Showing papers by "Northwick Park Hospital published in 2003"

The exercise-induced growth hormone response in athletes.

Abstract: Human growth hormone (hGH) is secreted in a pulsatile fashion, generally following a circadian rhythm. A number of physiological stimuli can initiate hGH secretion, the most powerful, non-pharmacological of which are sleep and exercise. hGH has many varied roles throughout life, from growth itself, including the turnover of muscle, bone and collagen, to the regulation of selective aspects of metabolic function including increased fat metabolism and the maintenance of a healthier body composition in later life.

A survey of chronic noncancer pain patients prescribed opioid analgesics.

Abstract: Objectives. Opioid analgesic drugs are sometimes advocated for chronic noncancer pain (CNCP). However, due to the paucity of studies assessing problematic opioid drug use in this population, evidence for such is inconclusive, and this issue remains controversial. This survey assessed problematic drug use among CNCP patients. Patients/Setting. Patients (N=104) prescribed opioids (mean duration of treatment 14.1 months) for severe CNCP at a pain clinic within a National Health Service hospital in London, United Kingdom. Design. A review of pain clinic records to identify CNCP patients who had been prescribed opioids and subsequent assessment of those patients for problematic drug use using a substance use questionnaire. Results. A total of 90 (86.5%) patients reported stopping opioid therapy at some point and, of these, 59 (65%) had ceased opioid therapy permanently. Of those patients who stopped opioids, 13 reported opioid withdrawal symptoms, two with severe and two with very severe symptoms. However, 72.5% of all patients derived benefit from opioids, although 77% of all patients reported opioid side effects. The addiction rate was 2.8%. Conclusion. These findings indicate that opioid therapy for CNCP does not necessarily lead to problematic drug use. Some problematic side effects are likely to be surmountable through appropriate prescribing. Further research is required into the long-term use of opioids in CNCP.

The prevalence of myocarditis and skeletal muscle injury during acute viral infection in adults: measurement of cardiac troponins I and T in 152 patients with acute influenza infection.

Abstract: Background Current literature suggests that myocarditis is a common event during influenza infection, occurring with a prevalence rate of up to 10%, but these studies have relied on relatively nonspecific techniques of varying sensitivities for the detection of myocyte injury. Using measurement of cardiac troponins I and T, this study sought to determine the prevalence of myocarditis in a large unselected cohort of patients with serologically confirmed acute influenza infection. Methods A total of 152 subjects were recruited from 60 primary care and university health centers. Serial creatine kinase (CK), CK-MB, and cardiac troponin I and T measurements were taken on days 1, 6, and 21 following presentation. Results Creatine kinase levels were elevated (mean ± SD levels, 830 ± 1531 U/L; range, 181-7280 U/L) during the collection period in 18 patients (12%). Twelve (67%) of these had elevated CK levels on day 1 of presentation. Overall CK-MB levels were higher than 25 U/L in 3 patients with elevated CK readings but in no patient was the CK-MB fraction greater than 6%. Cardiac troponin I and T levels were not raised in any of the patients. Conclusions Using more sensitive and specific markers of myocardial injury, we demonstrate that the prevalence of myocarditis during acute influenza infection is substantially lower than previously thought, whereas skeletal muscle injury is relatively common. Although we were unable to conclude that no myocardial inflammation was present, it seems likely that this complication is rare.

Does the human heart fatigue subsequent to prolonged exercise

Abstract: A reduction in left ventricular systolic and diastolic function subsequent to prolonged exercise in healthy humans, often called exercise-induced cardiac fatigue (EICF), has recently been reported in the literature. However, our current understanding of the exact nature and magnitude of EICF is limited. To date, there is no consensus as to the clinical relevance of such findings and whether such alterations in function are likely to impact upon performance. Much of the existing literature has employed field-based competitions. Whilst ecologically valid, this approach has made it difficult to control many factors such as the duration and intensity of effort, fitness and training status of subjects and environmental conditions. The impact of such variables on EICF has not been fully evaluated and is worthy of further research. To date, most EICF studies have been descriptive, with limited success in elucidating mechanisms. To this end, the assessment of humoral markers of cardiac myocyte or membrane disruption has produced contradictory findings partially due to controversy over the validity of specific assays. It is, therefore, important that future research utilises reliable and valid biochemical techniques to address these aetiological factors as well as develop work on other potential contributors to EICF such as elevated free fatty acid concentrations, free radicals and β-adrenoceptor down-regulation. In summary, whilst some descriptive evidence of EICF is available, there are large gaps in our knowledge of what specific factors related to exercise might facilitate functional changes. These topics present interesting but complex challenges to future research in this field.

