Jessica A. Starr

PURPOSE OF REVIEW: To summarize reports published since the 2013 American Society of Bone and Mineral Research Task Force Report on atypical femoral fractures (AFF). RECENT FINDINGS: The absolute incidence of AFFs remains low. AFFs are primarily associated with prolonged bisphosphonate (BP) exposure, but have also been reported in unexposed patients and those receiving denosumab for osteoporosis and metastatic bone disease. Asians may be more susceptible to AFFs. Lateral femoral bowing and varus hip geometry, which increase loading forces on the lateral femoral cortex, may increase AFF risk. Altered bone material properties associated with BP therapy may predispose to AFFs by permitting initiation and increasing propagation of micro-cracks. Relevant genetic mutations have been reported in patients with AFFs. Single X-ray absorptiometry femur scans permit early detection of incomplete and/or asymptomatic AFFs. Orthopedists recommend intramedullary rods for complete AFFs and for incomplete, radiologically advanced AFFs associated with pain and/or marrow edema on MRI. Teriparatide may advance AFF healing but few data support its efficacy. Greater understanding of biological and genetic predisposition to AFF may allow characterization of individual risk prior to initiating osteoporosis therapy and help allay fear in those at low risk for this complication, which remains rare in comparison to the osteoporotic fractures prevented by antiresorptive therapy.

Objective: To evaluate the literature regarding the use of intravenous tissue plasminogen activator (tPA) in the treatment of acute ischemic stroke, focusing on the appropriate usage criteria and administration time window. Data Sources: A PubMed and MEDLINE search was performed (1990-November 2010) using the key words alteplase, tissue plasminogen activator, thrombolytic, ischemic stroke, and cerebrovascular accident. Study Selection and Data Extraction: Clinical trials published in English were evaluated and relevant primary literature evaluating the use of tPA in acute ischemic stroke was included. Data Synthesis: The NINDS (National Institute of Neurological Disorders and Stroke) trial revealed clinical efficacy of tPA in the treatment of acute ischemic stroke when administered within 3 hours of stroke symptom onset and served as the foundation for the American Heart Association/American Stroke Association (AHA/ASA) acute ischemic stroke guideline recommendations. The ECASS (European Cooperative Acute Stroke Study) I, ECASS II, and ATLANTIS (Alteplase Thrombolysis for Acute Noninterventional Therapy in Ischemic Stroke), part A and B, trials each assessed the efficacy of tPA when administered beyond 3 hours of ischemic stroke onset, but the results of each trial did not support its use beyond 3 hours. The ECASS III trial showed clinical efficacy of tPA when administered up to 4.5 hours. The SITS-MOST (Safe Implementation of Thrombolysis in Stroke-Monitoring Study) and SITS-ISTR (Safe Implementation of Thrombolysis in Stroke International Stroke Thrombolysis Register) registries evaluated the safety and efficacy of tPA at both 3 and 4.5 hours and showed promising results. In 2009, the AHA/ASA stroke guidelines were updated to support the use of tPA in select patients up to 4.5 hours after symptom onset. Conclusions: tPA is effective when administered up to 4.5 hours after ischemic stroke symptom onset in select patients. However, timely administration remains paramount to achievement of optimal therapeutic outcomes.

Abstract Objective: This case report describes antivenin‐associated acute and delayed hypersensitivity reactions in a dog envenomated by an Eastern diamondback rattlesnake ( Crotalus adamanteus ), specifically reviewing the syndrome of antivenin‐associated serum sickness. Clinician awareness of this syndrome is important in order to allow for its recognition and appropriate treatment. Case summary: A Boxer dog was envenomated by an Eastern diamondback rattlesnake. Shock, echinocytosis, and coagulopathy were manifested, and the dog was given antivenin crotalidae polyvalent therapy and supportive care. The early onset of an anaphylactoid reaction was attributed to antivenin therapy and was managed with diphenhydramine and subcutaneous epinephrine therapy. Fever, chemosis, and limb edema occurred during the 3rd through 6th hospital days following antivenin therapy and were consistent with serum sickness syndrome as described in humans. Further immunoassay support reflecting complement activation and response to treatment were characteristic. New information provided: To our knowledge, this describes the first reported case of antivenin‐associated serum sickness in a dog.

A variety of disease states, disorders, hereditary conditions, environmental toxins, and drugs may cause thrombocytopenia. Fluoroquinolones, however, are not thought to be common offenders. We report the case of a 72-year-old woman who was receiving intravenous ciprofloxacin for a urinary tract infection and developed thrombocytopenia during her hospital stay. Her platelet count dropped from 147 x 10(3)/mm3 on admission to as low as 21 x 10(3)/mm3 . On discontinuation of the drug, her platelet counts began to return to normal. After discharge, the patient continued to improve clinically. Four days after discharge, her platelet count was 197 x 10(3)/mm3 . In the primary literature, we found two case reports on thrombocytopenia associated with ciprofloxacin and one case report with alatrofloxacin. In addition, six additional case reports were found in non-English journals that describe fluoroquinolone-associated thrombocytopenia. Clinicians should be aware of the possible relationship between thrombocytopenia and fluoroquinolones, and platelet counts should monitored accordingly.

OBJECTIVE: To assess physician knowledge regarding acetaminophen dosing, toxicity, and recognition of acetaminophen-containing products and counseling practices when prescribing acetaminophen-containing medications. METHODS: Resident and faculty physicians at 1 internal medicine and 2 family medicine residency programs in Alabama were asked to participate in a voluntary survey. Participants completed a 7-item self-administered questionnaire. Questions were designed to assess physician knowledge of acetaminophen dosing and toxicity, recognition of prescription and over-the-counter products containing acetaminophen, and education provided to patients when prescribing acetaminophen-containing products. Questions were formatted as multiple choice, yes/no, true/false, and short answer. Certain items contained an answer choice of "unsure." RESULTS: Of the 76 physicians who completed the survey, only 76% were aware of the maximum daily dose of acetaminophen. Although 93% recognized Lortab and 90% Percocet as acetaminophen-containing products, only 83% identified Lorcet and 75% Darvocet. More than 90% of physicians correctly identified nonacetaminophen prescription medications with the exception of OxyContin (84%) and Ultram (79%). Knowledge of over-the-counter products was generally less accurate. Ninety-eight percent recognized hepatotoxicity as the primary toxicity. Although 72% of physicians stated they provide specific instructions to patients when prescribing acetaminophen-containing medications, the information provided was limited. CONCLUSIONS: Many physicians are unaware of acetaminophen dosing and toxicity issues and have some difficulty identifying acetaminophen-containing products. Information provided by physicians when prescribing acetaminophen products was limited. How this may contribute to unintentional acetaminophen overdose is unclear but should raise concern. These results reinforce the importance of public awareness, patient counseling, and physician education regarding acetaminophen toxicity issues.