Panagiota V. Caralis

The effects of high-dose corticosteroids in patients with septic shock. A prospective, controlled study.

To determine whether corticosteroids are efficacious in severe septic shock, we conducted a prospective study of 59 patients randomly assigned to a methylprednisolone, dexamethasone, or control group. Patients were treated 17.5 +/- 5.4 hours (mean +/- S.E.M.) after the onset of shock, and 55 patients required vasopressor agents. Early in the hospital course, reversal of shock was more likely in patients who received corticosteroids than in those who did not. Four (19 per cent) of 21 methylprednisolone-treated, 7 (32 per cent) of 22 dexamethasone-treated, and none of 16 control patients had reversal of shock 24 hours after drug administration (corticosteroid groups vs. control group, P less than 0.05). Patients treated with corticosteroids within four hours after the onset of shock had a higher incidence of shock reversal (P less than 0.05). At 133 hours after drug administration, 17 (40 per cent) of 43 corticosteroid-treated patients had died, and 11 (69 per cent) of 16 control patients had died (P less than 0.05). However, these differences in reversal of shock and survival disappeared later in the course. Overall, 16 (76 per cent) of 21 patients receiving methylprednisolone, 17 (77 per cent) of 22 patients receiving dexamethasone, and 11 (69 per cent) of 16 controls in the hospital died. We conclude that corticosteroids do not improve the overall survival of patients with severe, late septic shock but may be helpful early in the course and in certain subgroups of patients.

Exercise intervention attenuates emotional distress and natural killer cell decrements following notification of positive serologic status for HIV-1

The impact of aerobic exercise training as a buffer of the affective distress and immune decrements which accompany the notification of HIV-1 antibody status in an AIDS risk group was studied. Fifty asymptomatic gay males with a pretraining fitness level of average or below (determined by predicted VO2 max) were randomly assigned to either an aerobic exercise training program or a no-contact control condition. After five weeks of training, at a point 72 hours before serostatus notification, psychometric, fitness and immunologic data were collected on all subjects. Psychometric and immunologic measures were again collected one-week postnotification. Seropositive controls showed significant increases in anxiety and depression, as well as decrements in natural killer cell number following notification whereas, seropositive exercisers showed no similar changes and in fact, resembled both seronegative groups. These findings suggest that concurrent changes in some affective and immunologic measures in response to an acute stressor might be attenuated by an experimentally manipulated aerobic exercise training intervention.

Attitudes of medical students, housestaff, and faculty physicians toward euthanasia and termination of life-sustaining treatment

ObjectivesMedical decisions concerning the prolongation of life, the right to die, and euthanasia are among the most extensively discussed decisions within medicine and law today. The responses of 360 physicians, housestaff, and medical students to a questionnaire were analyzed to identify attitudes toward these issues. DesignCase vignettes were utilized to simulate the clinical context within which to survey decisions regarding whether or not to allow and assist patients requesting to die. Measurements and Main ResultsThe majority of respondents (76%) consider withholding and withdrawing life-support therapy consistent with passive euthanasia. Passive euthanasia is more acceptable to the majority of the respondents (77%) and all three groups (physicians, housestaff, and students) are similarly more disturbed by active euthanasia. Of all respondents, 51% would accede to the patients wishes when lifesaving treatment is refused, but only 16% would do so when a patient requested assistance in dying. Despite the fact that a majority (68%) agree that there is a moral justification for assisting patients to die and feel “understanding” for a physician who assists a patient in dying, only 6% of those persons surveyed were willing to deliberately terminate the life of a patient by administering medication to cause respiratory arrest, and only 1.1% of those persons surveyed were willing to do so to cause cardiac arrest.In the case vignettes, the faculty placed their highest value on disease-based information as strongly determinative to their decisions, while students and housestaff preferred quality-of-life factors. Respondents uniformly found it easier to perform “passive” actions; they were more willing to perform “active” actions in case vignettes where patients had terminal illnesses. ConclusionsSocially and legally created “shades of gray” have blurred the distinctions between withholding or withdrawing therapies and euthanasia and have left physicians without guidelines. Health ethics education should focus on case-based teaching and on reducing the uncertainty at the bedside. (Crit Care Med 1992; 20:683–690)

Complement activation in septic shock patients.

To evaluate the status of the complement system and to determine the effects of corticosteroids on complement component levels in septic shock, C3, C4, and Factor B were measured in 42 patients with severe late septic shock. Serum levels of C4 and Factor B correlated with C3 levels (r = 0.48 and 0.64, respectively; p < .01) in patients in shock for more than 4 h, but only Factor B correlated with C3 (r = 0.85; p < .01) in patients in shock for 4 h or less. C3 and Factor B levels were significantly (p < .05) lower in patients who died (12,174 ± 1,524 CH50 U/ml and 14 ± 1 mg/dl, respectively) than in patients who survived (18,418 ± 2,833 CH50 U/ml and 21 ±2 mg/dl, respectively). Corticosteroids did not alter complement component levels.The alternative pathway appears to be activated early in septic shock, whereas the classical pathway is activated later. C3 and Factor B levels may predict survival of patients in septic shock. In this study, corticosteroids did not change the complement component levels of patients in late severe septic shock.

Hypertension in the Hispanic-American population

According to the 1988 census, there are 19.4 million Hispanics living in the United States. They represent 8.1 percent of the nations population, and that percentage is expected to rise significantly in the next 25 years. Demographic projections indicate that Hispanics will become the largest minority group in the United States by the year 2000, yet they remain a seriously understudied population. This article examines available clinical data, epidemiologic findings, and sociologic observations regarding the incidence of hypertension in this minority group and summarizes what is known about the detection, evaluation, treatment, and control of high blood pressure in Hispanics. In addition, the preliminary results of a multi-center, placebo-controlled trial comparing the efficacy and safety of a potassium-sparing diuretic (Dyazide; Smith Kline & French Laboratories) in Hispanic-American patients with mild-to-moderate hypertension are presented.