[Inhibitors of intra-cystic secretion: novel therapies in ADPKD (Autosomal Dominant Polycystic Kidney Disease)]

Autosomal dominant polycystic kidney disease (ADPKD) is the most common inherited human renal disorder. Progressive enlargement of the kidneys is due to aberrant proliferation of the cyst epithelial cells, together with accumulation of fluid within the cyst cavities due to transepithelial fluid secretion. Multiple studies have suggested that fluid secretion across ADPKD cyst-lining cells is driven by the transepithelial secretion of chloride, mediated by the apical cystic fibrosis transmembrane conductance regulator chloride channel (CFTR) and specific basolateral transporters. Increased levels of cAMP, probably reflecting modifications in intracellular calcium homeostasis and abnormal stimulation of the vasopressin V2 receptor, in mutant renal epithelia, play an important role in the pathogenesis of ADPKD and contribute to both transepithelial secretion of fluid and proliferation of cyst epithelia. For example, cAMP activates the CFTR leading to the stimulation of Cl- secretion into the cyst lumen. This review focuses on the pathophysiology and molecular mechanism of fluid secretion in ADPKD cysts examined during pre-clinical trials of potentially useful drugs for the treatment of this condition.

Flare, persistently active disease, and serologically active clinically quiescent disease in systemic lupus erythematosus: a 2-year follow-up study

OBJECTIVE

Several indices have been proposed to assess disease activity in patients with Systemic Lupus Erythematosus (SLE). Recent studies have showed a prevalence of flare between 28-35.3%, persistently active disease (PAD) between 46%-52% and serologically active clinically quiescent (SACQ) disease ranging from 6 to 15%. Our goal was to evaluate the flare, PAD and SACQ rate incidence in a cohort of SLE patients over a 2-year follow-up.

METHODS

We evaluated 394 SLE patients. Flare was defined as an increase in SLEDAI-2K score of ≥4 from the previous visit; PAD was defined as a SLEDAI-2K score of ≥4, on >2 consecutive visits; SACQ was defined as at least a 2-year period without clinical activity and with persistent serologic activity.

RESULTS

Among the 95 patients eligible for the analysis in 2009, 7 (7.3%) had ≥1 flare episode, whereas 9 (9.4%) had PAD. Similarly, among the 118 patients selected for the analysis in 2010, 6 (5%) had ≥1 flare episode, whereas 16 (13.5%) had PAD. Only 1/45 patient (2.2%) showed SACQ during the follow-up.

CONCLUSION

We showed a low incidence of flare, PAD and SACQ in Italian SLE patients compared with previous studies which could be partly explained by ethnic differences.

Exercise training increases interleukin-10 after an acute myocardial infarction: a randomised clinical trial

The present study assessed the effects of exercise training on biomarkers of inflammation in postinfarction patients. This single-centre prospective randomized controlled trial encompassed 42 patients after the first myocardial infarction divided into exercise-training (n=22) or usual care (n=20) groups. Complete randomization was performed by choosing one of 2 sealed envelopes. The exercise-training group participated in an 8-week programme comprising 3 aerobic exercise sessions per week. The control group received usual care. The main measures were changes in circulating levels of C-reactive protein, interleukin (IL)-6 and -10, soluble vascular cell adhesion molecule-1 (VCAM-1), soluble intercellular adhesion molecule-1 (ICAM-1), anthropometrics, dietary intake, daily physical activity, and cardiorespiratory fitness. 4 patients terminated the study prematurely, leaving 38 for the statistical analysis (exercise-training, n=20; control group, n=18). In comparison to control group, exercise-training group improved IL-10 levels [1.7(7.0) vs.  - 0.3(2.4) pg/mL, P<0.05], daily moderate-intensity physical activity (12.9±21.3 vs.  - 0.7±13.4 min, P<0.05), and cardiorespiratory fitness (3.0±3.5 vs. 0.3±4.1 ml/min/kg, P<0.05). Additionally, the change in VCAM-1 and ICAM-1 levels was significantly higher in the control group (respectively, 26.6±112.1 vs. 94.1±90.0 ng/mL and 7.3±41.0 vs. 35.0±39 ng/mL, P<0.05). In conclusion, exercise training improved the inflammatory profile in post myocardial infarction patients by enhancing the anti-inflammatory cytokine IL-10.

