Showing papers in "Postgraduate Medical Journal in 1999"

Textbook of biochemistry with clinical correlations

Abstract: Textbook of biochemistry with clinical correlations , 4th edn TM Devlin, ed pp xvii + 1186, illustrated Wiley-Liss, New York, 1997 £2995, hardback This beautifully illustrated and well-written book, with an impressive array of authors, is aimed at both undergraduate and postgraduate level As the editor states in the preface, it is not intended to be a compendium of biochemistry but rather emphasises the biochemistry of mammalian cells The first 22 chapters cover …

Tuberculosis of the central nervous system

Abstract: Tuberculous involvement of the brain and spinal cord are common neurological disorders in developing countries and have recently shown a resurgence in developed ones. Tuberculous meningitis is an important manifestation and is associated with high morbidity and mortality. Diagnosis is based on clinical features, cerebrospinal fluid changes, and imaging characteristics. Bacteriological confirmation is not possible in all cases as serological tests do not have sufficient sensitivity and specificity. The polymerase chain reaction shows promise for the future. Appropriate chemotherapeutic agents should be administered as early as possible, although there is no unanimity concerning chemotherapeutic regimens or optimal duration of treatment. The patient's clinical stage at presentation is the most important prognostic factor. The role of corticosteroids is controversial but they should be administered to all patients presenting in stage III. Surgical procedures are directed at management of the hydrocephalus. Focal lesions, intracranial tuberculomas, and tuberculous abscesses, are usually located in cerebral or cerebellar hemispheres, uncommonly in brainstem and very rarely in spinal cord. They do not usually require surgical intervention and respond well to antituberculous treatment, along with corticosteroids.

Lemierre's syndrome (necrobacillosis).

Abstract: Lemierre's syndrome or postanginal septicaemia (necrobacillosis) is caused by an acute oropharyngeal infection with secondary septic thrombophlebitis of the internal jugular vein and frequent metastatic infections. Fusobacterium necrophorum is the most common pathogen isolated from the patients. The interval between the oropharyngeal infection and the onset of the septicaemia is usually short. The most common sites of septic embolisms are the lungs and joints, and other locations can be affected. A high degree of clinical suspicion is needed to diagnose the syndrome. Computed tomography of the neck with contrast is the most useful study to detect internal jugular vein thrombosis. Treatment includes intravenous antibiotic therapy and drainage of septic foci. The role of anticoagulation is controversial. Ligation or excision of the internal jugular vein may be needed in some cases.

Acne: a review of immunologic and microbiologic factors

Abstract: Acne vulgaris is a self-limiting skin disorder seen primarily in adolescents, whose aetiology appears to be multifactorial. The four main aetiological factors are hypercornification of the pilosebaceous duct, increased sebum production, colonization with Propionibacterium acnes, and subsequently the production of inflammation. Considerable investigation has addressed the immunologic reaction to extracellular products produced by the acne-causing organism, P acnes. The immunologic response involves both humoral and cell-mediated pathways. Further research should clarify the role of complement, cytotoxins, and neutrophils in this acne-forming response. Keywords: acne vulgaris; Propionibacterium acnes

Classic diseases revisited: Hypokalaemic paralysis

Abstract: Hypokalaemic paralysis is a relatively uncommon but potentially life-threatening clinical syndrome. If recognised and treated appropriately, patients recover without any clinical sequellae. The syndrome of hypokalaemic paralysis represents a heterogenous group of disorders characterised clinically by hypokalaemia and acute systemic weakness. Most cases are due to familial or primary hypokalaemic periodic paralysis; sporadic cases are associated with numerous other conditions including barium poisoning, hyperthyroidism, renal disorders, certain endocrinopathies and gastrointestinal potassium losses. The age of onset, race, family history, medications, and underlying disease states can help in identifying the cause of hypokalaemic paralysis. Initial therapy of the patient with hypokalaemic paralysis includes potassium replacement and search for underlying aetiology. Further management depends on the aetiology of hypokalaemia, severity of symptoms, and duration of disease. This review presents the differential diagnosis for hypokalaemic paralysis and discusses management of the syndrome.

