An abbreviated hyperinsulinemic-euglycemic clamp results in similar myocardial glucose utilization in both diabetic and non-diabetic patients with ischemic cardiomyopathy.

BACKGROUND: Positron emission tomography (PET) with insulin-stimulated (18)F-2-deoxyglucose (FDG) uptake is the gold standard for myocardial viability. However, insulin stimulation is infrequently performed due to time and inconvenience. We therefore assessed the clinical applicability of an abbreviated hyperinsulinemic-euglycemic clamp. METHODS AND RESULTS: Dynamic FDG PET was performed in 50 patients with ischemic cardiomyopathy (ejection fraction: .30 +/- .10) using an abbreviated hyperinsulinemic-euglycemic clamp with separate Non-Diabetic (n = 26) and Diabetic (n = 24) protocols (American Society of Nuclear Cardiology guidelines), and supplemental potassium. In regions with normal resting perfusion ((13)N-ammonia uptake >or=80% maximal segment), there were no differences in either maximal (Non-Diabetic: .60 +/- .20 vs Diabetic: .60 +/- .17 micromol/min/g, P = .93) or mean rates of myocardial glucose uptake (MGU) (Non-Diabetic: .52 +/- .18 vs Diabetic: .52 +/- .14 micromol/min/g, P = .63) between the protocols. Multivariate analysis showed that diastolic blood pressure alone (maximal MGU, r (2) = .20, P = .001) or with NYHA Heart Failure Class (mean MGU, r (2) = .25, P = .003) could account for some of the variability in normal-region MGU. Potassium supplementation safely attenuated the decline in plasma levels. CONCLUSIONS: This abbreviated hyperinsulinemic-euglycemic clamp produced similar MGU values in normal resting myocardium in non-diabetic and diabetic subjects, which are no different than published rates with a standard insulin clamp. Thus, this abbreviated approach is sufficient to overcome myocardial insulin resistance.

Medical therapy in acute coronary syndromes: which medicines and at what doses?

Acute coronary syndrome (ACS) occurs when plaque rupture in a coronary artery is superimposed with thrombus formation. This accounts for 1.7 million hospital admissions in the United States annually and significant morbidity and mortality. Although there are advantages to an invasive approach to treating patients with ACS, the role of medical therapy is vital as an adjunctive treatment to reperfusion therapies and in stabilizing ruptured plaques and modifying the metabolic milieu that predisposes to plaque formation and rupture. This article reviews the most important drug classes for medical treatment of ACS patients, as well as optimal doses. This is an exciting time to be involved in the field of cardiovascular medicine, as we continue to see profound improvement from medical therapy in the morbidity and mortality associated with ACS.

Evaluation of the patient with hematuria.

There is little controversy regarding whether gross or visible hematuria requires complete upper and lower urinary tract evaluation. With regard to microscopic hematuria, investigators have disagreed on precisely which patients require a complete work-up. Most agree that older patients (> 40 years), patients with a history of cigarette use, and those with occupational exposure or history of chronic phenacetin use should absolutely undergo upper tract imaging, cystourethroscopy, and cytologic examination of the urine in addition to a thorough history and physical examination. A multidisciplinary group of oncologists, radiologists, urologists, and internists has published its recommendations as part of the American Urological Association best practice policy. The formal guidelines, which were distributed, rereviewed, and modified following a nationwide survey of clinicians, recommend complete urologic evaluation for all patients with microscopic hematuria who are over 40 years of age, and younger patients with a history suspicious for urologic disease. This identifies those at highest risk for malignancy while minimizing the number of evaluations in patients unlikely harboring significant disease.

Novel microlaparoscopic technique for peritoneal dialysis catheter placement.

We describe our technique of microlaparoscopic placement of continuous ambulatory peritoneal dialysis catheters. Visualization is achieved using a 2.7-mm microlaparoscope, and intra-abdominal manipulation, as well as catheter placement using the Seldinger technique, is accomplished through a single 5-mm port. The advantages of this method include accurate placement of the catheter, minimal patient morbidity, and immediate use of the catheter for peritoneal dialysis.