Signs Of Decompensation Research Articles

Using signs of decompensation as triggers for early intervention to reduce hospitalization.

Using signs of decompensation as triggers for early intervention to reduce hospitalization.

The pharmacokinetics of octreotide in cirrhosis and in healthy man

Background/Aim: The aim of the study was to evaluate the pharmacokinetics of octreotide in patients with cirrhosis compared to healthy volunteers. Methods: Seventeen patients with cirrhosis and nine normals received an intravenous bolus of octreotide (0.75 μg/kg), followed by a continuous infusion of 0.75 μg · kg −1 · h −1 for 12 h. Eight patients were decompensated with ascites, while nine were without signs of decompensation. Serum octreotide levels were followed by blood sampling during the infusion period and for 24 h afterwards. Results: The average clearance (±SEM) was 151±15 ml/min in normals compared to 102±9 ( p<0.05) and 105±9 ( p<0.05) in patients with compensated and decompensated cirrhosis, respectively. The average area under the serum octreotide curve was significantly increased by 53% ( p<0.05) in decompensated and 46% ( p<0.05) in compensated cirrhosis compared to healthy volunteers, while no difference was observed between the groups with cirrhosis. This difference was also reflected by an increased maximum serum concentration during the infusion period of 9797±580 ng/l in the patients with cirrhosis compared to 7081±547 ng/l ( p=0.006) in normals. The serum half-life for the beta-phase (T1/2β) was 165±26 min in normals, 200±21 min in the compensated and 216±26 min in the decompensated group (NS). The volume of distribution (V dβ) showed no difference between the three groups. Because of the slow equilibration between plasma and ascitic fluid in decompensated cirrhosis, the calculated clearance may have been overestimated and T1/2β and V dβ underestimated in these patients. Conclusions: The present study demonstrates that the pharmacokinetics of octreotide in cirrhosis is substantially different from that found in normals.

Metabolic and hemodynamic responses of bivascularly perfused rat liver to nerve stimulation, noradrenaline, acetylcholine and glucagon in thioacetamide-induced micronodular cirrhosis.

Thioacetamide-induced rat cirrhosis was characterized by single-cell necroses, fibrosis, nodular parenchyma, decrease in parenchymal volume density and an increase in liver weight per body weight so that the total amount of parenchyma was not altered. The glycogen content was normal, and signs of decompensation were not found. Isolated livers were single-pass perfused by way of both the hepatic artery and the portal vein. In the normal livers stimulation of the nerve plexuses around the hepatic artery or portal vein (7.5 Hz; 2 msec) and infusions of noradrenaline (1 mumol/L) by way of either vessel and of acetylcholine (10 mumol/L) by way of the artery only increased glucose output, reduced both portal and arterial flow and increased the intravascular pressures. Glucagon (0.5 nmol/L) augmented glucose release and had no hemodynamic effects. In chronically thioacetamide-injured livers all stimuli caused smaller metabolic alterations per gram of liver weight and decreased portal flow more and arterial flow less with stronger enhancements of intravascular pressures than in the controls. The lowered metabolic responsiveness per gram of cirrhotic liver was largely compensated by the increase in liver weight. Thus despite massive histological alterations and pronounced increases in stimulation-dependent resistances - predominantly in the portal system - cirrhotic rat livers responded in their glucose metabolism to nervous and hormonal stimuli in almost the same manner as normal livers.

Bifocal glasses for non-presbyopic patients (author's transl)

A disturbance of the physiological relation between accommodation and convergence which is defined by the AC/C ratio results in a manifest convergent squint. After a short reference to the typical accommodative esotropia, the atypical accommodative esotropia ("convergence excess") and its treatment with bifocal lenses are discussed in greater detail. Bifocal glasses are also used in the following disturbances of binocular vision: in partially accommodative convergent squint with a larger deviation in near fixation, in primary and postoperative microtropia with a larger deviation in near fixation, in esophoria with signs of decompensation in near fixation, with an intermittent exotropia of the divergence excess type. In the last-mentioned case they are use exclusively in preoperative diagnostics. The use of bifocals is simple and does not take much time; contrary to cyclospastic drugs, it has no undesirable side effects. Experience has shown that even after wearing bifocals for years there is no danger of a permanent accommodation insufficiency.

Cardiac performance of hypertensive aorta-constricted rabbits.

A heart-lung preparation with flow limited to the coronary vessels was used to study cardiac performance 4 to 120 days after severe constriction of the abdominal aorta in rabbits. Cardiac performance was evaluated by finding the maximum mean arterial pressure against which the heart could pump. Cardiac performance began to exceed the normal, range by the second or third post operative week and was well above normal after the first month. A high cardiac performance was not necessarily associated with marked ventricular hypertrophy. Animals died of heart failure within the first month, and all had developed a much more rapid rate of blood pressure increase than those that survived without signs of decompensation. We conclude that the basic cause of heart failure after severe aorta constriction is a rapid rise in arterial pressure which exceeds the rate at which the heart develops an improved performance.

