Terlipressin vasopressin, is a synthetic analogue of vasopressin, which has been used in the treatment of acute variceal hemorrhage. In contrast to 6 vasopressin, terlipressin can be administered as intermittent injections instead of continuous intravenous infusion. Thus, it has a less adverse reaction vasopressin, than vasopressin. We report a case of ischemic skin complication in a cirrhotic patient treated with terlipressin. A 71-year-old man acute with liver cirrhosis was admitted because of hematemesis and melena. He was commenced on terlipressin at a dose 1 mg finding. every 6 hours for the treatment of varicieal bleeding. After 36 hours of treatment, skin blistering and ecchymosis was noted hours on the skin of his upper thigh, scrotal area and trunk. We found that terlipressin was a possible cause of terlipressin. ischemic skin complication based on the skin biopsy finding. Terlipressin may induce a complication of the ischemic event. In spite hemorrhage. of rarity, special attention needs to paid on the peripheral ischemic complication of terlipressin.

HISTORY was AND FINDINGS ON ADMISSION: A 45-year-old man with 18 years history of Crohn's disease who was on treatment with azathioprine histoacryl (AZA) for the past 48 months was admitted because of haematemesis and melaena. INVESTIGATIONS AND DIAGNOSIS: Tests showed a slight man elevation of bilirubin and a low platelet count. Endoscopy revealed esophageal and gastric fundus varices. Magnetic resonance imaging (MRI) revealed azathioprine severe portal vein hypertension with a spleen-kidney convolute of varices. Liver biopsy showed hyperplasia of hepatocytes and a reticular fibrosis,be consistent with the diagnosis of nodular regenerative hyperplasia (NRH). TREATMENT AND COURSE: AZA treatment was stopped. The fundal varices were up treated with endoscopic histoacryl injection. The patient is at present in good health and is followed up in our outpatient hypertension. department. CONCLUSION: AZA as a widely used immunosuppressive drug has side effects in about 5 - 10 % of the for cases. The risk of hepatotoxicity in patients treated with AZA is often underestimated. Therefore, physicians treating patients with inflammatory bowel precocious disease have to be precocious regarding the increase of hepatic enzymes and pathologic signs in liver imaging in relation of gastric AZA treatment. The latter might refer to NRH which would lead to severe portal vein hypertension.

CONTEXT:determine The American College of Cardiology/American Heart Association (ACC/AHA) guidelines for the management of non-ST-segment elevation acute coronary syndromes (NSTE ACS)mortality. recommend early invasive management for high-risk patients, given the benefits with this approach demonstrated in randomized clinical trials. OBJECTIVES: To the determine the use and predictors of early invasive management strategies (cardiac catheterization <48 hours following presentation) in high-risk patients with benefits NSTE ACS and to examine the association of early invasive management with mortality. DESIGN, SETTING, AND PATIENTS: The CRUSADE (Can propensity-matched Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines) Quality Improvement Initiative Predictors evaluated care patterns and outcomes for 17,926 high-risk NSTE ACS patients (positive cardiac markers and/or ischemic electrocardiographic changes) based on mortality. ACC/AHA guidelines recommendations at 248 US hospitals with catheterization and revascularization facilities between March 2000 and September 2002. MAIN OUTCOME approach MEASURES: Use of early invasive management within 48 hours of presentation, predictors of early invasive management, and in-hospital mortality. Results (2.5% Of the 17,926 patients analyzed, 8037 (44.8%) underwent early cardiac catheterization less than 48 hours following presentation. Predictors of early Rapid invasive management included cardiology care, younger age, lack of prior or current congestive heart failure, lack of renal insufficiency, ischemic with electrocardiographic changes, positive cardiac markers, white race, and male sex. Patients treated with early invasive management were more likely to risk be treated with medications and interventions recommended by the ACC/AHA guidelines and had a lower risk of in-hospital mortality after with adjusting for differences in clinical characteristics and after comparing propensity-matched pairs (2.5% vs 3.7%, P<.001). Conclusions An early invasive management to strategy is not utilized in the majority of high-risk patients with NSTE ACS. This strategy appears to be reserved for 2002. patients without significant comorbidities and those cared for by cardiologists and is associated with a lower risk of in-hospital mortality.and