Glycoprotein IIb-IIIa inhibitors in the emergency department for patients with non-ST-elevation acute coronary syndromes: principles and practices

Non-ST-elevation acute coronary syndrome is associated with significant morbidity and mortality. Although the benefit of platelet inhibition by glycoprotein (GP) IIb-IIIa inhibitors in patients undergoing percutaneous coronary intervention (PCI) is well established, emergency physicians and cardiologists have different perspectives regarding their optimum administration, especially upstream before PCI. In this article, two emergency physicians and two cardiologists analyze data and discuss relevant issues, including the ischemic benefits vs. the risk of bleeding associated with GP IIb-IIIa inhibitors in appropriate patients, for example, those with an elevated troponin level or who undergo revascularization. The emergency physicians support early identification of high-risk non-ST-elevation acute coronary syndrome patients and early administration of GP IIb-IIIa inhibitors, which are linked to improved patient outcomes. The cardiologists emphasize risk stratification to identify patients in whom the expected reduction in ischemic complications outweighs the risk of increased bleeding with these agents. GP IIb-IIIa inhibitors should be considered in patients with unstable angina and non-ST-segment elevation myocardial infarction (UA/NSTEMI) in whom PCI is planned, especially those with high-risk features or elevated serum troponin levels. It is reasonable to start this treatment upstream of intervention, pending further studies investigating the optimal timing of initiation of therapy in appropriate patients.     

Alternating ptosis associated with asialo-GM1 and GD1b antibodies

Miller Fisher syndrome (MFS), variant of acute inflammatory demyelinating polyradiculoneuropathy, is recognized as clinical triad (ophthalmoplegia-ataxia-areflexia). Ganglioside antibodies play an important role in the pathogenesis of acute polyradiculoneuropathy including MFS. To our knowledge, there has been no report of MFS presenting with atypical alternating ptosis or with concurrent elevation of serum GD1 and asialo-GM1 antibody titers, and negative titers of GQ1b antibody such as our patient. Our objective is to report MFS with unusual symptoms and to share our diagnostic approach. We report a rare case of MFS presenting with alternating eyelid ptosis, paresthesia, and ataxia after a respiratory infection. Initial neurological examination revealed left eyelid ptosis, hyporeflexia, positive Romberg sign, and ataxia. The ice pack test was negative. Three days later, contralateral ptosis was observed, associated with areflexia and worsened ataxia. However, there was significant improvement of the previous left eyelid ptosis. Serology revealed elevated asialo-GM1 and GD1b antibodies. Acetylcholine receptor antibodies were negative. Cerebral spinal fluid revealed elevated IgG index. Nerve conduction studies (NCS) performed four days after the onset of symptoms showed normal nerve conduction velocities and F-waves, and absent bilateral H-reflexes. Repetitive nerve stimulation (3 Hz) showed no decrement of compound muscle action potentials. Trial with a single dose of pyridostigmine showed no clinical improvement. The symptoms resolved without intervention. NCS 18 days after onset of symptoms showed mildly prolonged F-waves and absent H-reflexes. This case highlights an atypical presentation of MFS and raises the awareness of a rare autoantibody associated with it.     

Neuroprotective effects of bloodletting atJing points combined with mild induced hypothermia in acute severe traumatic brain injury

Bloodletting at Jing points has been used to treat coma in traditional Chinese medicine. Mild induced hypothermia has also been shown to have neuroprotective effects. However, the therapeutic effects of bloodletting at Jing points and mild induced hypothermia alone are limited. Therefore, we investigated whether combined treatment might have clinical effectiveness for the treatment of acute severe traumatic brain injury. Using a rat model of traumatic brain injury, combined treatment substantially alleviated cerebral edema and bloodbrain barrier dysfunction. Furthermore, neurological function was ameliorated, and cellular necrosis and the inflammatory response were lessened. These findings suggest that the combined effects of bloodletting at Jing points(20 μL, twice a day, for 2 days) and mild induced hypothermia(6 hours) are better than their individual effects alone. Their combined application may have marked neuroprotective effects in the clinical treatment of acute severe traumatic brain injury.     

Clinical Profiles and Short-Term Outcomes of Acute Disseminated Encephalomyelitis in Adult Chinese Patients

MethodsThis study retrospectively reviewed the clinical profiles of ADEM in adult Chinese patients.ResultsADEM occurred during summer and autumn in about two-thirds of the 42 included patients. Prior infection was found in five patients and no preimmunization was recorded. The most frequent clinical presentations were alterations in consciousness (79%) and behavior changes (69%), followed by motor deficits (64%) and fever (50%). About one-quarter (26%) of the patients showed positive results for oligoclonal bands, and about half of them exhibited increases in the IgG index and 24-hour IgG synthesis rate. Magnetic resonance imaging showed white- and gray-matter lesions in 83% and 23% of the patients, respectively. Steroids were the main treatment, and full recovery occurred in 62% of the patients, with residual focal neurological deficits recorded in a few patients. After a mean follow-up period of 3.4 years, two patients exhibited recurrence and one patient exhibited a multiphasic course. One patient was diagnosed with multiple sclerosis (MS).ConclusionsWith the exception of the seasonal distribution pattern and prior vaccine rate, the clinical profiles of ADEM in adult Chinese patients are similar to those in pediatric populations. No specific markers are available for distinguishing ADEM from MS at the initial presentation. Careful clinical evaluations, cerebrospinal fluid measurements, and neuroradiological examinations with long-term follow-up will aid the correct diagnosis of ADEM.     