Postoperative incidence of deep vein thrombosis after major lower extremity amputation

AIM

To determine the incidence of deep vein thrombosis of lower extremities up to the seven day after major lower extremity amputation in the amputated and contralateral limbs using color Doppler ultrasound.

METHODS

One hundred and twenty-eight patients (67 men) underwent major lower extremity amputation (69 above-knees and 59 below-knees). All participants received unfractioned subcutaneous heparin (5000 IU TID) as prophylaxis and were evaluated using color Doppler ultrasound immediately before amputation and on the second and seventh days after amputation. The sample was composed of patients with critical limb ischemia and a primary or secondary amputation. Prophylaxis was initiated at the time of hospitalization, discontinued 12 hours before operation, and resumed 12 hours postoperatively. The primary variable was postoperative venous thrombosis. Secondary variables were: age, obesity, myocardial infarction, heart failure, immobilization and level of amputation.

RESULTS

Of the 128 patients evaluated (age range: 44 to 97 years), 12 (9.4%) had venous thrombosis; in 8 (6.3%), thrombosis was ipsilateral, and in 4 (3.1%), contralateral to the amputated limb. Thrombosis was found in the thigh stump of 5 patients (3.9%); the other cases were found in the following venous segments: proximal in 2 (1.6%) patients; distal in 4 (3.1%); and proximal/distal in 1 (0.8%).

CONCLUSIONS

The incidence of deep vein thrombosis of lower extremities was 9.4% in a group of patients with ischemia who underwent primary or secondary major lower extremity amputation and received prophylaxis with unfractioned heparin.

The inverted trophic cascade in tropical plankton communities: impacts of exotic fish in the Middle Rio Doce lake district, Minas Gerais, Brazil

The present study deals with the ecological impacts of the introduction of two alien species of piscivorous fish in several lakes of the Middle Rio Doce lake district in Minas Gerais, Brazil. It was demonstrated that these effects were not restricted only to the fish community. The introduction of the predatory red piranha Pygocentrus nattereri and the tucunaré Cichla cf. ocellaris caused not only a sharp decrease in the number of native fish species, but also major shifts in other trophic levels. Just after the fish were introduced, most lakes began to show conspicuous changes in phytoplankton species composition, in which Cyanophyceae gradually came to dominate. The zooplankton community lost several species, and in some cases, such as Lake Carioca, all the cladoceran species disappeared. On the other hand, invertebrate predators, represented by the dipteran Chaoboridae, boomed in the lake, with higher densities of exotic species, probably as a result of the "ecological release" by reduction of the original fish fauna. There was a general trend of species loss in different trophic levels. All these changes are apparently associated with decreases in water quality. The present situation in these lakes demands new approaches to the management and conservation of these ecosystems.

The role of duplex ultrasonography in the diagnosis of lower-extremity deep vein thrombosis in non-hospitalized patients

AIM

The aim of this study is to reassess the diagnostic evaluation using duplex scanning in non-hospitalized patients, suspected of having deep vein thrombosis (DVT) of the lower limbs.

METHODS

In a period of 4 years, 589 patients suspected of having DVT of the lower limbs were submitted to duplex scanning for diagnostic confirmation. The patient complaints were pain, edema or color alteration of the extremity, associated with a risk factor or not. The time span between the beginning of symptoms and the ultrasound was considered as well, with the examination being conducted only on the member that presented the signs or symptoms, or on both in case of suspicion of pulmonary embolism. This study features 203 male patients and 386 female patients, aged 19 to 93.

RESULTS

In Group I, of the 139 patients who displayed acute venous thrombosis (N=77), 55.4% had at least one associated risk factor; in Group II, of the 96 patients with chronic thrombosis (N=72), 75% had an associated risk factor that predominated the previous history of illness; and in Group III, in 354 patients without DVT, 161 of them (45.5%) featured some associated risk factor.