The heart failure revascularisation trial (HEART): Rationale, design and methodology

Abstract: Background: Most patients with heart failure due to left ventricular systolic dysfunction (LVSD) secondary to coronary artery disease (CAD) have evidence of myocardium in jeopardy (reversible ischaemia and/or stunning hibernation). It is not known whether revascularisation in such cases is safe or beneficial. Aims To determine whether revascularisation will improve the survival of patients with LVSD and heart failure secondary to CAD and myocardium in jeopardy. Methods: This is a randomised controlled trial comparing revascularisation or not, in addition to optimal medical therapy with ACE inhibitors, beta-blockers, aldosterone antagonists and an anti-thrombotic agent. Patients must have heart failure requiring treatment with diuretics, a left ventricular ejection fraction <35% and evidence of coronary disease. Myocardial viability and ischaemia are assessed by a broad range of techniques including stress echocardiography and nuclear imaging. All imaging tests are reviewed in core laboratories to ensure uniform reporting. Any conventional revascularisation technique is permitted. The primary outcome measure is all cause mortality. Symptoms, quality of life and health economic issues will also be explored. Assuming an annual mortality of 10% in the control group and allowing for substantial cross-over rates, a study of 800 patients followed for 5 years has 80% power with an alpha of 0.05 (two-sided) to show a 25% reduction in mortality with revascularisation. Results: At the time of writing 180 patients have been screened for inclusion, 111 have consented to participate and 70 have been randomised. The results of viability testing are awaited in 22 patients. Twenty-six patients had been investigated for myocardial viability and/or by angiography prior to consent, as part of the routine practice in that cardiology department. Of 68 patients who have completed assessment only after consent, 47 (69%) were included. The principal reason for drop-out between consent and randomisation was lack of evidence of myocardial ischaemia or hibernation. Conclusion: The HEART trial will help to determine whether investigation of myocardial ischaemia and/or viability with a view to revascularisation should become part of the routine care of patients with heart failure due to LVSD and CAD.

Gadobenate dimeglumine-enhanced MRI of the breast: analysis of dose response and comparison with gadopentetate dimeglumine.

Abstract: OBJECTIVE: The purpose of this study was to evaluate the clinical efficacy and dose response relationship of three doses of gadobenate dimeglumine for MRI of the breast and to compare the results with those obtained after a dose of 0.1 mmol/kg of body weight of gadopentetate dimeglumine. SUBJECTS AND METHODS. Gadobenate dimeglumine at 0.05, 0.1, or 0.2 mmol/kg of body weight or gadopentetate dimeglumine at 0.1 mmol/kg of body weight was administered by IV bolus injection to 189 patients with known or suspected breast cancer. Coronal three-dimensional T1-weighted gradient-echo images were acquired before and at 0, 2, 4, 6, and 8 min after the administration of the dose. Images were evaluated for lesion presence, location, size, morphology, enhancement pattern, conspicuity, and type. Lesion signal intensity-time curves were acquired, and lesion matching with on-site final diagnosis was performed. A determination of global lesion detection from unenhanced to contrast-enhanced and combined images was performed, and evaluations were made of the diagnostic accuracy for lesion detection and characterization. A full safety evaluation was conducted. RESULTS: Significant dose-related increases in global lesion detection were noted for patients who received gadobenate dimeglumine (p < 0.04, all evaluations). The sensitivity for detection was comparable for 0.1 and 0.2 mmol/kg of gadobenate dimeglumine, and specificity was highest with the 0.1 mmol/kg dose. Higher detection scores and higher sensitivity values for lesion characterization were found for 0.1 mmol/kg of gadobenate dimeglumine compared with 0.1 mmol/kg of gadopentetate dimeglumine, although more variable specificity values were obtained. No differences in safety were observed, and no serious adverse events were reported. CONCLUSION: Gadobenate dimeglumine is a capable diagnostic agent for MRI of the breast. Although preliminary, our results suggest that 0.1 mmol/kg of gadobenate dimeglumine may offer advantages over doses of 0.05 and 0.2 mmol/kg of gadobenate dimeglumine and 0.1 mmol/kg of gadopentetate dimeglumine for breast lesion detection and characterization.

