Vasopressin as an alternative to norepinephrine in the treatment of milrinone-induced hypotension

OBJECTIVE

To determine whether vasopressin could be effective in treating the hypotension associated with phosphodiesterase III inhibition. Phosphodiesterase III inhibitors are cardiotonic agents that increase myocardial contractility and decrease vascular smooth muscle tone. The vasodilatory effect can be profound, and the resulting hypotension frequently requires the administration of catecholamine pressors.

DESIGN

Retrospective analysis of existing data.

SETTING

The medical or surgical intensive care unit of Columbia-Presbyterian Medical Center.

PATIENTS

Three consecutive patients receiving milrinone and requiring catecholamine pressors to maintain systolic arterial pressure of > or =90 mm Hg.

INTERVENTIONS

Vasopressin was administered to the three patients.

MEASUREMENTS AND MAIN RESULTS

Vasopressin (0.03-0.07 units/min) increased systolic arterial pressure from 90+/-4.7 to 130+/-2.3 mm Hg while reducing the administration of catecholamine pressors.

CONCLUSIONS

Vasopressin at very low doses appears to be an effective vasopressor for milrinone-induced hypotension.

When the drug trial fails: an approach to clinical drug studies

Drug development involves the chemical identification and characterization of a compound to determine stability and define the drug's preliminary actions. Preclinical research follows in animals to develop a pharmacokinetic profile to determine dose range, biotransformation, elimination, and toxicology. The 4 phases of clinical research, phase 1 to phase 4, encompass a progressive investigation of healthy subjects, otherwise healthy patients, to patients with a target disease to obtain US Food and Drug Administration (FDA) approval. Clinical studies include open-label noncomparative studies during phases 1 and 2, and double-blind, comparative, and placebo-controlled studies during phases 2 and 3. Approval from the FDA follows the successful evaluation of the drug. After drug marketing, phase 4 clinical trials continue to collect safety and efficacy information. Many drugs that undergo this drug development process succeed in obtaining FDA approval and are marketed for clinical use. There are several circumstances, however, that preclude the successful completion of drug development, FDA approval, and marketing. This study describes a clinical trial of a new benzodiazepine, Ro 48-6791. Ro 48-6791 was being developed as an ultra-short-acting benzodiazepine with clinical effects of shorter duration than midazolam. The purpose of this study was to define a safe dose range for the induction and maintenance of conscious sedation of patients in an outpatient gastroenterology laboratory. Efficacy criteria to be evaluated included time to onset of action, duration of action, and psychomotor fitness upon recovery. Patients were assessed by using the Observer's Assessment of Alertness/Sedation score (OAA/S) and a 5-m heel-toe-line-walk test (HTLW). The patients were divided into 2 groups. Group 1 patients received Ro 48-6791. Group 2 patients were premedicated with meperidine before administration of Ro 48-6791. Ro 48-6791 was titrated over 30 seconds, and patients were observed for 90 seconds before the next dose was given. The OAA/S score, oxygen saturation, and vital signs were charted every minute through induction and every 5 minutes during the procedure. Patients received Ro 48-6791 until they reached on OAA/S score of 3, corresponding to slowed patient response to name calling. Group 1 (Ro 48-6791 alone) required greater induction doses and increased time to induction. Maintenance doses were the same for both groups. The duration of action of Ro 48-6791 as measured by the OAA/S score and HTLW test did not differ between groups. Ro 48-6791 seemed to be a safe and effective agent to achieve conscious sedation in outpatients undergoing short invasive procedures. However, clinical drug development of Ro 48-6791 was stopped because it did not meet the efficacy criteria of an ultra-short-acting benzodiazepine.

Improving the quality of care for Medicare patients with acute myocardial infarction: results from the Cooperative Cardiovascular Project

CONTEXT

Medicare has a legislative mandate for quality assurance, but the effectiveness of its population-based quality improvement programs has been difficult to establish.

OBJECTIVE

To improve the quality of care for Medicare patients with acute myocardial infarction.

DESIGN

Quality improvement project with baseline measurement, feedback, remeasurement, and comparison samples.

SETTING

All acute care hospitals in the United States.

