The Mount Sinai journal of medicine, New York
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Atrial fibrillation (AF) is a risk factor for ischemic stroke. In randomized trials, AF raised the risk of stroke nearly sixfold, cumulating in a 35% risk over a lifetime. Anticoagulation with warfarin reduces the danger of ischemic stroke, but carries hemorrhagic risks, making this agent unsuitable for treating many patients. ⋯ Secondary analysis of patients given placebo identified predictors of thromboembolism, including a history of hypertension, congestive heart failure, and prior stroke or transient ischemic attack, and echocardiographic findings of left ventricular dysfunction or left atrial enlargement. The absence of these risk factors selects a fairly large subgroup of AF patients at comparatively low risk of stroke, for whom the danger and inconvenience of chronic anticoagulation may not be warranted. It is becoming clear that specific clinical and echocardiographic features allow individualized antithrombotic approaches within the broad category of patients with AF, to enhance therapeutic benefit while minimizing hemorrhagic risk.
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Clinical Trial
Phase II trial of etoposide, carboplatin, and ifosfamide as salvage therapy in advanced ovarian carcinoma.
A phase II study combining etoposide with carboplatin and ifosfamide as salvage therapy in advanced ovarian cancer was undertaken. Objective responses were achieved in 37.5% of 16 evaluable patients with a mean progression-free interval of 8.6 months. Stable disease was present in 25% of patients; in 37.5% of patients the disease progressed on salvage. ⋯ No life-threatening, nonhematologic toxicities were seen. One death occurred secondary to nadir sepsis. The combination of etoposide, carboplatin, and ifosfamide is an active salvage regimen in patients with advanced ovarian carcinoma; however, severe myelotoxicities and inability to produce long-term responses underscore the need for continued trials to find a more durable salvage regimen.
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Acute pancreatitis was induced in 19 anesthetized dogs by retrograde injection of bile mixed with trypsin into the pancreatic duct. Two groups, of six animals each, were treated with intravenous infusion of synthetic antiproteases: gabexate mesilate and nafamostat mesilate in doses of 1 mg/kg per hr. One group of seven animals remained untreated. ⋯ In the untreated animals, cardiac output, mean arterial pressure, and left ventricular stroke volume decreased rapidly; an increase of pulmonary vascular resistance and systemic vascular resistance was observed. Synthetic antiproteases, given as a therapy, improved the hemodynamic parameters significantly and prevented the animals from developing shock. Gabexate mesilate and nafamostat mesilate seem to be of value in the treatment of experimentally produced acute pancreatitis in dogs.
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There is conflicting evidence of the effect of intravenous fat emulsions on pancreatic secretion. Intralipid is a safe component of intravenous nutritional support in patients with pancreatic fistulas, though it may minimally increase the volume, as well as the bicarbonate and amylase concentrations, of the output. Intravenous fat emulsions may rarely cause pancreatitis; this may be more likely in patients with Crohn's disease, given that three of the four reported cases occurred in patients with Crohn's disease. ⋯ Intravenous fat emulsions appear to be a safe component of intravenous nutritional support for the patient with pancreatitis, based on multiple studies proving their safety in a total of nearly 100 patients. It seems prudent to avoid hypertriglyceridemia secondary to intravenous fat emulsions, as this alone is a cause of pancreatitis, albeit uncommon, in patients with abnormalities of triglyceride metabolism. However, hypertriglyceridemia resulting from parenteral nutrition may be caused by glucose intolerance and not intravenous fat emulsion administration.
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Postoperative pain management in children is a topic that has been neglected in the past but is currently an active field of interest and effort. Clearly, the child's cognitive understanding of and emotional response to pain are different than an adult's, and these differences make pain assessment and control more difficult. ⋯ The effects of untreated pain in children are similar to those in adults but may have more long-term consequences in children. In the past, postoperative pain treatment in children was often inadequate, but newer techniques, such as continuous infusion of opioids, patient-controlled analgesia, epidural administration of opioids, and regional analgesia, hold promise for improved care in the future.