Bench-to-bedside review: Antidotal treatment of sulfonylurea-induced hypoglycaemia with octreotide

The major potential adverse effect of use of sulfonylurea agents (SUAs) is a hyperinsulinaemic state that causes hypoglycaemia. It may be observed during chronic therapeutic dosing, even with very low doses of a SUA, and especially in older patients. It may also result from accidental or intentional poisoning in both diabetic and nondiabetic patients. The traditional approach to SUA-induced hypoglycaemia includes administration of glucose, and glucagon or diazoxide in those who remain hypoglycaemic despite repeated or continuous glucose supplementation. However, these antidotal approaches are associated with several shortcomings, including further exacerbation of insulin release by glucose and glucagon, leading only to a temporary beneficial effect and later relapse into hypoglycaemia, as well as the adverse effects of both glucagon and diazoxide. Octreotide inhibits the secretion of several neuropeptides, including insulin, and has successfully been used to control life-threatening hypoglycaemia caused by insulinoma or persistent hyperinsulinaemic hypoglycaemia of infancy. Therefore, this agent should in theory also be useful to decrease glucose requirements and the number of hypoglycaemic episodes in patients with SUA-induced hypoglycaemia. This has apparently been confirmed by experimental data, one retrospective study based on chart review, and several anecdotal case reports. There is thus a need for further prospective studies, which should be adequately powered, randomized and controlled, to confirm the probable beneficial effect of octreotide in this setting.     

THE ENHANCEMENT OF MACROPHAGE BACTERIOSTASIS BY PRODUCTS OF ACTIVATED LYMPHOCYTES

It was reported previously that the incubation of normal guinea pig macrophages with partially purified products of activated lymphocytes resulted in altered macrophage function including increased cell adherence to culture vessels, spreading, phagocytosis, and glucose carbon-1 oxidation. Studies reported here demonstrate that such macrophages also exhibit enhanced bacteriostasis. Lymphocytes were stimulated with concanavalin A, the culture supernatant was chromatographed over Sephadex G-100 and the fraction of mol wt 25,000–55,000, rich in lymphocyte mediators, was cultured with normal guinea pig macrophages for 1–3 days. Macrophages incubated with fractions from unstimulated lymphocyte cultures served as controls. The resulting macrophage monolayers were infected with Listeria monocytogenes. Macrophages incubated with mediator-rich fractions exhibited 2- to 10-fold enhanced bacteriostasis compared to controls. Further studies indicate that this enhancement was attributable to intrinsic changes in the macrophages and not simply a consequence of the number of macrophages on the monolayers. The studies support the concept that macrophage bacteriostasis can be enhanced by lymphocyte mediators. However, macrophages, which have been preincubated directly with sensitive lymphocytes and antigen exhibit even greater bacteriostasis and sometimes bactericidal capacity, suggesting that either a labile lymphocyte factor or direct lymphocyte macrophage interaction may also be involved in bactericidal activity.     

Autonomic and Cardiovascular Responses of Preschool Children to Television Programs

This exploratory study examined the heart rates (HR) and skin temperatures (ST) of 18 preschool children while they viewed two clips of everyday children's television (TV) programming. The measurements were made in a day care setting, in a naturalistic environment designed to mimic the real world of children's TV viewing. The purpose of the study was to determine whether cardiovascular and autonomic arousal to TV programming might occur in some children. Since a large body of psychosocial literature addresses the affects of TV violence on children, HR and ST were examined during exposure to scenes from Mr. Roger's Neighborhood and G.I. Joe cartoons. The Mr. Roger's clip was slow, rhythmic, prosocial, and nonviolent, while the G.I. Joe clip was fast-paced, staccato, colorful, and full of verbal and action violence. The study found a significant effect of exposure to the cartoon violence on HR, with HR increasing. ST decreased, but not significantly, and there was a significant effect of time on the ST, due possibly to habituation. This finding has relevance to nursing assessment, intervention, and education of parents and children, since TV viewing is a pervasive cultural phenomenon. The possibility of excessive or inappropriate autonomic and cardiovascular responsiveness in some children to TV must be considered.     

Potential cardiovascular effects of COX-2 selective nonsteroidal antiinflammatory drugs

The newly developed nonsteroidal antiinflammatory drugs (NSAIDs) that selectively inhibit cyclooxygenase-2 (COX-2), are effective against pain and inflammation and appear to have less gastrointestinal toxicity than conventional NSAIDs. Their COX-2 selectivity, however, has raised concerns regarding their cardiovascular safety, since they do not inhibit COX-1, the isoform of the enzyme that is active in thrombosis and vasoconstriction. At this point there is no conclusive evidence that COX-2 inhibitors cause ischemic vascular events, because retrospective post hoc analyses conflict one another, and no specific randomized trials have yet been done. Renal effects, edema and hypertension appear to be similar between conventional NSAIDs and COX-2-selective inhibitors. Aspirin is still required for patients with cardiovascular risk who are prescribed a COX-2-selective inhibitor.     

