Anorexigen-related cardiopulmonary toxicity.

Three years after the withdrawal of fenfluramine and dexfenfluramine from the market, the magnitude and prevalence of their deleterious cardiopulmonary effects remain undetermined. The links between these anorexigens and valvular heart disease and primary pulmonary hypertension, however, are clearly established. Because some evidence indicates that the valvular lesions may regress with cessation of the drug, management guidelines are still in flux. Patient reassurance and close surveillance, including serial echocardiography in selected cases, are warranted.

Appetite suppressants and cardiac valvulopathy. Current clinical perspectives.

Primary pulmonary hypertension (PPH) in association with weight loss treatment was initially observed in the late 1960s and early 1970s with the diet pill aminorex fumarate. Recent data from large-scale studies and single sites have found prevalence rates of anorexic-associated valvulopathy ranging from 15% to 30%. But overall, no increased prevalence of VHD has been observed among case control groups. In March 1998, the American Heart Association and American College of Cardiology released guidelines for the management of valvular heart disease. A section of the report was dedicated to patients exposed to anorectic drugs, and those statements are outlined in this article.

Transient ischemic attacks (TIA): current issues in diagnosis and management.

Transient ischemic attacks (TIAs) affect more than 500,000 Americans each year. Stroke risk approximates 4% to 8% within 1 month and increases to 12% to 13% at one year. This has led to stroke being one of the leading causes of death and disability. TIAs are focal neurologic events that are temporary in nature and warn of potential stroke. Most TIAs resolve within 24 hours. Hypertension, smoking, heart disease, and diabetes are the major risk factors for stroke. A comprehensive history of symptoms can help identify carotid vs. vertebrobasilar disease. Timely evaluation of TIAs should be performed according to recent guidelines set forth by the American Heart Association. Aspirin continues to be the gold standard for stroke prevention, conferring a 48% risk reduction in stroke or death. The use of ticlopidine has been recommended as a second-line agent in patients with aspirin intolerance. Surgical intervention (carotid endarterectomy) is indicated in symptomatic patients with high grade stenosis of 70% or greater. For patients with less significant stenosis, inconclusive data exists regarding the benefit of medical vs. surgical treatment. Patient education should address identification of symptoms, the need for prompt medical attention, and risk factor modification. A collaborative plan between clinician and client will facilitate early intervention ultimately leading to preservation of function and prevention of the catastrophic sequelae of stroke.

Early extubation: preliminary experience in the cardiothoracic patient population.

BACKGROUND: Changing trends and economic forces that emphasize reduced length of stay and early discharge have commanded the need for redesign in the perioperative management of cardiovascular surgical patients. In an effort to explore alternative strategies a multidisciplinary group developed an early extubation program. OBJECTIVES: To determine the safety and efficacy of early extubation in terms of patient outcome, satisfaction and psychologic recovery, and cost and resource utilization. METHODS: A prospective analysis was conducted on patients who met eligibility criteria. Data were acquired from the medical record and through patient interviews. RESULTS: Forty-seven patients successfully participated in the early extubation program over a 10-month period; 15% were older than 70 years. The incidence of reintubation, cardiac arrest, or death was zero. The mean postoperative length of stay was 5.8 days. Two thirds of patients completed a one-step transfer model conferring a modest cost reduction and improved resource utilization. Findings also demonstrated reduced weight gain, earlier mobilization, and improved psychologic recovery. CONCLUSIONS: The preliminary findings demonstrate that early extubation is a safe and effective practice in selected cardiovascular surgical patients. Factors such as rising acuity, advanced age, and multisystem disease must be considered. Further research is warranted to validate the continued safety and efficacy of this practice to ensure positive patient outcomes.

Current challenges, concepts, and controversies in chest tube management.

Competent chest tube management represents the mainstay of postoperative care for the cardiothoracic patient. Patency and integrity of mediastinal and pleural catheters is crucial to preservation of cardiopulmonary performance. Despite the relatively brief period of time these catheters dwell, knowledge of their placement, function, and current research findings relevant to their care is essential for appropriate nursing interventions. This article addresses application and management of chest tubes, autotransfusion techniques, and areas for future nursing research.

Primary Hodgkin's disease of bone. A report of two cases in adolescents and review of the literature.

The presentation of Hodgkin's disease as a primary bony lesion is unusual. Seventeen such cases have been reported, only three of which appear in the orthopedic literature. The prognosis for survival in these patients is poor, possibly because of difficulty in arriving at the correct early diagnosis. In two adolescent girls (ages 12 and 17) with primary Hodgkin's disease of bone, the diagnosis was made with uncertainty or delay. One of the patients died and the other has progressive disease, two and one-half years after the diagnosis was established. Earlier recognition may lead to better outcomes.