CONCLUSION

It was concluded that duplex scanning is a useful tool for offering a prompt and efficient diagnosis of venous thrombosis as well as displaying alterations in adjacent structures, thus facilitating the differential diagnostic with other conditions, although in many patients (32.7%) the examination was done unnecessarily, with irrelevant clinical signs and in the absence of any evident risk factor.

Association of Increased Levels of Homocysteine and Peripheral Arterial Disease in a Japanese-Brazilian Population

OBJECTIVES

Our aim was to evaluate the possible association between homocysteine levels and peripheral arterial disease (PAD) in a population-based study of Japanese-Brazilians.

MATERIALS AND METHODS

This cross-sectional study was derived from a population-based survey on the prevalence of diabetes and associated diseases conducted in Japanese-Brazilians. A total of 1330 male and female subjects aged>or=30 years were submitted to clinical examination and laboratory procedures including homocysteine measurement. The ankle-brachial index (ABI) was calculated; subjects with ABI values <0.9 were diagnosed with PAD. The evaluable population included 1008 subjects. Logistic regression was used taking PAD as the dependent variable.

RESULTS

Mean age of the population was 56.5 years and overall prevalence of PAD was 20%. A worse cardiovascular profile was found in male patients, including significantly higher homocysteine levels (11.9+/-1.8 vs. 9.1+/-1.1micromol/L, p<0.001). Men with PAD had higher prevalence rates of hyperhomocysteinemia compared to women (22.7% vs 7.6%). Univariate analysis showed an odds ratio of hyperhomocysteinemia for PAD of 1.51 [1.02-2.25] in men and 1.69 [1.06-2.68] in women. After adjustment for other cardiovascular risk factors, higher levels of homocysteine were only significantly related to PAD in men.

CONCLUSION

In a Japanese-Brazilian population, elevated levels of homocysteine are associated with PAD in men. Prospective studies are necessary to confirm this finding.

Anatomical Study of the Gastrocnemius Venous Network and Proposal for a Classification of the Veins

OBJECTIVES

To present a detailed description of the gastrocnemius venous network.

DESIGN

Anatomical study in cadavers.

MATERIAL AND METHODS

Forty lower limbs from 20 adult male cadavers were studied. All gastrocnemius veins were dissected from the gastrocnemius muscle heads proximally toward their drainage site.

RESULTS

Eighty heads of 40 gastrocnemius muscles showed 438 gastrocnemius veins. The number of veins per muscle head varied between 2 and 12. There were 221 gastrocnemius trunks distributed as 95 main gastrocnemius trunks, 81 axial and 45 collateral ones. From the 95 main gastrocnemius trunks, 83 (87%) drained into the popliteal vein. Direct observation of the gastrocnemius venous network allowed us to classify the anatomical distribution as four distinct types.

CONCLUSIONS

The majority of main gastrocnemius venous trunks drain into the popliteal vein. There is wide variability in the number of gastrocnemius veins. We propose a classification of four distinct types of anatomical pattern.

Prevalence of varicose veins and venous anatomy in patients without truncal saphenous reflux

OBJECTIVES

To determine the prevalence and distribution of primary venous reflux in the lower limbs in patients without truncal saphenous reflux.

DESIGN

Prospective cohort study.

PATIENTS AND METHODS

One thousand and seven hundred and twelve patients with suspected venous disease were examined by duplex ultrasonography. Seven hundred and thirty-five patients had primary varicose veins with competent saphenous trunks. Limbs with truncal saphenous reflux, deep vein reflux or obstruction, previous injection sclerotherapy or vein surgery, arterial disease and inflammation of non-venous origin were excluded from further consideration. The CEAP classification system was used for clinical staging. Systematic duplex ultrasound examination was undertaken to assess the distribution of incompetent saphenous tributaries.

RESULTS

The prevalence of primary reflux with competent saphenous trunks was 43%. Reflux of GSV calf tributaries was the most common. The majority of the limbs (96%) belonged to chronic venous disease classes C1 and C2 of the CEAP classification.

CONCLUSIONS

Superficial venous reflux causing varicose veins in the presence competent saphenous trunks is very prevalent in this series in contrast to other studies, presumably reflecting differing patient populations. Our data clearly show that varicose veins may occur in any vein and do not depend on truncal saphenous incompetence. Careful duplex ultrasound evaluation allows the pattern of venous reflux to be established in this group of patient ensuring appropriate management of varices.