Methods of obtaining peripheral venous access in difficult situations

Abstract: Peripheral venous access is frequently required in the hospital environment. This can occasionally be difficult to obtain. We have reviewed the pertinent literature and propose a structured algorithmic approach to reduce patient discomfort and to minimise the time involved in securing venous access.

Fever of unknown origin.

Abstract: A 68-year-old man presented with a history of low-grade, continuous fever and malaise for 3 years. There was no associated history of cough, breathlessness, palpitations, headache, vomiting, joint pains, rash, urinary or bowel disturbances. The patient had been investigated on many occasions in the past for the fever. The investigations, including haemoglobin, blood counts, peripheral smear examination, kidney and liver functions tests, chest X-ray and ultrasonography of the abdomen, were all normal. The only abnormality detected was a persistently elevated erythrocyte sedimentation rate (ESR) of between 65 and 130 mm in the first hour. The patient had received several courses of antibiotics and was currently receiving antitubercular drugs prescribed empirically by a practitioner. Examination revealed a conscious, febrile male with pulse 100 beats/min regular, and blood pressure 130/70 mmHg. The respiratory, cardiovascular, abdominal and neurological examination was unremarkable. The laboratory investigations of …

Alterations in enzymatic antioxidant defence in diabetes mellitus − a rational approach

Abstract: Defence against the reactive oxidants produced during aerobic metabolism is a complex process and is provided by a system of enzymes and antioxidant compounds capable of preventing excess radical production, neutralising free radicals and repairing the damage caused by them. Regulation of the antioxidant system must provide sufficient, properly located, antioxidant compounds and enzymes. Damage to this system has been proved to play a role in various disorders. Long-term complications of diabetes mellitus are supposed to be partially mediated by oxidative stress. The authors summarise experimental and clinical investigations in this field and analyse the possible importance of the changes in the antioxidant system in the development of diabetic vascular complications.

Necrotizing soft tissue infections

Abstract: Necrotizing soft tissue infections are a group of highly lethal infections that typically occur after trauma or surgery. Many individual infectious entities have been described, but they all have similar pathophysiologies, clinical features, and treatment approaches. The essentials of successful treatment include early diagnosis, aggressive surgical debridement, antibiotics, and supportive intensive treatment unit care. The two commonest pitfalls in management are failure of early diagnosis and inadequate surgical debridement. These life-threatening infections are often mistaken for cellulitis or innocent wound infections, and this is responsible for diagnostic delay. Tissue gas is not a universal finding in necrotizing soft tissue infections. This misconception also contributes to diagnostic errors. Incision and drainage is an inappropriate surgical strategy for necrotizing soft tissue infections; excisional debridement is needed. Hyperbaric oxygen therapy may be useful, but it is not as important as aggressive surgical therapy. Despite advances in antibiotic therapy and intensive treatment unit medicine, the mortality of necrotizing soft tissue infections is still high. This article emphasizes common treatment principles for all of these infections, and reviews some of the more important individual necrotizing soft tissue infectious entities.

Medical restrictions to driving: the awareness of patients and doctors

Abstract: The study was set up to investigate the awareness of elderly patients and medical doctors of medical restrictions to driving. Separate questionnaires were completed by patients and doctors. All were interviewed face-to-face, without prior warning and their immediate answers were recorded. In total, 150 elderly patients from the acute elderly care wards, rehabilitation wards and day hospital, and 50 doctors (including all grades from consultant to junior house officer) were interviewed. The main outcome measures were numbers of patients currently driving and previously driving; patients' awareness of how their medical condition affected their ability to drive; doctors' spontaneous knowledge of medical conditions which restrict driving, current licensing policy, and restrictions for five specific medical conditions (epilepsy, myocardial infarction, stroke, 5-cm abdominal aortic aneurysm, and diabetes). Only 21 patients were current drivers, and six of these should not have been driving. While 103 perceived themselves eligible to drive, 46 had medical restrictions to driving. Seventeen of the 47 patients who perceived themselves not eligible to drive possibly did not have restrictions to driving. Doctors' knowledge of the current licensing policy and action to be taken if a patient was not eligible to drive was very poor. Knowledge of medical restrictions to driving was scanty, with few doctors giving the correct driving restrictions for the five specific conditions. We recommend that education of doctors regarding medical restrictions to driving should begin at an undergraduate level and be continued throughout their postgraduate career.