Quantification and cytokine production of circulating lymphoid and myeloid cells in acute myelogenous leukaemia.

Abstract: A simple assay was developed to assess the potential of patients with acute myelogenous leukaemia (AML) to respond to immunotherapy. Lymphocytes, monocytes and leukaemic blasts with their corresponding intracellular cytokine profiles were evaluated by four-colour flow cytometry. In 50 μl samples of whole blood, surface labelling for CD45, CD8 and CD3 was used for cell identification prior to intracellular staining for interleukin (IL)-4, IL-10, IL-12 and interferon (IFN)-γ. Absolute numbers of CD8+ and CD8− (putative CD4+) T-cells, NK cells (CD8+/CD3−) and monocytes were determined by reference to a fixed number of added fluorescent beads. The absolute numbers of CD8− and CD8+ T-cells in the blood of patients with AML were similar to those of normal controls. More of the lymphocytes in the blood of leukaemic patients spontaneously produced cytokines compared with those of controls. Furthermore, primary AML blasts secreted predominantly IFN-γ. After recovery from chemotherapy, lymphocyte counts tended to be lower than in normals and reduction of NK cells reached significance after the second chemotherapy (P=0.01). A prominent CD8lo/CD3lo-int lymphocyte subset appeared after recovery in some patients. This laboratory application of the study of cell subsets and intracellular cytokines in patients undergoing treatment may be helpful in monitoring immunological responses in AML.

Serum levels of low molecular weight advanced glycation end products in diabetic subjects

Abstract: Aims One of the principal theories of the development of diabetic complications proposes that increased levels of advanced glycation end products (AGE) are formed in diabetes by prolonged exposure of proteins, lipids and nucleotides to glucose. Such AGEs may contribute to the development of diabetic complications by a number of mechanisms. Circulating AGEs can be detected in serum, and in the present study, we analysed the clinical correlates of circulating serum low molecular weight AGE (LMW-AGE). Methods Serum LMW-AGE was measured in 106 non-diabetic and 499 diabetic subjects using fluorescence spectroscopy. Results were calibrated against an in-house AGE albumin preparation, and expressed as absolute fluorescence units (AFU). Results Serum LMW-AGE values were significantly higher in diabetic than non-diabetic subjects [median 7.5 (range 0–595.5) vs. 5.3 (1.0–15.5) AFU, P < 0.01]. In the normal subjects, there were significant correlations between serum LMW-AGE and age (r = 0.42, P < 0.01) and serum creatinine (r = 0.39, P < 0.01). In the diabetic patients, serum LMW-AGE correlated significantly with age (r = 0.315, P < 0.01), systolic blood pressure (r = 0.141, P = 0.002), serum creatinine (r = 0.449, P < 0.01) and urinary albumin/creatinine ratio (ACR) (r = 0.265, P < 0.01). There was no correlation between serum LMW-AGE and HbA1c. On regression analysis, with serum LMW-AGE as the dependent variable, serum creatinine emerged as the most significant factor (t = 8.1, P < 0.01), followed by age (t = 4.0, P < 0.01) and ACR (t = 2.9, P = 0.004). There was no significant difference in serum LMW-AGE between those with and without retinopathy or in those with vascular disease. Conclusions We conclude that circulating LMW-AGEs are increased in diabetic subjects. The major determinant appears to be renal dysfunction in the form of raised albumin/creatinine ratio or creatinine. There was no association with other markers of vascular disease or presence of diabetic complications. Diabet. Med. 20, 575–579 (2003)

Usefulness of myocardial contrast echocardiography using low-power continuous imaging early after acute myocardial infarction to predict late functional left ventricular recovery.

