Ascites: Its correction by peritoneovenous shunting

Patients with refractory ascites and HRS should be considered to present an urgent indication for peritoneovenous shunting. The shunt offers a method of continuous reinfusion of ascitic fluid which corrects avid sodium retention, oliguria and azotemia. Severe encephalopathy, jaundice or peritoneal sepsis-common complications of cirrhosis-contraindicate installation of the shunt before improvement occurs. Associated cardiac disease does not contraindicate the use of the shunt provided that ascitic fluid is removed at the time of operation and large amounts of diuretics are used. This operation has also proved useful in ascites attributed to causes other than cirrhosis. The main complications include disseminated intravascular coagulopathy, hepatic coma and sepsis in a few patients. Results of a randomized prospective study indicate that the shunt should probably be considered in patients with diet-resistant massive ascites even before they prove to be refractory to diuretic therapy.     

Hairy cell leukemia: Clinical effects of the methanol extraction residue (MER) of BCG, lithium carbonate and mononuclear cell-enriched leukocyte transfusions

The effect of MER, lithium carbonate or mononuclear cell-enriched leukocyte transfusions was investigated in eleven patients with hairy cell leukemia. These therapeutic modalities were intended to enhance hematopoiesis and restore the immune abnormalities which occur in these patients. Treatment programs consisted of either MER (0.1–0.5 mg/m² i.v. weekly) or one to two series of three consecutive mononuclear cell transfusions (MNCT), each transfusion containing a mean of 10.6 ± 1.5 × 10⁹ cells/mm³ (8.4 ± 2.9 × 10⁹ lymphocytes and 1.96 ± 1.5 × 10⁹ monocytes) or both. A number of patients were given lithium carbonate followed by MER and then lithium with MER on alternate weeks. A complete hematologic response (CHR) was defined as: hemoglobin above 12 g/dl; neutrophil count > 1500 cells/mm³ and platelet count of > 100,000 mm³. A partial hemotological response (PHR) was defined as recovery of at least two of these parameters. Two CHR and two PHR were seen in patients who received MNCT. Three additional patients who received MER or lithium-MER showed improvement in one hematological parameter. The incidence of infection was significantly lower in the patients who responded to treatment than in those who did not (p < 0.04).

Biological stimulation with allogenic cells improved bone marrow failure in patients with HCL. It is expected that hematological recovery and a decrease in the incidence of infections will result in prolonged survival for patients. The contribution of immunoadjuvants or pharmacological agents such as lithium to this therapeutic approach in HCL or other leukemic states where chemotherapy is not desirable requires further investigation.     

Portopulmonary hypertension in childhood presenting as sudden death.

We present the case of a 9-year-old boy with portal hypertension who died suddenly and unexpectedly due to pulmonary hypertensive crisis during a routine endoscopic procedure. He had known portal hypertension with esophageal varices but had no preceding clinical symptoms suggestive of significant pulmonary hypertensive disease despite postmortem histological evidence of advanced pulmonary vascular changes. Portopulmonary hypertension is a well-described and distinct clinical syndrome that is rare in childhood and is associated with a relatively poor prognosis. Occasional patients with histologically advanced disease may remain asymptomatic but present with pulmonary hypertensive crisis. Children with portopulmonary hypertension should be considered at high risk for surgical procedures, and pulmonary hypertensive complications should be excluded as a cause of death in all children dying suddenly in the setting of portal hypertension.     

An Overview of the Allopathic Match

The number of allopathic emergency medicine (EM) programs has been progressively increasing over the years. In 2018, allopathic EM postgraduate year-1 spots, compared with 2012, increased by around 60% to reach 2278 positions. EM is considered a competitive specialty and therefore, in this article we help guide students interested in EM through the allopathic match requirements, application process, interviews, and ranking EM programs. Additionally, we tackle the combined emergency medicine residency programs, namely the combined EM-Family Medicine (FM), EM-Anesthesiology, EM-Internal Medicine (IM), EM-IM-Critical Care Medicine, and EM-Pediatrics residency programs. Finally, we explain the increased likelihood of matching with the single graduate medical education accreditation system expected to happen in the year 2020.     

Aldosterone antagonism and congestive heart failure: a new look at an old therapy

PURPOSE OF REVIEW: More than 5 million people in the United States alone have congestive heart failure, and an estimated 40 million have established risks and warrant therapy. Mineralocorticoid antagonists have emerged as a new paradigm for the treatment of congestive heart failure. They have established benefits among patients with chronic symptomatic systolic dysfunction, and recent studies have demonstrated substantial effect on the morbidity and mortality among patients with heart failure after myocardial infarction. The exact biologic mechanism is thus far unknown. RECENT FINDINGS: Within the last 5 years, efforts have intensified to help define better the biologic mechanisms by which mineralocorticoid receptor antagonisms exert the observed clinical benefit. Elegant human studies have demonstrated some important observations. First, under conditions of increased plasma aldosterone concentrations, the heart will extract aldosterone. Second, aldosterone extraction in the heart stimulates increased collagen turnover culminating in ventricular remodeling. Third, among people with chronic systolic or diastolic heart failure, aldosterone is actually produced and secreted by the heart. Finally, antagonism of the mineralocorticoid receptor will attenuate or abrogate many of these deleterious effects. SUMMARY: Combined clinical and detailed mechanistic investigations have established mineralocorticoid receptor antagonism as the new treatment paradigm for congestive heart failure. Recent clinical data have demonstrated that treatment of patients with a combination of mineralocorticoid receptor antagonism (eplerenone) and angiotensin converting enzyme-inhibitor (ACE-I) results in substantial reduction in left ventricular mass. Furthermore, a federally funded initiative to treat more than 6000 patients with diastolic heart failure with spironolactone is in its final phases of planning. It is foreseeable that, along with ACE-I and beta-blockers, mineralocorticoid receptor antagonism will become part of the treatment paradigm for people across the entire spectrum of cardiovascular disease.