The metabolic syndrome, insulin resistance and cardiovascular disease.

The metabolic syndrome (MS) is a common lifestyle disease in the western world and has significant morbidity and premature mortality, especially regarding cardiovascular disease (CVD). Although insulin resistance (and hyperinsulinaemia) is an early marker of MS and future adverse cardiovascular outcomes, it is not known if on its own this is sufficient. The issue is further clouded in prospective studies by the development in study subjects of some, or all of the components of MS, each of which is an independent risk factor for CVD. Therefore, in spite of a number of appropriate long-term studies, the exact contributions of the individual components of MS remain unclear. Their combination is unequivocally responsible for this presentday epidemic of CVD.

The metabolic syndrome--pathogenesis, clinical features and management.

The metabolic syndrome is a highly prevalent clinical entity, which is often overlooked and may have far-reaching health implications for the patient. Up to 80% of patients with the metabolic syndrome die as a result of cardiovascular complications. Insulin resistance is the central component of this complex syndrome and should be appropriately addressed to ensure the best possible outcome for our patients. Recent advances in the pathogenesis and management of this syndrome is discussed in this article.

Dislodgement of a vein graft thrombus by angiographic injection of native coronary artery.

A case of retrograde dislodgement of thrombus in a saphenous vein graft during injection of the native right coronary artery is presented. Attention to this previously undescribed complication may allow for timely treatment with emergency surgery or thrombolysis.

Withholding and withdrawal of life support from the critically ill.

We investigated decisions to withhold or withdraw life support from patients in the medical-surgical intensive care units at the Moffitt-Long Hospital of the University of California and San Francisco General Hospital, from July 1987 through June 1988. Among 1719 patients admitted to the two intensive care units, life support was withheld from 22 (1 percent) and withdrawn from 93 (5 percent). The reason for limiting care was poor prognosis. Of these 115 patients (18 of whom were considered brain-dead), 89 died in the intensive care unit (accounting for 45 percent of all deaths there), and all but 1 of the remaining patients died after transfer from the intensive care unit. Thirteen (11 percent) had earlier expressed the wish that their terminal care be limited, but this affected care in only four cases. Only 5 of the 115 patients made the actual decision to limit care; the others were incompetent at the time. Of the latter, 102 had families who participated in the decision; family members of the other 8 incompetent patients could not be found, and the decisions were made by physicians. Only 10 families initially disagreed with the recommendations to limit care, and they later agreed. The median duration of intensive care among the patients from whom life support was withheld or withdrawn was eight days at Moffitt-Long Hospital and four days at San Francisco General, as compared with medians of three and one days, respectively, for other patients who died in the intensive care units. We conclude that although life-sustaining care is withheld or withdrawn relatively infrequently from patients in the intensive care unit, such decisions precipitate about half of all deaths in the intensive care units of the hospitals we studied. In most of these cases the patients are incompetent, but physicians and families usually agree to limit care.

Malaria in Cape Town. A report of 3 cases and a review of current therapy and prophylaxis.

Three cases of malaria seen within 1 week at the Somerset Hospital in Cape Town are reported. One of these patients developed cerebral malaria and severe brain damage. The management of acute malaria and its complications, as well as the prophylaxis, is briefly reviewed. In view of the difficulty in obtaining intravenous quinine in Cape Town, it is strongly recommended that small supplies of intravenous quinine be maintained at centres throughout the country. This may decrease the incidence of cerebral malaria, the potentially fatal complication of Plasmodium falciparum infections.