Abstract: Microvascular perfusion is a prerequisite for ensuring viability early after acute myocardial infarction (AMI) For adequate assessment of myocardial perfusion, both myocardial blood volume and velocity need to be evaluated Due to its high frame rate, low-power continuous myocardial contrast echocardiography (MCE) can rapidly assess these parameters of myocardial perfusion We hypothesized that the technique can accurately differentiate necrotic from viable myocardium after reperfusion therapy in AMI Accordingly, 50 patients underwent low-power continuous MCE using intravenous Optison (Amersham Health, Amersham, Middlesex, United Kingdom) 7 to 10 days after AMI Myocardial perfusion (contrast opacification assessed over 15 cardiac cycles after the destruction of microbubbles with high energy pulses) and wall thickening were assessed at baseline Regional and global left ventricular (LV) function was reassessed after 12 weeks Out of the 297 dysfunctional segments, MCE detected no contrast enhancement during 15 cardiac cycles in 172 segments, of which 160 (93%) failed to show improvement MCE demonstrated contrast opacification during 15 cardiac cycles in 77 segments, of which 65 (84%) showed recovery of function The greater the extent and intensity of contrast opacification, the better the LV function at 3 months (p <0001, r = -091) Almost all patients (94%) with <20% perfusion in dysfunctional myocardium (assessing various cut-offs) failed to demonstrate an improvement in LV function MCE and peak creatine kinase proved to be independent predictors of functional recovery (p <0001) In conclusion, low-power continuous MCE is an accurate and rapid bedside technique to identify microvascular perfusion after AMI This technique may be utilized to reliably predict late recovery of function in dysfunctional myocardium after AMI

Comparison of an rK39 dipstick rapid test with direct agglutination test and splenic aspiration for the diagnosis of kala-azar in Sudan.

Abstract: Summary We compared an rK39 dipstick rapid test (Amrad ICT, Australia) with a direct agglutination test (DAT) and splenic aspirate for the diagnosis of kala-azar in 77 patients. The study was carried out under field conditions in an endemic area of north-east Sudan. The sensitivity of the rK39 test compared with splenic aspiration was 92% (46/50), the specificity 59% (16/27), and the positive predictive value 81% (46/57). Compared with the diagnostic protocol used by Medecins sans Frontieres, the sensitivity of the rK39 test was 93% (50/54), the specificity 70% (16/23), and the positive predictive value 88% (50/57). Compared with splenic aspirates, the sensitivity of a DAT with a titre ‡1:400 was 100% (50/50), but its specificity only 55% (15/27) and the positive predictive value was 80% (50/62). Using a DAT titre ‡1:6400, the sensitivity was 84% (42/50), the specificity 85% (23/27) and the positive predictive value 91% (42/46). All four patients with DAT titre ‡1:6400 but negative splenic aspirate were also rK39 positive; we consider these are probably true cases of kala-azar, i.e. false negative aspirates, rather than false DAT and rK39 seropositives. There were no false negative DATs (DAT titre £1:400 and aspirate positive), but there were four false negative rK39 tests (rK39 negative and aspirate positive). The rK39 dipstick is a good screening test for kala-azar; but further development is required before it can replace the DAT as a diagnostic test in endemic areas of the Sudan.

Myocardial contrast echocardiography is superior to other known modalities for assessing myocardial reperfusion after acute myocardial infarction

