Acute recognition and management of congestive heart failure

The acute recognition and management of CHF is challenging. A basic understanding of the determinants of cardiac performance and myocardial O2 consumption along with the pathophysiology of CHF is essential knowledge for the physician undertaking to treat this serious disorder. The basic value of the patient history and physical examination along with assessment of noninvasive tests remains unquestioned, but in addition much relevant and sophisticated information can be gained by invasive hemodynamic monitoring. The cardiopulmonary profile generated by such monitoring allows the physician to use specific hemodynamic and circulatory data for the purpose of manipulating these variables favorably for the heart and circulation. A wide array of therapeutic options is currently available, but, in general, respiratory support and pharmacotherapy are the mainstays of treatment. The traditional agents like digitalis and diuretics have assumed a lesser role during the last decade because of the availability of potent new vasodilator and inotropic agents. In addition, certain mechanical, procedural, and surgical options can be used if circumstances are urgent. In the final analysis, physicians who manage these patients must possess strong cognitive skills but also the clinical reflexes to carry them out: for every hemodynamic and circulatory action, they must be prepared to counter quickly and decisively with a clinical reaction which utilizes these principles to optimize cardiac function. It is hoped that the strategies presented in this article will allow them to perform in such a manner.     

Primary arteriovenous fistula between common iliac vessels: ultrasound, computer tomographic, and angiographic findings--a case report

A giant aneurysm of the right common iliac artery presenting with an arteriovenous fistula (AVF) between the iliac artery and iliac vein and deep venous thrombosis of the right lower extremity is reported. The clinical signs and the radiologic and surgical management of the condition are discussed. In addition a brief review of the literature is given.     

Oxidated sterols--a contributing factor in atherogenesis?

Sterols are not only important metabolic precursors, they are also indispensable structural components of cell membranes. There is some evidence that synthesis of cholesterol is regulated by oxidized derivatives of cholesterol. They are able to inhibit the key enzyme of cholesterol synthesis, i.e. 3-hydroxy-3-methylglutaryl-CoA-reductase. In addition, oxidized sterols are inserted into the lipid bilayer of the cell membrane as cholesterol analogues. This insertion results in serious disturbances of morphology and function of the membrane. In animal models oxidized sterols have angiotoxic effects; they are also found in atheromas of human arteries. Therefore they may be a causative factor in atherogenesis.     

The use of urinary diagnostic indices in pre-eclampsia-associated oliguria

A case is presented of severe pregnancy-induced hypertension that was complicated by oliguria and managed with the aid of a pulmonary artery catheter. This case illustrates that urinary diagnostic indices may be unreliable in predicting the etiology of oliguria. Although urinary diagnostic tests are advocated routinely as reliable in the nonobstetric literature, possible misinterpretation of these values in severe pre-eclampsia with oliguria may require confirmation with hemodynamic data obtained from a pulmonary artery catheter.     

The predictive value of steroid hormone receptor analysis in breast, endometrial and ovarian cancer

The predictive value of female sex steroid, estrogen and progesterone, receptor (ER and PR, respectively) assays in breast, endometrial and ovarian cancer is reviewed with emphasis on comparative aspects of these malignant tumors in relation to their hormone dependency. The endocrine etiology of these three tumor types seems to be at least partly different, and so is the expression of these receptors in normal and malignant tissues of the breast, endometrium and ovary. There is a tendency for decreased receptor concentrations and disappearance of these receptors in association with advancement of these malignancies. There is also a decrease in the presence and concentrations of ER and PR in relation to loss of differentiation in breast and endometrial cancer. Receptor analyses have an established position in the selection of patients with advanced breast cancer for endocrine treatment, and they give promise of a similar application in endometrial cancer and in endometrioid cancer of the ovary. It is not clear whether the disease-free interval is related to the presence or concentrations of ER or PR as such in the tumor tissue. There is better survival in breast cancer patients with receptor-positive tumors, which might be due to a response to endocrine treatment. The same seems to be true for patients with endometrial cancer. Future progress in the application of female sex steroid receptor analyses in breast, endometrial and ovarian cancer needs additional controlled clinical trials and more highly developed receptor assays.