Aspirin, heparin, or both to treat acute unstable angina

We tested the usefulness of aspirin (325 mg twice daily), heparin (1000 units per hour by intravenous infusion), and a combination of the two in the early management of acute unstable angina pectoris in a double-blind, randomized, placebo-controlled trial involving 479 patients. The patients entered the study as soon as possible after hospital admission (at a mean [+/- SD] of 7.9 +/- 8.0 hours after the last episode of pain), and the study was ended after 6 +/- 3 days, when definitive therapy had been selected. Major end points--refractory angina, myocardial infarction, and death--occurred in 23, 12, and 1.7 percent of the 118 patients receiving placebo, respectively. Heparin was associated with a decrease in the occurrence of refractory angina (P = 0.002). The incidence of myocardial infarction was significantly reduced in the groups receiving aspirin (3 percent; P = 0.01), heparin (0.8 percent; P less than 0.001), and aspirin plus heparin (1.6 percent, P = 0.003), and no deaths occurred in these groups. There were too few deaths overall to permit evaluation of the effect of treatment on this end point. The combination of aspirin and heparin had no greater protective effect than heparin alone but was associated with slightly more serious bleeding (3.3 vs. 1.7 percent). We conclude that in the acute phase of unstable angina, either aspirin or heparin treatment is associated with a reduced incidence of myocardial infarction, and there is a trend favoring heparin over aspirin. Heparin treatment is also associated with a reduced incidence of refractory angina.     

Availability of services to treat patients with acute low back pain.

Guidelines for the management of acute low back pain were published in 1994. This national survey, conducted soon after, showed that the availability of services for general practitioners (GPs) to treat acute back pain fell short of the guideline recommendations. A repeat survey will be performed to measure the impact of guideline publication and dissemination.     

Structured approach to treat patients with acute liver failure: A hepatic emergency

Acute liver failure (ALF) is a condition of acute hepatic emergency where rapid deterioration of hepatocyte function leads to hepatic encephalopathy, coagulopathy, cerebral edema (CE), infection and multi-organ dysfunction syndrome resulting in a high mortality rate. Urgent liver transplantation is the standard of care for most of these patients in Western countries. However, in India, access to liver transplantation is severely limited and, hence, the management is largely based on intensive medical care. With earlier recognition of disease, better understanding of pathophysiology and improved intensive care, ALF patients have shown a significant improvement in spontaneous survival. An evidence base for practice for supportive care is still lacking; however, intensive organ support as well as control of infection and CE are likely to be key to the successful outcome in this acute and potentially reversible condition without any sequel. A structured approach to decision making about intensive care is important in each case. Unlike in Western countries where acetamenophen is the most common cause of ALF, the role of a specific agent, such as N-acetylcysteine, is limited in India. Ammonia-lowering therapy is still in an evolving phase. The current review highlights the important medical management issues in patients with ALF in general as well as the management of major complications associated with ALF. We performed a MEDLINE search using combinations of the key words such as acute liver failure, intensive treatment of acute liver failure and fulminant hepatic failure. We reviewed the relevant publications with regard to intensive care of patients with ALF.     

超声引导下PTCD在恶性梗阻性黄疸术前减黄的实用价值

本文对30例恶性梗阻性黄疸患者进行了分析,20例术前减黄组均采用超声引导下PTCD,减黄前血清胆红素平均13mg/dl,减黄到6mg/dl时施行手术。不减黄者血清胆红素平均为7.8mg/dl时施行手术。两组手术并发症和死亡率无显著差异。作者认为减黄组在13mg/dl时不减黄就怍切除术则术后并发症和死亡率会更高,因此主张术前减黄。超声具有无痛苦、无创伤,实时动态,移动方便等特点,即能降低并发症的发生率又可确保PTCD的顺利完成,PTCD应首选超声引导下,由技术熟练的外科医师实施。     

Improved removal of small proteins using continuous venovenous hemofiltration to treat acute renal failure

Continuous venovenous hemodialysis (CVVHD) or hemofiltration conducted with pre- (CVVHpre) or post- (CVVHpost) dilution modes are recommended to treat patients with acute renal failure (ARF) and cardiovascular instability. The efficiency of the three techniques was compared in a study including 18 critically ill patients with ARF. Their mean age was 62.1 +/- 16.7 years, and their mean SAPS II score was 59.5 +/- 14.3. They were treated sequentially with the three techniques for periods of 24 hours each (randomized assignment to one technique the first 24 hours followed by the two others). The PRISMA device and M 100 (AN69S) membrane were used in all instances. Blood and replacement (or dialysis) flow rates were kept at 150 and 25 ml/min, respectively. Urea, creatinine, uric acid, inorganic phosphorus, beta2 microglobulin (beta2m), and retinol binding protein (RBP) were measured every 12 hours in plasma and in 12 hours filtrate collection for 3 days. The results are expressed as filtrate/mean plasma (F/P) ratio for the 12 hour period. Removal of small molecules was 16% higher using CVVHD and CVVHpost than CVVHpre. For beta2m and RBP, CVVHpre was, respectively, 43% and 26% more efficient than CVVHD. CVVHpost gave higher but statistically different removal than CVVHpre only for beta2m. CVVHpost was the most efficient technique for removal of small proteins, but this advantage could be easily counterbalanced using higher volume substitution.     