Abstract: Background: Angiographic flow measurements do not define perfusion accurately at a microvascular level, so other techniques which assess flow at a tissue level are to be preferred. Objectives: To compare intravenous myocardial contrast echocardiography (MCE) with other methods of assessing microvascular reperfusion for their ability to predict left ventricular function at one month after acute myocardial infarction. Design: 15 patients underwent primary percutaneous coronary angioplasty for acute myocardial infarction, with restoration of TIMI grade 3 flow. Corrected TIMI frame count (cTFC), myocardial blush grade (MBG), and percentage ST segment resolution at 90 and 180 minutes were recorded. Baseline regional wall motion score index (WMSI) and regional contrast score index (RCSI) were obtained 12–24 hours after the procedure, with a final regional WMSI assessment at one month. Results: Mean (SD) cTFC was 27 (9.4), and ST segment resolution was 69 (22)% at 90 minutes and 77 (20)% at 180 minutes. MBG values were 0 in six patients, 2 in two, and 3 in seven. Baseline regional WMSI, RCSI, and follow up WMSI were 2.7 (0.71), 1.5 (0.71), and 1.6 (0.73), respectively. The correlation coefficient between RCSI and follow up WMSI was 0.82 (p = 0.0012). Peak CK correlated with follow up WMSI (R = 0.80). None of the other reperfusion assessment techniques correlated significantly with follow up WMSI. Multiple regression analysis showed that a perfused hypokinetic or akinetic segment was 50 times more likely to recover function than a non-perfused segment. MCE predicted segmental myocardial recovery with a sensitivity of 88%, a specificity of 74%, and positive and negative predictive values of 83% and 81%, respectively. Conclusions: MCE is currently the best and most accurate measure of reperfusion at a microvascular level and an excellent predictor of left ventricular function at one month following acute myocardial infarction.

Portable echocardiography: an innovative tool in screening for cardiac abnormalities in the community.

Abstract: Aims: Heart failure is placing an increasing burden on society. This has led to calls for echocardiographicbased programmes to screen for left ventricular systolic dysfunction and other cardiac abnormalities. Echocardiography using new fully portable echocardiography devices would allow community-based cost-effective screening programmes once validated. This study was undertaken to evaluate this further in both high and low-risk subjects. Methods and Results: 562 consecutive subjects attending a community-based heart failure screening programme, some at high-risk and some at low-risk of cardiac abnormalities, underwent echocardiography by both portable and traditional echocardiography machines. An ‘eyeball’ estimate of left ventricular ejection fraction was made on the portable device and compared to a quantitative measure of ejection fraction on the traditional machine. Qualitative measures of valvular regurgitation and quantitative measures of left ventricular hypertrophy were also compared. An estimate of ejection fraction was possible in 97% of cases using portable echocardiography. It gave a sensitivity, specificity and negative predictive value in diagnosing left ventricular systolic dysfunction of 96%, 98% and 99.6%, respectively. Inter-observer variability gave a mean difference in ejection fraction of 2%, and 95% limits of agreement of −8% to +12%. All cases of moderate or severe valvular regurgitation and 29 of 31 cases of significant left ventricular hypertrophy were correctly identified as abnormal on the portable device. Conclusions: Thus, echocardiography performed by experienced sonographers using these new fully portable devices is an accurate and reproducible technique for detecting left ventricular systolic dysfunction, left ventricular hypertrophy and valvular regurgitation in both high-risk and low-risk members of the community. Its very high negative predictive values would allow their use in future community-based screening programmes.

Parental psychiatric illness: the implications for children

Abstract: SummaryDespite a large evidence base we need further research to clarify the ways in which parental mental illness impacts on children, specific risk (and protective factors) and the role of fathers. We need to know more about the reciprocal relationship between parents and children. As yet we have

Identification and progression of a desmoid precursor lesion in patients with familial adenomatous polyposis.

Abstract: Background Desmoid tumours occur in about 10 per cent of patients with familial adenomatous polyposis (FAP), and are an important cause of morbidity and death. The natural history of desmoids was investigated by documenting prospectively the prevalence and progression of possible precursor lesions. Methods A group of patients with FAP and controls were examined at laparotomy. Another group, with FAP and no clinical evidence of desmoid, and a group of controls, underwent abdominopelvic computed tomography. Results At laparotomy 13 of 42 patients with FAP had fibromatous mesenteric plaques; seven of these had not had surgery. Seven had more extensive mesenteric fibromatosis and had undergone significantly more laparotomies than the rest. Of 103 patients scanned, two had desmoid tumours and 22 (21 per cent) had mesenteric fibromatosis. On follow-up both desmoid tumours grew rapidly; mesenteric fibromatosis was unchanged in eight and resolved in four of the 12 patients rescanned. Conclusion A model of desmoid tumour development is suggested, analogous to the adenoma–carcinoma sequence, in which a less benign phenotype emerges as molecular genetic abnormalities accumulate: mesenteric plaque-like desmoid precursor lesions arise in many patients with FAP before surgery as a result of abnormal fibroblast function; some, perhaps stimulated by surgery, progress to mesenteric fibromatosis; these in turn can give rise to desmoid tumours. © 1998 British Journal of Surgery Society Ltd