Do Indo-Asians have smaller coronary arteries?

Abstract: There is a widespread belief that coronary arteries are smaller in Indo-Asians. The aim of the present study was to compare the size of atheroma-free proximal and distal epicardial coronary arteries of Indo-Asians and Caucasians. We analysed normal coronary angiograms from 77 Caucasians and 39 Indo-Asians. The two groups were comparable for dominance of the coronary arteries. Indo-Asian patients had generally smaller coronary arteries, with a statistically significant difference in the mean diameters of the left main coronary artery, proximal, mid and left anterior descending, and proximal and distal right coronary artery segments. There was a non-significant trend towards smaller coronary artery segment diameters for the distal left anterior descending, proximal and distal circumflex, and obtuse marginal artery segments. However, after correction for body surface area, none of these differences in size were statistically significant. Thus, the smaller coronary arteries in Indo-Asian patients were explained by body size alone and were not due to ethnic origin per se. This finding nevertheless has important therapeutic implications, since smaller coronary arteries may give rise to technical difficulties during bypass graft and intervention procedures such as percutaneous transluminal coronary angioplasty, stents and atherectomy. On smaller arteries, atheroma may also give an impression of more severe disease than on larger diameter arteries.

Funduscopy: a forgotten art?

Abstract: Funduscopy is an integral part of the physical examination, especially in older patients in whom visual problems and systemic diseases affecting the fundi (eg, diabetes mellitus) are more common. We have assessed the views of hospital doctors to funduscopy via a questionnaire survey, reviewed the case notes to see whether or not funduscopy is carried out on older patients, and assessed the views of older patients on vision via a questionnaire survey. Review of the case notes showed only three of 100 patients had had funduscopy. Most patients reported a visual problem on specific enquiry. Whilst most hospital doctors believed funduscopy was important, many felt they had insufficient training in this procedure and felt their skills could be improved. We conclude that older patients are missing out on routine funduscopy. Hospital doctors should be aware that not all patients complain of visual problems and specific enquiry should be made. The issue of training and encouragement to perform funduscopy needs to be addressed before funduscopy becomes a forgotten art.

Non-organic visual loss

Abstract: Visual complaints without a physical basis are not uncommon presentations to the general physician, the neurologist, or the ophthalmologist. These alleged visual disturbances may be psychogenic or feigned. The diagnosis is made when all possible contributory pathology of the visual system is excluded, and reassurance remains the cornerstone of management.

Diagnostic work-up in peripheral neuropathy: an analysis of 171 cases.

Abstract: Summary This study was set up to evaluate retrospectively the eYcacy of a standard diagnostic procedure, including noninvasive and invasive (spinal tap, nerve/ muscle biopsy) investigations, in the diagnosis of peripheral neuropathy. The medical records of 171 in-patients with the final diagnosis of peripheral neuropathy of determined or undetermined cause were reviewed and each individual diagnostic work-up was analysed. Basic investigations included the patient’s history, a clinical examination and basic laboratory tests. Depending on the individual presentation, course, and severity, further noninvasive and invasive examinations were added according to the department’s standard diagnostic procedure. The aetiology could be clarified in 124 patients (73%) and remained unclear in 47 cases. Excluding cases with acute and chronic inflammatory polyneuropathy (n=14), the number of idiopathic peripheral neuropathies dropped to 33. Non-invasive investigations were suYcient to reveal the underlying aetiology in 114 cases (83 %). It is concluded that, with the application of a standard procedure for the diagnosis of peripheral neuropathy, the aetiology can be clarified in 81% of patients. In the other 19% of patients the aetiology remains idiopathic. In the majority of cases, noninvasive investigations were suYcient for diagnosis.

Hyponatraemia and seizures after ecstasy use

Abstract: A patient presented to our unit with seizures and profound hyponatraemia after ingestion of a single tablet of ecstasy. The seizures proved resistant to therapy and ventilation on the intensive care unit was required. Resolution of the seizures occurred on correction of the metabolic abnormalities. The pathogenesis of seizures and hyponatraemia after ecstasy use is discussed. Ecstasy use should be considered in any young patient presenting with unexplained seizures and attention should be directed towards electrolyte levels, particularly sodium.

