There appeared to be no differentiation between the administration of
anabolic steroids (substances based on or manufactured to mimic
testosterone) and corticosteroids (substances which are markedly catabolic
and reduce inflammation through limiting the gene expression of
inflammatory cytokines etc) in the studies of the two bodybuilders in the
September issue.
There appeared to be no differentiation between the administration of
anabolic steroids (substances based on or manufactured to mimic
testosterone) and corticosteroids (substances which are markedly catabolic
and reduce inflammation through limiting the gene expression of
inflammatory cytokines etc) in the studies of the two bodybuilders in the
September issue.
Not many bodybuilders would ever inject or use corticosteroids
illicitly as the systemic effects are counter to the aims of the sport.
Some bodybuilders will even go so far as to obtain illicit corticosteroid
blocking drugs to reduce catabolic breakdown of skeletal muscle.
It is true that most bodybuilders have a degree of reluctance to
admit ANABOLIC steroid use, this is for reasons of legality more than
anything else. The Police have been known to prosecute users as suppliers
because of the ambiguity about the difference between the two in terms of
the amount of drugs involved.
Injection of drugs is used by more experienced bodybuilders (not to
mention athletes) as it avoids the liver toxicity of 17-alpha-alkylated
oral steroids. Unfortunately, since the authorities stepped up their
campaign to outlaw their use, the availability of REAL steroids has
decreased whereas the amount of dangerous counterfeit steroids, which may
be infected or at best not sealed in sterile conditions, has grown beyond
control. It is this and not poor technique that has contributed most
significantly to the increase in soft tissue infections that is now being
seen both here and the USA.
Finally, bodybuilders started some time ago to administer Glycerol
and fat products directly in the aim not of promoting muscle growth but of
making the muscles bigger temporarily. This practice is usually done
before a competition as the effect is not long lasting most of the time.
However, it became the vogue for a while to inject directly into muscle
groups using less androgenic and more anabolic steroids (such as
Stanozolol - Winstrol V) in the mistaken belief that these relatively
short acting compounds would have a locally anabolic effect on smaller
muscle groups. There were specific instructions circulated by some
"authorities" as to exactly how to administer these injections - without
any scientific basis, rather optimism.
I hope that this helps a few people who have no involvement in
bodybuilding to understand a few of the unfortunate mistakes that
bodybuilders make.
I read with interest the last article about paediatric sedation.[1] I
feel that some of the evidence about adverse events is put forward in a
slightly misleading way. Dr Doyle states that "...at least 52 deaths and 27
episodes of serious morbidity including six episodes of permanent
neurological damage and 15 prolonged hospitalisations attributed to
sedation. The causes of these events were mainly d...
I read with interest the last article about paediatric sedation.[1] I
feel that some of the evidence about adverse events is put forward in a
slightly misleading way. Dr Doyle states that "...at least 52 deaths and 27
episodes of serious morbidity including six episodes of permanent
neurological damage and 15 prolonged hospitalisations attributed to
sedation. The causes of these events were mainly drug overdose, inadequate
monitoring, inadequate training of the personnel involved, or premature
discharge."[2] This statement is placed in the middle of a paragraph about
sedation events occurring in emergency departments and might be taken to
imply that these events occurred in emergency departments. This series
about adverse sedation events was drawn from a wide variety of
specialities. Indeed, 29 of the deaths occurred in dental practice and 11
in radiology. There were no deaths or permanent neurological injuries
resulting from children sedated in emergency medicine and only 4 cases
resulting in prolonged hospitalisation in this series. One would hope that
the ability of emergency physicians to manage complications of sedation
would exceed that of community dentists. It is easy to imagine how adverse
events can occur in the dark, isolated corners of the radiology
department.
The safety of paediatric sedation is vexed and difficult question and it
is important that the evidence, such as it is, is appraised correctly.
References
(1) Doyle E. Emergency analgesia in the paediatric population. Part
IV Paediatric sedation in the accident and emergency department: pros and
cons. Emer Med J 2002;19:284-287.
(2) Cote CJ, Notterman DA, Karl HW, Weinberg JA, McCloskey C.
Adverse sedation events in Pediatrics: A Critical Incident Analysis of
Contributing Factors. Pediatrics 2000; 105(4):805-814.
Having already recieved correspondence via the BestBETs website regarding
various writer's preferred method of tick removal it would seem that
applying an evidence base to the subject was not as laughable as our work
colleagues first thought.
With reference to the De Boer paper,[1] although the authors felt that
rotation was justified by their results, these figures can equally be
applied to...