Tamoxifen-Induced Severe Acute Pancreatitis: A Case Report

Acute pancreatitis is a condition that leads to destruc-tionand necrosis of pancreatic tissue and frequentdevelopment of multiple organ failure. Most cases arerelated to gallstones or heavy alcohol intake. Amongthe numerous other causes are hypertriglyceridemia,hypercalcemia, abdominal trauma, drugs, vasculitis, viralinfection, peritoneal dialysis, cardiopulmonary bypass,and endoscopic retrograde cholangiopancreatography.Approximately 2 to 5% of cases of acute pancreatitisare drug related, including such drugs as azathioprine,mercaptopurine, asparaginase, pentamidine, didanosine,valproic acid, tetracyclines, estrogen, sulfonamides,thiazides, furosemide, pentamidine, dideoxyinosine, andpossibly glucocorticoids.Tamoxifen is a nonsteroidal estrogen antagonist thathas been widely used in adjuvant hormonal therapy ofprimary breast cancer. The side effects of tamoxifenare generally mild, including effects on lipoproteinmetabolism (1-3). Tamoxifen lowers total and low-densitylipoprotein cholesterol and increases triglycerideand high-density lipoprotein cholesterol levels. However,there are some cases of marked, tamoxifen-induced,hypertriglyceridemia. Hypertriglyceridemia may occa-sionallyproduce severe, lethal pancreatitis (4-8). Here,we report a case of tamoxifen-induced severe, acutepancreatitis. The patient was a woman who had hyper-triglyceridemiaand breast cancer. After mastectomy, bothtamoxifen and antihyperlipidemic agents were adminis-tered.But she withdrew the lipid-lowering agent 2 yearslater on her own. Then she developed tamoxifen-inducedsevere hypertriglyceridemia and pancreatitis.     

Aberrant Fanconi anaemia protein profiles in acute myeloid leukaemia cells

Fanconi anaemia (FA) is an autosomal recessive disease strongly predisposing to bone marrow failure and acute myeloid leukaemia (AML). Four FA genes, corresponding to complementation groups A, C, F and G, have been cloned, but the molecular functions of the corresponding proteins are unknown. The high risk of AML in FA patients suggests that the 'FA pathway' helps to prevent AML in non-FA individuals. We examined 10 AML cell lines, as well as primary cells from 15 AML patients representing the French-American-British subclasses M1-M5a, for possible deficiencies in the 'FA pathway'. Cellular lysates were analysed for the presence of the FA proteins FANCA, FANCC, FANCF and FANCG, as well as the complexes reported to be formed between these proteins, using immunoprecipitation and Western blot analysis. Aberrant protein profiles were observed in five of the 10 cell lines and in 11 of the 15 primary AML samples. Aberrations, that included absence or reduced presence of FA proteins and/or their complexes, were noted in the subclasses M1-M4, but not in M5a (n = 3). Our results suggest that a significant proportion of general AML is characterized by a disturbance of the 'FA pathway' that may represent an early event in the development of this type of leukaemia.     

Prediction of in-hospital ventricular fibrillation from admission data in acute myocardial infarction

We studied retrospectively 26 readily obtainable clinical and electrocardiographic variables in 22 consecutive patients who experienced primary ventricular fibrillation in association with an episode of acute myocardial infarction. Twenty-eight consecutive patients who had an uncomplicated course after acute myocardial infarction served as controls. The clinical profile of the two groups was similar except that patients who had primary ventricular fibrillation smoked more and had a higher peak creatinine phosphokinase level at the time of infarction. The data was evaluated using univariate and stepwise logistic regression analysis. This analysis demonstrated that patients who developed primary ventricular fibrillation had, on admission (1) more evidence of congestive heart failure (Killip classification), (2) a lower diastolic blood pressure, (3) greater ST-segment elevation, (4) a longer QTc interval, and (5) a less distinguishable J point on the electrocardiogram. This method of logistic analysis that utilizes easily obtainable hospital admission data serves as a preliminary model for prediction of the relative risk of primary ventricular fibrillation in a patient with acute myocardial infarction. The ability to identify patients at risk has important therapeutic implications.     

生长抑素和栀子联合应用治疗重症急性胰腺炎的实验研究

目的探讨生长抑素联合栀子对实验性急性坏死性胰腺炎(ANP)的治疗作用。方法经胰胆管逆行注射1.5%去氧胆酸钠0.05ml/100g体重建立大鼠ANP模型。实验动物随机分为5组对照组、ANP组、善宁组、栀子组、联合组(善宁 栀子),观察各组3d死亡率、血清淀粉酶、NO、内毒素、TNF-α、IL-6的变化,并对胰腺组织进行病理学检查。结果与对照组比较,ANP组3d死亡率、血清淀粉酶、NO、内毒素、TNF-α、IL-6均明显升高(P<0.05),光镜下胰腺组织病理损害明显;栀子组、善宁组及联合组上述各检测指标均较ANP组明显改善(P<0.05),但以联合组降低最明显(P<0.05)。结论联合应用善宁和栀子治疗ANP有协同作用,疗效优于单一的西药或中药治疗。