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A Comparison of Lorazepam, Diazepam, and Placebo for Out-of-Hospital Status Epilepticus
Paramedics commonly treat patients with seizures and status epilepticus. This study examined whether administration of lorazepam or diazepam by paramedics was beneficial, as compared with placebo, in adults in whom status epilepticus developed outside the hospital. Both benzodiazepines were safer and more effective than placebo, and lorazepam appeared to be a better treatment than diazepam.
One concern about administering injections of benzodiazepines outside the hospital is that patients may have complications, such as respiratory depression. The finding of a trend toward more complications in the placebo group and better control of seizures in the lorazepam and diazepam groups suggests that emergency-medical-services systems may wish to consider using treatment with benzodiazepines for patients with status epilepticus.
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Preoperative Radiotherapy plus Total Mesorectal Excision for Resectable Rectal Cancer
In this multinational study, more than 1800 patients with rectal cancer underwent total mesorectal excision either alone or after preoperative radiotherapy. Two years after surgery, the local-recurrence rate was 2.4 percent in the group given preoperative radiotherapy and 8.2 percent in the group given surgery alone. Survival was similar in the two groups.
In the United States, rectal cancer causes about 9000 deaths annually. The preferred treatment for resectable tumors is total mesorectal excision, but the rate of recurrence after this complex operation can reach 45 percent. When participating surgeons received special instruction and supervision, the local-recurrence rate was reduced. Preoperative radiotherapy decreased it further.
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Prevention of Recurrent Variceal Bleeding
Patients who have had bleeding from esophageal varices are at high risk for further bleeding. This study of 144 patients with cirrhosis who were hospitalized because of bleeding from esophageal varices compared endoscopic ligation with combined medical treatment (with nadolol and isosorbide mononitrate). The combined medical therapy was more effective than endoscopic ligation for the prevention of recurrent bleeding and was associated with a lower rate of major complications. There was no difference in survival.
After control of acute bleeding has been established, therapy with medications is probably superior to ligation therapy for patients at risk for recurrent bleeding from esophageal varices. The potential benefit seems to be greatest in patients who have a hemodynamic response to therapy, as indicated by a marked reduction in the hepatic venous pressure gradient.
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The Risk of Seizures after Receipt of Whole-Cell Pertussis or MMR Vaccine
This cohort study at four large health maintenance organizations included 340,386 children who received the diphtheria and tetanus toxoids and whole-cell pertussis (DTP) vaccine and 137,457 children who received the measles, mumps, and rubella (MMR) vaccine. Receipt of DTP vaccine was associated with an increased risk of febrile seizures only on the day of vaccination, whereas receipt of MMR vaccine was associated with an increased risk 8 to 14 days later.
These researchers found that about 6 to 9 febrile seizures per 100,000 children are attributable to the receipt of DTP vaccine and about 25 to 34 per 100,000 to MMR vaccine. There was no increase in the risk of developmental disabilities in the children who had vaccine-related febrile seizures. The benefit of the vaccines far outweighs the morbidity from seizures.
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Mortality among Patients Admitted to Hospitals on Weekends as Compared with Weekdays
The level of staffing in hospitals is often lower on weekends than on weekdays, but it is not known whether patients admitted to the hospital on the weekend have an increased risk of death. In this study, involving over 3 million emergency hospitalizations in Ontario, Canada, mortality for all three prespecified serious diseases was higher among patients admitted on a weekend than among those admitted on a weekday.
Patients with some life-threatening medical conditions have higher mortality rates if they are admitted to the hospital on a weekend than if they are admitted on a weekday. Reduced staffing in acute care hospitals on weekends may be a factor, although this study did not examine staffing levels.
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Medical Progress: Gastroesophageal Variceal Hemorrhage
This serious complication of cirrhosis of the liver and portal hypertension accounts for 10 to 30 percent of all cases of upper gastrointestinal bleeding, and about 30 percent of initial episodes are fatal. There have been numerous advances in the primary and secondary prevention of variceal bleeding and in the treatment of active bleeding. This article reviews pharmacologic interventions, such as the use of beta-blockers, nitrates, and octreotide, and procedural interventions, such as endoscopic approaches and transjugular intrahepatic portosystemic shunting.
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