Randomized comparison of enoxaparin with unfractionated heparin following fibrinolytic therapy for acute myocardial infarction.

AIMS: To compare the efficacy and safety of low molecular weight heparin with unfractionated heparin following fibrinolytic therapy for acute myocardial infarction. METHODS AND RESULTS: Three-hundred patients receiving fibrinolytic therapy following acute myocardial infarction were randomly assigned to low molecular weight heparin as enoxaparin (40 mg intravenous bolus, then 40 mg subcutaneously every 8 h, n=149) or unfractionated heparin (5000 U intravenous bolus, then 30 000 U. 24 h(-1), adjusted to an activated partial thromboplastin time 2-2.5x normal, n=151) for 4 days in conjunction with routine therapy. Clinical and therapeutic variables were analysed, in addition to use of enoxaparin or unfractionated heparin, to determine independent predictors of the 90-day composite triple end-point (death, non-fatal reinfarction, or readmission with unstable angina). The triple end-point occurred more frequently in patients receiving unfractionated heparin rather than enoxaparin (36% vs. 26%; P=0.04). Logistic regression modelling of baseline and clinical variables identified the only independent risk factors for recurrent events as left ventricular failure, hypertension, and use of unfractionated heparin rather than enoxaparin. There was no difference in major haemorrhage between those receiving enoxaparin (3%) and unfractionated heparin (4%). CONCLUSION: Use of enoxaparin compared with unfractionated heparin in patients receiving fibrinolytic therapy for acute myocardial infarction was associated with fewer recurrent cardiac events at 90 days. This benefit was independent of other important clinical and therapeutic factors.

Subdural hygroma versus atrophy on MR brain scans: "the cortical vein sign".

PURPOSE: To determine if the position of the superficial cerebral cortical veins can be used to distinguish subdural hygroma from atrophy on MR brain scans. METHODS: Retrospective review of MR scans obtained in cases of extracerebral fluid collections, separating these into two groups, ie, subdural hygroma or atrophy. FINDINGS: All cases of atrophy in this study showed cortical veins and their branches traversing widened cerebrospinal fluid spaces over the cerebral convexities. None of the subdural hygroma patients showed this finding. Cortical veins in hygroma patients were seen only at the margin of the displaced cortex, and did not traverse the fluid collections over the cerebral convexities. CONCLUSIONS: The authors call the visualization of cortical veins and their branches within fluid collections at the cerebral convexities "the cortical vein sign." They believe this sign to be prima facie evidence of atrophy; its presence rules out the diagnosis of subdural hygroma in the region of interest.

Providing cost-effective psychotherapy in a Health Maintenance Organization.

The authors share responsibility for providing psychotherapy for adults and children who are subscribers to the Health Maintenance Plan, Cincinnati. The limited resources in such a setting led them to combine the general-systems-theory proposition that the least expensive defenses against stress should be used first with the principle of effective parsimony, which calls for a particular sequence of action in providing mental health care. Thus their approaches include involving the patient in planning the frequency of therapy sessions, including entire families in the sessions, and setting reasonable goals and time frames for meeting the goals. They also use nonmedical mental health professionals, under the supervision of a psychiatrist, and other primary providers in the HMO who are interested in psychotherapy and are willing to call on a psychiatrist when necessary.