The evolution of today's hospital emergency departments —Current problems and challenges

The announcement of the National Heart Attack Alert Program by the National Heart, Lung and Blood Institute in June of 1991 prompted leaders of the Florida Chapter of the American College of Cardiology to develop a statewide program to reduce the morbidity and mortality from acute myocardial infarctions within Florida. It became apparent that the success of such a program would require the prompt institution of thrombolytic agents or other revascular-ization procedures in appropriate patients. No longer could the decision regarding institution of therapy await discussion by telephone and/or the arrival at the emergency department (ED) of the patient's primary care physician or cardiologist. Efforts to establish appropriate protocols for therapy revealed that many of the 25,000 or more physicians currently staffing the 5,600 or so EDs in this country were moonlighting residents or practitioners from a variety of specialties or subspe-cialties with limited or no formal EM training. Furthermore, it was learned that there were in the entire country only about 800 postgraduate, year-one Council for Graduate Medical Education accredited training positions. There were only 21 such training positions in the entire state of Florida. The reasons for these deficiencies are discussed and a challenge to correct this person power crisis is issued, not principally to the leadership of EM, but to the entire medical profession.     

The therapeutic value of vasodilator prostaglandins in multiple organ failure associated with sepsis

There is considerable evidence from animal and human studies of sepsis and acute lung injury that prostacyclin and PGE₁ may have a beneficial effect on tissue perfusion with a reduction in the severity of tissue damage associated with these disorders. As yet, there are no good data from controlled clinical trials that these agents improve survival and it is not clear whether in the future such data will be forthcoming. Nevertheless, using various physiological end-points, both prostaglandins seem to be beneficial in sepsis and when used in combination with the whole process of Intensive Therapy, may contribute to the survival of some cases. Although the assessment of combinations of agents designed to inhibit mediator release might be more useful, it remains to be seen whether the relatively insensitive controlled clinical trial, with survival as its endpoint, is the appropriate tool for assessing efficacy in the ITU. Perhaps, the consensus approach has something to offer in this situation!     

PSYCHOPHYSIOLOGY AND MEDICINE

Psychophysiology is just as closely related to internal medicine as it is to psychiatry. “Psychological variable” has two distinct meanings: a) an external sensory stimulus, or b) an organismic state described in psychological language. “Psychological” and “Physical” are names of two different languages. There is no such thing as a non-physical illness. Asking whether emotions cause diseases, or diseases cause emotions, leads to many difficulties and is unprofitable. It is far more useful to ask about stimulus-response relationships. There are more kinds of specificity relations in psychophysiology and psychosomatic medicine than are usually recognized, and the usual specificity statements in psychosomatic medicine are not concerned with I-R or S-R specificity. There are many problems in medicine which psychophysiology could help to solve.     

Evidence-based medicine, medical decision analysis, and pathology

Recent advances in molecular pathology and other technologies such as proteomics present pathologists with the challenge of integrating the new information generated with high-throughput methods with current diagnostic models based mostly on histopathology and clinicopathologic correlations. Parallel developments in the field of medical informatics and bioinformatics provide the technical and mathematical methods to approach these problems in a rational manner. However, it remains unclear whether pathologists or other medical specialists will become primarily responsible for the development and maintenance of these multivariate and multidisciplinary diagnostic and prognostic models that are hoped to provide more accurate, individualized patient-based information. Evidence-based medicine (EBM) and medical decision analysis (MDA) are relatively new disciplines that use quantitative methods to assess the value of information, differentiate fact from myth, and integrate so-called best evidence into multivariate models for the assessment of prognosis, response to therapy, selection of laboratory tests, and other complex problems that influence individual patient care. We review from an epistemological viewpoint the current approach to information in pathology and describe some of the concepts developed by the practitioners of EBM and MDA.     

Pathway to biomarker discovery in psoriatic arthritis

ABSTRACT

Introduction

Biomarkers may help influence long-term outcomes of psoriatic disease by improving the objective assessment of the presence and severity of psoriatic arthritis (PsA) and by guiding treatment selection. However, there are no validated biomarkers for PsA.     

Suppressive effects of Sairei-to on monoclonal antibody 1–22–3-induced glomerulonephritis: Analysis of effective components

The effects of treditional Chinese medlclne (Salrel-to) on experimental glomerulonephritls Induced In rats by monodonal antibody (mAb) 1–22–3 lnjectlon was examined. The level of proteinuria in the Sairel-to-treated group was significantly lower than that In the PBS treated group. This suppressive effect was caused by the major component of Sealer-to, Syo-salko-to but not by another component, Gorel-san. The suppressive effect of Syo-salko-to was Identified In Its components ( Bupleuri radix, Pindilae tuber and Zingibers rhizoma ), but not In the other combined components ( Ginseng radix and Zizyphl fructus ). Further study weeled that the suppressive effects of the combined components were mainly derived from Bupleuri radix . It was demonstrated that the actual active Ingredient is probably Salkosaponin-d. Light microscopy revealed that Sairel-to and Its effective components suppressed the proliferation of mesanglal cells and mesanglal matrix expansion. Semi quantitative morphological studies of glomerular lesions on the eighth day showed that Syo-salko-to and Its combined components ( Bupleuri radix, Zinglberis rhizoma and Pinelliae tuber ) suppressed mesanglal matrix expansion significantly compared with phosphate-buffered saline control groups (matrix score: 28.0±19.1 vs 102.3±14.1; 30.9±30.1 vs 102.3±14.1, p<0.005, respectively). It was concluded that Salkosaponln-d, as well as Bupleuri radix , Syo-salko-to and Sairel-to can suppress proteinurla and morphological changes In the rat glomerulonephritls model Induced by mAb 1–22–3.     

