Junior versus senior physicians for informing families of intensive care unit patients

To compare the effectiveness of information delivered to family members of critically ill patients by junior and senior physicians, we performed a prospective randomized multicenter trial in 11 French intensive care units. Patients (n = 220) were allocated at random to having their family members receive information by only junior or only senior physicians throughout the intensive care unit stay; there were 92 and 93 evaluable cases in the junior and senior groups, respectively, with no significant differences in baseline characteristics. Between Days 3 and 5, one family representative per patient was evaluated for comprehension of the diagnosis, prognosis, and treatment in the patient; satisfaction with information and care; and presence of symptoms of anxiety and depression. No significant differences were found between the two groups for any of these three criteria. Family members informed by a junior physician were more likely to feel they had not been given enough information time (additional time wanted: 3 [0-6.5] vs. 0 [0-5] minutes, p = 0.01) and to have sought additional explanations from their usual doctor (48.9 vs. 34.4%, p = 0.004). Specialty residents, if given opportunities for acquiring experience, can become proficient in communicating with families and share this task with senior physicians.     

Acute iliofemoral thrombosis secondary to Merkel cell carcinoma compressing the inferior vena cava

Merkel cell carcinoma (MCC) is an aggressive small cell neoplasm of the skin characterized by neuroendocrine differentiation. It most commonly involves the head and neck of elderly Caucasians. We present a patient with MCC of the buttock, who 32 months after primary surgery and 18 months after combined chemoradiotherapy developed retroperitoneal metastases causing inferior vena cava (IVC) compression and lower extremity thrombosis. He received anticoagulants, but died 2 months later. This is the first report of MCC causing IVC compression and iliofemoral venous thrombosis. This case illustrates the precarious natural history of this tumor and the controversies that surround its treatment.Presented at The 16th Annual Congress, The Phlebology Society of America, New York, New York, March 1996     

Genetic and environmental influences on total plasma homocysteine and its role in coronary artery disease risk

BackgroundElevated levels of total plasma homocysteine are a risk factor for atherosclerotic disease.AimsThe rationale behind this study is to explore the correlation between degree and site of coronary lesion and hyperhomocysteinemia in Lebanese CAD patients and assess environmental and genetic factors for elevated levels of total plasma homocysteine.MethodsA total of 2644 patients were analyzed for traditional CAD risk factors. Logistic regression was performed to determine the association of hyperhomocysteinemia with degree and site of coronary lesions controlling for risk factors. Environmental and genetic factors for hyperhomocysteinemia were analyzed by logistic regression using a candidate gene approach.ResultsTraditional risk factors were correlated with stenosis. Hyperhomocysteinemia associated with increased risk of overall stenosis, and risk of mild and severe occlusion in major arteries. Hyperhomocysteinemia and hypertension were highly correlated suggesting that hyperhomocysteinemia acts as a hypertensive agent leading to CAD. Diuretics and genetic polymorphisms in MTHFR and SLCO1B1 were associated with hyperhomocysteinemia.ConclusionsHyperhomocysteinemia is a medical indicator of specific vessel stenosis in the Lebanese population. Hypertension is a major link between hyperhomocysteinemia and CAD occurrence. Genetic polymorphisms and diuretics’ intake explain partly elevated homocysteine levels. This study has important implications in CAD risk prediction.