Showing papers by "Leicester General Hospital published in 1991"

Metabolic acidosis and skeletal muscle adaptation to low protein diets in chronic uremia.

Abstract: To maintain nitrogen equilibrium when prescribed a low protein diet (LPD), metabolic adaptations occur involving a reduction protein turnover, principally decreased muscle protein degradation. Studies suggest that in patients with chronic renal failure (CRF) uncomplicated by metabolic acidosis (MA), these adaptive responses are intact. Because MA stimulates muscle proteolysis, this study examined the hypothesis that in CRF complicated by MA, the adaptation to LPD may be impaired, inducing a nitrogen wasting state. Six adults with CRF (mean GFR: 12.8 +/- 1.5 ml/min) and MA (mean serum bicarbonate: 17.0 +/- 1.0 mM/liter) receiving an unrestricted diet (protein intake: 1.2 g/kg body wt/day) were converted to an isocaloric LPD (protein: 0.6 g/kg body wt/day). Two weeks later total urinary nitrogen losses decreased, but skeletal muscle protein catabolism (SMPC), assessed from the urinary 3-methyl histidine:creatinine ratio, increased, demonstrating impairment in the adaptive down-regulation of SMPC. The LPD was continued for a further two weeks and MA was corrected with oral sodium bicarbonate (mean serum bicarbonate: 24.3 +/- 1.2 mM/liter). Correcting MA decreased SMPC to a level below that measured prior to protein restriction. The decreased SMPC was paralleled by further decreases in urinary nitrogen losses, confirming that MA impaired nitrogen utilization. It is concluded that MA can override the expected metabolic adaptive response to a LPD. The associated impairment of nitrogen utilization not only diminishes the efficacy of the diet, but also accelerates the loss of lean body mass.

The Prevalence of Diabetes in Elderly People

Abstract: The prevalence of diabetes mellitus was investigated in a sample of people aged 65 to 85 years, using a modified oral glucose tolerance test and 1985 WHO criteria. Of the sample of 861, 52 had previously been diagnosed diabetic; 583 consented to be tested and 19 were diabetic. The prevalence of previously diagnosed diabetes was 6.0 (95% CI 4.3 to 8.1)%, and the prevalence of previously undiagnosed diabetes was 3.3 (95% CI 2.0 to 5.0)%. The high prevalence of previously diagnosed diabetes might be due to the longstanding community diabetes care in the area studied

The management of impotence in diabetic men by vacuum tumescence therapy.

Abstract: The treatment of impotence in diabetic men with vacuum tumescence therapy was studied in a specialist clinic. Of 54 diabetic men referred with impotence, seven declined treatment, three chose self-injection with papaverine, and 44 chose vacuum therapy. Patients underwent autonomic function testing (heart rate response to respiration), measurement of penile blood flow (duplex Doppler scanning), and estimation of serum prolactin and testosterone levels. After 2 months, 33 men (75%) were able to have satisfactory intercourse using vacuum therapy. Three others could produce a satisfactory erection with vacuum therapy but their partners found it unacceptable. Eight men (18%) were unable to have satisfactory intercourse; six of these were later treated by self-injection. The median frequency of use of vacuum therapy was 5.5 (1-26) times a month. Outcome was independent of penile blood flow, autonomic function or endocrine status. Impotent diabetic men should be given counselling and offered a choice of the available treatments. Vacuum tumescence therapy is an effective and simple treatment which requires little investigation.

Skeletal muscle degradation and nitrogen wasting in rats with chronic metabolic acidosis.