The molecular basis for the thalassaemias in Sri Lanka

Abstract: The beta-globin gene mutations and the alpha-globin genes of 620 patients with the phenotype of severe to moderate thalassaemia from seven centres in Sri Lanka were analysed. Twenty-four beta-globin gene mutations were identified, three accounting for 84.5% of the 1240 alleles studied: IVSI-5 (G-->C) 56.2%; IVSI-1 (G-->A) 15.2%; and haemoglobin E (codon (CD)26 GAG-->GAA) 13.1%. Three new mutations were found; a 13-bp deletion removing the last nucleotide in CD6 to CD10 inclusively, IVSI-129 (A-->C) in the consensus splice site, and a frame shift, CD55 (-A). The allele frequency of alpha+ thalassaemia was 6.5% and 1.1% for -alpha3.7 and -alpha4.2 deletions respectively. Non-deletion alpha-thalassaemia was not observed. Triplicate or quadruplicate alpha-globin genes were unusually common. In 1.5% of cases it was impossible to identify beta-thalassaemia alleles, but in Kurunegala detailed family studies led to an explanation for the severe thalassaemia phenotype in every case, including a previously unreported instance of homozygosity for a quadruplicated alpha-globin gene together with beta-thalassaemia trait. These findings have implications for the control of thalassaemia in high-frequency populations with complex ethnic histories.

Patient perceptions of MRSA.

Abstract: Drug-resistant nosocomial infections are an increasing problem. This issue has received considerable media coverage. To our knowledge there have been no studies investigating patient awareness and perceptions of nosocomial infections. A total of 113 surgical out-patients completed a questionnaire stating whether they had heard of either superbugs or MRSA. A series of questions were asked about the source of any information; methods of transmission and prevention; the consequences of infection and their emotional response if they were to acquire MRSA. Fifty patients (44%) had heard of superbugs or MRSA mainly via the media (58%) or from hospital staff (44%). The majority would feel either angry or afraid if they acquired MRSA in hospital, but there was good awareness of both methods of infection control and the consequences of infection. From our study, we conclude that the media is at least as important as health professionals in providing information. Concerns regarding nosocomial infection may need to be addressed prior to admission.

Role of myocardial perfusion imaging for risk stratification in suspected or known coronary artery disease

Abstract: Nuclear cardiology is an evolving specialty that has recently benefited from technological and radiopharmaceutical advances. As a result there has been an increase in the accuracy of myocardial perfusion imaging (MPI) with gated single photon emission computed tomography (SPECT) for assessing the diagnosis and prognosis of coronary artery disease. Moreover, ECG gated SPECT allows the simultaneous assessment of both myocardial perfusion and left ventricular function, which provides additional prognostic value. With increasing concern over early detection of coronary artery disease and its effective treatment, myocardial perfusion imaging is ideally placed to provide a full "one stop" functional assessment for any patient, irrespective of their exercise capacity. This applies not only to patients with chest pain but also to those with myocardial infarction, revascularisation, and heart failure, and those being assessed for non-cardiac surgery. The focus of this review is the use of myocardial perfusion imaging in risk stratification for coronary artery disease.

