Abstracts 369

??DEXAMETHASONE AND BACTERIAL MENINGI- 0 EVALUATION AND COMPARISON OF THE AD- TIS, A META-ANALYSIS OF RANDOMIZED CON- VERSE EFFECTS OF STREPTOKINASE AND AL- TROLLED TRIALS. Geiman, BJ, Smith, AL. West J TEPLASE. Tisdale JE, Colucci RD, Ujhelyi MR. Pharma- Med. 1992;157:27-31. cotherapy. 1992;12(6):440-444.

The efficacy of dexamethasone therapy combined with antibacterial therapy in preventing sequelae of pediatric bacterial meningitis was evaluated with a meta-analysis of six randomized, controlled studies. One study included both adults and children and was analyzed separately. There was not a significant difference in the case fatality rate between the dexamethasone and placebo pediatric study groups. There was an increased relative risk of non- auditory neurologic sequelae in the placebo group during the period less than 6 weeks after discharge and during the period beginning 6 months after discharge. The relative risk of bilateral hearing loss was significantly increased in the placebo group (RR = 4.12, 95% CI 1.74 to 9.79). There was not a significant difference between the two groups when comparing unilateral hearing loss. The au- thors conclude that dexamethasone when used as an ad- junct to antimicrobial therapy in treating children with bac- terial meningitis reduces the risk of bilateral hearing loss and neurologic sequelae. [Charles Simmons]

The frequency and severity of adverse effects resulting from the administration of streptokinase and alteplase (t- PA) were monitored during a 19 month period in 126 con- secutive patients with acute myocardial infarction (MI) in a large community hospital. Adverse effects were based on patient assessment before, during, and after administration of a standard dose of thrombolytic. Adverse effects were defined as major bleeding, minor bleeding, hypotension, allergic reactions, and fever. 90 patients (71.4%) received alteplase and 36 (28.6%) received streptokinase. No patient in either group experienced a major bleeding episode and the frequency of minor bleeding episodes caused by the two agents was not significantly different (alteplase 7.8070, streptokinase 13.9%). However, the frequency of hypoten- sion caused by streptokinase (22.2%) was significantly higher than that caused by alteplase (5.6%). All cases of thrombolytic-induced hypotension were transient, easily managed, and associated with no sequelae. Two patients who received streptokinase developed allergic reactions, and two developed fever. No patient receiving alteplase experienced either of these. In summary, the frequency of nonhemorrhagic adverse effects associated with streptoki- nase, particularly hypotension, is significantly higher than that associated with alteplase. [Tracy L. Martig] 0 PREDICTING SEVERITY OF TRICYCLIC ANTI-

DEPRESSANT OVERDOSE. HultCn B-A, Adams R, Askenasi R, Dallos V, Dawling S, Volans G, Heath A. Clinical Toxicology. 1992;30(2):161-169.

Tricyclic antidepressant agents are commonly used in self-poisoning. This study evaluates the prognostic value of QRS duration, coma level, and plasma TCA concentra- tion in predicting toxicity. Sixty-seven patients were in- cluded and complications (convulsions, need for intuba- tion, dysrythmias, and hypotension) were recorded. Seventy percent of the patients had mixed intoxications, but the TCA component was felt to be the primary cause of toxicity. QRS duration longer than 100 msec predicted complications with a sensitivity of .86 and specificity of .75. Matthew-Lawson coma grade of III or greater (compa- rable to Glascow Coma Score of 8 or less) predicted with sensitivity and specificity of .65 and .94. Plasma level of TCA greater than 1000 micrograms/L had a sensitivity of .67 and specificity of 60. Coma grade was found statisti- cally to be the best predictor of complications; addition of QRS duration improved predictions only slightly. Plasma TCA concentration was of little additional value in predict- ing outcome. Most transfers from the intensive care unit occurred prior to thirty-six hours. No serious complica- tions occurred after transfer. The authors suggest that the alert, oriented patient with a QRS duration less than 100 ms can be safely transferred from the ICU, and that plasma TCA concentration is of little utility in making the decision for transfer.

[Marc David Taub, MD]

Editor’s Comment: Of note is that plasma TCA levels are of no utility in predicting TCA toxicity.

0 RUPTURE OF THE BOWEL AFTER BLUNT AB- DOMINAL TRAUMA: DIAGNOSIS WITH CT. Mirvis SE, Gens DR, Shanmuganathan K. AJR. 1992;159:1217- 1221.

In this paper, the authors present a study that was de- signed to determine the sensitivity of Computerized To- mography (CT) in diagnosing post-traumatic bowel rup- ture. Over a 51 month period, the authors analyzed interpretations of CT scans performed in 16 patients with surgically proved bowel rupture.

CT findings considered diagnostic of bowel perforation were detected prospectively in 59% of scans (10 of 17). These characteristics included pneumoperitoneum without intrathoracic source of prior diagnostic peritoneal lavage; extraperitoneal gas in the mesentery, bowel wall or retro- peritoneum; and direct visualization of bowel discontinu- ity. Prospective findings considered suggestive of bowel rupture were present on 29% of scans (5 of 17). These included diffuse thickening of the bowel wall, gross ante- rior peritoneal fluid without a known source, and transmu- ral hematoma. In two patients, findings were discovered on retrospective review only.

With these results, the authors concluded that CT is sensitive for the diagnosis of bowel rupture in the setting of blunt trauma, but caution that close attention to technique, including artifact reduction and optimal use of bowel con- trast material is important. [Cathy Northrop, MD]