Abstract: 1. Chronic metabolic acidosis is associated with impaired growth and negative nitrogen balance, suggesting that it promotes endogenous protein catabolism. 2. Skeletal muscle is the major repository of body protein and is a potential target for stimuli of protein catabolism. 3. This study in vivo examines the effects of chronic metabolic acidosis on the relationship between growth, nitrogen disposal and skeletal muscle catabolism in the rat. 4. Growth, nitrogen utilization and acquisition of body mass were significantly impaired in acidotic animals compared with pair-fed controls. 5. Total nitrogen excretion was significantly increased in acidotic rats despite decreased urea production. The time course of this response to acidosis was synchronous with that of accelerated protein catabolism in skeletal muscle. 6. It is proposed that metabolic acidosis impairs growth by stimulating skeletal muscle protein catabolism. It is suggested that this forms part of a co-ordinated multi-organ homoeostatic response to acidosis, skeletal muscle and down-regulated urea production supplying the nitrogen required for renal ammoniagenesis.

Delusion: what did Jaspers really say?

Abstract: “Since time immemorial, delusion has been taken as the basic characteristic of madness To be mad was to be deluded” (Jaspers, 1963, p 93)

Urological complications of renal transplantation: the impact of double J ureteric stents.

Abstract: In a 10 year series of 350 consecutive renal transplant operations, the overall urological complication rate was 7.7%. During this period double J stents were introduced and were used either in the treatment of actual urological complications or as a prophylactic measure to protect ureters which had been damaged at retrieval. A total of 34 double J stents were used in 33 patients. The indications were: ureteric obstruction (n = 13), urinary leak (n = 5), short transplant ureter anastomosed using an extravesical ureteroneocystostomy (n = 10) and ureteric injury at the time of organ retrieval (n = 6). Thirty-two double J stents were inserted at open operation and two were inserted by an antegrade method after percutaneous nephrostomy. Improvement in renal function occurred in 16 out of the 18 cases of urological complications. No kidneys were lost and there were no deaths as a direct result of these complications. In a number of cases the insertion of a double J stent was the only treatment, thus eliminating the need for more complex surgery. All 16 patients who had a ureteric stent inserted as a prophylactic measure at the time of transplantation made uncomplicated postoperative recoveries. Urinary tract infection was relatively common (27%) after double J stent insertion, but other complications were rare. In conclusion, double J stents have proved to be a useful adjunct in the management of renal transplant related urological complications.

Circadian variation in the frequency of onset of chest pain in acute myocardial infarction.

Abstract: The time of onset of chest pain was studied prospectively in 1154 consecutive patients admitted to a coronary care unit with myocardial infarction during a five year period. Statistical analysis confirmed a previous finding in a retrospective study of a bimodal frequency distribution with peaks in the time of onset of chest pain between 2330 and 0030 hours and between 0630 and 0830 hours.

The DQw7 allele at the HLA-DQB locus is associated with susceptibility to IgA nephropathy in Caucasians.

Abstract: The DQw7 allele at the HLA-DQB locus is associated with susceptibility to IgA nephropathy in Caucasians. The frequencies of the MHC class II HLA-DR and DQ alleles in 36 Caucasian patients with IgA nephropathy (IgAN) were analyzed by RFLP analysis and allele specific oligonucleotide (ASO) probing of specifically amplified genomic DNA. The class II alleles HLA-DR4 (52.7%) and DR5 (30.5%) were increased in the patient group compared to 1103 UK Caucasoid controls, but these increases were not statistically significant. However, there was a significant increase in the HLA-DQw7 allele frequency (71%) (c = 27.8%, χ 2 = 29.2, P

The role of omentectomy in continuous ambulatory peritoneal dialysis.

Abstract: Long-term survival of the peritoneal catheter is essential for successful CAPD. In our unit, all CAPD catheters are now placed by an open surgical technique, which in some cases has included performing a partial omentectomy. The aim of this study was to assess the influence of omentectomy on CAPD catheter survival. Three hundred consecutive CAPD catheters inserted over a 5-year period were analyzed. Omentectomy was performed in 113 cases (38%). Data relating to a number of potentially significant risk/benefit factors were analyzed using multiple regression analysis (proportional hazards method of Cox). Performing a partial omentectomy at the time of catheter insertion was found to significantly improve CAPD catheter survival (p = 0.0002).

