What's new in stroke?

More than 30,000 strokes occur each year in Texas, even though most strokes can be prevented by currently available and well-tolerated therapies. Antiplatelet therapy with aspirin or ticlopidine reduces stroke by about 25% in many patients with transient ischemic attack or initial stroke. Warfarin should not be used routinely for primary cerebrovascular disease but is useful to prevent cardioembolic stroke. Carotid endarterectomy is highly beneficial for patients with symptomatic, high-grade carotid stenosis, but its value for lesser degrees of symptomatic carotid plaque and for asymptomatic stenosis is less clear. Patients with nonvalvular atrial fibrillation have a substantial risk for stroke; most should be treated with warfarin. Risk-factor management (eg, control of hypertension, cessation of smoking, and treatment of hyperlipidemia) is as important as antithrombotic or surgical therapies for most patients with threatened stroke. Treating isolated systolic hypertension in elderly patients reduces stroke risk. Determining the cause of threatened stroke strongly influences preventive management. The tools are at hand to prevent most strokes; the challenge remains to apply them optimally.     

What's new in pediatric nephrology?]

Advances in pediatric nephrology has been mainly characterized during the last years by a burst of knowledge in the area of genetic renal diseases: 1/almost complete understanding of Alport syndrome related to mutations of COL4A5 or COL4A3/A4 genes of collagene; 2/the mapping and cloning of the nephronophthisis gene which is deleted in 75% of cases; 3/the mapping and cloning of the cystinosis gene coding for a protein of the lysosomal membrane; 4/the mapping and cloning of the Finnish-type congenital nephrotic syndrome gene; 5/the linkage to the SNR 1 gene on chromosome 1 of a large number of familial corticoresistant nephrotic syndromes, and the disclosure of mutations of the WT1 gene in diffuse mesangial sclerosis and in Frazier syndrome. The understanding of Bartter syndrome has been also enlightened by the discovery of mutations in several ionic channels located in the distal tubule. It has been also shown that a corticoresistant nephrotic syndrome or a chronic tubular interstitial nephropathy are possible phenotypes for mitochondrial cytopathies. In the area of therapeutics, recombinant growth hormone was shown to improve statural growth of children with chronic renal failure; in addition, renal transplantation benefits from new immunosuppressants as tacrolimus and mycophenolate mofetil.     

A new cardiology patient simulator

The apolipoprotein E (APOE) epsilon4 allele is a risk factor in Alzheimer disease (AD), but not in vascular dementia (VaD). We have investigated whether the epsilon4 allele is more common in twin pairs concordant for AD, compared with those discordant for AD, and whether the epsilon4 allele is more common in AD twins than in VaD twins. In addition, we have investigated the relationship of the epsilon4 allele and the age at onset in AD and VaD. APOE genotype was analysed in 29 senile demented twin pairs. The epsilon4 allele was associated with AD and not with VaD. However, there was no difference in the frequency of the APOE epsilon4 allele in concordant (33.3%) and discordant (31.3%) AD dizygotic twin pairs. Age at onset in AD was significantly lower in epsilon4 homozygotes than in individuals with one or no copies of epsilon4 (62.4 vs. 73.5, p<0.01). In concordant AD twin pairs, the epsilon4 allele frequency was somewhat higher in the twins with earlier onset (41.7% vs. 25%), but the difference was not statistically significant. In the VaD group the age at onset was not significantly different between individuals with or without epsilon4 in their genotypes.     

What's new about evidence-based assessment?

A clear consensus has emerged around the world concerning the desirability and even the urgency of basing health care delivery systems on evidence. Among behavioral health care providers such as psychologists, evidence-based practice (EBP) has been focused largely on interventions. Psychologists have long emphasized a scientifically based psychometric approach to the development of assessment procedures. Nevertheless, the era of evidence-based assessment highlights 2 somewhat different issues. First, sophisticated assessment is closely integrated with our emerging conceptions of psychopathology, rather than standing separate from these conceptions. Second, broad-based ongoing outcomes assessment systems are increasingly required for EBP on the part of governments and health care policymakers. This article summarizes these developments and looks to the future. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

What's new in preventing and treating osteoporosis?

Women should be encouraged to maintain an adequate calcium intake throughout their life so they have good BMD when they reach menopause. The most effective choice for prevention and treatment of osteoporosis after menopause is estrogen or combined estrogen-progestin. The addition of progestin to estrogen therapy to prevent endometrial cancer does not impair effectiveness of estrogen in increasing BMD. In women who have contraindications to or do not wish to take estrogen, alendronate is the most effective alternative. Raloxifene has been found to protect BMD but not to the extent of estrogen or alendronate, and it does not provide the other benefits offered by estrogen. Calcitonin-salmon has an excellent long-term safety record, but its effectiveness in preventing fracture remains to be fully demonstrated. Adequate calcium intake and exercise are important adjuncts to other therapies but alone do not prevent osteoporosis in most women.     