Effects of a 5-HT2 receptor agonist, DOI (2,5-dimethoxy-4-iodoamphetamine), and antagonist, ketanserin, on the performance of rats on a free-operant timing schedule

This experiment examined the effect of a 5-HT2 receptor agonist DOI (2,5-dimethoxy-4-iodoamphetamine), and antagonist, ketanserin, on temporal differentiation performance. Twelve rats were trained under the free-operant psychophysical procedure to press two levers (A and B) in 50-s trials in which sucrose reinforcement (0.6 mol/l, 50 microl) was provided intermittently for responding on A during the first half, and on B during the second half of the trial. Psychometric curves were derived from percent responding on B (%B), recorded in successive 5-s epochs of the trials; logistic functions were fitted to these data for the derivation of timing indices (T50 [time corresponding to %B=50%], epsilon [slope of the logistic curve], Weber fraction). Cumulative probability of switching in successive 5-s epochs was used to estimate the mean switching time, S50. DOI (0.0625, 0.125 and 0.25 mg/kg, s.c.) dose-dependently reduced T50 and S50. These effects of DOI (0.25 mg/kg) were antagonized by ketanserin (1.0 mg/kg). The results show that DOI alters temporal differentiation in the free-operant psychophysical procedure. The antagonistic effect of ketanserin indicates that the effect of DOI was probably mediated by 5-HT2A rather than 5-HT2C receptors, since ketanserin is relatively selective for 5-HT2A receptors. Comparison of these results with our previous findings with a 5-HT1A receptor agonist indicates that 5-HT1A and 5-HT2A receptors mediate qualitatively similar effects on temporal differentiation.

Further evidence that the discriminative stimulus properties of indorenate are mediated by 5-HT 1A/1B/2C receptors

Indorenate (5-methoxytryptamine beta-methylcarboxylate, INDO) is a serotonin (5-hydroxytryptamine, 5-HT) agonist that has affinity for 5-HT(1A/1B/2C) receptors. Unlike other anxiolytics such as 5-HT receptor agonists, INDO may not share tolerance or dependency with the benzodiazepine anxiolytics. It has been reported that the discriminative stimulus properties of 5-HT(1A/1B/2C) agonists, but not those of 5-HT(3/4) agonists, generalize to INDO. Therefore, the aim of the present study was to obtain further evidence on the differential involvement of 5-HT(1A/1B/2C) receptors in the discriminative stimulus properties of INDO by evaluating its interactions with antagonists of the 5-HT(1A), 5-HT(1B), 5-HT(2C), and 5-HT(3/4) receptor subtypes. Rats were trained to discriminate INDO from saline in a conditioned taste aversion paradigm. For Group D(+)S(-), administration of INDO signalled that saccharin flavour was followed by LiCl, while injection of vehicle signalled safe consumption of saccharin solution. Group D(-)S(+) had the contingencies reversed. After this training, rats had generalization tests where INDO administration was preceded by different doses of the following antagonists: WAY100635 (5-HT(1A)), NAN190 (5-HT(1A)), methiothepin (5-HT(1A/1B/2C)), GR127935 (5-HT(1B/1D)), ketanserin (5-HT(2A/2C)), ritanserin (5-HT(2C/2A)), mesulergine (5-HT(2C/2A)), metergoline (5-HT(2C/2A)), SB206553 (5-HT(2B/2C)), and tropisetron (5-HT(3/4)). In Group D(+)S(-), the order of potency to block the discriminative stimulus properties of INDO was WAY100635>ketanserin>ritanserin>GR127935>mesulergine congruent with SB206553>metergoline>methiothepin>NAN190, while in Group D(-)S(+), the order was WAY100635>GR127935>ketanserin>ritanserin>mesulergine congruent with SB206553>metergoline>methiothepin>NAN190. Tropisetron did not produce any alteration of the discriminative control by INDO. These results suggest that the discriminative signal of INDO is mediated by 5-HT(1A/2C/1B) receptors and that blockade of any of its components produces a degradation of its discriminative effects.

