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BACKGROUND: The American Academy of Orthopaedic Surgeons (AAOS) and the American College of Chest Physicians (ACCP) have both developed evidence- based guidelines to prevent venous thromboembolism (VTE) in high-risk orthopedic surgery patients. Recent changes to these documents have brought them into agreement as to the inclusion of aspirin as an appropriate option for VTE prophylaxis in this patient population. OBJECTIVE: To evaluate the appropriateness of aspirin to prevent VTE in high-risk orthopedic surgery patients. DATA SOURCES: Guidelines published by the AAOS in 2011 and the ACCP in 2012 were compared regarding their recommendations on the use of aspirin for the prevention of VTE. A literature search was also conducted to identify clinical trials that evaluated the use of aspirin for the prevention of VTE in this patient population. Search terms included the MeSH terms venous thromboembolism; venous thrombosis; pulmonary embolism; aspirin; arthroplasty, replacement, knee; arthroplasty, replacement, hip; and hip fractures/surgery. STUDY SELECTION AND DATA EXTRACTION: Any study that evaluated aspirin, even in combination with another method of prophylaxis (such as pneumatic compression devices), and had been published during or after 1985 was included. DATA SYNTHESIS: Randomized controlled trials, meta-analyses, and other large pooled and retrospective reviews have failed to consistently arrive at similar conclusions regarding the efficacy and safety of aspirin as an option for VTE prophylaxis in patients undergoing total knee arthroplasty (TKA), total hip arthro- plasty (THA), or hip fracture surgery (HFS). Disagreements in the appropriateness of surrogate markers for safety and efficacy have resulted in differing recommen- dations from the ACCP and AAOS. The primary argument lies in the appropriate- ness of deep vein thrombosis as a surrogate marker for more serious outcomes such as pulmonary emboli. CONCLUSIONS: Recent changes to both the ACCP and AAOS guidelines are in agreement for those who choose to use aspirin for chemoprophylaxis of VTE. Current surgical care improvement project measures do not include aspirin as an appropriate sole option for the prevention of VTE, but in patients undergoing elective TKA or who have a contraindication to pharmacologic prophylaxis and undergo a THA or HFS, aspirin in conjunction with compression devices as part of a multimodal approach would meet these measures. Data do not support the hypothesis that aspirin is less likely to cause adverse bleeding events than more potent anticoagulants.

Objective: To review the literature regarding therapeutic options for accidental epinephrine exposure via EpiPen (Mylan Specialty Inc.) autoinjector devices and to suggest a treatment algorithm based on the most common approaches found therein. Data Sources: A literature search of MEDLINE (1950-March 2012) was conducted, using the search term accidental epinephrine injection in combination with the terms adrenaline, EpiPen, anaphylaxis, autoinjector, and treatment. Case reports, case series, and systematic reviews were evaluated for efficacy and safety data. In addition, the references of the reviewed articles were examined to identify additional reports or data. Study Selection and Data Extraction: All English-language articles describing accidental exposure to epinephrine were identified. Our search included both pediatric and adult patient populations. Articles were excluded if the exposure to epinephrine was purposeful and the EpiPen described in the report was being used as intended or the outcome was not clear. Individual case reports were described in detail whereas case series and systematic reviews were included but were not described in detail. To our knowledge, there have been no clinical trials that describe or compare therapeutic options for accidental exposure to epinephrine. Data Synthesis: Accidental exposure to epinephrine is an underreported phenomenon that could warrant medical attention. The importance of this issue has recently been emphasized with the legislative requirement of many schools to store epinephrine (EpiPen) autoinjector devices. The available therapeutic options can be divided into pharmacologic and nonpharmacologic categories. The most common pharmacologic options described in the literature include phentolamine, subcutaneous terbutaline, topical nitrates, and calcium channel blockers. Nonpharmacologic options include observation and/or warm water soaks. Treatment recommendations in our proposed algorithm were based solely on the available data that we describe in our review. Conclusions: The literature did not provide clear guidance on the most appropriate management of accidental epinephrine injection. However, if pharmacologic therapy is necessary, phentolamine appears to be considered the most effective. Guidelines may be helpful in improving the management of accidental epinephrine injection, as well as in preventing unnecessary therapy.

