Clinical review: Vasculitis on the intensive care unit – part 2: treatment and prognosis

The second part of this review addresses the treatment and prognosis of the vasculitides Wegener's granulomatosis, microscopic polyangiitis, Churg–Strauss syndrome and polyarteritis nodosa. Treatment regimens consist of an initial remission phase with aggressive immunosuppression, followed by a more prolonged maintenance phase using less toxic agents and doses. This review focuses on the initial treatment of fulminant vasculitis, the mainstay of which remains immunosuppression with steroids and cyclophosphamide. For Wegener's granulomatosis and microscopic polyangiitis plasma exchange can be considered for first-line therapy in patients with acute renal failure and/or pulmonary haemorrhage. Refractory disease is rare and is usually due to inadequate treatment. The vasculitides provide a particular challenge for the critical care team. Particular aspects of major organ support related to these conditions are discussed. Effective treatment has revolutionized the prognosis of these conditions. However, mortality is still approximately 50% for those requiring admission to intensive care unit. Furthermore, there is a high morbidity associated with both the diseases themselves and the treatment.     

Activity of nedocromil sodium in mast-cell-dependent reactions in the rat

Nedocromil sodium, a pyranoquinoline dicarboxylic acid derivative which differs structurally and physiochemically from sodium cromoglycate, was nonetheless shown to be effective in classical models of anti-allergic activity in the rat. These models, based on immediate hypersensitivity reactions in the passively sensitized rat, involve release of mediators from mast cells following cross-linking of membrane-bound IgE antibodies by specific antigen. In this system, nedocromil sodium exhibited a similar profile of activity to that of sodium cromoglycate. Whilst not predictive for therapeutic activity, rat models of immediate hypersensitivity are believed to reflect one component of obstructive airways disease. The results suggest that nedocromil sodium is worthy of clinical evaluation in this indication.     

Psychological adjustment after cardiac transplantation

Cardiac transplantation is viable therapeutic alternative for patients with end-stage heart disease, which offers a favourable short- and medium-term prognosis. The survival has improved from 20% of patients who survived at one year after transplantation in the 1960s to the present figures of 80%-85% of patients who are alive at one year, and 50%-70% of patients who are alive at five years, after transplantation. Therefore, it seems timely to focus attention on the psychological well-being of cardiac-transplant recipients. The medical literature is scant in regard to the psychiatric and the psychosocial impact of cardiac transplantation on recipients, and a systematic and prospective study of the psychosocial adaptation of recipients is lacking. Since 1984, we have been studying the emotional impact of cardiac transplantation on recipients and their families. This article presents the results for a group of recipients who have been assessed before transplantation, then followed-up at discharge from hospital and at four, eight and 12 months after transplantation. The study attempted to quantitate the recipients' anxiety, depression, body image and subjective quality of life by way of standardized self-assessment questionnaires. The recipients' satisfaction with relationships or their marital situation also was reported, as were their degree of rehabilitation at 12 months and their attitudes to various aspects of treatment after the transplantation. Before the transplantation, 53% of patients reported an increase in anxiety and 34% of patients recorded scores that indicated mild-to-moderate levels of depression. Thirty-seven per cent of patients showed a deterioration in the quality of their lives and 34% of patients had a negative body image. After the transplantation, significant improvements occurred in all parameters, which were maintained at follow-up.     

The management of adult respiratory distress syndrome: 2

In the second article in this series we describe some of the newer options in respiratory support and pharmacological intervention which, although largely experimental at present, may prove to be of benefit in the future.