Full substitution of the discriminative cue of a 5-HT(1A/1B/2C) agonist with the combined administration of a 5-HT(1B/2C) and a 5-HT(1A) agonist

The present study examined whether animals attend to the individual components of the cue produced by a drug that stimulates different 5-hydroxytryptamine (5-HT) receptor populations, using a drug discrimination task based on the conditioned taste aversion (CTA) procedure. The training drug was indorenate (5-methoxytryptamine beta-methylcarboxylate) (INDO) that has been described as a 5-HT(1A/2C/1B) agonist able to exert discriminative control in both operant and CTA procedures. The principal objective was to examine generalization with the combined administration of agonists for the different receptor sites that may mimic the mechanism of action of the training drug. Male Wistar rats, deprived of water, were trained to discriminate INDO from saline; during the drug trials, the administration of INDO preceded saccharin-LiCl pairings, while, during the saline trials, the administration of saline preceded the saccharin-saline pairings. In generalization tests, INDO, 8-hydroxy-2-(di-n-propylamino)tetralin (8-OH-DPAT, a 5-HT(1A) agonist), 1-(3-trifluoromethylphenyl)piperazine (TFMPP, a 5-HT(1B) agonist), alpha-methyl-5-HT (a 5-HT(2C) agonist) or 2-methyl-5-HT (a 5-HT(3) agonist), were administered alone or in combination. The results showed that 8-OH-DPAT, TFMPP and alpha-methyl-5-HT produced dose-dependent generalization, up to 88% in the case of 8-OH-DPAT. The combined administration of the following pairs of drugs, 8-OH-DPAT+TFMPP or 8-OH-DPAT+ alpha-methyl-5-HT, at doses that produced only 15-55% generalization when administered alone, produced greater than 80% generalization to INDO. However, the single administration of 2-methyl-5-HT produced only saline-like responding and its combined administration with 8-OH-DPAT did not modify the generalization produced by the single administration of 8-OH-DPAT. These results suggest that animals attend to the individual components of the drug cue; in the case of INDO, which has three elements, each mediated by a different receptor subpopulation (5-HT(1A), 5-HT(1B) and 5-HT(2C) ), the separate stimulation of at least two receptor subpopulations was 'interpreted' by the subject as the presence of the training drug.

Hyperhomocysteinemia increases the risk of venous thrombosis independent of the C677T mutation of the methylenetetrahydrofolate reductase gene in selected Brazilian patients

Fasting total homocysteine (tHcy) and the methylenetetrahydrofolate reductase (MTHFR) C677T mutation were evaluated in 91 patients with venous thromboembolism and without acquired thrombophilia, and in 91 age-matched and sex-matched controls. Hyperhomocysteinemia was detected in 11 patients (12.1%) and in two controls (2.2%), yielding an odds ratio (OR) for venous thrombosis of 6.1 [95% confidence interval (CI), 1.3-28.4]. After excluding 21 patients and four controls with other known genetic risk factors for venous thrombosis, the OR was not substantially changed (7.0; 95% CI, 1.5-33.1). The prevalence of the MTHFR 677TT genotype was not significantly different in patients (9.9%) and in controls (5.5%), with an OR for venous thrombosis of 1.8 (95% CI, 0.6-5.8). Subjects with the MTHFR 677TT genotype showed higher levels of tHcy compared with the 677CC genotype in patients (P = 0.010) and in controls (P = 0.030). In conclusion, we found that fasting hyperhomocysteinemia is a risk factor for venous thrombosis in patients without known acquired thrombophilia and other genetic risk factors for venous thrombosis. Although tHcy levels are significantly higher in those homozygous for the MTHFR C677T mutation, this genotype does not increase the thrombotic risk in our study population.

