Protective effects of pamiteplase, a modified t-PA, in a rat model of embolic stroke

The effects of alteplase (tissue plasminogen activator, t-PA) and pamiteplase (a modified t-PA with longer half-life and increased potency) were compared in a clinically relevant model of embolic stroke. Rats were treated with pamiteplase (0.5 mg/kg or 1 mg/kg bolus), alteplase (10 mg/kg infusion) or normal saline. Pamiteplase (1 mg/kg) was as effective as alteplase in reducing 24 h brain infarct volumes, neurological deficit scores and residual clot grades. Cerebral blood flow recovery at 30 min after thrombolytic treatment was partial and did not correlate with 24 h infarct volumes or neurological deficits. However, there was good correlation between 24 h residual clot grades and infarct volumes, suggesting a delayed timeframe for pamiteplase- and alteplase-induced reperfusion.     

Intertrochanteric fractures in adults younger than 40 years of age

This study reviewed 66 intertrochanteric fractures in patients younger than 40 years old (average 33.0 years old; range 17-40 years old). In contrast to the usual population with intertrochanteric fractures, the factors male predominance (46/66), less pre-injury comorbidity (9/66), more outdoor high energy trauma (47/66), and more associated injuries (32/66) were evident. The distribution of associated injuries was wide. Some of them were life threatening. According to Boyd's classification, 20 were type I, 24 were type II, 13 were type III, and 9 were type IV. Twenty-nine were stable, and 37 were unstable. Stratified by the mechanism of injury, the difference in distribution between the subgroups was significant (p = 0.027, two-tail Fisher's exact test). Simple falls only caused Boyd type I and II fractures. Boyd type III or IV fractures were found more often after vehicular trauma or falls from a height. All the intertrochanteric fractures healed on average 70.5 days (range 31-213 days) after operation. The fractures resulting from vehicular trauma or fall from a height healed significantly more slowly (p = 0.02, univariant log-rank test). There were 6 intertrochanteric fracture-related complications. The mechanism of injury determines the character of intertrochanteric fractures in young adults. Given tougher bone stock, better healing ability, and less co-morbidity, proper management can lead to healing of all intertrochanteric fractures. The extent of functional recovery was also determined by the associated injuries.     

Shunt malfunctions

Shunt failure remains a disheartening complication of shunt surgery. The number of adjustable factors in attempting to reduce the rate is small. The clinical presentation and timing of shunt malfunction are well documented. Although the shunt design trials have been negative to date, valves have important effects that have not as yet been translated to improved outcome.     

Prevention of cerebral vasospasm by a capsaicin derivative, glyceryl nonivamide, in an experimental model of subarachnoid hemorrhage

BACKGROUND: Cerebral vasospasm after aneurysmal subarachnoid hemorrhage (SAH) remains a major complication in patients suffering from SAH. In our previous study, we reported that stimulating vascular K(+) channel activity prevented the development of cerebral vasospasm. Recent evidence indicates that glyceryl nonivamide (GLNVA), a capsaicin derivative, has a vasorelaxant effect on the aortic vascular smooth muscle due to the release of coronary calcitonin gene-related peptide, which in turn stimulates K(+) channel opening. The purpose of the present study was to examine the preventive effects of GLNVA on vasospasm. METHODS: New Zealand white rabbits were subjected to experimental SAH by injecting autologous blood into the cisterna magna. GLNVA or vehicle was injected intrathecally immediately after the induction of SAH. All animals were killed by perfusion-fixation at 48 hours after SAH. The basilar arteries were removed and sectioned, and their cross-sectional areas were measured. RESULTS: The average cross-sectional areas of basilar arteries were reduced by 69% and 71% in the SAH only and SAH plus vehicle groups, respectively, when compared with the healthy controls. After treatment with 0.35, 1.75, and 3.5 mg/kg GLNVA in rabbits subjected to SAH the average cross-sectional area was decreased by 46%, 12% and 2%, respectively, when compared with the healthy controls. The protective effect of GLNVA achieved statistical significance at all dosages. Morphologically, corrugation of the internal elastic lamina of vessels was often observed in the vehicle-treated group, but was not prominent in the GLNVA-treated groups or healthy controls. CONCLUSION: The findings showed that GLNVA dose-dependently attenuated cerebral vasospasm after SAH in the rabbit. These results suggest that intrathecal administration of GLNVA could be an effective strategy for preventing cerebral vasospasm after SAH.     

Patients' attitudes toward cost control bonuses for managed care physicians

Physicians' cost containment incentives may create conflicts of interest. To understand how patients view these incentives, we interviewed 1,050 patients regarding a 10 percent cost control bonus and a combined cost control/quality bonus. Seventy-three percent said that the cost control bonus was a bad idea; 49 percent viewed the combined bonus more favorably than the cost control bonus; and 91 percent favored disclosure of bonuses. We conclude that patients find bonuses worrisome and favor their disclosure. A quality component reassures some, but not all, patients. Initiating a dialogue with patients about practicing medicine in an era of limited resources may help health plans and physicians to address patients' concerns.