Paediatricians and child protection: the need for effective education and training

Abstract: “Child protection training is essential for all health professionals engaged in services for children. It is not an optional extra” (Barry Capon, Chair of Independent Inquiry into Death of Lauren Wright)1 Child maltreatment has become increasingly topical, and recent high profile cases of fatal abuse have attracted considerable attention from the media.2 Furthermore, independent inquiries have not only highlighted system failures in the child protection process, but have also been critical of the actions undertaken by health professionals and social workers. The most significant case in this respect is that of Victoria Climbie, whose death at the hands of her carers has prompted a major review of child protection procedures led by Lord Laming. His report is now available and should be carefully considered by all professionals who care for children and their families.3 Of a total of 108 recommendations made by Laming, 26 are specific to health. The report refers to poor standards in note keeping, inadequate communication between individuals and agencies, and ineffective and poorly coordinated intervention once child protection concerns are raised. A key message is that a case of suspected abuse or neglect should be treated with the same level of urgency as any other potentially fatal childhood disorder. The importance of child protection training for all relevant health care professionals is stressed. In addition, it is recommended that all consultant paediatricians should be periodically revalidated with respect to management of deliberate harm to children and subsequent multidisciplinary investigation. Relatively little in the Laming report is new. A previously published study of Part 8 reviews has already identified similar themes and conclusions.4 The child protection process and associated legislation varies in specific detail from one country to another. However, most systems require clinicians to remain vigilant for the possibility of abuse or …

The relationship between assessments of jet lag and some of its symptoms.

Abstract: The power of the symptoms of jet lag in predicting the amount of jet lag measured at the same and different times of the day has been investigated. A total of 85 subjects was studied for 6 days after a flight from the UK to Australia (10 time zones to the east). At 08:00, 12:00, 16:00, 20:00, and 24:00h, the subjects recorded their jet lag and fatigue. At 08:00h, they also assessed their sleep. At 12:00 and 16:00h, they assessed their attitude to a meal, as well as their motivation, commitment, and irritability. On retiring, they recorded bowel activity. Assessments were by visual analog scales. Jet lag was treated as the dependent variable and the symptoms as covariates in ANCOVAs. Fatigue was a powerful predictor of jet lag, provided it was measured at the same time, and some aspects of sleep predicted jet lag measured on retiring or rising. The other symptoms predicted jet lag less powerfully and/or at a wider range of times. It is concluded that, even though jet lag at any time of the day can be predi...

Médecins Sans Frontières interventions against kala-azar in the Sudan, 1989–2003

Abstract: Since 1989, Medecins Sans Frontieres (MSF) has provided medical humanitarian assistance duringoutbreaks of visceral leishmaniasis (VL, kala-azar) in Sudan. First, in western Upper Nile in southern Sudan, where a VL epidemic occurred after the resumption of the civil war in Sudan in 1983, with an estimated 100 000 deaths. Later, MSF started interventions in eastern Upper Nile and Gedaref State. In these 2 endemic regions VL incidence has risen markedly since 2001, which could be the start of a new epidemic cycle. Outbreaks of VL in Sudan remain unpredictable, and access to affected populations in war-torn southern Sudan is often hampered by insecurity. Therefore, MSF takes a flexible approach, establishing treatment centres where patients can be accessed. From 1989 to 2002, MSF treated > 51 000 VL cases in Sudan. Despite very basic field conditions, high cure rates of 95% are being achieved. Lack of diagnostics is a major obstacle to treatment, especially during epidemic situations. Therefore, development of simple and rapid technologies is required, allowing reliable diagnosis under field conditions. For treatment of VL there is a limited choice of effective, affordable drugs. There are strong indications of an emerging resistance to antimonials in Malakal. Introduction of combination therapies is urgently needed to prevent the further emergence and spread of resistance to antimonials, which are still the mainstay of VL treatment in eastern Africa. Experience with combination therapy with sodium stibogluconate (SSG) and paromomycin is promising, and combinations of SSG with liposomal amphotericin B and miltefosine are currently being explored.

