abuse Grows Quickly

In a little over four years (the drug was first introduced in December 1995), OxyContin's sales have hit $1 billion, more than even Viagra's. A powerful sustained release narcotic, the drug has become a useful adjunct for legitimate pain management as well as earning the distinction, from DEA officials, as the presecription drug with the steepest rise (in the past 20 years) in illegal abuse after its intro-duction to the market.

Some insiders cite the drug's manufacturer, Purdue Pharma, for an extraordinarily aggressive marketing campaign, getting physicians to aggressively utilize the drug in pain management. Physicians have complained about the countless free trips offered by the company for seminars (some 7,000 seminars thusfar) in which the drug is touted, and aggressive drug sales representatives who often oversold benefits and undersold potential for abuse of the drug in office presentations. Purdue has also contributed to foundations supporting research on pain, to pharmacy schools and to Internet sites aimed at educating consumers.

OxyContin was originally thought to be less prone to abuse because its narcotic (the synthetic version of morphine called oxycodone), was locked in a time-release formula. Sustained pain management has been a major selling point for use with patients experiencing chronic or protracted pain, such as in cancer and back injury cases. Although other pain medicine contains oxycodone, OxyContin differs in two key respects: it's time-release formula, and it could be delivered in larger doses because it did not contain the type of nonprescription pain relievers that in larger quantities could cause liver damage. But abusers quickly discovered how to disarm the time-release formula by simply crushing the tablet, then either swallowing, inhaling or injecting the powder.

Abuse and addiction involving OxyContin has spread quickly in the last two years, despite now being one of the most tightly regulated drugs on the market. Major illegal abuse trends have flared up in at least a dozen states. In the past year, 59 deaths in Kentucky's mountain region, and 32 deaths in Virginia have been connected to abuse of OxyContin. Law enforcement reports increases in pharmacy robberies, as well as bank and residential burglaries, by those supporting their addiction to OxyContin. Kentucky police arrested more than 200 people in a single day on OxyContin-related charges. While the illegal use of "Oxy"---as it's known on the streets, took root in rural areas along the East Coast, it is rapidly moving into cities like Philadelphia and westward. Abusers say getting the drug is easy---a person simply had to find the right doctor, claim great pain and get a prescription. Others just stole prescription pads and wrote their own.

Several east coast law-enforcement officials, federal health agency representatives, and officials from Purdue Pharma met recently to discuss possible solutions to the growing epidemic. Company officials revealed plans to educate health care providers about pre-scription drug abuse and educating physicians about tamper-resistant prescription pads (to reduce forged prescriptions). The Food and Drug Administration is reassessing how it reviews pre-scription narcotics for potential abuse. "We've learned something from this," said Dr. Cynthia McCormick, director of the F.D.A.'s division of anesthetics, critical care and addiction drug products. Dr. McCormick acknowledged that the F.D.A. had failed to re-search all the ways abusers might tamper with OxyContin, an oversight she said her agency did not want to repeat. The F.D.A. approved OxyContin for those with moderate to severe pain lasting more than a few days.

Advanced Trauma Life Support (ATLS): Suggestions for Improvement?


(Note: Iowa, in its statewide trauma plan initiative, has embraced ATLS has a core required component in ongoing trauma education for physicians; this recently published (small) west coast survey, represents some of the perspectives and feedback on the course itself, by physicians.)

A survey (conducted by Richards, Panacek, and Brofeldt of the Division of Emergency Medicine, University of California, Davis Medical Center in Sacremento), was conducted to determine con-cerns and differences in perspective towards Advanced Trauma Life Support (ATLS) between emergency medicine (EM) physicians and other specialties (OS). It also aimed to assess the course's perceived value in the management of acute trauma, and identify areas in the course which might be revised or updated. The survey was completed by physicians after completing ATLS. Of 26 course participants, there were 11 EM physicians (42 percent), four family practitioners (15 percent), four surgeons (15 percent), four internists (15 percent), two pediatricians (8 percent), and one anesthesiologist (4 percent). Both groups said that ATLS was useful and relevant, but also reported that there was little deviation from their prior management of acute trauma. Unclear topics identified were; airway, spine trauma, and burns/cold injury as reported by emergency medicine physicians, while topics on head, abdominal, and pediatric trauma were most often cited by non-EM physician attendees. Significant differences between grouops were noted in the following feedback: 91 percent of the EM physicians vs. 13 percent OS physicians felt ATLS could be shortened into a one-day course (p = 0.002); 64 percent of the EM group vs. 7 percent OS physicians thought the laboratory could be omitted (p = 0.003), and all EM physicians vs. 60 percent OS physicians believed the course could be taught by EM physicians as effectively as surgeons (p = 0.02). EM disagreed with OS over the proposed requirement that all EM physicians be required to take ATLS ( p = 0.03). It should be noted that the EM group reported doing greater than 20 per year of airway, vascular, and thoracostomy procedures in their own practice, whereas OS physicians did significantly fewer. Proposed changes from the EM perspective include shortening ATLS to one day, increased use of EM instructors, clarifying certain portions of the manual, and omitting the laboratory section or making it optional.

