This is Journal Watch, a medical-literature
survey produced by the Massachusetts Medical
Society.
  Twice a week, our physician-editors summarize
important new clinical research from a group
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  Contents copyright 1994, Mass. Medical Society.

Journal Watch Summaries for November 4, 1994

RETHINKING EARLY FLUID RESUSCITATION AFTER TRAUMA.
  N Engl J Med 1994 Oct 27; 331:1105-9.

NATURAL METASTASIS INHIBITOR ISOLATED.
  Cell 1994 Oct 21; 79:315-28.

SMOKING AND MORTALITY: WORSE THAN WE THOUGHT.
  BMJ 1994 Oct 8; 309:901-11.

{*filter*} AND MORTALITY: BETTER THAN WE THOUGHT.
  BMJ 1994 Oct 8; 309:911-8.

TASK FORCE: THE RISKS OF WEIGHT CYCLING ARE UNPROVEN.
  JAMA 1994 Oct 19; 272:1196-202.

PTCA vs. CABG FOR SYMPTOMATIC MULTIVESSEL DISEASE.
  N Engl J Med 1994 Oct 20; 331:1037-43.

REDUCING FEVER AND BACTEREMIA IN GRANULOCYTOPENIC
CANCER PATIENTS.
  JAMA 1994 Oct 19; 272:1183-9.

METHOTREXATE BOOSTS EFFICACY OF MISOPROSTOL FOR
{*filter*}.
  JAMA 1994 Oct 19; 272:1190-5.

{*filter*}S AMONG YOUTHS.
  MMWR 1994 Oct 14; 43:725-7.

RETHINKING EARLY FLUID RESUSCITATION AFTER TRAUMA.
   The standard approach to hypotension after penetrating
trauma is to administer fluids aggressively until internal
bleeding can be controlled surgically. But some animal and
human studies suggest that early, aggressive fluid
resuscitation could be detrimental, perhaps disrupting
thrombi, diluting coagulation factors, or lowering {*filter*}
viscosity.
   To examine this issue, researchers in Houston enrolled
598 {*filter*}s with penetrating torso injuries (mostly gunshots
or stab wounds) and a prehospital systolic BP of 90 mm Hg or
less. Half the patients received rapid infusions of isotonic
crystalloid during prehospital transport and in the
emergency department; the other half did not receive
vigorous infusions until they arrived in the operating room.
   Rates of survival to hospital discharge were 62 percent
in the immediate-fluid resuscitation group and 70 percent in
the delayed-fluid group, a significant difference. Moreover,
among the 238 patients who survived surgery, the immediate-
fluid group had a trend toward more postoperative
complications (30 vs. 23 percent).
   Comment: These results challenge the conventional wisdom
about fluid resuscitation after trauma with hypotension.
However, before these results are translated into routine
practice, the authors and an editorialist suggest further
studies to define more fully the situations in which
immediate fluid resuscitation is harmful. --AS Brett.
   Citation: Bickell WH; et al. Immediate versus delayed fluid
resuscitation for hypotensive patients with penetrating torso injuries.
N Engl J Med 1994 Oct 27; 331:1105-9.
   Citation: Jacobs LM. Timing of fluid resuscitation in trauma.
N Engl J Med 1994 Oct 27; 331:1153-4.

NATURAL METASTASIS INHIBITOR ISOLATED.
   Over 30 years ago, Harvard's Judah Folkman pointed out
that the growth of new {*filter*} vessels (angiogenesis) into a
tumor is a central feature of its ability to grow and
metastasize. Over the years, various natural angiogenesis
factors have been identified, and so have various synthetic
inhibitors of angiogenesis, such as thalidomide (see Proc
Nat Acad Sci USA 1994; 91:4082-5.). Now, Folkman's laboratory
reveals that there is a natural angiogenesis
inhibitor whose production is triggered by the primary
tumor.
   First, the researchers created a mouse model in which
removal of a primary lung tumor led to angiogenesis and
growth of metastases (as occurs after removal of certain
human tumors). Then, they showed that serum and urine from
animals with intact primary tumors contained a factor --
named angiostatin -- that dramatically inhibited
angiogenesis and metastatic tumor growth when infused into
mice whose primary tumors were removed. They next found a
similar angiostatin compound in humans that inhibited
metastatic tumor growth in the mice. Finally, in preliminary
tests, human angiostatin also inhibited the growth of
primary tumors in mice, without apparent toxicity.
   Comment: We can throw the usual caution to the wind:
given the central role of angiogenesis in cancer and other
diseases (such as diabetic retinopathy), the discovery of a
potent, nontoxic natural inhibitor of angiogenesis could be
of the profoundest therapeutic importance. --AL Komaroff.
   Citation: O'Reilly MS; et al. Angiostatin: a novel angiogenesis
inhibitor that mediates the suppression of metastases by a Lewis lung
carcinoma. Cell 1994 Oct 21; 79:315-28.