PATIENTS

Preintervention and postintervention samples included all Medicare patients in Alabama, Connecticut, Iowa, and Wisconsin discharged with principal diagnoses of acute myocardial infarctions during 2 periods, June 1992 through December 1992 and August 1995 through November 1995. Indicator comparisons were made with a random sample of Medicare patients in the rest of the nation discharged with acute myocardial infarctions from August 1995 through November 1995. Mortality comparisons involved all Medicare patients nationwide with inpatient claims for acute myocardial infarctions during 2 periods, June 1992 through May 1993 and August 1995 through July 1996.

INTERVENTION

Data feedback by peer review organizations.

MAIN OUTCOME MEASURES

Quality indicators derived from clinical practice guidelines, length of stay, and mortality.

RESULTS

Performance on all quality indicators improved significantly in the 4 pilot states. Administration of aspirin during hospitalization in patients without contraindications improved from 84% to 90% (P< .001), and prescription of beta-blockers at discharge improved from 47% to 68% (P < .001). Mortality at 30 days decreased from 18.9% to 17.1% (P = .005) and at 1 year from 32.3% to 29.6% (P < .001). These improvements in quality occurred during a period when median length of stay decreased from 8 days to 6 days. Performance on all quality indicators except reperfusion was better in the pilot states than in the rest of the nation in 1995, and the differences were statistically significant for aspirin use at discharge (P < .001), beta-blocker use (P < .001), and smoking cessation counseling (P = .02). Postinfarction mortality was not significantly different between the pilot states and the rest of the nation during the baseline period, although it was slightly but significantly better in the pilot states during the follow-up period (absolute mortality difference at 1 year, 0.9%; P = .004).

CONCLUSIONS

The quality of care for Medicare patients with acute myocardial infarction has improved in the Cooperative Cardiovascular Project pilot states. Performance on the defined quality indicators appeared to be better in the pilot states than in the rest of the nation in 1995 and was associated with reduced mortality.

Assessments of trust in intimate relationships and the self-perception process

Assessments of trust in intimate relationships are often based on perceptions of a partner's behaviors; however, people's own actions, increased self-awareness, and individual differences (e.g., exchange or communal orientation) may also affect their trust in their partners. Communally or exchange-oriented members of heterosexual dating couples, students in a U.S. university, displayed either trusting or irrelevant behaviors under conditions of increased self-awareness. They then completed measures of interpersonal trust. The participants' trusting behaviors significantly determined their level of trust; heightened self-awareness and a communal orientation further enhanced the participants' trust in their partners.

Values of hypercompetitive and personal development competitive individuals

The value systems of hypercompetitive and personal development competitive individuals were examined in a sample of university undergraduates. As expected, people higher in hypercompetitiveness and in personal development competitiveness were both more likely to endorse values related to self-contained individualism such as achievement, hedonism, and a striving for an exciting and challenging life, but only hypercompetitives endorsed the value of power and control over others. Moreover, the data indicated that people higher in personal development competitiveness were more prone to endorse values related to ensembled individualism. In particular, they strongly endorsed values associated with social concern, that is, with caring about the well-being of others and with treating them with respect and as equals, whereas hypercompetitives expressed a lack of such concern. Discussion centered on the socialization process and how it can foster the development of different competitive orientations.

Determinants of appropriate use of angiotensin-converting enzyme inhibitors after acute myocardial infarction in persons > or = 65 years of age

We sought to determine how often angiotensin-converting enzyme (ACE) inhibitors are prescribed as a discharge medication among eligible patients > or = 65 years old with an acute myocardial infarction; to identify patient characteristics associated with the decision to prescribe ACE inhibitors; and to determine the factors associated with the decision to obtain an evaluation of left ventricular function among patients who have no contraindications to ACE inhibitors. We addressed these aims with an observational study of consecutive elderly Medicare beneficiary survivors of an acute myocardial infarction hospitalized in Alabama, Connecticut, Iowa, and Wisconsin between June 1992 and February 1993. Among the 5,453 patients without a contraindication to ACE inhibitors at discharge, 3,528 (65%) had an evaluation of left ventricular function. Of the 1,228 patients without a contraindication to ACE inhibitors who had a left ventricular ejection fraction < or = 40%, 548 (45%) were prescribed the medication at discharge. In a multivariable analysis, an increased prescribed use of ACE inhibitors at discharge was correlated with several factors, including diabetes mellitus, congestive heart failure, ventricular tachycardia, and loop diuretics as a discharge medication. Patients admitted after the publication of the Survival and Ventricular Enlargement (SAVE) trial were significantly more likely to receive ACE inhibitors, although the absolute improvement in utilization was small in the 6 months after the trial results were published. In conclusion, improving the identification of appropriate patients for ACE inhibitors and increasing the prescription of ACE inhibitors for ideal patients may provide an excellent opportunity to improve care.