Patients' views on how to run hospital outpatient clinics.

Abstract: To investigate patients' views and expectations when attending outpatient clinics a questionnaire-based study was performed. The questionnaires asked about appointment systems, continuity of care, staff appearance, chaperons and medical students. Patients wanted fixed appointment times, to see the same doctor on successive visits, for the staff to be formally dressed and to have chaperons during examination. The number of medical students should be restricted especially for women patients. Staff should be sensitive to patients' needs.

Inflammatory bowel disease: patients' expectations in the 1990s.

Abstract: A group of 70 patients with inflammatory bowel disease were asked to complete a questionnaire about their disease counselling preferences, 59 replied. Seventy-five per cent wanted further advice about their disease. Of these, 60% wished to receive the advice by discussion with a trained advisor. Seventy-six per cent wanted this person to be a hospital specialist, but 50% would accept advice from a specialty trained nurse. Eighty-six per cent would like this in conjunction with 'same day' telephone advice from a hospital specialist and 85% of patients wish to be taught how to adjust their own therapy. There is an increasingly important role for nurse counsellors in the management of these diseases.

Treatment of Recurrent Urethral Strictures Using Clean I ntermittent Self‐catheterisation

Abstract: The treatment of urethral strictures has been greatly improved by the use of the optical urethrotome. However, there remains a group of patients with recurrent strictures for whom the alternatives remain long-term dilatation/urethrotomy or urethroplasty. Over the last 3 years we have treated 65 such patients using clean intermittent self-catheterisation as a method of self-dilatation. This has resulted in a dramatic decrease in the number of operations performed on these patients, with no significant reduction in urinary flow rate over an average follow-up period of 20 months. The method offers the possibility of long-term cure and should be offered to all all such patients, reducing still further the number of patients who require urethroplasty.

Cholesterol Feeding Following Unilateral Nephrectomy in the Rat Leads to Glomerular Hypertrophy

Abstract: Experimental glomerulosclerosis is associated with hyperlipidaemia and the deposition of lipid in glomeruli. Glomerulosclerosis is typically preceded by glomerular hypertrophy. To investigate a possible pathogenic role of lipids in glomerulosclerosis, glomerular structure and cellular composition were studied in rats fed either a control diet or one supplemented with 4% cholesterol and 1% cholic acid for 21 weeks following unilateral nephrectomy. On the cholesterol diet there were significant increases in glomerular cross-sectional area (13.11 +/- 0.39 x 10(3) vs. 11.13 +/- 0.44 x 10(3) mu 2, p less than 0.01) and mesangial area (1.81 +/- 0.07 x 10(3) vs. 1.50 +/- 0.08 x 10(3) mu 2, p less than 0.02). These changes were significantly correlated with proteinuria, which was significantly greater on the cholesterol diet (mean area under curve for duration of diet = 3.11 +/- 0.38 vs. 1.42 +/- 0.35 g, p less than 0.02). There was a significant increase in glomerular leukocytes on the cholesterol diet (4.10 +/- 0.44 vs 2.86 +/- 0.25 OX-1 positive cells/10(4) mu 2, p less than 0.05). Mesangial foam cells, derived from macrophages, were associated with adhesions to Bowman's capsule. These results demonstrate that hyperlipidaemia exacerbates the development of glomerular hypertrophy and that this may be mediated by factors released during the phagocytosis of lipoprotein deposits by macrophages.

Plasma erythropoietin levels and acquired cystic disease of the kidney in patients receiving regular haemodialysis treatment

Abstract: Acquired cystic disease of the kidney (ACDK) in patients with end-stage renal failure can be associated with development of polycythaemia. The relationship between plasma erythropoietin levels and ACDK in 17 patients on long-term haemodialysis treatment was studied. There was a significantly higher level of plasma erythropoietin in patients with multiple renal cysts than in those patients with less than five cysts or no cysts. Haemoglobin tended to be higher in the ACDK group, but the difference was not significant. These results indicate that the development of renal cysts results in increased secretion of erythropoietin.