Sudden unexpected death in epilepsy

Abstract: The majority of persons with epilepsy develop lasting remission from seizures, although mortality is significantly greater than that of the age-matched general population. Of the deaths that are thought to be directly related to seizures, sudden unexpected death in epilepsy is probably the commonest category; more so than status epilepticus or seizure-related accidents. Annual incidence rates vary from 1 in 200 patients with chronic epilepsy to about 1 in 1000 in more population-based studies. Young adults with severe, intractable epilepsy appear to be the most frequently affected group and may have even higher incidence rates. Other risk factors may also be important. An area of great research interest, several pathogenetic mechanisms have been postulated, centering mainly around cardiac rhythm and central hypoventilation. Given the frequent devastation caused by sudden unexpected death in epilepsy, the importance of seizure control is emphasised.

Assessment of glycaemic control in stable type 2 black South African diabetics attending a peri-urban clinic.

Abstract: Glycaemic control was assessed in type 2 black diabetics attending the diabetic clinic at a peri-urban hospital. Baseline glycosylated haemoglobin levels were measured and a subsequent estimation was carried out in those patients who attended a follow-up consultation to see whether current recommended targets for glycosylated haemoglobin levels were being attained. Out of 708 patients, mean age 56.3 years, 14.7% were insulin treated and 85.3% were non-insulin-treated. Target values of HbA1c < 7% were achieved in only 20.1% (142) of patients. Although mean glycosylated haemoglobin levels were significantly higher in females (p= 0.03), the proportion of poorly controlled diabetics was similar in the two sexes. Patients whose HbA1c levels fell within the target values had diabetes of significantly shorter duration than those exhibiting poor control (5.0+0.2 vs 7.03+0.5 years). Obesity was present in 562 patients (79.4%). Target values were only achieved in 16.4% of non-obese and 21% of obese diabetics, with mean glycosylated haemoglobin levels being significantly higher (p<0.05) in the former group (10.3+0.4% vs 9.5+0.2%). Similar results were observed with respect to type of treatment, with only 14.4% of insulin-treated and 21% of non-insulin-treated diabetics achieving target values. The follow-up HbA1c estimation did not show any difference in the glycaemic control status of patients, with only 19.9% of them achieving the target values. Dietary advice (though minimal) seemed to have no impact on the metabolic control of our patients. These results suggest that glycaemic control was poor irrespective of sex, duration, BMI, educational status, dietary advice and type of treatment with recommended target values not being achieved in the majority of patients. Behavioural changes through health educational programmes need to be instituted with both patient and medical personnel being motivated to take this process forward. Keywords: diabetes mellitus; black South Africans; glycaemic control

HIV infection and seizures.

Abstract: New-onset seizures are frequent manifestations of central nervous system disorders in patients infected with human immunodeficiency virus (HIV) Seizures are more common in advanced stages of the disease, although they may occur early in the course of illness In the majority of patients, seizures are of the generalised type Status epilepticus is also frequent Associated metabolic abnormalities increase the risk for status epilepticus Cerebral mass lesions, cryptococcal meningitis, and HIV-encephalopathy are common causes of seizures Phenytoin is the most commonly prescribed anticonvulsant in this situation, although several patients may experience hypersensitivity reactions The prognosis of seizure disorders in HIV-infected patients depends upon the underlying cause

Cogan's syndrome: an oculo-audiovestibular disease

Abstract: Typical Cogan's syndrome is a rare disease of young adults consisting of flares of interstitial keratitis and sudden onset of Meniere-like attacks (nausea, vomiting, tinnitus, vertigo and hearing loss). Life-threatening aortic insufficiency develops in 10% of reported cases. Atypical Cogan's syndrome (audiovestibular dysfunction with other types of inflammatory eye disease) is associated with vasculitis in 20% of cases and has a less favourable prognosis than typical Cogan's syndrome.

General hospital services for deliberate self-poisoning : an expensive road to nowhere?

