Low Dose Buprenorphine Initiation: A Guide for the Inpatient Clinician

Low dose buprenorphine initiation (LDBI) is a dosing strategy used to transition patients from full opioid agonists to buprenorphine. The purpose of LDBI is to circumvent obstacles associated with disruption in analgesia, precipitated withdrawal, and prerequisite opioid withdrawal prior to initiating buprenorphine, as not all patients are able to tolerate physical withdrawal symptoms recommended by national guidelines. No literature exists directly comparing traditional buprenorphine initiation to LDBI. Until information on long-term outcomes is available, these dosing strategies should be reserved for patients unable to tolerate traditional buprenorphine initiation. Available published research suggests LDBI strategies will allow some patients to successfully transition to buprenorphine with minimal or no symptoms of withdrawal. Ensuring access to pharmacotherapy during hospital admission is a crucial time for potential intervention and should be considered when appropriate. This narrative review discusses the background of LDBI strategies as well as practical clinical and operational considerations for the inpatient clinician.

Nestling Physiology Is Independent of Somatic Development in a Common Raptor, the American Kestrel (Falco sparverius)

AbstractAlthough many studies have documented the developmental trajectory of somatic traits in birds, few measure physiological traits, and even fewer document individual variation in developmental trajectory across ecological context. Hematological traits underlying aerobic capacity can be predictive of nestling survival, fledgling flight ability, and ultimately recruitment. This study aimed to assess individual variation in the developmental trajectory of two physiological traits that underlie aerobic capacity, hematocrit and hemoglobin concentration, in relation to somatic development and ecological context. Our study species, the American kestrel (Falco sparverius), is sexually dimorphic and therefore likely to show sexual variation in developmental trajectory and nestling maturity. We used lay date, year, brood size, nestling sex ratio, and parental nest visit rate to assess ecological context. Although somatic traits showed similar trajectories across nestlings, developmental trajectory for hematocrit and hemoglobin concentration showed individual variation not previously documented. This individual variation in developmental change, or trajectory, for physiological traits could not be explained by somatic development, sex, parental nest visit rate, lay date, year, brood size, or nestling sex ratio. However, we did find higher final hemoglobin concentration in 2018 and in nests with earlier lay dates. These findings demonstrate the importance of assessing physiological traits that capture aspects of individual quality distinct from somatic traits. Future studies are needed to understand the causes of individual variation in developmental trajectory, which cannot be explained by the ecological variables presented here, and the potential fitness consequences of this variation.

Comparison of risk stratification tools in predicting outcomes of patients with higher-risk myelodysplastic syndromes treated with azanucleosides

Established prognostic tools in patients with myelodysplastic syndromes (MDS) were largely derived from untreated patient cohorts. Although azanucleosides are standard therapies for higher-risk (HR)-MDS, the relative prognostic performance of existing prognostic tools among patients with HR-MDS receiving azanucleoside therapy is unknown. In the MDS Clinical Research Consortium database, we compared the prognostic utility of the International Prognostic Scoring System (IPSS), revised IPSS (IPSS-R), MD Anderson Prognostic Scoring System (MDAPSS), World Health Organization-based Prognostic Scoring System (WPSS) and the French Prognostic Scoring System (FPSS) among 632 patients who presented with HR-MDS and were treated with azanucleosides as the first-line therapy. Median follow-up from diagnosis was 15.7 months. No prognostic tool predicted the probability of achieving an objective response. Nonetheless, all five tools were associated with overall survival (OS, P=0.025 for the IPSS, P=0.011 for WPSS and P<0.001 for the other three tools). The corrected Akaike Information Criteria, which were used to compare OS with the different prognostic scoring systems as covariates (lower is better) were 4138 (MDAPSS), 4156 (FPSS), 4196 (IPSS-R), 4186 (WPSS) and 4196 (IPSS). Patients in the highest-risk groups of the prognostic tools had a median OS from diagnosis of 11-16 months and should be considered for up-front transplantation or experimental approaches.

