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Classic inotropic agents such as beta-adrenergic agonists and phosphodiesterase III inhibitors have beneficial but transitory hemodynamic effects in patients with acute and chronic heart failure. In this context, the available data suggest that long term inotropic therapy has a negative impact on morbidity and mortality in patients with heart failure. For this reason, these agents are mainly used for the treatment of refractory episodes of decompensation and they are also used as a "bridge" (transplant, revascularization, recovery) or as a palliative measure. We present a revision of the general aspects of inotropes including main published clinical trials and some findings of its combined use with beta blockers. Furthermore, we describe a promising and differential therapeutic approach represented by calcium sensitizer agents (levosimendan).

Recurrence of sarcoidosis following complete remission and after a prolonged time of inactivity is considered a very unusual clinical event. The aim of this study was to investigate the clinical characteristics of a series of patients diagnosed as having recurrent sarcoidosis.Recurrent sarcoidosis was defined as reappearance of the disease following complete spontaneous clinical, radiographic and other markers of activity resolution or following resolution after corticosteroid treatment and maintained for at least during 3 years without therapy. The clinical records of patients diagnosed as having episodes of recurrent sarcoidosis during a period of 28 years at the university hospital of Bellvitge in Barcelona, Spain, were reviewed.Seventeen patients suffering from 24 recurrences were identified. All but one patient were women. The mean follow-up time was 143 +/- 80 months (range: 52 to 282 months). Two patients had 3 recurrences, 3 had 2 and 12 had 1. The disease-free interval without treatment between the time when the disease became inactive after the initial presentation until the first recurrence varied from 10 months to more than 17 years, and the time of inactive disease without therapy between recurrences fluctuated from 23 months to more than 12 years. All the cases but one at onset and 17 at recurrence presented as Löfgren syndrome. At the time of the last control, 14 patients showed complete remission of the disease, one of them under corticosteroid therapy, 2 still had activity because of a recent recurrence, and 1 developed into chronic sarcoidosis.Acute sarcoidosis, and particularly Löfgren's syndrome, may recur many years after complete remission and, in general, still has a good outcome. In consequence, a long-term follow-up is recommended even in patients with inactive disease. This clinical observation strongly suggests that a re-exposure to or reinfection by an extrinsic antigen triggers the new flare-ups of the disease.

The aim of the study was to evaluate palliative decision-making in non- oncological patients who died in an acute care hospital.293 patients64 years old were analyzed. These patients suffered from dementia (46%), end-stage congestive heart failure (31%) and end-stage chronic obstructive pulmonary disease (23%). We evaluated written information about: do not resuscitate (DNR) orders, graduation of therapeutic decisions, information provided to relatives about prognosis, total withdrawal of other drug therapy and provision of terminal care.DNR orders were specified in 37% of cases, graduation of therapeutic decisions in 18% and knowledge of the prognosis by relatives in 57%. Drug withdrawal was carried out in 56% and palliative care in 65% patients.Identification and provision of palliative care, in an acute care hospital, of elderly patients at their last admission prior to death because of non-oncological end-stage diseases must be improved.

The t(14;18)(q32;q21) chromosomal translocation is the hallmark of follicular lymphomas (FL). The translocation induces the overexpression of the Bcl-2 protein and prolongs the survival of clonogenic cells. Tumor cells may acquire additional molecular alterations that may be associated with histologic progression or with chemo-resistance.We analyzed the distribution and association of bcl-6 and p53 mutations in 55 consecutive bcl-2/Jh+ lymphoma samples derived from 43 patients obtained at the time of diagnosis and, in 5 of these patients, during follow-up. A total of 29 bcl-6 point mutations were detected in seventeen patients (40%) associated with major or minor breakpoints of the bcl-2/Jh fusion gene. In seven cases a p53 mutation was detected. Three cases corresponded to FL with the minor breakpoint in the bcl-2 gene and these patients had a favorable clinical evolution, whereas the 4 patients with p53 mutations and the major breakpoint had a bad clinical outcome with morphologic transformation to high-grade lymphoma in three cases. The sequential analysis of 5 patients showed a different timing in the acquisition of mutations: one patient showed bcl-6 and p53 mutations at diagnosis, another patient showed bcl-6 mutations at diagnosis and acquired a p53 mutation later whereas the third patient had a p53 mutation before the appearance of the bcl-6 mutation.We did not find significant differences in survival between patients with FL who showed exclusively bcl-6 mutations and those without bcl-6 mutations, but those patients with a high International Progostic Index score and p53 mutations showed the lowest overall survival (p = 0.002).These findings suggest that bcl-2/Jh lymphomas show molecular heterogeneity and that bcl-6 and p53 mutations may be acquired during the evolution of such lymphomas. Bcl-6 mutations, by themselves, do not seem to be associated with a bad prognosis. Rearrangements at the minor bcl-2 locus may have a different molecular evolution.