Why are impotent diabetic men not being treated

Abstract: The prevalence of impotence among a group of 158 consecutive men attending a diabetic clinic was studied by questionnaire. The frequency of reporting of impotence and the advice and treatment patients had received were determined. The prevalence of impotence was 36.7%. Forty-nine of the impotent men (84%) wanted treatment; 21 had never asked for medical advice because of embarrassment, ignorance of availability of treatments or a belief that impotence was normal at their age. Twenty-eight had consulted a doctor, nine presented at the diabetic clinic and were treated successfully; 19 consulted their general practitioner alone and were advised incorrectly. Most impotent diabetic men want treatment but do not ask for help or are advised incorrectly. Both patients and doctors need to be better informed about the management of impotence in diabetes.

Possible impairment of the sympathetic nervous system response to postprandial hypotension in elderly hypertensive patients

Abstract: In a randomised, single-blind, cross-over study, the effects of a high carbohydrate meal or 'no meal' on BP, pulse rate, blood glucose, plasma insulin and catecholamine levels were assessed in eight fit, untreated, elderly hypertensive subjects. A significantly greater fall in supine (P = 0.006) and erect (P = 0.03) systolic blood pressure (SBP) occurred post-meal compared with the no meal phase. The maximum postprandial fall in supine SBP (-24 mmHg, 95% CI -16 to -32 mmHg) occurred at 60 minutes and was associated with a significant rise in supine pulse rate. No overall difference in diastolic BP was seen between the two phases and orthostatic control of BP was maintained. Blood glucose and plasma insulin levels rose after the meal but plasma noradrenaline levels were unchanged during both phases. Thus in these elderly hypertensive subjects the postprandial fall in SBP was not associated with an overall increase in sympathetic nervous system (SNS) activity (as gauged by plasma noradrenaline levels), unlike the findings previously reported in normotensive elderly and young subjects. These changes in BP and the possible impairment of the SNS response to postprandial hypotension should be considered when assessing the BP control, particularly after therapeutic intervention, in elderly hypertensive patients.

Care of women with puerperal psychiatric disorders in England and Wales.

Abstract: We present a survey of the current provision of psychiatric mother and baby inpatient facilities among the health authorities of England and Wales

Information Requirements and Sedation Preferences of Patients Undergoing Endoscopy of the Upper Gastrointestinal Tract

Abstract: Patients' attitudes to sedation and their information needs before undergoing endoscopy were investigated using a questionnaire. One hundred and two patients completed the study; 32 had undergone endoscopy before. Sixty-six (94 %) of the new patients and all follow-up patients knew why they were undergoing the procedure; 65 (93 %) new and 28 (88 %) follow-up patients understood how the procedure was carried out. Forty-one percent of the new and 25 % of the follow-up patients wanted an information booklet about their disease and its management. Most patients chose to be sedated during the endoscopy. The proportion wishing to be sedated did not differ significantly between the new and follow-up patient groups. Sedation and information should be offered to all patients undergoing endoscopy.

Inflammatory bowel disease in Indian migrants in Fiji.

Abstract: A pilot study to estimate the incidence of inflammatory bowel disease in Fiji is reported. Data from 1985 and 1986 for Indian migrants, Melanesians and other groups show the incidence of ulcerative colitis was 1.7/10(5)/year, in Indians, 0.15/10(5)/year in Melanesians and 1.4/10(5)/year in others. The minimum incidence of Crohn's disease is 0.14/10(5)/year. Indians are at significantly greater risk than Melanesians of developing ulcerative colitis.