Construction of a personal development competitive attitude scale

Theory development and research in the area of psychologically healthy competition has been impeded by the lack of a psychometrically sound instrument. Four studies were conducted as part of a research program designed to remedy this deficiency by constructing an individual difference measure of general personal development competitive attitude with satisfactory psychometric properties. In Studies 1 and 2, a 15-item scale was derived primarily through item-total correlational analysis; it demonstrated satisfactory internal and test-retest reliabilities. Studies 3 and 4 were concerned with establishing the construct validity of the scale. Both Studies 3 and 4 showed the scale's discriminant validity through its lack of association with hypercompetitiveness. In addition, its construct validity was seen in its negative association with neurosis and its positive links with personal and social self-esteem and optimal psychological health. Also, as expected, personal development competitiveness was positively correlated with needs for affiliation, whereas hypercompetitiveness was unrelated to affiliation needs. Although hypercompetitive individuals were more aggressive, dominant, and exhibitionistic, this was not the case for personal development competitors.

Quality of care for Medicare patients with acute myocardial infarction. A four-state pilot study from the Cooperative Cardiovascular Project

OBJECTIVE

To develop and test indicators of the quality of care for patients with acute myocardial infarction (AMI).

DESIGN

Retrospective medical record review.

SETTING

All acute care hospitals in Alabama, Connecticut, Iowa, and Wisconsin.

PATIENTS

All hospitalizations for Medicare patients discharged with a principal diagnosis of AMI between June 1, 1992, and February 28, 1993, were identified (N = 16,869).

MAIN OUTCOME MEASURE

Percentage of patients receiving appropriate interventions as defined by 11 quality-of-care indicators derived from clinical practice guidelines that were modified and updated in consultation with a national group of physicians and other health care professionals.

RESULTS

We abstracted data from 16,124 (96%) of the hospitalizations, representing 14,108 primary hospitalizations and 2016 hospitalizations resulting from transfers. Potential exclusions to the use of standard treatments in AMI care were common with 90% and 70% of patients having potential exclusions for thrombolytics and beta-blockers, respectively. In cohorts of "ideal candidates" for specific interventions, 83% received aspirin, 69% received thrombolytics, and 70% received heparin during the initial hospitalization; 77% received aspirin and 45% received beta-blockers at discharge.

CONCLUSIONS

These data demonstrate that many Medicare patients may not be ideal candidates for standard AMI therapies, but these treatments are underused, even in the absence of discernible contraindications. Hospitals and physicians who apply these quality indicators to their practices are likely to find opportunities for improvement.

Informed consent

Under the law of informed consent, physicians must disclose to patients certain information about their medical condition and potential courses of treatment, and must obtain their consent to proceed. This article delineates the basic standards that govern such disclosure, with special reference to legal cases that have dealt with ophthalmic concerns. It concludes by discussing a number of special issues that have recently arisen in this area.

Social perceptions of male and female extreme mesomorphs

In this study, male and female university students in the United States were exposed to mesomorphic or nonmesomorphic stimuli as reflected by photographs of either male body builders and non-body builders or female body builders and non-body builders. Then they were asked to attribute various personality traits and sex-role behaviors to them. Subjects, irrespective of their sex, perceived male and female body builders as possessing more traditionally masculine and less traditionally feminine personality characteristics than male and female non-body builders. Also, male and female body builders were seen as possessing less socially desirable traits than non-body builders. As predicted, female body builders were perceived generally as being more likely to engage in traditionally masculine sex-role behaviors in their dating and marriage relationships than female non-body builders. Contrary to expectation, however, male body builders were not perceived as more likely to engage in higher levels of masculine sex-role behaviors than male non-body builders.

