Screening in cyberspace: The next generation?

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Internal medicine in the next millennium: whither vascular medicine?

Cardiovascular diseases cause a staggering amount of morbidity and mortality. The knowledge derived from advances in vascular biology and vascular medicine has provided the practicing clinician with an already impressive number of effective treatments, but these treatments need to be applied more consistently and more effectively. The field of vascular medicine is growing at a high rate. In order to better apply existing knowledge and to be prepared for new developments, education in vascular medicine should be enhanced both in the training programme for Dutch internists and in postgraduate education. Academic and large community hospitals should consider the founding of multidisciplinary centres for vascular medicine. General internists should play a coordinating role in such centres.     

The flesh-eating bacterium: what's next?

Since the 1980s, there has been a marked increase in the recognition and reporting of highly invasive group A streptococcal (GAS) infections associated with shock and organ failure, with or without necrotizing fasciitis. Such dramatic cases have been defined as streptococcal toxic shock syndrome (StrepTSS). Strains of GAS isolated from patients with invasive disease have been predominantly M types 1 and 3, which produce either pyrogenic exotoxin A or B or both. The clinical and demographic features of streptococcal bacteremia, myositis, and necrotizing fasciitis are presented and compared with those of StrepTSS. Current concepts in the pathogenesis of invasive streptococcal infection will be presented, with emphasis on the interaction between GAS virulence factors and host defense mechanisms. Finally, new concepts in the treatment of StrepTSS will be discussed.     

Inflammation and ischemic heart disease: The next therapeutic target?

Inflammation plays an important role in several stages of the cardiovascular continuum. In recent decades a plethora of studies have provided new data highlighting the role of inflammation in atherogenesis and atherothrombosis in two-way interactions with various cardiovascular risk factors and further influencing these dynamic processes. The concept of targeting residual inflammatory risk among individuals with ischemic heart disease (IHD) is therefore gaining increasing attention. Recently, several landmark randomized controlled trials have assessed different pharmacological approaches that may mitigate this residual risk. The results of some of these studies, such as CANTOS with canakinumab and COLCOT and LoDoCo2 with colchicine, are promising and have provided data to support this concept. Moreover, though several aspects remain to be clarified, these trials have shown the potential of modulating inflammation as a new target to reduce the risk of cardiovascular events in secondary prevention patients. In the present review, we aim to present a pragmatic overview of the complex interplay between inflammation and IHD, and to critically appraise the current evidence on this issue while presenting future perspectives on this topic of pivotal contemporary interest.     

Does a vascular closure device affect the imbalance in complications between radial and femoral access?

• There exists a robust evidence base of superior outcomes in ST-Elevation Myocardial Infarction (STEMI) with radial as opposed to femoral access
• Benefit of vascular closure devices to decrease femoral access complications remains a matter of contention; the evidence base is largely incomplete
• Vascular site complications and access site related bleeding may be as much, or more affected by access technique as by method of vascular closure

     

Reminiscence intervention in nursing homes: what and who changes?

The results of experimental studies of reminiscing are not as uniformly optimistic about its therapeutic value as is the theoretical literature. Moreover, anecdotal evidence regarding the impact of reminiscence interventions is more positive than the statistical evidence. This study suggests reasons for these previous findings, and examines data from a discussion group intervention in thirty nursing homes, in which 185 residents completed pre- and posttests. It analyzes the characteristics of participants in relation to modifications in selected attitudes and behaviors over the intervention period. Analysis of variance and discriminant analysis revealed no significant relationships between attitudinal or behavioral modifications and demographic or other characteristics, with one exception. Value-choices made by participants were related to such modifications. The findings are interpreted in terms of the "mental adaptability" of participants and the compensatory nature of reminiscence in an institutional setting.