Having already recieved correspondence via the BestBETs website regarding
various writer's preferred method of tick removal it would seem that
applying an evidence base to the subject was not as laughable as our work
colleagues first thought.
With reference to the De Boer paper,[1] although the authors felt that
rotation was justified by their results, these figures can equally be
applied to the conclusions we took from the work to answer the three part
question given. For example, in the removal of adult female ixodes ticks,
pulling removed an undamaged tick in 41 % whilst rotation achieved this in
0 %. De Boer's conclusions stem from the fact that in those cases where the
tick was damaged the percentage of the mouthparts still in situ was 70 %
for pulling and 20 % for rotation. The conclusion we took from this was
that pulling was more likely to successfully remove an intact tick, but
when it does fail it is to a greater extent than the almost guaranteed
failure of rotation.
Although De Boer et al felt that rotation uses less force than a
straight pull this was not based on any reproducible measurement and there
is no scientific basis to say that the force of a straight pull is more
likely to cause regurgitation than the torque of rotation.
Finally De Boer states "taking what we know into consideration it is
not easy to make a firm recommendation on the preferred method" before
recommmending rotation. However, taking both available papers into
consideration we felt that mechanical methods are certainly superior and
of these a slow straight appears to have the edge.
Reference
(1) De Boer R, van den Bogaard AE. Removal of attached nymphs and adults of Ixodes ricinus (Acari: Ixodidae). J Med Entomol 1993;30:748–52.
We read with interest your article on tick removal and
agree with Mr McGlone in his assessment of the evidence as presented and
feel that rotation is indeed the best method for tick removal. We also feel
that a useful practical point to raise is that the use of Ethyl Chloride
to freeze the body of the tick and crystallise its stomach contents will
reduce the risk of regurgitation during removal.
We read with interest your article on tick removal and
agree with Mr McGlone in his assessment of the evidence as presented and
feel that rotation is indeed the best method for tick removal. We also feel
that a useful practical point to raise is that the use of Ethyl Chloride
to freeze the body of the tick and crystallise its stomach contents will
reduce the risk of regurgitation during removal.
The paper by Lockey on 'Recognition of death and termination of
cardiac resuscitation attempts by UK ambulance personnel' [1] demonstrates inconsistencies across UK ambulance services in
following previously published recommendations for the recognition of
adult death by ambulance crews. His findings are timely given our recent
remit from the Joint Royal Colleges Ambulance Liaison Committee to review
the...
The paper by Lockey on 'Recognition of death and termination of
cardiac resuscitation attempts by UK ambulance personnel' [1] demonstrates inconsistencies across UK ambulance services in
following previously published recommendations for the recognition of
adult death by ambulance crews. His findings are timely given our recent
remit from the Joint Royal Colleges Ambulance Liaison Committee to review
the existing guidelines and update policy based on currently available
evidence and examples of good practice.
Our terms of reference include consideration of:
*Those conditions where death is 'obvious' and resuscitation inappropriate
*Ambulance 'Not for Active Resuscitation' policies
*A revised protocol to be recommended to support a presumptive diagnosis
of death by attending ambulance crews
*Guidelines for the discontinuation of active resuscitation
*A common (generic) ambulance procedure to be followed when dealing with
sudden death in the home.
Our deliberations will include consultations with coroners’ and
forensic pathology services.
As Lockey has indicated, a number of ambulance authorities already
have locally determined practices and procedures in place. We would
appreciate hearing from those services who might wish to share best
practice with the wider community. Correspndence should be sent to michael.ward@nda.ox.ac.uk
in order for us to have our tasks completed by end 2002.
The Specialty of Emergency Medicine has evolved over the last 25
years. During this time it has had to work hard to establish its
credentials as being integral to the provision of emergency services. In
tandem with this, the name of the discipline has changed from Casualty to
Accident and Emergency Medicine to Emergency Medicine. This has also been
reflected in the name of the specialty journal.
The Specialty of Emergency Medicine has evolved over the last 25
years. During this time it has had to work hard to establish its
credentials as being integral to the provision of emergency services. In
tandem with this, the name of the discipline has changed from Casualty to
Accident and Emergency Medicine to Emergency Medicine. This has also been
reflected in the name of the specialty journal.
As Emergency Physicians, we, like our peers throughout the UK
continue to try to overcome outdated perceptions of our specialty amongst
our professional colleagues. It is regrettable therefore that the EMJ
should publish an article[1] containing obsolete terms such as Casualty
Department and Casualty Officer. This undermines our progress and hinders
future developments.