Geography of the circadian gene clock and photoperiodic response in western North American populations of the three-spined stickleback Gasterosteus aculeatus

Controlled laboratory experiments were used to show that Oregon and Alaskan three-spined stickleback Gasterosteus aculeatus, collected from locations differing by 18° of latitude, exhibited no significant variation in length of the polyglutamine domain of the clock protein or in photoperiodic response within or between latitudes despite the fact that male and female G. aculeatus are photoperiodic at both latitudes. Hence, caution is urged when interpreting variation in the polyglutamine repeat (PolyQ) domain of the gene clock in the context of seasonal activities or in relationship to photoperiodism along geographical gradients.

Increased GFAP and S100beta but not NSE serum levels after subarachnoid haemorrhage are associated with clinical severity

Assessment of initial disease severity after subarachnoid haemorrhage (SAH) remains difficult. The objective of the study is to identify biochemical markers of brain damage in peripheral blood after SAH. Hospital admission S100beta, glial fibrillary acidic protein (GFAP) and neuron-specific enolase (NSE) serum levels were analysed in 67 patients with SAH. Disease severity was determined by using the World Federation of Neurological Surgeons (WFNS) scale and the Fisher CT (computerized tomography) grading scale. Mean astroglial serum concentrations taken at hospital admission were increased (S100beta 2.8-fold and GFAP 1.8-fold) compared with the upper limit of normal laboratory reference values (P95). The mean NSE concentration was within normal limits. S100beta (P < 0.001) and GFAP (P =0.011) but not NSE levels were higher in patients who were in coma at the time of hospital admission compared with patients who were not. Similarly S100beta and GFAP but not NSE serum levels increased with higher WFNS scores, raised intracranial pressure and higher CT Fisher grade scores. Concerning the location of the aneurysm, S100beta and GFAP serum levels were within normal limits after a perimesencephalic type of haemorrhage and significantly increased after aneurysmal type SAH. Increased glial (S100beta and GFAP) but not neuronal (NSE) protein serum concentrations are found after SAH, associated to the clinical severity of the initial injury.

Volunteering for early phase gene transfer research in Parkinson disease

BACKGROUND

For early phase trials of novel interventions-such as gene transfer for Parkinson disease (PD)--whose focus is primarily on safety and tolerability, it is important that participants have a realistic understanding of the goals of such research. Recently, some have expressed concern that patients with PD may have unrealistic expectations.

METHODS

The authors examined why patients with PD might volunteer for invasive early phase research by interviewing 92 patients with PD and comparing those who would (n = 46) and those who would not (n = 46) participate in a hypothetical phase I gene-transfer study.

RESULTS

The two groups' demographic, clinical, functional, and quality of life measures, as well as their understanding of the research protocol, were similar. The groups did not differ on their perception of potential for personal benefit nor on the level of likelihood of benefit they saw as a precondition for volunteering. However, those willing to participate tended to perceive lower probability of risk, were tolerant of greater probability of risk, and were more optimistic about the phase I study's potential benefits to society. They also appeared more decisive and action-oriented than the unwilling group.

CONCLUSIONS

It is likely that the decision whether to participate in early phase PD gene transfer studies will depend mostly on patients' attitudes regarding risk, optimism about science, and an action orientation, rather than on their clinical, functional, or demographic characteristics.

Creatine in Huntington disease is safe, tolerable, bioavailable in brain and reduces serum 8OH2'dG

In a randomized, double-blind, placebo-controlled study in 64 subjects with Huntington disease (HD), 8 g/day of creatine administered for 16 weeks was well tolerated and safe. Serum and brain creatine concentrations increased in the creatine-treated group and returned to baseline after washout. Serum 8-hydroxy-2'-deoxyguanosine (8OH2'dG) levels, an indicator of oxidative injury to DNA, were markedly elevated in HD and reduced by creatine treatment.

Glial and neuronal proteins in serum predict outcome after severe traumatic brain injury

OBJECTIVE

To study the ability of glial (glial fibrillary acidic protein [GFAP] and S100b) and neuronal (neuron specific enolase [NSE]) protein levels in peripheral blood to predict outcome after severe traumatic brain injury.

METHODS

Eighty-five patients with severe traumatic brain injury (admission Glasgow Coma Score [GCS] < or = 8) were included. Blood samples taken at the time of hospital admission were analyzed for S100b, GFAP, and NSE. Data collected included demographic and clinical variables. Outcome was assessed using the Glasgow Outcome Scale (GOS) at 6 months post injury.