What's new in transplant immunology: problems and prospects

In the past 40 years, transplantation has moved from an experimental form of therapy used almost exclusively for renal failure to an accepted treatment for end-stage kidney disease, heart disease, liver disease, lung disease, and diabetes mellitus. Tissue transplantation for conditions from thermal injury to Parkinson disease is being investigated. The primary barrier in transplantation medicine is the immunologic reaction of the recipient to donor organs and tissues. Currently available drugs permit excellent short-term graft survival but have not led to reliable long-term survival. Recent advances in the understanding of this immune response have suggested new approaches to induction of immunologic tolerance and reduction of late graft losses. Because of the excellent short-term success of current agents, integration of these new approaches into clinical trials is challenging and raises important questions about the design of such trials.     

Evaluation of data in cardiology by new software tools

We describe an analysis of cardiology data using new software tools. First we use data of 1417 men aged 40 to 50 years living in the center of Prague gathered in the twenty years lasting longitudinal study. We show some results of application of the programs E.T. (Epidemiology Tools) and CORE (COnstitution and REduction of data). Second we show the way of application of the program HYPERTENSION, that supports decision making in therapy of arterial hypertension.     

What's new: the AHCPR guideline update on urinary incontinence

The Agency for Health Care Policy and Research (AHCPR) released their first updated guideline in March, 1996. Three documents were released: the Clinical Practice Guideline, Urinary Incontinence in Adults: Acute and Chronic Management; the Quick Reference Guide, Managing Acute and Chronic Urinary Incontinence; and the Patient Guide, Understanding Incontinence. The new areas are outlined and addressed. Unlike the 1992 version, the update emphasizes the problem of urinary incontinence (UI) in a specific population, those with chronic "intractable" incontinence. It provides an algorithm in the Quick Reference Guide for selecting appropriate behavioral, pharmacologic, and surgical treatments and supportive devices for use in managing UI. The concept of "prevention" of UI and the promotion of healthy bladder habits is introduced. The updated guideline developed recommendations for each assessment and treatment method. Specific interventions that can impact individuals with chronic "intractable" incontinence are discussed including toileting assistance programs, physical and environmental alterations, fluid and dietary management, management of nighttime voiding, and other measures and supportive care. Skin care and social and organizational environmental factors are also discussed. In August, 1996 the AHCPR released two additional, original documents, the Caregiver Guide, Helping People with Incontinence, and Alert for Directors of Nursing, which are briefly discussed.     

Anticoagulation in cardiology

The various applications of anticoagulation in cardiology concern primary prevention, treatment of angina and infarction, revascularization either by angioplasty or by bypass grafts, treatment after artificial valve replacement, treatment of atrial fibrillation and, finally, as a precaution in the case of impaired ventricular function. Several methods of anticoagulation can be used in each of these indications: thrombin antagonists, vitamin K antagonists, antiaggregants and thrombolytics, although this last group is not discussed in this article.     

Forty-two years in cardiology

1. Incubation of proximal segments of the rat isolated duodenum with NG-nitro-L-arginine (L-NOARG; 3-100 microM) produced a concentration-dependent increase in both resting tone and the amplitude of the spontaneous contractions. These effects were attenuated by concurrent incubation with L-arginine (1 mM) but not D-arginine (1 mM). 2. These changes in resting tone and motility induced by L-NOARG (30 microM) were substantially reduced by concurrent incubation with tetrodotoxin (1 microM) or hexamethonium (10 microM), implicating the involvement of a local neuronal response. 3. The L-NOARG-induced increase in duodenal motility was not, however, inhibited by atropine (1 microM), guanethidine (6.4 microM) phentolamine (1 microM), or indomethacin (10 microM), indicating a non-cholinergic, non-adrenergic and non-prostanoid-mediated contractile response. 4. The NK1/NK2 tachykinin receptor antagonist, (D-Pro2, D-Trp7.9 substance P, 1-10 microM), and the NK2-receptor antagonists, MEN 10,207 and MEN 10,376 (1-5 microM), concentration-dependently reduced the effect of L-NOARG (30 microM) on spontaneous duodenal motility. 5. The resting tone and amplitude of the spontaneous contractions was likewise increased by incubation with NG-monomethyl-L-arginine (L-NMMA; 100-1000 microM). However, incubation with L-NMMA (100 microM) attenuated the actions of more potent L-NOARG (30 microM) on resting motility. 6. Administration of E.coli endotoxin (3 mg kg-1, i.v.) to the rat 5 h prior to tissue removal, at a time of known induction of NO synthase, reduced the amplitude of spontaneous contractions of the isolated duodenum, an effect inhibited by pretreatment of the rats with dexamethasone (1 mg kg-1) 2 h prior to endotoxin challenge. 7. These findings indicate a role of endogenous NO in the modulation of spontaneous tone and motility in the rat duodenum. Induction of NO synthase may result in a reduction in spontaneous motility of the tissue. By contrast, inhibition of constitutive NO biosynthesis unmasks a contractile response that is neuronally mediated and involves tachykinin NK2 receptors.