BACKGROUND: The American Academy of Orthopaedic Surgeons (AAOS) and the American College of Chest Physicians (ACCP) have both developed evidence- based guidelines to prevent venous thromboembolism (VTE) in high-risk orthopedic surgery patients. Recent changes to these documents have brought them into agreement as to the inclusion of aspirin as an appropriate option for VTE prophylaxis in this patient population. OBJECTIVE: To evaluate the appropriateness of aspirin to prevent VTE in high-risk orthopedic surgery patients. DATA SOURCES: Guidelines published by the AAOS in 2011 and the ACCP in 2012 were compared regarding their recommendations on the use of aspirin for the prevention of VTE. A literature search was also conducted to identify clinical trials that evaluated the use of aspirin for the prevention of VTE in this patient population. Search terms included the MeSH terms venous thromboembolism; venous thrombosis; pulmonary embolism; aspirin; arthroplasty, replacement, knee; arthroplasty, replacement, hip; and hip fractures/surgery. STUDY SELECTION AND DATA EXTRACTION: Any study that evaluated aspirin, even in combination with another method of prophylaxis (such as pneumatic compression devices), and had been published during or after 1985 was included. DATA SYNTHESIS: Randomized controlled trials, meta-analyses, and other large pooled and retrospective reviews have failed to consistently arrive at similar conclusions regarding the efficacy and safety of aspirin as an option for VTE prophylaxis in patients undergoing total knee arthroplasty (TKA), total hip arthro- plasty (THA), or hip fracture surgery (HFS). Disagreements in the appropriateness of surrogate markers for safety and efficacy have resulted in differing recommen- dations from the ACCP and AAOS. The primary argument lies in the appropriate- ness of deep vein thrombosis as a surrogate marker for more serious outcomes such as pulmonary emboli. CONCLUSIONS: Recent changes to both the ACCP and AAOS guidelines are in agreement for those who choose to use aspirin for chemoprophylaxis of VTE. Current surgical care improvement project measures do not include aspirin as an appropriate sole option for the prevention of VTE, but in patients undergoing elective TKA or who have a contraindication to pharmacologic prophylaxis and undergo a THA or HFS, aspirin in conjunction with compression devices as part of a multimodal approach would meet these measures. Data do not support the hypothesis that aspirin is less likely to cause adverse bleeding events than more potent anticoagulants.

Objective: To review the literature regarding therapeutic options for accidental epinephrine exposure via EpiPen (Mylan Specialty Inc.) autoinjector devices and to suggest a treatment algorithm based on the most common approaches found therein. Data Sources: A literature search of MEDLINE (1950-March 2012) was conducted, using the search term accidental epinephrine injection in combination with the terms adrenaline, EpiPen, anaphylaxis, autoinjector, and treatment. Case reports, case series, and systematic reviews were evaluated for efficacy and safety data. In addition, the references of the reviewed articles were examined to identify additional reports or data. Study Selection and Data Extraction: All English-language articles describing accidental exposure to epinephrine were identified. Our search included both pediatric and adult patient populations. Articles were excluded if the exposure to epinephrine was purposeful and the EpiPen described in the report was being used as intended or the outcome was not clear. Individual case reports were described in detail whereas case series and systematic reviews were included but were not described in detail. To our knowledge, there have been no clinical trials that describe or compare therapeutic options for accidental exposure to epinephrine. Data Synthesis: Accidental exposure to epinephrine is an underreported phenomenon that could warrant medical attention. The importance of this issue has recently been emphasized with the legislative requirement of many schools to store epinephrine (EpiPen) autoinjector devices. The available therapeutic options can be divided into pharmacologic and nonpharmacologic categories. The most common pharmacologic options described in the literature include phentolamine, subcutaneous terbutaline, topical nitrates, and calcium channel blockers. Nonpharmacologic options include observation and/or warm water soaks. Treatment recommendations in our proposed algorithm were based solely on the available data that we describe in our review. Conclusions: The literature did not provide clear guidance on the most appropriate management of accidental epinephrine injection. However, if pharmacologic therapy is necessary, phentolamine appears to be considered the most effective. Guidelines may be helpful in improving the management of accidental epinephrine injection, as well as in preventing unnecessary therapy.

Pelvic inflammatory disease (PID) remains a relevant public health concern due to long-term effects on reproductive potential. Despite being the most common gynecologic infection,programs focusing on prevention are lacking. Given the correlation between PID and sexual activity,practitioners should be cognizant of this disease in adolescents and young adults. The treatment of PID should include antimicrobials with activity against common sexually transmitted pathogens as well as other vaginal microflora.

Genital herpes continues to be a relevant public-health concern because of its prevalence and its association with an increased risk of acquiring other sexually transmitted diseases. Genital herpes may present as vesicular lesions that can rupture and become painful; however, more than 80% of individuals are asymptomatic, which makes it difficult to contain the spread of disease. The treatment of genital herpes serves to shorten symptom duration and improve quality of life, but it does not cure the disease. Strategies to prevent transmission include chronic suppressive therapy in serodiscordant couples, safe-sex practices, and avoidance of sexual intercourse during outbreaks. Currently available therapies are well tolerated and highly effective, and some newer therapeutic options are being investigated.

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