RESULTS

The median serum levels of S100b, GFAP, and NSE were raised 18.3 fold (S100b), 4.6 fold (GFAP), and twofold (NSE) compared to normal reference values. S100b, GFAP, and NSE serum levels correlated significantly with the injury severity score and CT findings but not with age, sex, or GCS. S100b, GFAP, and NSE levels were significantly higher in patients who died or had a poor outcome 6 months post injury than in those who were alive or had good outcome. S100b level >1.13 microg/L was the strongest predictor of death with 100% discrimination, but GFAP (>1.5 microg/L) and NSE (>21.7 microg/L) levels also strongly predicted death (adjusted odds ratios 5.82 [for GFAP] and 3.91 [for NSE]). S100b, GFAP, and NSE all strongly predicted poor outcome (adjusted odds ratios 5.12 [S100b], 8.82 [GFAP], and 3.95 [NSE]).

CONCLUSIONS

These results suggest that determination of serum levels of glial and neuronal proteins may add to the clinical assessment of the primary damage and prediction of outcome after severe traumatic brain injury.

In vitro release of mitomycin C from collagen implants

PURPOSE

To study Mitomycin C Loaded Collagen Implant (CI) pharmacokinetics behaviour in vitro.

METHODS

The CI were incubated for 15 minutes in different MMC loading solutions with the following concentrations: 0.03 mg/mL (n = 9), 0.3 mg/mL (n = 10) and 3.0 mg/mL (n = 10). The loaded CI were transferred in 100 micro L of 0.9% NaCl. Aqueous flow of 5 micro L/min was simulated. The MMC concentrations of the samples were determined by high performance liquid chromatography (HPLC). Dissolution kinetics were evaluated by a first-order process. The half-life of dissolution and the time of 95% dissolution were determined.

RESULTS

The CI absorbed on average a MMC dose of 0.054, 0.530 and 6.090 micro g when incubated in the different MMC loading solutions containing 0.03 mg/mL, 0.3 mg/mL, 3.0 mg/mL of MMC, respectively. In the release experiments, the mean total dose delivered by CI was 0.0493, 0.585 and 5.291 micro g. A linear correlation between loading concentration and the estimated total dose released was demonstrated. The kinetic parameters showed a fast MMC dissolution. The half-life of the 3 series was 8.8, 10.1 and 10.5 min.

CONCLUSIONS

Commercially available CI can be loaded with MMC, and could provide relatively slower release than sponge delivery of MMC. Clinical implications of these results warrants further studies.

[Recognition of case histories by a third party]

A case report of psittacosis during pregnancy resulting in death of the child was published in this journal. The item was taken up by a newspaper, whereupon the owners of the birds that had been implicated realised that they were being described. They now felt responsible for the tragedy and complained. Anonymising patient information will never prevent recognition by the patient himself or herself. When publishing a patient history, the authors must be aware that third parties may be involved as well.

Music and the brain: the impact of music on an oboist's fight for recovery

A 20-year-old female, alias Sara, was an aspiring professional oboist who studied music performance at college level. While wading across a river she lost her balance, was swept down river, and suffered profound injuries including severe hypothermia, cardiac arrest, and hypoxic brain injury. While recovering, her family and friends surrounded Sara with music. Her oboe teacher placed Sara's oboe in her hand and played tapes of Sara's past performances. Her mother played recordings of her favourite music in hopes that the music would remind her of her life's passion and, thus, stimulate her mind and soul while she recovered. Two years post-injury, Sara continues to strive to improve her quality of life. In this case study, Sara's musical and medical recovery is detailed using quantitative and qualitative data. This data gathered allows one to provide an analysis of the powerful role of music in Sara's fight to recover.

Clinical and economic effectiveness of an inpatient anticoagulation service

We conducted a prospective cohort study to evaluate clinical and economic end points achieved by a pharmacist-managed anticoagulation service compared with usual care (50 patients/group). The primary therapeutic end point was the time between starting heparin therapy and surpassing the activated partial thromboplastin time therapeutic threshold. The primary economic end point was the direct variable cost of hospitalization from admission to discharge. No significant differences between groups were noted for the primary therapeutic end point. Total hospital costs were significantly lower for patients receiving pharmacist-managed care than for those receiving usual care ($1594 and $2014, respectively, 1997 dollars, p=0.04). Earlier start of warfarin (p=0.05) and shorter hospital stay (5 and 7 days, p=0.05) were associated with the pharmacist-managed group.