Effect of sequential intermittent pneumatic compression on both leg lymphedema volume and on lymph transport as semi-quantitatively evaluated by lymphoscintigraphy

Sequential Intermittent Pneumatic Compression (SIPC) is an accepted method for treatment of peripheral lymphedema. This prospective study evaluated the effect in 11 patients of a single session of SIPC on both lymphedema volume of the leg and isotope lymphography (99Tc dextran) before SIPC (control) and 48 hours later after a 3 hour session of SIPC. Qualitative analysis of the 2 lymphoscintigrams (LS) was done by image interpretation by 3 physicians on a blind study protocol. The LS protocol attributed an index score based on the following variables: appearance, density and number of lymphatics, dermal backflow and collateral lymphatics in leg and thigh, visualization and intensity of popliteal and inguinal lymph nodes. Volume of the leg edema was evaluated by measuring limb circumference before and after SIPC at 6 designated sites. Whereas there was a significant reduction of circumference in the leg after SIPC (p<0.05), there was no significant difference in the index scores of the LS before and after treatment. This acute or single session SIPC suggests that compression increased transport of lymph fluid (i.e., water) without comparable transport of macromolecules (i.e., protein). Alternatively, SIPC reduced lymphedema by decreasing blood capillary filtration (lymph formation) rather than by accelerating lymph return thereby restoring the balance in lymph kinetics responsible for edema in the first place.

Discriminative stimulus properties of indorenate in a conditioned taste aversion paradigm

Indorenate (5-methoxytryptamine beta-methylcarboxylate, INDO) is a serotonin (5-hydroxytryptamine, 5-HT) agonist that has affinity for 5-HT(1A/1B/2C) receptors. It possesses anxiolytic and antihypertensive actions mediated by 5-HT(1A) receptors and anorectic activity mediated by 5-HT(2C/1B) receptors. This study examined whether INDO may exert discriminative control using a conditioned taste aversion (CTA) paradigm, and whether differential participation of 5-HT receptor subtypes may be involved in its cue. Male Wistar rats trained to drink their daily water in a 30-min period were trained to discriminate INDO from saline. One group received the intraperitoneal administration of INDO (10.0 mg/kg) before saccharin-LiCl pairings; on alternate days, rats received saline before the saccharin-saline pairings (Group D(+)S(-)). The other group had the contingencies reversed (i.e., the administration of INDO preceded saccharin-saline pairings: Group D(-)S(+)). In two-bottle generalization tests (one bottle containing saccharin, the other plain water), the preference for saccharin was evaluated after different doses of INDO, [3H]-8-hydroxy-2-(di-N-propylamino)tetralin (8-OH-DPAT) (5-HT(1A)), buspirone (5-HT(1A)), RU24969 (5-HT(1A/1B)), TFMPP (5-HT(1B/2C)), MK212 (5-HT(2C)), alpha-Me-5-HT (5-HT(2C/2A)), 2-Me-5-HT (5-HT(3)) and cisapride (5-HT(4)). The results showed that INDO, RU24969, TFMPP, alpha-Me-5-HT and MK 212 produced a dose-dependent generalization; 8-OH-DPAT and buspirone produced only partial generalization, while 2-Me-5-HT and cisapride did not produce generalization. The results indicate that INDO administration may exert discriminative control over saccharin preference mediated mainly by 5-HT(1B/2C) receptors, but with an important contribution of 5-HT(1A) receptors.

Assessment of insecticide resistance in five insect pests attacking field and vegetable crops in Nicaragua

Field populations of Hypothenemus hampei (Ferrari), Plutella xylostella (L.), Spodoptera exigua (Hübner), Helicoverpa zea (Boddie) and Bemisia tabaci (Gennadius) were tested for resistance to several insecticides commonly used in Nicariagua. Assays were conducted to estimate the LD50s or LC50s and the corresponding resistance ratios. A diagnostic concentration was used to discriminate between susceptible and resistant strains of H. hampei. The tests with >6,000 H. hampei adults collected from six different sites indicate the absence of resistance to endosulfan. Resistance to cypermethrin, deltamethrin, chlorfluazuron, thiocyclam, and methamidophos was documented in six field populations of P. xylostella. High levels of resistance to cypermethrin and deltamethrin, but moderate levels of resistance to chlorpyriphos and methomyl, were also documented in two field populations of S. exigua. Moderate levels of resistance to cypermethrin, deltamethrin and chlorpyriphos were also documented in three field populations of H. zea. Moderate to high levels of resistance to bifenthrin, methamidophos and endosulfan were documented in four field populations of B. tabaci. The presence of significant correlations between LD50s or LC50s suggests the occurrence of cross-resistance or simultaneous selection for resistance by different insecticides with different modes of action. Our data could not differentiate between these two possibilities. Because insecticides will continue being used in Nicaragua, a resistance management program is urgently needed. The implementation of integrated pest management tactics must be accompanied by specific regulations for pesticide registration. In the future, pesticide registration regulations in Nicaragua should include periodic resistance monitoring. The mechanisms to cover the costs of resistance monitoring and resistance management should also be established.

