Survey of nutritional status in newly hospitalized patients with stage III or stage IV pressure ulcers.

OBJECTIVE: To examine the nutritional status of newly hospitalized patients with Stage III or Stage IV pressure ulcers. DESIGN: Descriptive survey. STUDY PARTICIPANTS: 405 newly admitted hospitalized non-ICU patients were eligible for inclusion in the study. Patients included in the study had Stage III or Stage IV pressure ulcers on their trunk, had weight indices available, and had prealbumin levels measured. One hundred and twenty patients were included in the analysis. INTERVENTIONS AND MAIN OUTCOME MEASURES: Measurements of weight, prealbumin and albumin levels, nutritional intake, type of diet, gender, age, type of pressure ulcer, and type of residence prior to admission. RESULTS: Analysis of the data revealed that a majority of the patients were elderly, had a Stage III sacral ulcer, were below their usual body weight, had a low prealbumin level, and were not taking in enough nutrition to meet their needs. CONCLUSION: The results of this study suggest that a majority of newly hospitalized patients with severe pressure ulcers are malnourished and aggressive nutritional therapy may be warranted.

Long-term results following free tissue transfer for venous stasis ulcers.

Venous stasis ulcers of the lower extremity are a common problem usually treated successfully with conservative measures or skin grafting. However, for a minority of wounds that are refractory to standard therapy, microsurgical flap reconstruction has been used to introduce new tissue with its own healthy microvenous system. This retrospective study analyzes the long-term outcome of venous ulcers treated with free tissue transfer. Between 1983 and 1993, 14 free flap reconstructions of chronic leg wounds were performed (mean follow-up, 5.4 years). A complication rate of 43% occurred in the postoperative period, with two complete flap failures. Development of new ulcers was noted in all patients by an average of 17.2 months. In all patients the ulcers developed in previously intact skin, usually at the margin of the flap, but in some instances they developed distant to the original area of involvement. It is inferred that the ongoing effects of venous hypertension in the leg lead to ulcer recurrence, and therefore the widest possible resection of all chronically inflamed tissue around the ulcer is recommended. This report suggests that microsurgical flap reconstruction is a palliative measure for venous stasis ulcers, rather than a permanent solution. However, even with recurrent ulceration, many of the patients appeared to have had some symptomatic improvement from the use of free flaps.

Fatal venous air embolism after removal of a central venous catheter.

Venous air embolism is an infrequent, but potentially disastrous, occurrence after the insertion or removal of central venous catheters. The authors describe fatal venous air embolism after removal of a central venous catheter in a 43-year-old man recovering from coronary artery bypass surgery. They discuss the pathophysiology, diagnosis, treatment, and prevention. Several practical considerations are necessary to prevent this complication of central venous catheterization, a procedure commonly delegated to junior house officers.

Synthesis and antiarrhythmic activity of cis-2,6-dimethyl-alpha,alpha-diaryl-1-piperidinebutanols.

A series of alpha,alpha-diaryl-1-piperidinebutanols was evaluated for antiarrhythmic activity in the coronary ligated dog model. Structure-activity relationship studies indicated that the 2,6-dimethylpiperidine group yielded compounds with the best antiarrhythmic profiles in this series. The length of the methylene chain separating the diarylcarbinol and the amino group was not crucial. Substitution of a hydrogen or a number of functional groups for the hydroxyl group had little effect on efficacy or duration but yielded compounds that produced severe tachycardias. Replacement of one of the aryl groups by hydrogen or a pyridinyl or cyclohexyl group had little effect on efficacy but decreased the duration of action. Compound 18 (pirmenol) was ultimately chosen for further studies and is now being investigated in man.

Synthesis and antiarrhythmic activity of alpha-[(diarylmethoxy)methyl]-1-piperidineethanols.

A series of alpha-[(diarylmethoxy)methyl]-1-piperidineethanols was evaluated for antiarrhythmic activity in the coronary artery ligated dog model. Structure-activity relationship studies indicated that the 2,6-dimethylpiperidine group afforded the best antiarrhythmic agents in this series and was essential for long duration of action. This investigation indicated that quaternary ammonium salts were not essential for a long duration of action. It was also shown that the antiarrhythmic activity could be separated from the tachycardia frequently caused by this type of agent.

Pirmenol: preclinical pharmacology.

