Dying to be thin: a dinitrophenol related fatality

2, 4-dinitrophenol (DNP) was originally used as an explosive and later introduced in the 1930's to stimulate metabolism and promote weight loss. It's also a component of pesticides still available globally. Concerns about hyperpyrexia lead to DNP being banned as a dietary aid in 1938. A 22-y-old male presented to the Emergency Department (ED) with a change in mental status 16 h after his last dose of DNP. On admission he was diaphoretic and febrile with an oral temperature of 102 F, but lucid and cooperative. He became agitated and delirious. Intravenous midazolam was initiated with mechanical cooling. Pancuronium was administered later and the patient was intubated. Over the next hour the patient became bradycardic, then asystolic, and despite resuscitative efforts, died. Advertisements claim DNP safe at the dose our patient ingested. It is widely available and with the potential to cause severe toxicity is an understudied public health concern.

Antithrombotic therapy is associated with better survival in patients with severe heart failure and left ventricular systolic dysfunction (EPICAL study)

BACKGROUND

In patients with congestive heart failure (CHF), clinical trials have demonstrated the benefit of a number of drugs on morbidity and mortality. Nevertheless so far, there is no published controlled study of long-term antithrombotic therapy in patients with CHF. The aim of this work was to identify the relationship between cardiovascular drug use, especially antithrombotic therapy, and survival of CHF patients in current clinical practice, using an observational, population-based database.

METHODS

The EPICAL study (Epidémiologie de l'Insuffisance Cardiaque Avancée en Lorraine) has identified prospectively all patients with severe CHF in the community of Lorraine. Inclusion criteria were age 20-80 years in 1994, at least one hospitalisation for cardiac decompensation, NYHA III/IV HF, ventricular ejection fraction < or =30% or cardiothoracic index > or =60% and arterial hypotension or peripheral and/or pulmonary oedema. A total of 417 consecutive patients surviving at hospital discharge were included in the database. The average follow-up period was 5 years. Univariate Cox models were used to test the relationship of baseline biological and clinical factors to survival. Cardiovascular drug prescriptions were tested in a multivariate Cox model adjusted by other known predictive factors.

RESULTS

Duration of disease >1 year, renal failure, serum sodium > or =138 mmol/l, old age, serious comorbidity, previous decompensation, high doses of furosemide and vasodilators use were independently associated with poor prognosis at 1 and 5 years. Oral anticoagulants, aspirin, lipid lowering drugs and beta-blockers use were associated with better survival. There was no interaction between aspirin and angiotensin converting enzyme inhibitor use on survival.

CONCLUSION

Antithrombotic therapy was associated with a better long-term survival in our study population of severe CHF. These results together with other previously published circumstantial evidence urge for a prospective, controlled and randomised trial specifically designed to evaluate optimal oral anticoagulants and aspirin in patients with congestive heart failure.

[Ascending bipolar nailing using elastic nails in the treatment of fractures of the upper end of the humerus (author's transl)]

In the treatment of non-impacted fractures of the upper end of the humerus, the tendency of many surgeons is to use nailing with the fracture site closed, from the supra-olecranon fossa. This would seem to merit certain criticisms. Following reduction of the fracture, we use Ender elastic nails and two modified nails of a smaller calibre, one inserted via the epicondyle and the other via the epitrochlea. The technique of this ascending bipolar nailing using elastic nails is carried out in a horizontal supine position, which facilitates manoeuvres of reduction and facilitates anaesthesia. Apart from non-impacted fractures of the upper end of the humerus, other indications exist.

[Action of injected disopyramide on ventricular arrhythmias and atrioventricular conduction]

The authors have studied the bathmotropic and dromotropic effects of intravenous injection of 100 mg of disopyramide, the therapeutic dose being 1 to 2 mg/kg. Out of the 28 severe arrhythmias studied, it was the ventricular extrasystoles which benefited most from treatment (79% completely successful, while there was a lesser degree of success in treating the ventricular tachycardias (35% completely successful, 30% partially successful). The negative dromotropic effect of injected disopyramide on sub-nodal conduction was studied by an endocavitary technique in 10 patients presenting with a spontaneous onset of disordered intracardiac conduction; the effects were moderate. With the exception of 4 cases who sustained complications involving rhythm and haemodynamics, the clinical and cardiovascular tolerance of patients to the drug appeared to be satisfactory.