Treatment of fever and associated symptoms in the emergency department: which drug to choose?

OBJECTIVE: Fever is a frequent cause of admission to the Emergency Department (ED) worldwide. Although it can be caused by a wide range of conditions, the most effective treatment based on its etiology is still undetermined. PATIENTS AND METHODS: This prospective, single-center, observational study enrolled adult patients who accessed the ED for fever. Physicians were free to administer paracetamol 1,000 mg (P), the combination paracetamol 500 mg/ibuprofen 150 mg (PI) or Ibuprofen 600 mg (I). The primary endpoint was both 1-degree and 1-point reduction in body temperature for all associated symptoms on the Numerical Rating Scale (NRS) after 1 hour (T1). The secondary endpoint was the reduction of at least 2 points on the NRS after two hours (T2). Adverse events, the need for rescue therapy, and the response based on the underlying etiology (bacterial, viral, or immune/neoplastic) were also evaluated. RESULTS: 324 patients (170 males, mean age 71±6 years) were enrolled: 187 had bacterial, 80 viral, and 57 neoplastic/inflammatory fever. Fever was treated with Paracetamol 1,000 mg (P) in 189 patients and with Paracetamol/Ibuprofen 500/150 mg (PI) in 135 subjects, while none of the patients were primarily treated with I. Based on the fever etiology P was administered to 113 patients with bacterial fever (59.8%), 48 patients with viral fever (25.4%), and 28 subjects with neoplastic/inflammatory fever (14.8%). PI was administered to 74 patients with bacterial fever (54.8%), 32 patients with viral fever (23.7%), and 29 subjects with neoplastic/inflammatory fever (21.5%). The primary endpoint was achieved by 126 patients, 70 of them (37.0%) were treated with P and 56 (41.5%) with PI (p=0.418). The secondary endpoint was achieved by 295 patients, 171 (90.5%) of them treated with P and 124 (91.9%) treated with PI (p=0.669). No significant differences were found between groups treated with P and PI concerning rescue therapy (15 vs. 6 patients; p=0.893). Interestingly, PI was more effective than P in patients with bacterial fever at T1 (P 33.6% vs. PI 48.6%; p=0.040), while efficacy of P and PI was similar at T2 for all kind of fever. CONCLUSIONS: Paracetamol 1,000 mg represents the first choice for the treatment of fever in the ED, followed by Paracetamol/Ibuprofen 500/150 mg. Interestingly, Paracetamol/Ibuprofen combination resulted in being more effective in patients with bacterial fever one hour after its administration.

Anthracycline and trastuzumab-induced cardiotoxicity in breast cancer.

OBJECTIVE: Breast cancer is the most common cancer among women. In the last twenty years early diagnosis, neoadjuvant and adjuvant systemic treatment that targeted to specific molecular targets have significantly reduced the mortality from breast cancer. However, the increase in survival has allowed to observe the cardiotoxic effects of anticancer therapy and increased mortality from cardiovascular causes, resulting in a large literature where experts try to identify the correct management of this critical problem. Even thought the increased attention in this field, many questions have not yet answers and new studies are needed. MATERIALS AND METHODS: We conducted a broad search of the English-language literature in Medline using the following search terms: cardiotoxicity, anthracyclines, trastuzumab, breast cancer, left ventricular dysfunction, heart failure. A manual examination of the articles found has been performed. RESULTS: We provide a comprehensive assessment of the current knowledge about cardiotoxicity induced by anthracycline plus trastuzumab in women affected by breast cancer. CONCLUSIONS: Early identification and prompt treatment of subclinical cardiotoxicity may improve cardiologic prognosis of these patients and may allow oncologists to avoid withdrawal of chemotherapy. That is why it becomes always more important the creation of multidisciplinary teams where cardiologists and oncologists work together to ensure optimal care to oncologic patients treated with cardiotoxic agents.

[Prolongation of the Q-T interval and hyperkinetic ventricular arrhythmias probably induced by terfenadine use in liver cirrhosis patients]. / Allungamento dell'intervallo Q-T ed aritmie ventricolari ipercinetiche probabilmente indotte dall'uso di terfenadina in paziente con cirrosi epatica.

The authors describe the prolongation of Q-T interval and secondary appearance of ventricular sustained ectopic beats in a 57 years old cirrhotic female treated for 4 days with antihistaminic drug (terfenadine) 240 mg/die/os. The pro-arrhythmic properties of terfenadine may be due to the quinidine-like mechanism of the drug and is strictly linked to the direct effect of the drug on H1 histaminergic receptors, which cause the prolongation of the myocardial cells action potential.

[Alcoholic hepatopathy, deficiency pathology and serum transaminases. Presentation of 2 clinical cases]. / Epatopatia alcolica, patologia carenziale e transaminasi sieriche. Presentazione di due casi clinici.

The authors describe two cases of Vit B1 and B6 deficiency in alcoholics with malnutrition. In the first case serum levels of AST and ALT, initially below norm became higher after Vit B1 and Vit B6 intake; the second, with AST and ALT above norm in previous months, had AST and ALT with normal activity during the disease. The authors suggest that normal activity of AST and ALT during alcoholic hepatopathy could be related to a depletion of Vit B1 and Vit B6.

[Increase of liver enzymes during treatment of myocardial infarct using intravenous nitro-derivatives]. / Aumento di enzimi di pertinenza epatica in corso di trattamento dell'infarto miocardico con nitroderivati per via endovenosa.

A transitory serum elevation of hepatocellular enzyme alanine-aminotransferase (ALT) and gamma GT is reported during i.v. treatment with nitroderivatives of acute myocardial infarction. authors have reviewed 144 case (105 males and 39 females) admitted to the emergency ward for acute myocardial infarction: of the 144 cases reviewed, 54 males and 16 females (48.6% of the total) presented a significative increase of ALT and gamma GT, up to the maximum value of 220 U/l, during the first week of continuous i.v. therapy with nitroderivatives. This elevation was transient, with return to normal values during the first month. The AA postulate that this increase is dose-dependent, linked to individual susceptibility and possibly due to the production of free oxygen radicals.

[A case of wet beriberi]. / Su di un caso di beri-beri umido.

The AA. report a case of thymine acute deficiency in a 35 year old chronic alcoholic and malnourished male, who was admitted to the hospital because of high-output heart failure, peripheral polyneuropathy, cortico-cerebellar atrophy (associated with RMN), ataxia and peripheral edema. The diagnosis of wet Beri-beri combined with Wernicke-Korsakoff syndrome was made and appropriate therapy with pulse daily dose of parenteral thymine instituted. At the fifth day of therapy the cardio-circulatory hyperkinetic syndrome was markedly improved and after three weeks neurological damage was also alleviated. The AA. outline the importance of early diagnosis and treatment for this form of high-output heart failure, which has a poor prognosis and, if left untreated, can determine the death of the patient in a few days.