[A very serious course of psittacosis in pregnancy]

A 33-year-old pregnant woman was admitted because of atypical pneumonia. She developed adult respiratory distress syndrome complicated by premature birth and perinatal mortality. The diagnosis 'psittacosis' was established on clinical grounds and confirmed serologically (complement fixation test). She was treated with doxycycline 200 mg i.v. daily for 3 weeks and was discharged in good condition after three months. Indirect case history revealed infected birds from the neighbours as the likely source of infection. Psittacosis is caused by Chlamydia psittaci and is acquired after inhalation of dry secreta or excreta from infected animals. Retrospective direct questioning often reveals contact with birds. Diagnostic delay can be considerable. Doxycycline is contraindicated in pregnant women, but erythromycine can be prescribed. Pregnant women should be advised to avoid contact with infected birds as they run an increased risk of a severe disease course.

Regulation of E2F4 mitogenic activity during terminal differentiation by its heterodimerization partners for nuclear translocation

E2F/DP heterodimers play a pivotal role in the regulation of cell growth and differentiation. A decrease in E2F/DP activity occurs during cell cycle arrest and differentiation. However, very little is known about the specific role of the various E2F/DP members along the transition from proliferation to terminal differentiation. We have previously shown that E2F4 accounts for the vast majority of the endogenous E2F in differentiating muscle cells. Here, we show that E2F4, which lacks a nuclear localization signal (nls), is distributed in both the nucleus and the cytoplasm, in either asynchronously growing myoblasts or differentiated myotubes. E2F4 nuclear accumulation is induced by the binding in the cytoplasm with specific partners p107, pRb2/p130, and DP3delta, an nls-containing spliced form of DP3, which provide the nls. Although overexpression of E2F4/DP3delta reactivates the cell cycle in quiescent cells, the E2F4 nuclear accumulation induced by pRb2/p130 and p107 correlates with cell growth arrest Moreover, E2F4/DP3delta-induced cell cycle reactivation is efficiently counteracted by either p107 or pRb2/p130 overexpression. Reinduction in quiescent cells of DNA synthesis by E2F1/DP1 overexpression is abrogated by coexpression of pRb and is hampered by MyoD overexpression. Both pRb2/p130 and pRb, as well as MyoD, are up-regulated in myotubes. Accordingly, multinucleated myotubes, which are induced to reenter the S-phase by oncoviral proteins, are refractory to cell cycle reactivation by forced expression of E2F4/DP3delta or E2F1/DP1. Thus, E2F/DP repression represents only one of multiple redundant circuits that control the postmitotic state in terminally differentiated cells and that are targeted by adenovirus E1A and SV40 large T antigen.

Constitutive expression of Bcl-xL or Bcl-2 prevents peptide antigen-induced T cell deletion but does not influence T cell homeostasis after a viral infection

We examined the CD8+ T cell response to lymphocytic choriomeningitis virus (LCMV) in mice doubly transgenic for an LCMV-specific TCR and for either bcl-xL or bcl-2. Clonal down-sizing of the anti-viral CD8+ T cell response and the generation of T cell memory was not influenced by constitutive expression of these anti-apoptotic proteins in T cells. Expression of Bcl-xL or Bcl-2 did, however, prevent LCMV peptide-induced peripheral deletion of mature CD8+ T cells in vivo and apoptosis of activated LCMV-specific effector T cells in vitro. The CD8+ T cells "rescued" by Bcl-xL or Bcl-2 from peptide antigen-induced cell death were anergic and this could not be reversed by addition of IL-2 in vitro or by adoptive transfer into antigen-free recipient mice followed by LCMV infection in vivo. Taken together, we show here that 1) Bcl-xL or Bcl-2 are functionally equivalent in their ability to modulate CD8+ T cell survival in vivo, 2) distinct apoptosis signaling pathways exist in CD8+ T cells, one that can be inhibited by Bcl-2 or Bcl-xL and one that cannot be blocked, and 3) apoptosis of CD8+ effector T cells during the declining phase of an immune response is not prevented by constitutive expression of the anti-apoptotic proteins Bcl-xL and Bcl-2.