Apparent asymmetric septal hypertrophy due to angled interventricular septum

A distinct geometric pattern is described in patients whose M mode echocardiogram falsely indicates asymmetric septal hypertrophy. Sixty-four patients were referred because of clinically suspected idiopathic hypertropic subaortic stenosis. Thirty-six of these patients had M mode echocardiograms showing asymmetric septal hypertrophy (septal/free wall ratio 1.3 or greater). On two dimensional study, only 16 of the 36 had this finding; each of the remaining 20 had a normal interventricular septum. The apparent asymmetric septal hypertrophy on M mode echocardiography was due to anterior angulation of the septum: The thickness of the septum was exaggerated because of its oblique orientation with respect to the path of the single dimensional echocardiographic beam. This anterior direction of the septum was indicated by measuring the angle between the mid line axis of the aortic root and that of the septum. In patients with apparent asymmetric septal hypertrophy this angle was lower (97 ° ± 2.6 ° [mean ± standard error of the mean]than in patients with true asymmetric septal hypertrophy (124 ° ± 2.9 °, p <0.001) or in normal subjects (128 ° ± 1.9 °, p <0.001).M mode echocardiograms were similar in the groups with apparent and true asymmetric septal hypertrophy with respect to septal velocity and percent thickening. The two groups were likewise similar with respect to clinical features (chest pain, palpitation, systolic murmur). The group with true asymmetric septal hypertrophy had a larger proportion of electrocardiographic abnormalities. Because of limitations in technique, M mode echocardiography may allow overdiagnosis of asymmetric septal hypertrophy in certain patients. When a more secure diagnosis of this abnormality is necessary, two dimensional echocardiography is helpful.     

LWMH与VKA对DVT患者院外抗凝效益-风险对比

【目的】通过对经住院治疗后下肢深静脉血栓形成(deep venous thrombosis,DVT)患者院外分别继续应用低分子肝素(low molecule weight heparin,LMWH)或维生素K拮抗剂(vitamin K antagonists,VKA)的效益-风险比的对比研究,探讨较为有效、安全、简便的抗凝方案。【方法】将2008年12月-2011年3月符合纳入标准的患者随机分为A组(应用低分子肝素钙)和B组(应用华法林),并随访6个月,期间通过定期监测凝血功能及血小板计数,调整用药方案;每2个月做1次全面随访,包括有无出血、肝素诱导的血小板减少和复发事件的发生。【结果】两组均取得有效的抗凝效果,并且A组副作用发生率在各监测点明显低于B组(P<0.05),随访中发现两组DVT复发率无差异(P>0.05),但随着抗凝时间延长,两组患者出血发生率增加。在DVT复发患者中,髂股深静脉血栓形成者复发率最高,其次是股静脉、腘静脉。患者对应用A治疗方案的依从性较高。【结论】DVT患者院外继续应用LWMH抗凝效果可靠,用药安全性高,副作用较小,操作及监测简单,与应用VKA相比效益-风险比较高。     

Stapled diverticulectomy for solitary caecal diverticulitis

Caecal diverticulitis is an uncommon phenomenon in western countries. The clinical diagnosis is often difficult as it mimics other acute abdominal conditions like appendicitis, colitis or neoplasia. Diagnosis is often made at operation. Operative strategy has been controversial and there is no broad consensus emerging. We report the case of a 71-year-old woman, known to have chronic obstructive pulmonary disease, who presented acutely with right iliac fossa pain. A clinical diagnosis of appendicitis was made. At laparoscopy, a solitary, inflamed, gangrenous caecal diverticulum was found. A laparoscopic stapled diverticulectomy was performed. The patient made a steady post-operative recovery. Histology confirmed diverticulitis. We conclude that stapled diverticulectomy for solitary caecal diverticulitis is a safe and effective surgical strategy when confronted with this scenario.     

Maternal Predictors of Toddler Health Status

PURPOSE.  The purposes of this study were to examine the relationships among maternal and environmental variables in the first 6 months postpartum and toddler health status, and to identify predictors of toddler health .
DESIGN AND METHODS.  A secondary analysis was conducted on an existing dataset of a longitudinal parent–child survey .
RESULTS.  Maternal stress predicted 8% of the variance in child health status at 18 months of age. Children in nonparental care more than 20 hr per week were perceived as less healthy .
PRACTICE IMPLICATIONS.  Pediatric nurses should assess levels of maternal stress in the early months postpartum and anticipate poorer health status in toddlers who spend more than 20 hr per week in nonparental care .