COARCTATION OF THE AORTA IN INFANTS

A review of 108 cases of coarctation of the aorta diagnosed under 1 year of age, and admitted to The Hospital for Sick Children, Toronto, over a 12-year period, is presented. Preductal coarctation accounted for 90% of the fatalities under 1 year. Patency of the ductus arteriosus occurned in 98% of cases in the first 6 months of life. Forty-nine per cent of cases of coarctation of the aorta under 1 year of age have major cardiac anomalies other than patent ductus: ventricular septal defect, 33%; transposition of great vessels, 10%; and atrial septal defect, 6%. Problems in diagnosis occurred when blood pressure readings were equivocal. Operative mortality for coarctation of the aorta in the first year of life was 41%, while after 1 month of age it was only 29%. Mortality in patients not operated on during the first year of life was 50%, while for those less than 1 month of age with symptoms and signs of decompensation and not operated on, the mortality was 87%. In dealing with coarctation of the aorta in the first year of life the following are recommended: 1) When blood pressure readings in the arms and legs are equivocal, the readings should be repeated frequently until the diagnosis is clarified; 2) aortogram should be performed on patients difficult to diagnose; 3) babies presenting with symptoms in the first month of life should be operated on promptly unless they show a dramatic response in a 12-hour trial of treatment with digitalis; 4) babies after 1 month of age who respond to digitalis may be kept on this medication until adequate adjustment in circulatory hemodynamics has taken place and surgery can be performed at the optimum age.

A biologic test for digitalis effect

It has long been known that the abnormal BCG in human cardiac decompensation will revert toward normal as the heart contractile force is augmented by digitalization. It has not been accepted that digitalis can, in a like manner, augment the cardiac contractile force in patients who show no clinical symptoms or signs of decompensation. Nevertheless, in the cases presented here this seems to be the most likely explanation for the reversion of the abnormal tracings to normal. The increased peripheral load caused by arterial hypertension in these patients resulted in abnormal BCG's. Despite the fact that the hypertensive load remained the same, the traces were normalized by digitalis. The balance between propulsive force and resistive force was restored, albeit at a higher level. Applied to the quantitative study of digitalis, it may safely be assumed that the dose required to normalize a given BCG is near the optimal digitalizing dose for that particular patient at that particular time. No further assumptions can be made. But even this limited information has two important applications. In the first place, if the patient's cardiac status and blood pressure load remains unchanged, the method should be useful in comparing the therapeutic range of various cardiac glycosides. Secondly, in a given decompensated patient, it seems that the method might be helpful in determining the quantity of digitalis required for maximum therapeutic effect. Parenthetically, in a preliminary investigation of this application it was immediately apparent that the minimal dose was higher and the therapeutic range was narrower than those reported in this study. Further studies are in progress using smaller increments of digitalis to titrate more accurately the therapeutic ranges of several digitalis preparations. Another study will attempt to correlate the clinical, electrocardiographic, and ballistocardiographic signs of restored compensation in patients with congestive heart failure.

Effect of Meals on the Electrocardiogram of Cardiac Patients.

In a previous communication,1 we reported, for 12 normal men, the effect of meals on electrocardiograms recorded 30 and 60 minutes later. Most of the electrocardiographic functions, especially the T-wave, showed statistically significant changes, although the electrocardiograms remained within clinically normal limits. In 20 cardiac patients, mostly definite or suspected coronary disease, we recorded the standard limb leads, 3 chest leads (CF1, CF2, CF4) and the heart sounds before and at 30 and 60 minutes after a 1000-calorie meal. In 2 patients additional chest leads were taken. The location for the chest leads was marked on the chest by means of a colored pencil.Out of 10 patients with some symptoms of angina pectoris but with normal electrocardiogram before the meal and without any signs of decompensation, the electrocardiogram became abnormal after the meal. The abnormality involved inversion of the T-wave in lead CF2 or CF4 or increase in the size of a Q-wave in lead III. These patients felt no disc...

CARCINOMA OF THE LIMBUS

Primary carcinoma of the limbus is relatively uncommon. The following case is significant and of interest because (1) it illustrates a similarity to cases already reported, (2) the only sign remaining after treatment was a small conjunctival scar, and (3) no recurrence, metastases or complication has resulted at the time of writing. <h3>REPORT OF A CASE</h3> A white man aged 47 was admitted to Bellevue Hospital on Oct. 9, 1940 complaining of itching and tearing of the left eye. The family and the past history were essentially unimportant except to reveal the fact that the patient had been punched in this eye about seven years before. . Examination showed that he was underweight, and the apex of the right lung contained an area of old, healed tuberculosis. Auricular fibrillation was present, but there were no signs of decompensation. The Wassermann test of the blood was negative. Examination of the blood showed

Cardiac disease in pregnancy

In conclusion, we may state that pregnant patients suffering from heart disease may in general be divided into three groups, although these groups are not definite and often overlap one another. In Group I we may place those who have some history of heart disease, who show a heart lesion, either congenital or acquired, but who have not had any sign or symptom of cardiac decompensation and who are able to withstand the usual strain of everyday life without any signs of decompensation. These patients are able to climb stairs, one or two flights without undue dyspnea, they are not conscious of cardiac embarrassment, except, perhaps, on extreme muscular effort. In Group II we may place those patients who have a cardiac lesion, have no history of cardiac decompensation, but who are forced to limit their activities. A specific instance of such a patient would be a woman who is unable to climb a flight of stairs without resting at the completion of it and yet does not show any definite sign or symptom of a break in cardiac compensation. The patient in this class is conscious of the fact that her activities must be limited in order to live comfortably.In Group III we place those patients who have a definite history of cardiac decompensation. These patients have been incapacitated at some time or other during their life because of that heart disease. The treatment in this class of patient should undoubetdly be radical. In general, a pregnancy should not be allowed to continue, and a subsequent pregnancy should be prevented by sterilization.The treatment in the first class of patient usually consists in careful antenatal examinations and observation, admission to the hospital a week or two before term, with spontaneous delivery under ether anesthesia. The treatment in the second class of patient is an even closer vigilance, admission to the hospital a month or more before term is reached, and avoidance of the second stage of labor by forceps application on full dilatation of the cervix.