We believe it should be editorial policy that the only acceptable
terms for the departments in which we work are the Emergency Department or
the Department of Emergency Medicine.
References
(1) Carroll W D, Willis T A. Cardioversion by venepuncture in sustained
stable supraventricular tachycardia. Emerg Med J 2002;19:358-9.
I very much enjoyed reading Dr Carroll's two papers in this month's EMJ;
however I was disappointed to see the reference to "casualty department"
which should be strongly discouraged. My colleagues at Stoke have used the
term "emergency department" for many years. I was glad to see the correct
terminology used in Dr Carroll's second paper.
Living in a tick endemic area I have already researched this topic,
so I was surprised on reading the "clinical bottom line".
De Boer [1] and his co-authors state, "When the tick is removed by
pulling without rotation, large portions of tick tissue (possibly
containing pathogens) often are left behind in the skin. Pulling also
applies more pressure on the tick. We therefore recommend rotation ra...
Living in a tick endemic area I have already researched this topic,
so I was surprised on reading the "clinical bottom line".
De Boer [1] and his co-authors state, "When the tick is removed by
pulling without rotation, large portions of tick tissue (possibly
containing pathogens) often are left behind in the skin. Pulling also
applies more pressure on the tick. We therefore recommend rotation rather
than pulling." This is one of the papers quoted by the authors of this
BET, yet they state that a straight pull is superior!
Applying significant pressure on the tick's abdomen could cause
regurgitation of some of the gut contents into the patient! De Boer found
that turning a tick around its body axis required less pressure than
pulling it out.
Mechanical devices are available for tick removal, ask your local
vet.
A word of reassurance - Lyme disease is infrequently transmitted before
the tick has been attached for 48 hours and a single 200 mg dose of
doxycycline given within 72 hours after a tick bite can prevent the
disease.[2]
References
(1) De Boer R, van den Bogaard AE. Removal of attached nymphs and
adults of Ixodes ricinus (Acari: Ixodidae). J Med Entomol 1993;30:748–52.
(2) Nadelman RB. Nowakowski J. Fish D. Falco RC. Freeman K. McKenna
D. Welch P. Marcus R. Aguero-Rosenfeld ME. Dennis DT. Wormser GP. Tick
Bite Study Group. Prophylaxis with single-dose doxycycline for the
prevention of Lyme disease after an Ixodes scapularis tick bite.
[Clinical Trial. Journal Article. Multicenter Study. Randomized Controlled
Trial] New England Journal of Medicine 2001;345(2):79-84.
I have some experience in the removal of ticks. Not on humans but on
dogs, during the spring in particular almost weekly.
I use a couple of drops of 'Frontline' (a household flee
spray) to kill the tick, and then remove it with a small curved hook
device with a 'V' shaped notch (available at vets). I have 100 % success in
removing ticks with their mouth parts intact with this method.
I have some experience in the removal of ticks. Not on humans but on
dogs, during the spring in particular almost weekly.
I use a couple of drops of 'Frontline' (a household flee
spray) to kill the tick, and then remove it with a small curved hook
device with a 'V' shaped notch (available at vets). I have 100 % success in
removing ticks with their mouth parts intact with this method.
The suffocation method also works but takes some hours to achieve a
result.
I read with interest the case report by MacCarthy et al.[1]
describing the use of transthoracic echocardiography during cardiac arrest due to
massive pulmonary embolism (PE). Such cases raise the question of whether
thrombolysis could be used routinely during all non-traumatic cardiac arrests, not just
those known to be caused by PE.
Up to 70 % of cardiac arrests have thrombosis (PE or myocardial inf...
I read with interest the case report by MacCarthy et al.[1]
describing the use of transthoracic echocardiography during cardiac arrest due to
massive pulmonary embolism (PE). Such cases raise the question of whether
thrombolysis could be used routinely during all non-traumatic cardiac arrests, not just
those known to be caused by PE.
Up to 70 % of cardiac arrests have thrombosis (PE or myocardial infarction) as their
underlying cause.[2] Thrombolysis is of proven therapeutic benefit in both these
conditions. Bottiger has prospectively studied administration of recombinant tissue
plasminogen activator (r-tPA) in patients suffering out-of-hospital cardiac arrest.[2]
Compared to controls, patients who received thrombolysis were significantly more
likely to have return of spontaneous circulation and survive to admission to a
coronary intensive care. There was no significant difference in survival to discharge,
although numbers were very small. Several retrospective studies of out-of-hospital
arrests of all causes have shown similar results.[2]
Administration of thrombolysis not only treats the direct cause of the cardiac arrest,
but it has also been shown to improve blood flow in the microvascular circulation of
the brain during the post-arrest period.[3] This may account for the excellent
neurological status of the survivors in several of the studies.
