Nelson W. Barker

Hypercholesteremia and nicotinic acid: A long-term study

Abstract Nicotinic acid, in doses of 1.5 to 6 gm. a day by mouth, has been administered to sixty-six persons with hypercholesteremia. A direct dose-response relationship was demonstrated. Eighty per cent of the fifty-one persons treated for at least one year, whose mean pretreatment value for plasma cholesterol was 327 mg. per 100 ml., had a mean value of less than 250 mg. per 100 ml. for plasma cholesterol during the three month interval of optimal response. The hypocholesteremic effect of nicotinic acid was sustained with continued treatment and was associated with a decrease of fatty acids and of the ratio of cholesterol to phospholipid in the plasma. Although subjective improvement in respect to symptoms of coronary and peripheral arterial insufficiency was noted by many persons during treatment with nicotinic acid, objective evidence of improvement in regard to clinical signs of atherosclerosis was lacking, and death from the complications of atherosclerosis occurred in eleven persons during or after treatment. Side effects, particularly gastrointestinal irritation and cutaneous flushing, abnormal results in tests of hepatic function and carbohydrate tolerance, occurrence of hyperuricemia and, more rarely, of jaundice, have been associated with use of large doses of nicotinic acid. The mechanism by which this substance decreases plasma lipids or causes many of the side effects noted is unknown. The continued careful use of this agent in the investigative treatment of hypercholesteremia is warranted and may ultimately provide insight into the possible value of lowering elevated levels of cholesterol in the blood as a means of treatment or prevention of atherosclerosis.

Dicumarol: Its action, clinical use and effectiveness as an anticoagulant drug

Abstract Dicumarol is a potent and valuable anticoagulant drug. When used properly it appears to prevent intravascular thrombosis in almost all patients. There is considerable and unpredictable variation in sensitivity to dicumarol among different patients. Dosage of dicumarol must be guided by the effect produced in each patient as indicated by the degree and duration of prothrombin deficiency which develops and is indicated by determinations of the concentration of prothrombin in the blood. It is unwise to use dicumarol unless adequate facilities for determining the prothrombin time are available. If the prothrombin is kept between 10 and 30 per cent of normal by administration of dicumarol, thrombosis will almost certainly be prevented and serious bleeding is very unlikely to occur. The action of dicumarol is delayed. When a rapid anticoagulant effect is desired concurrent heparinization is necessary for the first few days. We have found that dicumarol has prevented fatal pulmonary embolism and recurrence or extension of venous thrombosis in patients who have had postoperative nonfatal pulmonary embolism or thrombophlebitis. There is some incomplete evidence to the effect that it will prevent peripheral thrombosis, pulmonary embolism and further coronary thrombosis in patients who have had acute myocardial infarction. Dicumarol with preliminary heparinization is valuable in the treatment of acute arterial occlusion of the extremities. It has also been used safely in patients in whom thrombophlebitis and pulmonary embolism complicated the puerperium and various diseases, in patients with idiopathic recurrent thrombophlebitis and in those with chronic occlusive arterial disease. While statistical confirmation is lacking, it is our impression that in many of these patients thrombosis and embolism have been prevented by administration of dicumarol.

The treatment of occlusive arterial disease of the legs by means of the Sanders vasocillator (Sanders bed)

Abstract The following is an attempt to summarize the value of the Sanders bed in the treatment of occlusive arterial diseases of the extremities, based on the effects observed in the eighty-eight cases. We have found no contraindications to the use of this method of treatment, with the possible exception of the presence of marked infection in association with gangrene. The bed can be used for comparatively short periods, or patients can be kept on it continuously for days or weeks. In comparison with other mechanical methods of treatment of peripheral circulatory diseases, it possesses the advantage of avoiding any constriction of the leg or obstruction to the venous circulation. It can be used in conjunction with vasodilating procedures, such as artificially induced fever, drugs given by mouth, or increased environmental heat. To secure the best effects, it is necessary to vary the position and timing of the cycle in accordance with the needs of the individual patient. This form of treatment produces slight objective improvement in circulation, and slight, but incomplete, vasodilatation. Its most striking therapeutic effect appears to be the immediate relief of pretrophic pain, the pain of ischemic neuritis, and the pain of ulceration and gangrene. Relief of these types of pain is not necessarily maintained when the treatment is discontinued. The bed apparently has minimal, if any, beneficial effects on the pain which causes intermittent claudication. It constitutes a valuable addition to the armamentarium for the treatment of peripheral arterial diseases, but it should not supplant other methods of treatment.