The proliferative and synthetic response of isolated calvarial bone cells of rats to cyclic biaxial mechanical strain.

Isolated bone cells from the calvaria of newborn rats were grown in monolayer on polyurethane membranes in specially constructed culture chambers. These were subjected to cyclic biaxial mechanical strains of 0.02 per cent (200 microstrain), 0.04 per cent (400 microstrain), and 0.1 per cent (1000 microstrain) at a frequency of one hertz for periods ranging from fifteen minutes to seventy-two hours. DNA content, an index of proliferation, was significantly increased at a strain of 0.04 per cent applied for fifteen minutes and for twenty-four and forty-eight hours. DNA content was not increased at the other amplitudes of strain that were evaluated, nor was it increased after prolonged mechanical stimulation for forty-eight hours or longer. Synthesis of collagen, non-collagenous protein, and proteoglycan, as well as activity of alkaline phosphatase, all indicators of macromolecular synthesis, were significantly decreased at a strain of 0.04 per cent applied for fifteen minutes and for twenty-four, forty-eight, and seventy-two hours. Macromolecular synthesis was not affected by the other amplitudes of strain that were evaluated in this study. At a strain of 0.04 per cent, prostaglandin E2 content was significantly increased after five, fifteen, and thirty minutes of mechanical stimulation, whereas net cAMP content did not change significantly. This suggests that the described cellular events (increased proliferation and decreased macromolecular synthesis) that occur secondary to mechanical strain are mediated, at least in part, by prostaglandin E2.

Total body burdens and tissue concentrations of lead, cadmium, copper, zinc, and ash in 55 human cadavers.

Trace metal contents of human tissues and total body burdens are useful for studies of nutrition and certain diseases. Data are summarized and analyzed for individuals exposed to the normal Cincinnati environment, for 29 tissues from 55 cadavers for lead and ash concentrations, and from 26 cadavers for cadmium, copper, and zinc concentrations. Total body burdens also were calculated and correlated against each other and age. The distributions for ash, copper, and zinc were close to normal, but those for lead and cadmium were closer to lognormal. Bone lead increased with age, whereas soft tissue lead did not. The calculated mean percentage of total body lead in the bones ranged from 78% at age 20 to 96% at age 80. Correlations of blood concentrations with total body burdens were negligible for cadmium and zinc. For copper the correlation coefficient was a poor 0.54. For lead in blood vs soft tissue burden it was a very poor 0.37, and vs total body lead it was negligible. Thus the use of blood samples as a convenient clinical measure of body burdens for these metals may be of limited value. These and other findings provide a useful bank of information for health studies.

The effect of ascorbic acid on the metabolism of rat calvarial bone cells in vitro.

Addition of 50 micrograms/ml sodium ascorbate to confluent cultures of isolated rat calvarium bone cells resulted in a 21% increase in DNA production, a 50-60% increase in incorporation of [14C]proline into collagenous and noncollagenous proteins, and a 200% increase in alkaline phosphatase activity; under identical conditions, [35S]sulfate incorporation into proteoglycans (glycosaminoglycans) was not affected. These results suggest that ascorbate may be important in maintaining or stimulating the osteogenic phenotype of normal bone cells.

Cadmium in liver, kidney, and hair of humans, fetal through old age.

Cadmium concentrations were measured in the liver, kidney, and hair of 107 individuals from the Cincinnati area. The tissue samples were obtained from hospital and coroner autopsy cases and represent a cross-section of individuals from fetal to old age. The sections used were standardized and analyzed for cadmium by atomic absorption. Information obtained at the time of autopsy included the cause of death, the conditions of the tissues, the body height and weight, the amount of anthracosis in the lungs, as well as age, sex, and race. The liver concentrations increased steadily until the late decades. The kidney concentrations increased to the fourth decade, peaked, and decreased steadily from the sixth decade thereafter. The leveling effect in the liver may have been due to the increased presence of fatty livers, and the kidney decreases to nephrosclerosis. The kidney and liver were statistically well correlated. Hair, which achieved a surprisingly high Cd concentration in early infancy, tended to decrease throughout the rest of the age span and correlated poorly with the liver and kidney. There seemed to be no relationship between the amount of pulmonary anthracosis and the cadmium found in any of the tissues. The results obtained here for liver and kidney were in line with other reports in the literature; however, the hair results were somewhat different.