Factors Determining the Acute Pressor Response to Alcohol

Abstract: The pressor response to acute alcohol loading is variable and the factors influencing it are unknown. Data from 34 standardized alcohol loading studies were analysed to try to identify any factor(s) that might predict the pressor response to oral alcohol. The maximum blood pressure rise following an acute alcohol load was assessed for each subject over a 4 hour period. Age, weight, recent alcohol intake, baseline blood pressure, pulse rate and serum gamma glutamyl transferase levels were entered, as the independent variables, into a multiple linear regression analysis with the maximum blood pressure response as the dependent variable. Alcohol consumption in the week prior to the study predicted the systolic blood pressure pressor response to acute alcohol loading. None of the independent variables entered had any predictive value for diastolic or mean arterial blood pressure response.

Total knee arthroplasty in the presence of active tuberculosis

Abstract: The ten-year result of a knee arthroplasty performed in the presence of active tuberculous infection of the knee is presented. This case suggests that it is feasible to obtain a satisfactory outcome in these circumstances provided the diagnosis is established and adequate postoperative antituberculosis chemotherapy is given. Case report. In September 1980 a 67-year-old man with generalised rheumatoid arthritis underwent a Cintor

Pharmacokinetics of theophylline and its metabolites during acute renal failure. A case report.

Abstract: After unsuccessful therapy with salbutamol syrup and inhaled terbutaline a 3-year-old boy with an acute exacerbation of asthma was treated with nebulised salbutamol (albuterol), intravenous aminophylline and hydrocortisone. His condition continued to deteriorate and he required artificial ventilation. Subsequently, he became anuric, with liver dysfunction, nonspecific encephalopathy and limb tremor. Peritoneal dialysis was started. Plasma theophylline concentrations were monitored and maintained in the therapeutic or subtherapeutic range. Despite this, he was hyper-reflexic with limb tremor. Excessively high plasma concentrations of the principal theophylline metabolite, 1,3-dimethyluric acid, were found [maximum 92 mg/L (470 µmol/L)], which cleared only with the return of normal renal function. Plasma concentration monitoring of drugs other than theophylline was not performed. After the patient recovered, a pharmacokinetic study demonstrated that normal methylxanthine metabolism was re-established. Pharmacokinetic analysis indicated that the undue accumulation of the metabolites was a result of an inability to clear these compounds. Thus, pharmacologically and toxicologically active metabolites of theophylline may accumulate in anuric patients on peritoneal dialysis, producing clinical symptoms of toxicity. However, in the present case the possible role of metabolites of other drugs cannot be definitely excluded.

Effects of carbohydrate type on postprandial blood pressure, neuroendocrine and gastrointestinal hormone changes in the elderly.

Abstract: Previous studies have demonstrated that blood pressure falls postprandially in fit elderly subjects, the greatest changes occurring after meals with a high carbohydrate content. To evaluate the influence of the type of carbohydrate on postprandial blood pressure, the effects of equivalent energy content (2.4 MJ) high complex (starch) and high simple (monosaccharide) carbohydrate meals were studied in seven healthy elderly subjects. Blood pressure, heart rate, autonomic function, plasma catecholamines, insulin and neurotensin levels were measured pre- and postprandially. Greater falls in supine and erect systolic blood pressure occurred after the high simple than the high complex carbohydrate meal (p < 0.05). No differences were found in supine or erect diastolic blood pressure, heart rate or in any of the biochemical parameters measured between the meal types. It is concluded that a simple carbohydrate meal results in a greater postprandial fall in blood pressure than an equivalent energy complex carbohydrate meal in the elderly, although the mechanisms for these changes are unknown.

Management of myocardial infarction in the elderly: admission and outcome on a coronary care unit.

Abstract: A data base of 1,511 patients admitted to a single Coronary Care Unit was analysed to examine the potential impact of thrombolytic therapy in elderly patients with myocardial infarction. Age was confirmed as a highly significant prognostic factor, and cost utility analysis showed that the cost of thrombolytic therapy with streptokinase in the elderly was lower per quality adjusted life year than in younger patients. However, median delay time of admission from onset of symptoms was significantly greater in this age-group, suggesting a need for a greater awareness of the benefits of thrombolytic therapy in elderly people.