Postoperative mortality: Atenolol is associated with fewer deaths than metoprolol

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Perioperative beta-blockade reduces postoperative adverse cardiac events in both the short and long term, and current guidelines recommend prophylactic beta-blockade for high-risk patients undergoing noncardiac surgery.

In this retrospective study, 30-day mortality (1% in the atenolol group vs 3% in the metoprolol group; P < .001) and 1-year mortality (7% vs 13%, respectively; p < .001) differed between the 2 beta-blockers.

The investigators concluded that perioperative beta-blockade using atenolol is associated with reductions in both short- and long-term postoperative mortality compared with metoprolol.

In 2009, on the basis of evidence from many studies, the American College of Cardiology/American Heart Association updated their guidelines, stating that perioperative beta-blockade is a class IIa recommendation for patients with cardiac risk and should be considered during surgery.

CDC: New Recommendations for Treating Gonorrhea

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  • The treatment recommendations for gonorrhea have changed substantially during the past 5 years.
  • Because of a high rate of antimicrobial resistance, fluoroquinolones are no longer recommended to treat gonorrhea.
  • To treat a potential coinfection with chlamydia, the treatment regimen for gonorrhea should include either a single dose of azithromycin or 1 week of doxycycline, even if testing for Chlamydia trachomatis is negative at the time of treatment.
  • The mainstays of treatment for gonorrhea have been intramuscular ceftriaxone or oral cefixime.
  • However, there is concern regarding the susceptibility of Neisseria gonorrhoeae to cefixime.
  • The CDC now recommends that gonorrhea be treated with ceftriaxone 250 mg intramuscularly in a single dose, not with cefixime. Ceftriaxone should be combined with azithromycin 1 g once only or doxycycline 100 mg twice daily for 7 days.

New Guidelines: Thyroid Disease during Pregnancy

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The Endocrine Society’s clinical practice guideline for the management of thyroid disease during pregnancy and after birth has been updated from its 2007 version. [August issue of the Journal of Clinical Endocrinology and Metabolism]

Diagnosing and treating patients with thyroid-related medical issues before, during, and immediately after pregnancy.

  • Trimester-specific reference ranges for pregnant women, using a free T4 assay, should be established.
  • The nonpregnant total T4 range (5–12 μg/dL or 50–150 nmol/liter) can be adapted in the second and third trimesters by multiplying this range by one and a half-fold.
  • Free T4 index appears to be a reliable assay during pregnancy.
  • Propylthiouracil (PTU) should be the first-line drug for treatment of hyperthyroidism during the first trimester of pregnancy.
  • Methimazole (MMI) may also be prescribed if PTU is not available or not tolerated.
  • Clinicians should change treatment of patients from PTU to MMI after completion of the first trimester because of the potential for liver toxicity.
  • Breast-feeding women should maintain a daily intake of 250 μg iodine to ensure breast-milk provides 100 μg iodine per day to the infant.
  • Once-daily prenatal vitamins should contain from 150 to 200 μg iodine in the form of potassium iodide or iodate
  • Thyroid receptor antibodies should be measured before 22 weeks’ gestational age in mothers with “1) current Graves’ disease; or 2) a history of Graves’ disease and treatment with 131I or thyroidectomy before pregnancy; or 3) a previous neonate with Graves’ disease or 4) previously elevated [thyroid-stimulating hormone receptor antibodies (TRAb)].
  • In women with TRAb at least 2- to 3-fold the normal level and women treated with antithyroid drugs, fetal thyroid dysfunction should be screened for during the fetal anatomy ultrasound done in the 18th–22nd week and repeated every four to six weeks or as clinically indicated.
  • Evidence of fetal thyroid dysfunction could include thyroid enlargement, growth restriction, hydrops, presence of goiter, advanced bone age, tachycardia, or cardiac failure.
  • Women with nodules from 5 mm to 1 cm in size should be considered for fine-needle aspiration (FNA) if they have a high risk history or suspicious findings on ultrasound, and women with complex nodules from 1.5 to 2 cm in size should also receive an FNA. “During the last weeks of pregnancy, FNA can reasonably be delayed until after delivery. Ultrasound-guided FNA is likely to have an advantage for maximizing adequate sampling,” the authors conclude. [Medscape]

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