Retinoic acid-induced inhibition of metastatic melanoma cell lung colonization and adhesion to endothelium and subendothelial extracellular matrix

The effect of pretreatment of metastatic B16 melanoma cells with 10(-6) M all trans-retinoic acid resulted in a significant inhibition of lung colonization following injection of 10(5) cells into the tail vein of syngeneic C57BL mice. Adhesion of melanoma cells to vascular endothelial cell monolayers, and subendothelial extracellular matrix was also inhibited by pretreatment with retinoic acid, as was tumour cell aggregation following seeding of pretreated cells on to 0.5% agar. Release of 35SO4 from radiolabelled subendothelial extracellular matrix by melanoma cells was essentially unaltered by retinoic acid pretreatment, as was the release of radiolabel from [3H]proline-labelled matrix, while plasminogen activator activity was enhanced in retinoic-acid-treated cells. These observed changes in adhesive properties may be responsible, at least in part, for the retinoic-acid-induced inhibition of lung colonization.

Modulation of melanoma cell adhesion to basement membrane components by retinoic acid

The effect of retinoic acid pretreatment on metastatic B16 melanoma cell adhesion in serum-free medium to tissue culture plastic precoated with fibronectin, laminin/nidogen, type I and type IV collagen was examined. Both control cells grown to subconfluence and cells treated with 10(−6) M-retinoic acid adhered and spread rapidly on fibronectin (greater than 75% following 1 h of incubation) but adhered poorly to type I collagen (less than 15%). Control cells adhered to laminin/nidogen (greater than 35%), type IV collagen (greater than 58%) and type IV collagen plus laminin/nidogen (greater than 80%), while retinoic acid-treated cells showed a reduced ability to attach and spread on these substrata, the number of adherent cells being reduced by 61% on laminin/nidogen, by 19% on type IV collagen, and by 41% on type IV collagen plus laminin/nidogen following 1 h of incubation. The minimum concentration of retinoic acid required to yield an effective reduction in adhesion was 10(−7) M for type IV collagen and 10(−10) M for laminin/nidogen. Melanoma cells harvested at low density showed a reduced adhesion to laminin/nidogen and type IV collagen compared to that of subconfluent control cultures, but also showed a reduced adhesion to fibronectin. The effect of retinoic acid on cell adhesion was not, however, due to reduced cell density, as the cells were seeded so that control and retinoic acid-treated cultures were of a similar density when harvested.

Different susceptibilities of melanoma cells to retinoic acid-induced changes in melanotic expression

The effect of retinoic acid on murine B16 melanoma cell growth, tyrosinase activity and melanin synthesis was investigated. Retinoic acid inhibited the growth of B16F1, B16F10 and B16BL6 melanoma cells, but enhanced melanin synthesis only in the B16F1 cells. The B16F10 and B16BL6 cells exhibited retinoic acid-induced suppression of tyrosinase activity and melanin synthesis, which was most apparent in the B16F10 cell variant. For comparison, Cloudman S91 melanoma cells proved to be particularly sensitive to retinoic acid-induced growth inhibition and stimulation of the expression of their melanotic phenotype. These results suggest considerable heterogeneity in the B16 melanoma with respect to their response to retinoic acid.

Angioimmunoblastic lymphadenopathy following typhoid AB vaccination and terminating in disseminated infection

Angioimmunoblastic lymphadenopathy (AIL) followed typhoid AB vaccination in a patient whose subsequent clinical course was rapidly progressive. At autopsy, extensive lymphadenopathy with features characteristic of AIL and disseminated infection with Escherichia coli, Candida, and Aspergillus were seen. Vaccination is a presumptive precipitating factor in AIL.

Acute epiglottitis: current management

Two hundred and sixty-one cases of acute epiglottitis treated at the Montreal Children's Hospital between 1951 and 1980 are reviewed. Clinical features of the disease are described. Treatment protocol at a major children's hospital is presented. Statistics related to age, season and sex are analyzed. The authors compare nasotracheal intubation and tracheostomy as primary treatment. Bacteriology and antibiotic treatment are updated.

Ultrasonography and hepatobiliary scintigraphy in the assessment of biliary-enteric anastomoses

Twenty-three patients with surgical diversion of the biliary tract were serially studied with ultrasonography and hepatobiliary scintigraphy using 99mTc-HIDA or 99mTc-disofenin. Refluxed biliary air resulted in nondiagnostic sonograms in 14% of cases. Persistent postoperative dilatation was present in five patients (22%). Scintigraphy allowed differentiation of biliary dilatation with obstruction from nonobstructed dilatation. By coordinating the noninvasive imaging results, those patients requiring study using direct injection of contrast material may be selected.

