Low-molecular-weight heparin (nadroparin) and very low doses of warfarin in the prevention of upper extremity thrombosis in cancer patients with indwelling long-term central venous catheters: a pilot randomized trial

BACKGROUND AND OBJECTIVES: Upper extremity thrombosis is a major complication of central venous catheters implanted for chemotherapy in cancer patients. Vitamin K antagonists and low-molecular-weight heparins have been recommended in this setting, but their relative benefit-to-risk ratios have never been compared. DESIGN AND METHODS: A prospective, randomized, open, parallel-group, multicenter trial was performed comparing the antithrombotic efficacy and safety of warfarin and the low-molecular-weight heparin, nadroparin, in cancer patients who had undergone central venous catheter implantation. Warfarin was given orally at a fixed daily dose of 1 mg and nadroparin was injected subcutaneously at a fixed daily dose of 2,850 IU for 90 days, or until venographically-confirmed thrombosis occurred. The primary efficacy outcome was the occurrence of upper extremity thrombosis confirmed by venography performed 90 days after insertion of the catheter, or earlier if symptoms of thrombosis had appeared. Safety end-points were bleeding and thrombocytopenia. RESULTS: Fifty-nine patients were included in the study. A total of 21 and 24 patients in the nadroparin and warfarin groups, respectively, were evaluable for primary efficacy. Six out of the 21 patients in the nadroparin group (28.6%) and 4 out of the 24 patients in the warfarin group (16.7%) had venographically-documented upper extremity thrombosis at day 90 (p=0.48). Safety was satisfactory and similar with both treatments. INTERPRETATION AND CONCLUSIONS: Warfarin at a fixed, very low dose and nadroparin at a fixed, prophylactic dose had comparable benefit-to-risk ratios in the prevention of thrombosis associated with central venous catheters in cancer patients.     

Acute Acalculous Cholecystitis Associated with Aortic Dissection: Report of a Case

Acute acalculous cholecystitis is uncommon, but not rare. Classically, this disease is observed in the intensive care unit associated with major trauma, burns, or surgery. Moreover, comorbidity such as infection, hypertension, and diabetes mellitus is often found. Although the exact pathogenesis is still not fully understood, it may be multifactorial and ischemia seems to play a central role. We herein report an unusual case of acute alithiasic cholecystitis predisposing to a de Bakey type III aortic dissection. A 57-year-old man was referred to our hospital for investigation of persistent right upper abdominal pain with tenderness and fever, associated with a newly diagnosed aortic dissection treated conservatively. The diagnosis of acalculous cholecystitis, which is often difficult to establish, was particularly delayed. An open cholecystectomy was performed, revealing a preperforating gangrenous gallbladder without any stones. The patient was discharged from hospital 9 days postoperatively without any early or late complications. No operative treatment for the aortic dissection was needed.     

Selective use of esophageal manometry and 24-Hour pH monitoring before laparoscopic fundoplication

BACKGROUND: Preoperative esophageal manometry and 24-hour pH monitoring commonly are used in preoperative evaluation of patients undergoing fundoplication. Here we review our experience with the selective preoperative workup of patients undergoing fundoplication to treat gastroesophageal reflux disease. STUDY DESIGN: A series of 628 consecutive antireflux procedures was reviewed. History and physical examination, upper endoscopy, and upper gastrointestinal videofluoroscopy were obtained preoperatively on all patients; the first 30 patients also underwent esophageal manometry and pH monitoring (routine evaluation group). Thereafter, pH monitoring only was performed for atypical reflux symptoms, and manometry only was performed for a history of dysphagia, odynophagia, or for abnormal motility on videofluoroscopy (selective evaluation group). All patients underwent a laparoscopic floppy Nissen fundoplication, and then endoscopy and fluoroscopy at 3 months and 12 months postoperatively. RESULTS: Eighty-five of the patients in the selective evaluation group (14%) required manometry, and 88 (15%) underwent pH monitoring. Eighteen of the 115 patients who underwent manometry (16%) had evidence of dysmotility. None of these 18 patients had increased dysphagia postoperatively; 8 of 18 reported improvement with swallowing. Five patients in the selective group (0.8%) had persistent postoperative dysphagia caused by technical error (four patients) or with no identifiable cause (one patient). The estimated charge or collection reduction with use of the selective evaluation was 1,253,100 US dollars or 395,000 US dollars, respectively. CONCLUSIONS: Selective use of manometry and pH monitoring was cost effective and safe in this series. Although esophageal manometry and 24-hour pH monitoring might be necessary with abnormal findings on videofluoroscopy or atypical symptoms, in our experience, their routine use is not essential in preoperative evaluation of patients undergoing fundoplication for gastroesophageal reflux disease.     

Protein-bound uremic retention solutes

Protein-bound uremic retention solutes are molecules with low molecular weight (MW) but should be considered middle or high MW substances. This article describes the best known substances of this group, which include p-cresol, indoxyl sulfate, hippuric acid, 3-carboxy-4-methyl-5-propyl-2-furan-propionic acid (CMPF), and homocysteine. At concentrations encountered during uremia, p-cresol inhibits phagocyte function and decreases leukocyte adhesion to cytokine-stimulated endothelial cells. CMPF has been implicated in anemia and neurologic abnormalities of uremia. CMPF could alter the metabolism of drugs of inhibiting their binding to albumin and their tubular excretion. Indoxyl sulfate administrated to uremic rats increases the rate of progression of renal failure. Hippuric acid inhibits glucose utilization in the muscle, and its serum concentration is correlated with neurologic symptoms of uremia. Homocysteine predisposes uremic patients to cardiovascular disease through impairment of endothelial and smooth muscle cell functions. The removal of protein-bound compounds by conventional hemodialysis is low. Other strategies to decrease their concentrations include increase in dialyze pore size, daily hemodialysis, peritoneal dialysis, reduction of production or acceleration of degradation, and preservation of residual renal function.     

Defense styles, impulsivity and suicide attempts in major depression

BACKGROUND: The aim of our study was to identify if defense mechanisms are associated with impulsivity and lifetime suicide attempts in depressed patients. SAMPLING AND METHODS: The Defense Style Questionnaire, the Impulsivity Rating Scale and the Impulse Control Scale were used in 77 depressed inpatients. RESULTS: Impulsivity was correlated positively with immature and neurotic styles and negatively with mature style. Some but not all defense mechanisms were relevant in this respect. The number of lifetime suicide attempts was positively correlated not only with impulsivity, but also with immature style and to a lesser extent with neurotic style. Several defense mechanisms were involved in these correlations: undoing, projection, passive aggression, acting out, splitting and somatization. CONCLUSIONS: Like impulsivity, defense styles may be relevant to discriminate recurrent suicide attempters in depression. Prospective assessment of defense styles and suicide attempts in depression is needed.