中晚期重型乙型肝炎血浆置换与内科治疗生存率的比较

观察血浆置换、内科治疗对中晚期重型乙型病毒性肝炎生存率的影响,探索中晚期重型肝炎的治疗方法。方法观察在内科治疗基础上给予血浆置换患者的肝功能、并发症及疾病的转归,与同期仅予内科综合治疗的患者相比较,对相应的临床资料进行统计学分析,从而了解两种治疗方法的疗效。结果血浆置换组36例,18例好转、18例死亡,内科治疗组32例,13例好转、19例死亡,两组之间患者生存情况无统计学差异;肝功能指标(ALT、AST、SB、ALB、TC、ChE和凝血酶原时间(PT)也无统计学差异。结论与内科治疗相比较,在其基础上给予血浆置换并不能提高中晚期重型病毒性肝炎生存率;中晚期重型肝炎患者的预后决定于其肝功能衰竭的程度。     

In vivo molecular targeted radiotherapy

Unsealed radionuclides have been in clinical therapeutic use for well over half a century. Following the early inappropriate clinical administrations of radium salts in the early 20th century, the first real clinical benefits became evident with the use of (131)I-sodium iodide for the treatment of hypothyroidism and differentiated thyroid carcinoma and (32)P-sodium phosphate for the treatment of polycythaemia vera. In recent years the use of bone seeking agents (89)Sr, (153)Sm and (186)Re for the palliation of bone pain have become widespread and considerable progress has been evident with the use of (131)I-MIBG and (90)Y-somatostatin receptor binding agents. Although the use of monoclonal antibody based therapeutic products has been slow to evolve, the start of the 21st century has witnessed the first licensed therapeutic antibody conjugates based on (90)Y and (131)I for the treatment of non-Hodgkin's lymphoma. The future clinical utility of this form of therapy will depend upon the development of radiopharmaceutical conjugates capable of selective binding to molecular targets. The availability of some therapeutic radionuclides such as (188)Re produced from the tungsten generator system which can produce activity as required over many months, may make this type of therapy more widely available in some remote and developing countries.Future products will involve cytotoxic radionuclides with appropriate potency, but with physical characteristics that will enable the administration of therapeutic doses with the minimal need for patient isolation. Further developments are likely to involve molecular constructs such as aptamers arising from new developments in biotechnology.Patient trials are still underway and are now examining new methods of administration, dose fractionation and the clinical introduction of alpha emitting radiopharmaceutical conjugates. This review outlines the history, development and future potential of these forms of therapy.     

Epidemiology of adverse drug reactions in intensive care units. A multicentre prospective survey

Summary Clinically relevant events possibly attributable to drug exposure have been monitored prospectively over a period of six months in 27 general intensive care units. Fifty-four events attributed to drugs were reported in 51 patients during their stay in hospital, corresponding to an overall incidence of 1.35%. The behaviour of the physicians following attribution of the events to a prescribed drug is analyzed and discussed in detail with respect to its relationship to the quality and severity of the reaction, and the classes of drugs. Twenty-four of the 4537 monitored admissions during the six months were due to life-threatening emergencies linked to the administration of drugs (14) and radio-contrast media (10) (overall incidence 0.5%). While the clinical burden attributable to adverse drug reactions in Intensive Care Units appears to be relatively small, the analysis shows that there is ample room for a greater reduction in their incidence. Coordinators: Drs M. L. Farina and G. Tognoni, Istituto di Ricerche Farmacologiche Mario Negri, Milan; Dr F. Procaccio, Neurosurgical ICU, Ospedale Ca' Granda, Niguarda, Milan.Investigators: Drs G. Barusco, Rovigo; F. Bassi, Milan; L. Bianchetti, Torino; E. Carchietti, Udine; G. Chilloni, Reggio Emilia; G. Costantini, Savigliano (CN); P. Ferrero, Aosta; E. Geat, Trento; F. Gorgerino, Torino; A. Lusini, Empoli (FI); G. Mantovani, Ferrara; S. Marchi, Bologna; P. Marcovigi, Forli; G. Marraro, Merate (CO); F. Merlo, Vicenza; E. Pagni, Bagno a Ripoli (FI); R. Pellegrino, Cuneo; C. Peruselli, Milan; A. Piovesano, Pordenone; R. Rinaldo, Cremona; R. Ruggerini, Piacenza; S. Sammartino, Torino; A. Sartore, Cittadella (PD); A. Scaglioli, Carpi (MO); G. Scopa, Terni; G. Zeffiro, Treviso; P. Zuccoli, Parma     

"银屑灵"治疗银屑病351例临床观察

本文报道用银屑灵治疗银屑病351例,疗程60天,对有效病例延长疗程可提高治愈率.临床痊愈率32.2%,总有效率73.8%,点滴状银屑病疗效最好.随访2年,复发率19.5%.仅少数病例有轻微胃肠道反应,但有6例治疗前发现肝功能异常,作者认为可能属银屑病的肝脏损害,经治疗后转正常.并对治疗机理作了初步探讨.