Should every patient undergo cardiac catheterization after myocardial infarction?

During the past few decades, management of patients with myocardial infarction has dramatically evolved. High-risk patients are now identified by a variety of noninvasive tests, and aggressive use of reperfusion strategies has improved clinical outcomes. Despite the benefits of reperfusion, only a few patients are eligible to receive thrombolytic therapy. Mortality rates among patients excluded from thrombolytic trials (15% to 20%) have been far greater than those eligible for treatment (3% to 10%). Because most deaths occur within the first few days of infarction, interventions designed to reduce mortality should be performed acutely. Immediate catheterization allows identification of high-risk anatomy that may benefit from surgery and allows coronary angioplasty to be performed as a reperfusion strategy (when appropriate). Furthermore, catheterization allows documentation of ejection fraction, vessel patency, number of diseased vessels, and residual stenosis, all of which have been predictive of prognosis. Conversely, frequently repeated noninvasive diagnostic tests are associated with increased cost, are generally performed in low-risk patients, and 60% to 80% of patients with myocardial infarction ultimately require catheterization anyway. It is possible that early catheterization and percutaneous transluminal coronary angioplasty when indicated may effectively risk stratify patients (eliminating the need for noninvasive testing), may reduce morbidity and mortality, and shorten the length of hospital stay.     

A comparison of propofol, midazolam, and methohexital for sedation during retrobulbar and peribulbar block.

STUDY OBJECTIVE: To compare the efficacy of propofol, methohexital, and midazalom in providing adequate sedation during administration of retrobulbar block and satisfactory postoperative amnesia. DESIGN: Retrospective chart review over a 4-month period. SETTING: Ambulatory patients in the main operating room of a university-affiliated hospital. PATIENTS: One hundred forty-seven ambulatory patients undergoing ophthalmologic surgery of less than 2 hours' duration under regional anesthesia consisting of retrobulbar or peribulbar block and intravenous (IV) sedation. INTERVENTIONS: One of three drugs--propofol 0.47 +/- 0.06 mg/kg, midazolam 0.02 +/- 0.005 mg/kg, or methohexital 0.45 +/- 0.16 mg/kg--was administered IV. Patients were observed for a minimum of 60 seconds or until adequate sedation was achieved, after which a retrobulbar or peribulbar block was performed. MEASUREMENTS AND MAIN RESULTS: Blood pressure, electrocardiogram, and oxygen saturation were monitored and recorded. Patients were observed for apnea, hiccups, pain on injection, excitement, tremor, grimacing, or verbal response during the block. The requirement for additional sedation intraoperatively was noted. Patients were questioned postoperatively in the ambulatory recovery room for recall of needle insertion or discomfort during the block, as well as about their satisfaction with the overall experience. CONCLUSIONS: Grimacing or verbal response during the retrobulbar or peribulbar block did not predict or correlate with patient recall. Propofol was equal to both midazolam and methohexital in providing adequate sedation and postoperative amnesia but possesses the added advantages of reduced postoperative vomiting, lower intraocular pressure, and earlier return-to-home readiness.     

Educating the Public About Stroke

Acute stroke affects large numbers of people worldwide. It causes significant morbidity and mortality. Data support the hypothesis that the public is not familiar with either the risk factors or the signs of stroke. Educating the public about stroke may result in a lower incidence of the disease as individuals modify their risk factors, and in improved outcomes as a result of reductions in delays to treatment. There is clear and convincing evidence that reducing delays to treatment of patients with acute stroke results in improved outcomes. Public education programs should be broad-based, tailored to individual audiences, and carry a common theme.     

Multi-visceral upper abdominal resection and orthotopic liver transplantation--a surgical treatment concept for regionally metastatic tumors of the endocrine pancreas]

Islet cell carcinoma is rare. Even in advanced metastasizing tumors, relatively long survival times were reported. Aim of surgical treatment is complete removal of the tumor mass, if possible. When not, palliative procedures were described to be efficient in some of the cases. In the literature, among the first patients with regional metastasizing intraabdominal malignancies and upper abdominal exenteration, some cases with neuroendocrine tumors were reported. Aim of the following study is to describe the results in 4 patients with metastasizing islet cell carcinomas, which were treated by multi-visceral upper abdominal exenteration and combined orthotopic liver transplantation.