(If you have follow-up comments or opinions regarding this survey that you wish to express/share (or read those of others in this area), please go to the discussion group postings online at www.acutecare. com and click on "emergency medicine discussion forum" or join other physicians on our ERDOCS listserv) to read and/or add your own thoughts.)

Study: Tinnitus May Be Linked to Eyes

The annoying ringing in the ears that marks tinnitus (at least some forms of it) could be linked to the eyes as well as to the ears, researchers said on Monday.

In some patients, the tinnitus they experience may actually involve the visual portion in addition to the auditory portion. Researchers at the State University of New York at Buffalo and the Veterans Administration found in eight patients that have GET (gaze-evoked tinnitus----in which it increases in volume and pitch with lateral gaze), whereas sideways gaze should suppress auditory brain activity.. Publishing in Neurology in its March issue, the researchers speculated that inability of the brain to prioritize between auditory and visual signals may play a significant role. Some 50 million Americans are afflicted with tinnitus. With no current effective treatment, and additional complaints of sleep disturbances, depression and anxiety, the authors of this study suggest that tinnitus may be more complicated and that focusing treatment on the auditory system only may be part of the problem in the search for effective treatment.

Low-Dose Aspirin to Reduce Risk of Pregnancy Complications?

British experts, including the Royal College of Obstetricians and Gynaecologists (RCOG), called for a reassessment of the use of low-dose aspirin during pregnancy after new research showed it may help reduce the risk of pre-eclampsia. Occurring in up to eight percent of pregnancies, preeclampsia can progress to eclampsia, which causes 10-15 percent of maternal deaths.

A review of 39 studies (30,000 women) on the use of low-dose aspirin, published in the British Medical Journal, concluded it can help reduce pre-eclampsia risk by about 15 percent.

The researchers found low-dose aspirin was further linked to a 14 percent cut in stillbirths and an eight percent drop in the risk of pre-term births, particularly when administered before 16, or even 12 weeks.

All of the women were given less than 75 milligrams of aspirin. The researchers said higher doses, while potentially more effective, could have serious side-effects such as gastric bleeding. Optimal dosing and best time to begin use have yet to be determined.

"It is important to understand that aspirin will not completely abolish the risk of pre-eclampsia, and even when pre-eclampsia occurs, aspirin will, at best, make a slight difference to the outcome," the RCOG added.

Activated Protein C Enlisted in Battle against Sepsis

Some 750,000 cases of sepsis are diagnosed in the U.S. each year, resulting in 225,000 deaths. Sepsis, arising from such problems as pneumonia, trauma, surgical complications and cancer, is currently treated with antibiotics, fluids and ventilatory support.

After over fifteen years of research focused on looking for a specific drug to effectively treat sepsis, a breakthrough may be at hand. 

Reviewers at The New England Journal of Medicine looked at a study scheduled to be published March 8, and urged release a month earlier, "due to the medical significance of the findings."


In a study coordinated by Vanderbilt University, in Nashville, Tenn.,  funded by Eli Lilly and Co. and involving 11 countries and 1,690 patients in 164 different locations, half of the patients were given the drug intravenously for four days, and the rest took a placebo. The patients were monitored for 28 days. While 25 percent of the patients given the drug died, 31 percent died in the placebo group. Patients who took the drug had a 19 percent greater chance of survival than the others. The most significant complication noted was that 3.5 percent of patients receiving the drug developed serious bleeding, compared with 2 percent within the placebo group. No studies are available yet focusing on
pediatric patients.

Sepsis, manifesting as a bacterial infection of the bloodstream, sets off a chain of chemical reactions that lead to excessive inflammation, clotting, and eventually organ failure. The new drug is derived from a natural blood product, activated protein C. In the blood, activated protein C curbs inflammation and clotting.

Eli Lilly has applied for approval from the FDA, and plans to market the drug under the name Zovant. Consultants say approval could come within six months.