Pirmenol, a novel pyridinemethanol derivative, is active in a variety of experimental arrhythmic models of diverse etiology. Animal pharmacology studies showed that pirmenol is highly efficacious whether the arrhythmias were atrial or ventricular in origin; chemically, mechanically, or electrically induced; or of the automaticity or reentrant types. The conscious coronary artery-ligated (Harris) dog model best allowed simulation of a variety of clinical situations in which pirmenol could be used either alone or in combination. Pirmenol was highly effective by both the intravenous and oral routes, causing immediate suppression, prevention, or termination of cardiac arrhythmias. Preclinical studies in the dog showed an excellent correlation between the dose of pirmenol, plasma levels, and antiarrhythmic efficacy. Administration of pirmenol in the dog at intentionally accelerated infusion rates suggested a relatively wide margin of safety for pirmenol compared with other class I agents. In vitro electrophysiologic studies in dog Purkinje fibers revealed possibly unique differences of pirmenol from other antiarrhythmic agents. It depresses fast and slow response automaticity and its electrophysiologic effects were less variable than other class I drugs over a spectrum of potassium levels. To test the relevance of the in vitro electrophysiologic results, pirmenol's antiarrhythmic efficacy was assessed in several in vivo dog models in which serum potassium was either increased or decreased. Studies comparing pirmenol and disopyramide clearly showed a relative lack of serum potassium dependence for pirmenol, suggesting a potential clinical advantage over disopyramide and other antiarrhythmics in variable potassium settings. The clinical relevance of these observations will have to be established in patients with variable potassium levels. Overall, pirmenol compared favorably with other reference agents in efficacy and safety in extensive preclinical investigations.

Preclinical pharmacology of pirmenol.

Pirmenol, a novel pyridinemethanol derivative, is active in a variety of experimental arrhythmic models of diverse etiology and has a favorable therapeutic index compared with other class I agents. Animal pharmacology studies showed that pirmenol is highly efficacious whether the arrhythmias were atrial or ventricular in origin, chemically, mechanically or electrically induced or of the automaticity or reentrant types. The conscious coronary artery-ligated (Harris) dog model best allowed simulation of a variety of clinical situations in which pirmenol could be used either alone or in combination. Pirmenol was highly effective by both the intravenous and oral routes, causing immediate suppression, prevention or termination of cardiac arrhythmias. Preclinical studies in the dog showed an excellent correlation between the dose of pirmenol, plasma levels and antiarrhythmic efficacy. Administration of pirmenol in the dog at intentionally accelerated infusion rates suggested a relatively wide margin of safety for pirmenol compared with other class I agents. Analysis of the pharmacokinetic data led to the modeling of a rapid infusion-slow infusion bolus for sustained intravenous administration, thereby optimizing therapeutic utility. In vitro electrophysiologic studies in dog Purkinje fibers revealed possibly unique differences of pirmenol from other antiarrhythmic agents. It depresses fast and slow response automaticity and its electrophysiologic effects were less variable than other class I drugs over a spectrum of potassium levels. To test the relevance of the in vitro electrophysiologic results, pirmenol's antiarrhythmic efficacy was assessed in several in vivo dog models in which serum potassium was either increased or decreased.(ABSTRACT TRUNCATED AT 250 WORDS)

Pirmenol hydrochloride (CI-845): antiarrhythmic profile in coronary artery ligated conscious dogs.

The antiarrhythmic profile of CI-845 (pirmenol hydrochloride) was assessed in conscious, coronary artery ligated dogs. In single-dose studies in these arrhythmic dogs, CI-845 administered by the intravenous, intranuscular, and oral routes was highly effective in restoring normal sinus rhythm. A 2.5 mg/kg dose was effective against the arrhythmias occurring on the second day after ligation, while 5 mg/kg was effective against the higher-rate arhythmias of the first day after ligation. The reference agents ajmaline, aprindine, disopyramide, lidocaine, mexiletine, procainamide, and quinidine were also tested, and in this model, CI-845 had greater efficacy, a longer duration of activity, and/or a wider safety margin. In slow rate intravenous infusion studies, 1-2 mg/kg/hr of CI-845 maintained near total arrhythmia conversion in first-day postligation dogs. Rapid rate intravenous infusion studies (10 mg/kg/hr) demonstrated a good correlation between the CI-845 dose, plasma level, and arrhythmia conversion, as well as a wide margin of safety. Mean conversions to 80% normal rhythm were achieved at 2.5 mg/kg, with associated plasma levels of 0.8 +/- 0.1 micron/ml, while first sings or gross toxicity occurred at 21.7 +/- 2.4 mg/kg at plasma levels of 6.2 +/- 0.4 micron/ml. There were minimal effects on cardiac conduction and blood pressure even at large doses. In drug interaction studies, CI-845 was safe and effective in combination with disopyramide, lidocaine, procainamide, propranolol, and quinidine. The results clearly show CI-845 to be an orally effective, long-acting antiarrhythmic agent with a favorable margin of safety in the coronary artery ligated dog model.