Continued experience with physical examination alone for evaluation and management of penetrating zone 2 neck injuries: results of 145 cases

PURPOSE

Our preliminary experience with physical examination alone in the evaluation of penetrating zone 2 neck injuries for vascular trauma was previously reported in 28 patients over a 2-year period (1991-1993). The purpose of the current study was to examine the results of this approach in a much larger group of patients over an 8-year period.

METHODS

The medical records for all patients admitted to our level I trauma center (all of them entered into our prospective protocol) between December 1991 and April 1999 with penetrating zone 2 neck trauma were reviewed for their initial presentation and any documented vascular injury.

RESULTS

A total of 145 patients made up the study group; in 30 of these patients, the penetrating trajectory also traversed zone 1 or 3. Thirty-one patients (21%) had hard signs of vascular injury (active bleeding, expanding hematoma, bruit/thrill, pulse deficit, central neurologic deficit) and were taken immediately to the operating room; 28 (90%) of these 30 patients had either major arterial or venous injuries requiring operative repair (the false-positive rate for physical examination thus being 10%). Of the 114 patients with no hard signs, 23 underwent arteriography because of proximity of the injury to the vertebral arteries or because the trajectory included another zone. Of these 23 arteriograms, three showed abnormalities, but only one required operative repair. This case had no complications relating to the initial delay. The remaining 91 patients with no hard signs were observed without imaging or surgery for a minimum of 23 hours, and none had any evidence of vascular injury during hospitalization or during the initial 2-week follow-up period (1/114; false-negative rate for physical examination, 0.9%).

CONCLUSIONS

This series confirms the earlier report indicating that patients with zone 2 penetrating neck wounds can be safely and accurately evaluated by physical examination alone to confirm or exclude vascular injury. The missed-injury rate is 0.7% (1/145) with this approach, which is comparable to arteriography in accuracy but less costly and noninvasive. Long-term follow-up is needed to confirm this management option.

[Improvement in the treatment of acute myocardial infarct by the establishment of a thrombolysis unit in a cardiology servic]

INTRODUCTION AND OBJECTIVES

Lack of available beds in the coronary care unit, makes time to thrombolysis still too long. Although fibrinolytic therapy is administered in the emergency department in most hospitals, mean in-hospital delay continues to be long. Our purpose was to improve the treatment of these patients and to evaluate if this delay could be shortened by creating a thrombolysis unit for the treatment of patients with acute myocardial infarction.

METHODS

A thrombolysis unit in the cardiology department was set up to treat patients with acute myocardial infarction who couldn't be admitted directly in the coronary care unit because of lack of available beds. Time to treatment in both groups of patients were compared.

RESULTS

Two hundred twenty-five patients with acute myocardial infarction and ST-segment elevation were included: 86 (38%) of them were admitted to the thrombolysis unit and the other 139 (62%) to the coronary care unit. There were no differences in baseline characteristics or in the pre-hospital delay between both groups. Time from hospital admission to thrombolysis was 59 minutes in patients treated in the thrombolysis unit versus 70 minutes in those treated in the coronary care unit (p < 0.001), and time from the admission to both units to fibrinolytic therapy was of 20 minutes versus 30 minutes respectively (p < 0.0001). There were no differences between both groups in the incidence of complications.

CONCLUSIONS

In-hospital delay in thrombolysis remains too long. Implementation of a thrombolysis unit in the cardiology department shortens this delay and offers the possibility to treat patients with acute myocardial infarction at least as well as in the coronary care unit, without dependence on the availability of free beds in this unit.