With the introduction of single bolus thrombolytic agents, administration of
thrombolysis during cardiac arrest would be a rapid, simple procedure. On the basis of
the current evidence however, thrombolysis could not be recommended as a routine
treatment in all cardiac arrests, but it should be considered on a case-by-case basis by
the arrest team leader. Large randomised controlled trials are needed to provide a
definitive answer to this important clinical question. Such a study, led by Bottiger, is
due to commence in Germany later this year (personal communication) and its results
are eagerly awaited.
Paul Knowles FRCSEd, FFAEM
References
(1) MacCarthy P, Worrall A, McCarthy G, Davies J
The use of transthoracic echocardiography to guide thrombolytic therapy
during cardiac arrest due to massive pulmonary embolism.
Emerg Med J 2002;19(2):178-9.
(2) Bottiger BW, Bode C, Kern S, et al.
Efficacy and safety of thrombolytic therapy after initially unsuccessful
cardiopulmonary resuscitation : a prospective clinical trial. Lancet 2001;357(9268):1583-85.
Dear Editor
There appeared to be no differentiation between the administration of anabolic steroids (substances based on or manufactured to mimic testosterone) and corticosteroids (substances which are markedly catabolic and reduce inflammation through limiting the gene expression of inflammatory cytokines etc) in the studies of the two bodybuilders in the September issue.
Not many bodybuilders would ever i...
Dear Editor
I read with interest the last article about paediatric sedation.[1] I feel that some of the evidence about adverse events is put forward in a slightly misleading way. Dr Doyle states that "...at least 52 deaths and 27 episodes of serious morbidity including six episodes of permanent neurological damage and 15 prolonged hospitalisations attributed to sedation. The causes of these events were mainly d...
Dear Editor
Having already recieved correspondence via the BestBETs website regarding various writer's preferred method of tick removal it would seem that applying an evidence base to the subject was not as laughable as our work colleagues first thought.
With reference to the De Boer paper,[1] although the authors felt that rotation was justified by their results, these figures can equally be applied to...
Dear Editor
We read with interest your article on tick removal and agree with Mr McGlone in his assessment of the evidence as presented and feel that rotation is indeed the best method for tick removal. We also feel that a useful practical point to raise is that the use of Ethyl Chloride to freeze the body of the tick and crystallise its stomach contents will reduce the risk of regurgitation during removal.
...Dear Editor
The paper by Lockey on 'Recognition of death and termination of cardiac resuscitation attempts by UK ambulance personnel' [1] demonstrates inconsistencies across UK ambulance services in following previously published recommendations for the recognition of adult death by ambulance crews. His findings are timely given our recent remit from the Joint Royal Colleges Ambulance Liaison Committee to review the...
Dear Editor
The Specialty of Emergency Medicine has evolved over the last 25 years. During this time it has had to work hard to establish its credentials as being integral to the provision of emergency services. In tandem with this, the name of the discipline has changed from Casualty to Accident and Emergency Medicine to Emergency Medicine. This has also been reflected in the name of the specialty journal.
...Dear Editor
I very much enjoyed reading Dr Carroll's two papers in this month's EMJ; however I was disappointed to see the reference to "casualty department" which should be strongly discouraged. My colleagues at Stoke have used the term "emergency department" for many years. I was glad to see the correct terminology used in Dr Carroll's second paper.
Dear Editor
Living in a tick endemic area I have already researched this topic, so I was surprised on reading the "clinical bottom line".
De Boer [1] and his co-authors state, "When the tick is removed by pulling without rotation, large portions of tick tissue (possibly containing pathogens) often are left behind in the skin. Pulling also applies more pressure on the tick. We therefore recommend rotation ra...
Dear Editor
I have some experience in the removal of ticks. Not on humans but on dogs, during the spring in particular almost weekly.
I use a couple of drops of 'Frontline' (a household flee spray) to kill the tick, and then remove it with a small curved hook device with a 'V' shaped notch (available at vets). I have 100 % success in removing ticks with their mouth parts intact with this method.
Th...
Dear Editor
I read with interest the case report by MacCarthy et al.[1] describing the use of transthoracic echocardiography during cardiac arrest due to massive pulmonary embolism (PE). Such cases raise the question of whether thrombolysis could be used routinely during all non-traumatic cardiac arrests, not just those known to be caused by PE. Up to 70 % of cardiac arrests have thrombosis (PE or myocardial inf...
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