Prior experience and complex procedures

The role of prior knowledge in learning complex procedures was investigated in a transfer task in which subjects learned two related procedures in sequence. In Experiment 1, we manipulated the conceptual and structural similarity between the two procedures; in Experiment 2, we manipulated whether the order of the steps within subprocedures was the same or different during training and transfer, or whether the order of the subprocedures was the same or different. The results lead us to hypothesize that transfer in complex procedures is mediated primarily by a memory for specific steps rather than by conceptual understanding or problem solving. In particular, we were able to model the results precisely on the assumption that subjects use superficial similarity to retrieve the sequences of steps needed to perform segments of the procedure.

A controlled trial of remacemide hydrochloride in Huntington's disease

We conducted a randomized, double-blind, placebo-controlled tolerability study of a N-methyl-D-aspartate (NMDA) glutamate receptor ion-channel blocker, remacemide hydrochloride, in 31 independently ambulatory patients (18 men, 13 women) with Huntington's disease (HD). Subjects were randomized to receive either placebo or active remacemide at dosages of 200 mg/day or 600 mg/day. The primary outcome measure was the proportion of subjects able to complete the study with the assigned treatment. Remacemide was generally well tolerated, and no significant differences between the treatment arms were found in the primary outcome measure. A trend toward improvement in chorea was observed among subjects administered remacemide 200 mg/day. Based on the tolerability and safety demonstrated during this short-term trial, remacemide warrants more extended controlled investigation in patients with HD.

Assessment of coenzyme Q10 tolerability in Huntington's disease

We performed a 6-month open-label trial to evaluate the tolerability and efficacy of coenzyme Q10 (CoQ) in 10 patients with Huntington's disease (HD). Subjects were evaluated at baseline, 3 months, and 6 months using the HD Rating Scale (HDRS), the HD Functional Capacity Scale (HDFCS), and standardized neuropsychological measures. Adverse events (AEs) were assessed by telephone interview every month. CoQ doses ranged from 600 to 1,200 mg per day. All subjects completed the study, although four subjects reported mild AEs, including headache, heartburn, fatigue, and increased involuntary movements. There was no significant effect of the treatment on the clinical ratings. The good tolerability of CoQ suggests that it is a good candidate for evaluation in long-term clinical trials designed to slow the progression of HD.

Response of primary leptomeningeal melanoma to intrathecal recombinant interleukin-2. A case report

BACKGROUND

Primary leptomeningeal melanomas are rare tumors that originate in the leptomeninges and are associated with a poor prognosis and no response to radiation and chemotherapy. These tumors rarely metastasize outside the central nervous system. Recombinant interleukin-2-(rIL-2) is a cytokine that activates natural killer cells and lymphokine-activated killer cells, augments their antitumor effects, and recruits and activates cytotoxic T lymphocytes. We have hypothesized that rIL-2 may prolong disease free survival in a patient with primary leptomeningeal melanoma.

METHODS

The patient was treated with intrathecal rIL-2 via lumbar puncture daily for 5 days, the weekly for 5 weeks. To investigate whether rIL-2 induced a favorable clinical response, the following parameters were monitored: survival, neurologic status, cerebrospinal fluid (CSF) analysis, visual fields, and magnetic resonance imaging (MRI) of the lumbosacral spine.

RESULTS

The patient is still alive and disease free 15 months after receiving rIL-2, and his neurologic status remains unchanged. The CFS glucose concentration, undetectable prior to therapy, has become normal. Repeated cytologic examinations of CSF were negative for malignant cells. The visual field examinations have remained unchanged. MRI scans of the lumbosacral spine have shown the development of arachnoiditis, but no recurrence of the mass lesion.

CONCLUSIONS

The tumor response in this patient, as measured by remarkable disease free survival and normalization of the CSF glucose concentration, illustrates the potential benefits of intrathecal rIL-2 in the treatment of patients with this otherwise rapidly fatal disease.