An inherited disorder with splenomegaly, cytopenias, and vision loss

We describe a novel inherited disorder consisting of idiopathic massive splenomegaly, cytopenias, anhidrosis, chronic optic nerve edema, and vision loss. This disorder involves three affected patients in a single non-consanguineous Caucasian family, a mother and two daughters, who are half-sisters. All three patients have had splenectomies; histopathology revealed congestion of the red pulp, but otherwise no abnormalities. Electron microscopic studies of splenic tissue showed no evidence for a storage disorder or other ultrastructural abnormality. Two of the three patients had bone marrow examinations that were non-diagnostic. All three patients developed progressive vision loss such that the two oldest patients are now blind, possibly due to a cone-rod dystrophy. Characteristics of vision loss in this family include early chronic optic nerve edema, and progressive vision loss, particularly central and color vision. Despite numerous medical and ophthalmic evaluations, no diagnosis has been discovered.     

Personal and family stress in individuals with diabetes and vision loss

The intrapersonl distress and the impact of diabetes and vision impairment on marital functioning were assessed. Significant degrees of intrapersonal distress were demonstrated by the Beck Depression Inventory, Rosenberg Self-Esteem Scale, and Rand Mental Health Index. Family functioning as assessed by the Family Assessment Device was significantly compromised. Vision impairment was a major stressor in the spousal relationship. Of 18 subjects who had been involved in a committed relationship at the onset of vision impairment, 9 had separated. Separation occurred at a mean of 1.6 years after the vision impairment. Totally blind individuals were at greater risk for separation than those who were legally, but not totally, blind. Psychological intervention was a limited benefit. Studies are necessary to identify the appropriate timing for further interventions.     

经皮“瓣上瓣”支架植入治疗急性主动脉瓣关闭不全的应用解剖

目的为经皮"瓣上瓣"支架植入治疗急性主动脉瓣膜关闭不全提供相关应用解剖。方法解剖5例外形大小正常的成年人心脏和升主动脉的标本;回顾性分析178例升主动脉CTA病人影像资料,其中男性131例,女性47例,以及85例主动脉瓣上造影(DSA)病人资料,其中男性45例,女性40例,测量不同位置升主动脉的内径及长度。结果根据升主动脉CTA测得D1、D2、L1、L2分别为(30.5±2.3)、(25.5±1.8)、(36.5±3.6)、(31.2±4.1)mm,经体表面积标准化后得出的SD1、SD2、SL1、SL2分别为(17.1±1.2)、(14.2±0.9)、(21.4±1.1)、(17.8±1.3)mm;根据升主动脉DSA测量得出的D1’、D2’、L1’、L2’分别为(28.7±2.8)、(24.4±2.1)、(34.3±2.9)、(29.4±3.6)mm,经体表面积标准化后得出SD1’、SD2’、SL1’、SL2’分别为(16.0±1.4)、(13.5±1.2)、(19.7±1.6)、(16.7±2.0)mm。结论经皮主动脉"瓣上瓣"支架具有成功的动物实验研究背景,可作为一种新技术用于临床,其瓣膜支架的大小和形状的设计应根据升主动脉段的内径和长度来选择。     

Central circulation in rats with different tolerance to acute blood loss

Study of the dynamics of cardiac output in rats with different tolerance to acute massive blood loss showed that the pumping ability of the heart remains intact during the entire posthemorrhagic period in all high-resistant and in 65% low-resistant rats. In 35% rats that were low-resistant to blood loss, the cardiac output deficiency syndrome developed after cessation of bleeding against the background fall in arterial pressure and a decrease in the hepatic blood flow, which are the signs of rapid variant of the dysfunction produced by acute blood loss. Translated fromByulleten' Eksperimental'noi Biologii i Meditsiny, Vol. 126, No. 10, pp. 384–388, October, 1998     

Response to a combination of severe head injury and acute massive blood loss

Acute experiments on dogs showed that the character of the response to a combination of craniocerebral trauma and acute blood loss depends on the order of infliction of these extremal conditions. Craniocerebral trauma inflicted in the early period of hemorrhagic shock does not significantly affect the dynamics and outcome of the underlying pathological process. Hemorrhagic shock arising after craniocerebral trauma does so as a result of a much smaller blood loss and it follows a more severe course.Experimental Laboratory, L'vov Military Hospital. (Presented by Academician of the Academy of Medical Sciences of the USSR N. A. Fedorov.) Translated from Byulleten' Eksperimental'noi Biologii i Metitsiny, Vol. 83, No. 4, pp. 413–416, April, 1977.     

Nerve growth factor in Alzheimer's disease: to treat or not to treat?

Several hypotheses can be proposed to link neurotrophic factors with neurodegenerative diseases. Not surprisingly, different hypotheses suggest completely different approaches to therapy; some would suggest use of neurotrophic factors, while others would propose that the actions of these factors be blocked. It has been suggested that NGF be used to prevent the loss of basal forebrain cholinergic neurons in Alzheimer's disease (AD). At this time it is not possible to conclude whether or not NGF is implicated in the causation or progression of this disorder. Nevertheless, experimental studies in animals have given a strong rationale for its use. Given the lack of an effective treatment for this disorder, the careful approach to NGF trials outlined by an ad hoc committee of the National Institute on Aging should be pursued.