Tidbits of Trivia

Dazzle your friends---
The average person falls asleep in about seven minutes;
The microwave was invented after a researcher walked by a radar tube and a chocolate bar in his pocket melted;
The average person will experience more than 140 colds during his/her lifetime;
The dots on a pair of dice are called pips-pips on opposite sides always add up to seven.

Things go better with Coke?
From the internet…
Coca-Cola was originally green;
In many states the highway patrol carries two gallons of Coke in the trunk to remove blood from the highway after a car accident;
To remove rust spots from chrome car bumpers: rub the bumper with a crumpled-up piece of Reynolds Wrap aluminum foil dipped in Coca-Cola;
The active ingredient in Coke is phosphoric acid. Its pH is 2.8. It will dissolve a nail in about 4 days.

Journalistic Distinction
Here are the top 5 winners of this year's Bulwer-Lytton Contest, wherein one writes the opening sentence of a bad  novel. (The contest is named for the Victorian author Edward George  Bulwer-
Lytton, who is famous-or is it infamous-for writing the novel  that began "It was a dark and stormy night.")

5. Although Ellen had an abnormal fear of mice, it did not keep her from eeking out a living at a local pet store.

4. Stanley looked quite bored and somewhat detached, but then penguins often do.

3. Like an overripe beefsteak tomato rimmed with cottage  cheese, the corpulent remains of Santa Claus lay dead on the hotel floor.

2. Dick Hardware was the kind of private eye who didn't know the meaning of the word fear, a man who could laugh in the face of danger and spit in the eye of death - in short, a moron with suicidal tendencies.

And  the winner...

1. The sun oozed over the horizon, shoved aside the darkness, crept along the greensward, and, with sickly fingers, pushed through the castle window, revealing the pillaged princess, hand at throat,  crown asunder, gaping in frenzied horror at the sated, sodden amphibian lying beside her, disbelieving the magnitude of the frog's deception, screaming madly, "YOU LIED, YOU LIED!!!!!!!"

Web Sites of Possible Interest

Following Infectious Disease Outbreaks       
http://www.promedmail.org:8070/promed/promed.home

The global electronic reporting system for outbreaks of emerging infectious diseases & toxins, open to all sources. Sponsored by the International Society for Infectious Diseases. This site can send you postings daily or you can receive digests of summary postings.

The Spring 2001 issue of Currents in Emergency Cardiovascular Care
http://www.currentsonline.com/adobe/spring2001.pdf

This issue is the latest from the American Heart Association , one of the quarterly updates based upon the 2000 Guidelines. This issue includes: a summary of new stroke standards and how to apply them in your EMS system, an important update for instructors about the Guidelines 2000, and a look at the new CPR in Schools training curriculum aimed at teenagers.

Learn More About Yourself
http://www.allthetests.com 

If you're interested in learning more through self-assessment, this may be of interest to you. It provides a directory of tests online, including IQ tests, personality tests, career tests, etc. Listings include a brief description and how long the test will typically take. Site listings include the name and URL of a site, a brief description, and some idea of how long the test will take (longer than an hour, less than 30 minutes, etc.).

Quotable Quotes

We have two ears and one mouth and should use them in that proportion.
--Epictetus

"Be a good listener because you never learn much from talking."
--Will Rogers

"The greatest problem with communication is the illusion it has been accomplished." 
--George Bernard Shaw


"Where is the wisdom we have lost in knowledge? Where is the knowledge we have lost in information?" T.S. Eliot

"You will become as small as your controlling desire; as great as your dominant aspiration."
--   James Allen, former CEO

"Everything that irritates us about others can lead us to an understanding of ourselves."
--  Carl Jung

ERDOCS e-mail group (listserv)

As a Clinician providing acute and emergency medical care, you are invited to visit and participate in our new ERDOCS group at eGroups, a free, easy-to-use email group service! You have plenty of experiences to share, questions to ask, concerns and opinions to voice, suggestions, news to post, tips to offer, etc.and can do so within this framework. this is a versatile system for posting things to be sent to a group to peruse, respond to, or simply be aware of. It eliminates conventional mail delays and allows you to review and post at your leisure. (We still have the more open-ended [any visitor can observe/post] discussion group at the ACUTE CARE, INC. web site). Our goal is to give you a variety of feedback and communication tools.

The manager/moderator for this ERDOCS egroup is the webmaster for the ACUTE CARE, INC. website (www.acutecare.com), Paul Hudson. You can subscribe by sending an e-mail indicating your wish to be included to Paul at paul@acutecare.com

As this site grows, it will feature news, calendars, links to references, resources, and other useful features. We hope you will support this effort to foster ongoing communication amongst EM providers.