Abstract: This study was designed to investigate the clinical and economic aspects of deliberate self-poisoning services in four teaching hospitals in Leeds, Leicester, Manchester and Nottingham. We investigated the management of the current self-harm episode, including direct in-hospital costs, in 456 individuals who presented to hospital on a total of 477 occasions with deliberate self-poisoning during a 4-week period in 1996. Fewer than half of the patients received specialist psychosocial assessment or follow-up. Patients were more likely to receive an assessment if they were already in contact with psychiatric services, had a history of previous overdoses, if they presented during working hours, or if they lived near the hospital. Patients who were admitted were nearly twice as likely to receive specialist assessment, and those who received a specialist assessment were nearly three times as likely to be offered follow-up. In-patient days and days on the intensive care unit accounted for 47% and 8% of the total costs, respectively. This study suggests that general hospital services are disorganised, with evidence of inequitable access to specialist assessment and aftercare. This state of affairs cannot be justified on financial or clinical grounds. Keywords: self-poisoning; service provision

Concordance of primary generalised epilepsy and carbamazepine hypersensitivity in monozygotic twins.

Abstract: In this paper we describe the previously unreported phenomenon of a carbamazepine-induced mucocutaneous syndrome in identical twins. These twins had developed primary generalised epilepsy within 2 months of each other.

Diabetic ketoacidosis precipitated by thyrotoxicosis

Abstract: We report two patients with type 1 diabetes mellitus, previously well controlled with good compliance, presenting with unexplained diabetic ketoacidosis. Following initial correction of the metabolic disorder, persisting tachycardia lead to the diagnosis of thyrotoxicosis. In both cases, treatment with propranolol and carbimazole helped in the stabilization of their metabolic states. Although thyrotoxicosis is known to destabilise diabetes control, we can find no reports of it precipitating diabetic ketoacidosis.

Drug-induced syndrome of inappropriate antidiuretic hormone secretion

Abstract: Drugs are a common cause of electrolyte abnormalities, and a careful drug history is essential in patients in whom these are demonstrated One of the more common electrolyte abnormalities that may be drug-induced is hyponatraemia A 50-year-old woman was admitted to hospital complaining of nausea, diarrhoea and abdominal pain Her medical history included depression, alcoholism and laryngeal carcinoma treated by laryngectomy and radiotherapy Her drug therapy on admission was atenolol 50 mg and loprazolam 1 mg, each once daily; sertraline 50 mg daily had been started 2 weeks prior to admission On examination she was thin but not clinically dehydrated She was apyrexial with a blood pressure of 145/100 mmHg and a pulse of 100 beats/min She had dry skin and palmar erythema Abdominal examination was normal There was no neurological deficit Chest X-ray, full blood count and clotting were normal, except that the mean corpuscular volume was 104 fl (normal range 78–98 fl) Her erythrocyte sedimentation rate was 30 mm/h, sodium 129 mmol/l (132–144), potassium 38 mmol/l (35–50), urea 56 mmol/l, creatinine 98 μmol/l and gamma-glutamyl transferase 151 U/l (5–35) …

The effect of passive smoking on pulmonary function during childhood.

Abstract: Passive smoking, especially of maternal origin, is known to influence adversely the development of children9s pulmonary function. In this study, the effect of parental smoking on the pulmonary function of 360 primary school children aged 9–13 (mean 10.8±0.7) years was investigated. Information on parental smoking history was collected using a questionnaire, and spirometric measurements were performed on the children. All spirometric indices were lower in children who had been passively exposed to parental tobacco smoke than those not exposed. The percentage of households in which at least one parent smoked was 81.5%. This figure was significantly lower for mothers (27.5%) than for fathers (79%). Paternal smoking was associated with reduced levels of forced expiratory flow between 25–75% of vital capacity, peak expiratory flow, and flow rates after 50% and 75% of vital capacity expired (p

