Ischemic stroke outcome: racial differences in the trial of danaparoid in acute stroke (TOAST).

OBJECTIVE: To determine racial differences in baseline stroke risk factors and other measures in the Trial of ORG 10172 in Acute Stroke Therapy (TOAST). Differences in these factors could influence response to acute stroke therapy and overall stroke outcome. METHODS: The authors compared baseline demographic, medical, stroke, physical examination, CT, laboratory, and neurologic factors among 292 African-American and 801 white patients who enrolled in the TOAST study. TOAST compared danaparoid (ORG 10172) with placebo among acute ischemic stroke patients who were treated within 24 hours of stroke onset. RESULTS: African-Americans were younger and more frequently had hypertension, diabetes mellitus, congestive heart failure, and prior strokes. In addition, African-Americans had higher mean diastolic blood pressure, more lacunar strokes, and more severe prestroke disability. There were no significant differences between African-Americans and white patients in outcomes at 7 days, overall number of adverse experiences, or occurrence of serious bleeds or hemorrhagic transformations. However, there was a trend toward a higher rate of favorable outcomes in white patients at 7 days. There was no significant difference in very favorable outcome at 3 months between African-American and white patients, but significantly more white patients had favorable outcome at 3 months. CONCLUSION: Although African-Americans possess a number of factors that should predict higher rates of poor stroke outcome after acute therapy, they have the capacity to respond similarly to white patients after acute stroke therapy. Perhaps younger age and presence of lacunar infarction are stronger predictors of good outcomes than was appreciated previously.

Laparoscopic common bile duct exploration: the past, the present, and the future.

BACKGROUND: The advent of laparoscopic cholecystectomy (LC) has created a dilemma for treating patients with known or suspected choledocholithiasis. With rapid technologic growth and experience in laparoscopic skills, many surgeons are now routinely performing laparoscopic common bile duct exploration (LCBDE) and questioning the wisdom of preoperative endoscopic retrograde cholangiography (ERC) with or without endoscopic sphincterotomy. The purpose of this article is to review the current literature on the subject of LCBDE and critically evaluate the clinical results of this emerging technology. METHODS: Medline and Science Citation Index databases were used to search English language articles published on LCBDE since 1989. RESULTS: Transcystic common bile duct exploration has a better clearance rate, and carries less morbidity and mortality compared with laparoscopic choledochotomy. Compared with two-stage ERCP and LC, one-stage LC and LCBDE seems to be associated with a shorter hospital stay, a quicker recovery, less expense, and less morbidity and mortality. CONCLUSIONS: LCBDE is a feasible, safe and effective procedure that carries a low morbidity and mortality and will decrease the need for unnecessary ERC in the future for suspected or proved choledocholithiasis.

Vancomycin anaphylaxis in a patient with vancomycin-induced red man syndrome.

Vancomycin is a powerful glycopeptide antibiotic that is increasingly being used owing to the emergence of highly resistant organisms such as methicillin-resistant Staphylococcus aureus. Although a generally safe medication, administration of vancomycin is not benign, and there have been a number of adverse reactions reported. We present the case of a patient with vancomycin-induced red man syndrome who developed vancomycin anaphylaxis. Our case illustrates that red man syndrome may be a marker for true vancomycin allergy, although it was generally not thought of as so in the past.

Systemic calciphylaxis in a patient with end-stage renal disease and a normal parathyroid hormone level taking erythropoietin intramuscularly.

OBJECTIVE: To describe a patient with systemic calciphylaxis. METHODS: We present a case of a 26-year-old woman with end-stage renal disease taking intramuscular injections of erythropoietin in whom systemic calciphylaxis subsequently developed. Both clinical and laboratory findings are reviewed. RESULTS: In a 26-year-old woman with end-stage renal disease who was taking erythropoietin intramuscularly, multiple, superficial ulcerative lesions developed on both lower extremities. Despite aggressive treatment, new lesions subsequently developed. Laboratory values showed an increased calcium-phosphate product and a normal parathyroid hormone level. A skin biopsy specimen showed necrotic skin and subcutaneous fat with foci of calcification around the vessels, findings that confirmed the diagnosis of calciphylaxis. The patient then underwent subtotal parathyroidectomy and responded with initial improvement; however, her condition later deteriorated, and she died of uncontrolled pulmonary hemorrhage. CONCLUSION: Systemic calciphylaxis is a rare but devastating complication of end-stage renal disease. This condition mimics many different disorders; therefore, a high index of suspicion is essential for early recognition and diagnosis, which is assisted by biopsy specimens of skin lesions. Treatment includes subtotal or total parathyroidectomy in conjunction with autotransplantation, administration of phosphate binders, aggressive treatment with antibiotics, and lowering of the calcium-phosphate product. Even though a successful outcome is possible when this disease is recognized early and treated aggressively, the morbidity and mortality associated with systemic calciphylaxis still remain high.

Enhancing clinical pathway placement.

Soaring health care costs have fueled the immense growth in managed care. To contain these costs, health care organizations have turned to clinical pathways. However, clinical pathways cannot do an effective job if health care personnel are not aware of their existence. The article presents a simple, effective, and efficient method to increase placement of clinical pathways in inpatient medical records.

Rural-urban migration and development in Africa: a case study of Sudan.

PIP: Hassaballa concludes that from colonial times to the present, African workers have been integrated into the capitalist mode of production as producers, while they actually remain outside this system in their roles as consumers. As long as African workers are consumers they are not controlling what they produce. In a system in which large segments of the population are transformed into consumers who own no means of production, workers must accept whatever wages offered so they may pay for the imported goods flooding the market. This cheap labor and the continuous excess of profits and economic surplus contributes to the underdevelopment of Third World countries. At the same time, it develops the central, or core, countries. The developing countries must break this vicious circle somehow; foreign investment, aid, or loans are not the answer. Hassaballa feels that only domestic savings can lead a country to integrated development, to serve the masses and to cater to the masses, interests and aspirations.^ieng