The pathogenesis and management of disseminated intravascular coagulation

The pathologic and progressive generation of thrombin in human blood can result in the development of disseminated intravascular coagulation (DIC), a syndrome associated with many underlying conditions and manifested as microvascular thrombosis, tissue hypoxia, and organ damage. DIC can be either acute or chronic, with acute DIC resulting from generation of a large amount of thrombin in a brief time period and chronic (compensated) DIC developing as a result of exposure of the coagulation system to small amounts of tissue factor leading to increased but nonacute levels of thrombin generation. DIC can also be considered a thrombohemorrhagic syndrome. Acute DIC at first manifests in a hypercoagulable state and leads to thrombosis, but can be followed by the development of a so-called hypocoagulable phase caused by depletion of clotting factors. This depletion can sometimes lead to bleeding. Bleeding is less common in chronic DIC, as coagulation factors and platelets are more likely to be able to be replenished in the majority of patients. Diagnosis of DIC can sometimes be difficult, depending upon the stage and presentation of the syndrome. During the thrombotic phase of DIC, many common laboratory parameters remain normal, with the important exception of an early drop in circulating platelets. DIC is easier to diagnose when the patient is bleeding, as abnormalities can normally be detected in global coagulation tests and factor assays. Therapy involves identification and treatment of the underlying condition, if possible. In the interim, measures to control bleeding can be administered, if necessary, and may include supportive care with blood products, antithrombin, heparin, and other agents.     

Gender differences in implantable cardioverter-defibrillator patients at the time of insertion

Gender differences in physical and psychological health and responses in persons receiving implantable cardioverter-defibrillators (ICDs) have been reported but are not well delineated. This study examined symptoms of pain and sleep difficulties, functional status, and psychological responses in 180 (75%) men and 60 (25%) women before and immediately following their first ICD implantation. Women were significantly younger, less likely to be married, and had less history of coronary artery disease than men. Forty-eight percent of women were New York Heart Association class III-IV vs. 27% of men (p<0.05). Women had lower functional status and were more likely to report symptoms of increased pain severity and sleep difficulties. Differences in functional status and pain were reduced after adjusting for New York Heart Association class and age, respectively. There were no differences in depressive symptoms or anxiety. Clinical implications of gender-related responses include the need to address symptoms of heart failure as well as increased pain and sleep difficulties in women at the time surrounding ICD implantation. Longitudinal studies and gender-focused nursing interventions should be developed to promote better understanding of responses and to improve recovery outcomes for ICD patients.     

Update on coronary angioscopy: review of a 20-year experience and potential application for detection of vulnerable plaque

Predicting the occurrence of future acute coronary syndromes remains an important challenge of contemporary cardiology. It is thought that detecting the individual vulnerable plaques in patients can be an important step to preventing myocardial infarction and sudden cardiac death. Coronary angioscopy can provide detailed information of the luminal surface of plaque, such as color, thrombus, or disruption, and is one of a few possibly useful imaging modalities for identifying vulnerable plaques. During its 20-year history, coronary angioscopy has been used as a diagnostic tool or to guide coronary angioplasty, and has contributed to our understanding of the pathophysiology of coronary artery disease. Yellow plaques seen during angioscopy seem to have many characteristics of high risk or vulnerable plaques, most consistent with the thin-cap fibroatheroma. Moreover, differences in yellow color have been reported to reflect differences in the structure or composition of plaques. Development of quantitative methods to assess plaque color and histopathologic correlations in conjunction with prospective natural history studies may lead to advances in vulnerable plaque detection by coronary angioscopy. Although current angioscopic devices are limited by the need to displace the column of blood in order to see the vessel wall, and by the lack of quantitative colorimetric methods, advances in technology may lead to new device versions that could be practical for expanded clinical use.     

Evaluation of minimal residual disease by interphase FISH in multiple myeloma: does complete remission exist?

As in other hematological malignancies, the achievement of a complete remission (CR) is important in multiple myeloma but is still based on common cytological and electrophoretic criteria. In this report, we studied 14 patients who achieved an apparent CR following high-dose therapy using fluorescence in situ hybridization (FISH) analysis. Although the results were difficult to interpret in two patients, 12 of 14 patients had unequivocal persistence of abnormal plasma cells in their bone marrow. Our results suggest that only a few patients, if any, are in true CR following one course of high-dose therapy and are in favor of post-transplantation treatments.     

Challenges to ART scale‐up in a rural district in Tanzania: stigma and distrust among Tanzanian health care workers,people living with HIV and community members

Objective To explore attitudes, perceptions and practices among health care workers, antiretroviral treatment (ART) patients and community members regarding ART care and the social consequences of ART roll‐out in rural Tanzania. Methods We performed focus group discussions and in‐depth interviews with health care workers, community members, ART patients, religious leaders, as well as social workers. Field observations and ethnographic assessments were conducted in parallel. Results We found widespread negative attitudes and perceptions of ART care HIV testing and the ART programme, a lack of trust in its sustainability, as well as lack of community and health worker involvement in the programme planning and treatment. HIV‐positive individuals on ART reported risky behaviours with the aim of revenge and were feared by community members. We also found that the ART availability was seen as an incentive to engage in HIV testing among some community members. Conclusion Our findings underline the importance of involving health workers and the community at a high level and their important role in promoting trust in the ART programme. There is an immense need to adjust interventions focusing on stigma reduction in the direction of ART scale‐up and to build awareness among ART patients so they understand how risky behaviours affect their personal well‐being and the community at large.