Epidemic dropsy in India

Abstract: Epidemic dropsy is a clinical state resulting from use of edible oils adulterated with Argemone mexicana oil. Sanguinarine and dehydrosanguinarine are two major toxic alkaloids of Argemone oil, which cause widespread capillary dilatation, proliferation and increased capillary permeability. Leakage of the protein-rich plasma component into the extracellular compartment leads to the formation of oedema. The haemodynamic consequences of this vascular dilatation and permeability lead to a state of relative hypovolemia with a constant stimulus for fluid and salt conservation by the kidneys. Illness begins with gastroenteric symptoms followed by cutaneous erythema and pigmentation. Respiratory symptoms such as cough, shortness of breath and orthopnoea progressing to frank right-sided congestive cardiac failure are seen. Mild to moderate anaemia, hypoproteinaemia, mild to moderate renal azotemia, retinal haemorrhages, and glaucoma are common manifestations. There is no specific therapy. Removal of the adulterated oil and symptomatic treatment of congestive cardiac failure and respiratory symptoms, along with administration of antioxidants and multivitamins, remain the mainstay of treatment. Selective cultivation of yellow mustard, strict enforcement of the Indian Food Adulteration Act, and exemplary punishment to unscrupulous traders are the main preventive measures.

Questionnaires: the use and abuse of social survey methods in medical research

Abstract: We present a working review of survey methods based on market research technology. The structure of questionnaires, their distribution and analysis, are considered, together with techniques for increasing response rates.

Progressive supranuclear palsy (Steele-Richardson-Olszewski disease).

Abstract: Progressive supranuclear palsy is a neurodegenerative disease which affects the brainstem and basal ganglia. Patients present with disturbance of balance, a disorder of downward gaze and L-DOPA-unresponsive parkinsonism and usually develop progressive dysphagia and dysarthria leading to death from the complications of immobility and aspiration. Treatment remains largely supportive but, potentially, treatments based on cholinergic therapy may be useful. As in Alzheimer's disease, the neuronal degeneration is associated with the deposition of hyperphosphorylated tau protein as neurofibrillary tangles but there are important distinctions between the two diseases. Evidence from familial fronto-temporal dementia with parkinsonism linked to chromosome 17 suggests that tau protein deposition is a primary pathogenic event in some neurodegenerative diseases. The understanding of the mechanism of tau deposition in progressive supranuclear palsy is likely to be of importance in unravelling its aetiology.

Tuberculosis presenting as deep vein thrombosis

Abstract: We present two cases, women of 21 and 60 years old, who presented with deep vein thrombosis. Both cases had retroperitoneal para-aortic and iliac lymph node enlargement without any malignancy or other predisposing thrombophilic factors. Investigations revealed tubercular aetiology of the lymph nodes causing venae caval obstruction.

Clinical presentation of thyroid dysfunction and Addison's disease in young adults with type 1 diabetes.

Abstract: Summary In a clinic population of 509 type 1 diabetic patients aged 16‐45 years, 55% had received treatment for thyroid disorders (20 hypothyroid, three males; eight thyrotoxicosis, four males), and Addison’s disease was present in four patients (08%, one male) In all patients, type 1 diabetes preceded the diagnosis of the other autoimmune disorder The clinical presentation of hypothyroidism was usually insidious with few symptoms,although an increased frequency of hypoglycaemic symptoms and/or raised serum cholesterol levels often prompted thyroid function testing In contrast, the patients with thyrotoxicosis had florid symptoms, weight loss (mean 812 kg), palpable goitres, increasing insulin requirements, and low cholesterol levels Six patients did not achieve remission or had recurrent thyrotoxicosis after oral antithyroid treatment and required 131 I or thyroid surgery A family history of autoimmune disease was present in 25% of patients with thyroid disorders (seven thyrotoxic and one hypothyroid) and in three of the four patients with Addison’s disease In this population of young adult type 1 diabetic patients, appropriate tests for thyroid dysfunction and Addison’s disease should be carried out if there is clinical suspicion and/or unexplained changes in diabetic metabolic control or serum cholesterol Careful follow-up of patients with a family history of these conditions is recommended

Efficacy of statin therapy: possible effect of phenytoin

Abstract: Statins are currently the most widely prescribed lipid-lowering drugs. Individual statins are known to be metabolised by the CYP3A4 isoform of the cytochrome P450 system. The effect of CYP3A4 inducers such as phenytoin on the metabolism and efficacy of these agents is unknown. We report a patient with familial hypercholesterolaemia and epilepsy in whom the introduction and subsequent discontinuation of phenytoin were associated with marked changes in the lipid response to treatment with simvastatin and atorvastatin. The serum activity of γ-glutamyl transpeptidase may have acted as a marker of microsomal induction by phenytoin, since it rose markedly when phenytoin was introduced and returned to normal after it was discontinued.