Evaluation of guanabenz added to hydrochlorothiazide therapy in hypertension

Guanabenz, a centrally acting alpha-adrenergic antihypertensive agent, produces neither the sodium retention seen with other centrally acting agents nor the metabolic abnormalities characteristic of diuretics. In this study, which involved 204 hypertensive out-patients, the additive effects of guanabenz and hydrochlorothiazide were compared with the effects of hydrochlorothiazide therapy alone. Before randomization to the 6-month blinded addition of either guanabenz or placebo, hydrochlorothiazide (50 or 100 mg/day; mean, 70 mg/day) was administered as sole therapy for 6 weeks. During this time, mean supine diastolic blood pressure (SDBP) decreased from 102 to 94 mm Hg (p less than 0.01), with a satisfactory clinical response rate of 62% and a mean weight loss of 2 lbs (p less than 0.01). No further change in mean SDBP occurred during the next 6 months of diuretic therapy, whereas the addition of guanabenz (mean dose, 24 mg/day) caused a further decrease in mean SDBP to 88 mm Hg (p less than 0.01), an increase in the response rate to 86%, and no weight change. Pulse rates in both groups were unchanged. The principal side-effects in both groups were dry mouth, drowsiness, weakness, and dizziness, with a greater incidence of each during the combination therapy. The usual laboratory abnormalities were associated with hydrochlorothiazide. Guanabenz was found to enhance the antihypertensive efficacy of hydrochlorothiazide without compromising its natriuretic properties or producing additional metabolic abnormalities.

Underrepresentation of women in new drug trials

Young women serve less frequently than young men as subjects in premarketing clinical drug trials. Moral, legal, and medical implications of this underrepresentation of women are considered. Risks of medical harm to female patients can increase because medication is withheld. Also, risks of toxicity increase when women receive certain new drugs only in the postmarketing phase. Remedies to increase participation of young, nonpregnant women in clinical trials are discussed.

Tc-99m HIDA scintigraphy in segmental biliary obstruction

Segmental biliary obstruction as a result of primary or secondary hepatic malignancy has been reported with increasing frequency. For two representative patients, the clinical and Tc-99m HIDA scintigraphic findings in segmental biliary obstruction are described. The presence of photon-deficient dilated bile ducts in one segment of the biliary tree is highly suggestive of localized biliary obstruction and should be considered in the patient with suspected or proven hepatic malignancy despite the absence of jaundice.

Acute experimental biliary obstruction in the dog: sonographic findings and clinical implications

Three dogs were serially studied with sonography after cholecystectomy and total acute biliary obstruction. Peripheral biliary dilatation could be diagnosed as early as 4 hr after biliary obstruction and before significant elevation of serum bilirubin. These experimental results support the thesis that total biliary obstruction may be diagnosed before the onset of icterus.

Wiser than the laws?: the legal accountability of the medical profession

This Article argues that many seemingly disparate questions in health law are related to the issue of how experts are to be held accountable to non-experts--how the principle that decisions should be made by those most affected is to be reconciled with the principle that decisions should be made by those with experience and training in the area. The basic subject matter of health law comprises a number of relationships between medical professionals, on the one hand, and laymen, on the other. In dealing with the proper allocation of decision-making authority within these relationships, the Article considers the social role of medical profession, the theoretical issues in the accountability of expertise, and the nature of medical expertise. On the basis of this discussion, the Article develops principles that can be applied throughout health law.

Disparate dilatation of the intrahepatic and extrahepatic bile ducts in surgical jaundice

Intrahepatic biliary dilatation on ultrasound has been reported as an early sign of biliary obstruction. This paper reports 12 patients with extrahepatic biliary obstruction in whome the extrahepatic biliary system was increased in caliber despite a normal appearance of the intrahepatic ducts. The bile ducts in all of these patients were evaluated with ultrasound and percutaneous transhepatic cholangiography. Computed tomography was performed in one case. The causes of obstructive jaundice included stricture, choledocholithiasis, and neoplasm. The common bile duct provides a sensitive indicator of biliary obstruction, and its demonstration by noninvasive or invasive means is mandatory even when the intrahepatic ducts appear to be normal.