Visualization, characterization, and turnover of CD8+ memory T cells in virus-infected hosts

The cellular basis of T cell memory is a controversial issue and progress has been hampered by the inability to induce and to trace long-term memory T cells specific for a defined antigen in vivo. By using the murine model of lymphocytic choriomeningitis virus (LCMV) infection and an adoptive transfer system with CD8+ T cells from transgenic mice expressing an LCMV-specific T cell receptor, a population of authentic memory T cells specific for LCMV was generated and analyzed in vivo. The transgenic T cells that have expanded (1,000-fold) and then decreased (10-fold) in LCMV-infected C57BL/6 recipient mice exhibited the following characteristics: they were (a) of larger average cell size than their naive counterparts but smaller than day 8 effector cells; (b) heterogeneous with respect to expression of cell surface "memory" markers; and (c) directly cytolytic when isolated from recipient spleens. The time-dependent proliferative activity of these LCMV-specific memory T cells was analyzed in the recipients by bromodeoxyuridine labeling experiments in vivo. The experiments revealed that LCMV-specific CD8+ memory T cells can persist in LCMV-immune mice for extended periods of time (>2 mo) in the absence of cell division; the memory population as a whole survived beyond 11 mo.

Psychogenic status epilepticus induced by a provocative technique

We report a patient who developed sustained psychogenic seizures after undergoing a provocative technique (PT) for the diagnosis of psychogenic seizures. Because patients are at risk for severe agitation with PT, these diagnostic maneuvers should be used selectively, and the clinician should be prepared to deal with this complication.

Functional decline in Huntington's disease

We prospectively evaluated 129 patients with manifest Huntington's disease (HD) to determine the rate of illness progression and the clinical features that correlate with functional decline. A single examiner evaluated each patient using the HD Functional Capacity Scale. Standardized motor performance was also assessed in 94 of the patients (73%) using the HD Rating Scale. Total Functional Capacity declined at a rate of 0.63 +/- 0.75 U per year. As functional capacity worsened, chorea lessened, and dystonia intensified. There was no correlation between rate of functional decline and age at onset of HD, body weight, gender of affected parent, or history of neuroleptic use.

Trinucleotide repeat length and progression of illness in Huntington's disease

The genetic defect causing Huntington's disease (HD) has been identified as an unstable expansion of a trinucleotide (CAG) repeat sequence within the coding region of the IT15 gene on chromosome 4. In 50 patients with manifest HD who were evaluated prospectively and uniformly, we examined the relationship between the extent of the DNA expansion and the rate of illness progression. Although the length of CAG repeats showed a strong inverse correlation with the age at onset of HD, there was no such relationship between the number of CAG repeats and the rate of clinical decline. These findings suggest that the CAG repeat length may influence or trigger the onset of HD, but other genetic, neurobiological, or environmental factors contribute to the progression of illness and the underlying pace of neuronal degeneration.

A quantitative assessment of limited joint mobility in patients with diabetes. Goniometric analysis of upper extremity passive range of motion

OBJECTIVE

The syndrome of limited joint mobility is a common but not widely recognized musculoskeletal complication of diabetes. The purpose of this study was to further characterize this syndrome using quantitative goniometric measures.

METHODS

Cross-sectional analysis of a sample population was performed to establish the prevalence, location, and severity of limited joint mobility and to determine its relationship to extraarticular manifestations and complications of diabetes. Passive range of motion of both upper extremities was measured by goniometry in 70 adult patients with insulin-dependent diabetes mellitus and 70 nondiabetic controls who were group-matched for age, sex, and general activity level. Joint mobility was assessed by both individual joint motions and a composite scoring technique.

RESULTS

Analysis of individual joints and composite scores revealed significant differences between dominant and nondominant extremities in both the control and the diabetic groups. Diabetic patients were generally less flexible than nondiabetic subjects throughout the arm, especially in shoulder and finger joints. In the full study population, multivariate analysis revealed that advanced age, male sex, and the presence of diabetes were associated with decreased passive range of motion for a majority of joints (P < 0.05). In the diabetes group, passive range of motion was significantly correlated (P < 0.05) with age, sex, duration of diabetes, and to a variable extent, glucose control, but was not correlated with the presence of clinically significant neuropathy, retinopathy, nephropathy, or peripheral vascular disease, with activity level, or with hand dominance. Stepwise regression analysis failed to identify single key joint motion(s) to serve as possible screening tests in predicting generalized limited joint mobility of the upper extremity. Finally, the effect of limb usage on range of motion in flexion may differ in diabetic and nondiabetic subjects.