What is the normal range of blood glucose concentrations in healthy term newborns

Abstract: You are the attending neonatal consultant. It is 6 pm on a Friday after a busy week on the unit. A rather flustered midwife appears from the postnatal ward with a baby and two anxious parents. The baby is full term and appropriately grown, following a normal vaginal delivery and just 8 hours old. Mum has been attempting to breast feed but the baby is reported to have been “not feeding well” and “jittery”. There are no prenatal risk factors for sepsis. Your examination of the baby is normal—he is now not “jittery”. A capillary heel prick blood test (Medisense) done on the postnatal ward has given a blood glucose reading of 2.6 mmol. Because this result is perceived to be abnormal (low), one of the neonatal trainees has suggested to …

An update on the controversies of tocolytic therapy for the prevention of preterm birth

Abstract: Preterm birth is the major cause of perinatal mortality and morbidity in the developed world. Where there are no contraindications to their use, tocolytics can improve neonatal survival rates by approximately 3% per day between 23 and 27 weeks gestation with a concomitant reduction in morbidity. The ultimate aim of tocolytic therapy is to prolong pregnancy until growth and maturation is complete, but even short-term delay may enable the administration of antepartum glucocorticoids to reduce hyaline membrane disease or to arrange transfer to a center with neonatal intensive care facilities. Both of these have been shown to reduce neonatal mortality and morbidity. Until recently, none of the currently used tocolytics, whether licensed or unlicensed, were developed specifically for the inhibition of preterm labor and consequently, they exhibit various potentially serious side-effects. As a result of the recent licensing of the oxytocin antagonist, atosiban, developed for the treatment of preterm labor and due to its high utero-specificity, obstetricians have experienced an advance in their options for the management of spontaneous preterm labor.

Comparison of Bronchoscopy and Gastric Washings in the Investigation of Smear-Negative Pulmonary Tuberculosis

Abstract: This study compares the utility of gastric washings (GWs) and bronchoscopy in the diagnosis of smear-negative pulmonary tuberculosis (TB). The aim of the study was to identify which investigation or combination of investigations provided the greatest yield of positive Mycobacterium tuberculosis cultures of samples from patients with smear-negative pulmonary TB. We retrospectively analyzed the medical records of 180 patients with smear-negative pulmonary TB. The positive culture yield for bronchoalveolar lavage fluid (62 [34%] of 180 patients) was significantly greater than that for specimens from 3 GWs (32 [21%] of 149 patients) (P=.02). Combining GW and bronchoscopy increased the positive culture yield: bronchoscopy combined with 2 GWs resulted in a positive culture rate of 38%. Bronchoscopy is superior to GW in the diagnosis of smear-negative pulmonary TB; however, the combination of bronchoscopy and 2 GWs should be regarded as optimal for the diagnosis of smear-negative pulmonary TB.

How good is clinical examination at detecting a significant patent ductus arteriosus in the preterm neonate

Abstract: A 25 week gestation infant aged 30 days has a continuous murmur and easily palpable pulses. He has already received a course of indomethacin for a “clinically diagnosed” patent ductus arteriosus (PDA). The baby is ventilator dependent. How good (or bad) is clinical examination at diagnosing a clinically important PDA? In a ventilator dependent neonate of very low birth weight (<1000 g) [patient], how good is clinical examination [intervention] at detecting patent ductus arteriosus [outcome]? A search string of [patent arterial duct] AND [diagnostic test] was used. ### Search results PubMed—three papers. Cochrane database—nil. SUMSearch—nil other than PubMed articles. Search done independently by DU and RN retrieved same three articles. See table 3. …

Audit of the diagnosis, assessment, and treatment of osteoporosis in patients with ankylosing spondylitis.

Abstract: OBJECTIVE: Osteoporosis (OP) is a well recognized complication of ankylosing spondylitis (AS), but there is no clear guidance to its appropriate management. To establish what might be considered as reasonable practice we surveyed the current practice of consultant rheumatologists in the United Kingdom. METHODS: A questionnaire comprising 14 questions relating to the management of OP in AS was sent to 449 British rheumatologists. Three hundred ten (69%) of the 449 questionnaires sent were returned. RESULTS: Only 98 respondents (31.6%) indicated that assessment of OP formed part of their routine management. Dual energy x-ray absorptiometry (DEXA) was the technique of choice for assessing bone mineral density (BMD) for 284 (91.6%). As general treatment, dietary advice was offered by 101 (32.6%) respondents, whereas 306 (98.7%) gave advice on exercise. Two case scenarios were presented and treatment choices recorded. When faced with a patient with osteopenia (-2.5