Very low calorie ketogenic weight reduction diet in patients with cirrhosis: a case series.

Weight reduction may be necessary in patients with end-stage liver disease (ESLD) before liver transplantation. Although very low calorie diets (VLCDs) are a highly effective weight loss strategy, they risk inducing protein-calorie malnutrition, sarcopenia and hepatic encephalopathy in ESLD patients. We report for the first time on the use of VCLDs in ESLD. Two severely obese individuals with ESLD underwent a modified VLCD to become eligible for liver transplantation. Patients consumed four protein supplements and one lean meal daily, equivalent to 800 kilocalories (kcal) and were closely monitored during the diet period. Subject 1, a 46-year-old male with alcoholic cirrhosis, lost 44.1 kg after 28 weeks on a modified VLCD. Liver function and MELD (model for end-stage liver disease) scores improved and he currently does not require listing for transplantation. Subject 2, a 64-year-old female with non-alcoholic steatohepatitis, lost 39.7 kg after a 30-week modified VLCD. She is awaiting liver transplantation listing with a stable MELD score. VLCDs were well tolerated by both patients without adverse effects. In conclusion, under close medical supervision VLCDs in patients with ESLD can be safe and effective in reducing weight, facilitating liver transplantation listing, and possibly improving liver damage.

Will your academic department survive managed care?

The current form of academic department is likely to vanish from many institutions. Changes occurring in health care are part of the evolution other industries have experienced, following the product life cycle. Physicians are becoming "deprofessionalized" and as such are beginning to resemble technical workers seen in other industries. The rearrangements in health care are bringing together organizations with different missions, priorities, culture and even language. An academic department may not be considered as an asset to the larger organization or network, representing but one option for product differentiation in the market place. There are strategies for maintaining the viability of the academic component of an organization that necessitate congruence with the overall strategy for the greater organization.

Efficacy and safety of intravenous sotalol for termination of paroxysmal supraventricular tachycardia. The Sotalol Versus Placebo Multicenter Study Group.

A double-blind, placebo-controlled, crossover, multicenter study was conducted to study the efficacy and safety of a single intravenous dose of sotalol (1.5 mg/kg over 10 minutes) in achieving normal sinus rhythm in paroxysmal supraventricular tachycardia (SVT) lasting greater than or equal to 15 minutes. Patients were randomized to either sotalol or placebo as initial treatment, and if the SVT was not terminated a crossover was performed after 20 minutes. A total of 43 patients were enrolled, 38 of whom with spontaneous (n = 14) or induced (n = 24) SVT were analyzed for sotalol efficacy. Most patients (n = 27) had atrioventricular (AV) nodal reentrant tachycardia, and an important subgroup (n = 11) had circus movement tachycardia, using an accessory pathway for retrograde conduction. The number of patients converting to sinus rhythm as a result of the initial treatment was significantly higher in the sotalol group than in the placebo group, for spontaneous (p less than 0.005) as well as for induced tachycardia (p less than 0.001). Sinus rhythm was achieved within 30 minutes in 83% of all patients who received sotalol as the first drug, compared with 16% of the patients first receiving placebo (p less than 0.0001). For sotalol safety analysis, 42 patients were included. A total of 37 patients received sotalol, 19 as the first treatment, and 18 as the second treatment, while 25 patients received placebo. A total of 15 possible adverse effects were reported, occurring in 10 patients with sotalol versus 4 with placebo. The only severe side effect (hypotension) necessitating termination of drug administration occurred with placebo. No proarrhythmic effects were observed.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of bucindolol on plasma HDL cholesterol subfractions and other plasma lipids in essential hypertensive patients.

The effect on plasma lipids of a new beta-blocker bucindolol, which possesses weak alpha-adrenergic blocking property and intrinsic sympathomimetic activity, given orally over a 3-month period as a monotherapy or with a thiazide diuretic to 44 patients with essential hypertension was studied. The mean level of plasma HDL cholesterol concentration increased significantly during 3 months monotherapy with bucindolol or with bucindolol and diuretic. This increase was due to the increase of HDL3 subfraction. There were no significant changes in the concentrations of plasma triglycerides or total cholesterol during treatment. The ratio of HDL cholesterol to total cholesterol increased significantly. The concentration of apoprotein A-I decreased significantly in both treatment groups, but the level of apoprotein B remained constant among treatment groups. The results support the earlier observations that beta-adrenergic blocking agents with different pharmacologic properties differ as regard to their effects on plasma lipids and lipoproteins.

Effect of beta-blocking drugs on red cell adhesive and rheological properties.

Abnormal cell-cell interactions at the vessel wall play an important role in the development of microvascular occlusions. Since beta-blocking drugs have been implicated in the long-term and short-term prevention of myocardial infarction, we investigated the possibility that these drugs might exert their action by interfering with red cell-endothelial interactions. 51Cr-labeled, washed erthrocytes were added to confluent monolayers of cultured human vascular endothelial cells. After incubation at 37 degrees C, the nonadherent red cells were removed by sequential washing. When red cells were pretreated by cardioselective or noncardioselective beta-blocking drugs (e.g., metoprolol and propranolol), significantly fewer erythrocytes remained adherent to the endothelial monolayers after repeated washing. Pretreatment of the endothelium did not result in decreased adherence, indicating that the inhibitory action of beta-blockers is exerted on the red cell itself. The specificity of red cell-endothelial interactions is illustrated by the finding that erythrocytes adhere significantly less to plastic surfaces. In parallel studies, we have shown that beta-blockers significantly both diminish erythrocyte viscosity and increase erythrocyte deformability. The precise mechanisms of cellular action by which beta-blockers exert these actions remain unknown. Differences in beta-receptor subtypes do not seem to be involved, but complex metabolic changes leading to alterations in physiological properties of the red cell membrane cannot be excluded. Finally, our results suggest that the presumed beneficial effects of beta-blockade in various prethrombotic conditions (e.g., hypertension, angina pectoris, reinfarction) may be partly due to the interference of these drugs with the normal and abnormal adhesive and rheological properties of human erythrocytes.