CONCLUSION

Limited joint mobility is a generalized phenomenon occurring throughout the upper extremities of many diabetic patients. It is significantly related to age, sex, and to a variable extent duration of diabetes and glucose control. It is not related to the standard complications of diabetes as defined in this study.

Utilization patterns of total parenteral nutrition in a university hospital. A methodological approach

To study the utilization of total parenteral nutrition, using methodology recommended by the World Health Organization, classification of components in accordance with the anatomical therapeutic chemical classification and defined daily dose system is necessary. Anatomical therapeutic chemical indices are available but defined daily dose values have not been established yet. In this article, a methodology to study both the total utilization of total parenteral nutrition, the utilization of individual substances and the composition of total parenteral nutrition is presented. To validate the proposed methodology, the utilization of total parenteral nutrition in a teaching hospital is studied, based on pharmacy computer data. The total utilization of total parenteral nutrition in the hospital in 1990 is 1.4 defined daily doses/100 bed-days. The composition of total parenteral nutrition varied greatly between the clusters. In this study we showed that utilization of total parenteral nutrition can be measured with the proposed methodology, using a defined daily dose for total parenteral nutrition in concurrence with a defined daily dose for the individual components.

Thrombosis of a flexible coil coronary stent: frequency, predictors and clinical outcome

OBJECTIVES

The aim of this study was to evaluate the predictors and clinical sequelae of stent thrombosis.

BACKGROUND

Although coronary artery stenting is being increasingly applied, the major unique complication of stent thrombosis is not well characterized.

METHODS

We studied 145 patients who underwent coronary artery stenting with the Gianturco-Roubin flexible coil design for abrupt vessel closure or to prevent restenosis. There were 17 stented vessel closures (11.7%), 7 as a result of acute (< 24 h) and 10 of subacute (days 1 to 21) thrombosis.

RESULTS

In seven patients successful coronary recanalization was achieved with thrombolytic agents and balloon angioplasty. Creatine kinase was significantly elevated in 13 patients, with a Q wave myocardial infarction in 11 and emergency coronary artery bypass grafting in 8. Comparisons (multivariate analysis) with a control cohort (n = 33) of patients without thrombosis matched for age, gender and vessel stented revealed lesion eccentricity (p = 0.003), unstable angina (p = 0.048) and indication for stent implantation (abrupt closure versus restenosis) (p = 0.002), as predictors of thrombotic occlusion of stented vessels. Subtherapeutic anticoagulation (activated partial thromboplastin time < 2 times control value, prothrombin time < 1.4 control value) occurred at least once during the hospital stay in all 10 patients with subacute thrombosis and in 20 of 33 control patients (p = 0.047). In 2 patients with subacute thrombosis and 11 control subjects, subtherapeutic anticoagulation was necessitated by bleeding.

CONCLUSIONS

Early thrombosis after coronary stenting was relatively common (> 10%), occurring predominantly in eccentric lesions and in patients with unstable angina pectoris. This complication is associated with significant adverse clinical outcomes and may be reduced by more intensive anticoagulation yet, in a delicate balance, can be precipitated by inadequate heparin therapy.

Complex coronary angioplasty: use of a new microprobe balloon catheter

Since the introduction of coronary angioplasty by Gruntzig et al. (Circulation [Suppl II] 56:84, 1977), a key determinant to overall success has been advancement in equipment technology. Major advances have been made in the availability of low-profile catheters in the last 5 years that have facilitated penetration of high-grade distal and complex lesions. The USCl probe TM catheter is an example of a low-profile catheter that has shown favorable applicability in dilating high-grade stenoses. Preliminary data indicate that this device has good trackability and an extremely low profile, which allows penetration of stenoses where other current low-profile catheters have failed.

[Steinert's disease and conduction disorders. Apropos of a familial study]

The authors reported a new family case of Steinert with twelve years follow-up. The study of potentials in the bundle of his was performed in all patients, showed an intra- and infra-hisian blocks. This study showed a discrepancy between muscular and myocardial evolutive injury, a very important knowledge for follow-up. Conduction disturbances were found in two cases and pacemaker insertion was performed in one patient. The authors specified the indication of electrophysiological studies during the onset and pacemaker implantation in all patient with a typical or suggestive history of syncope.