Moduretic-induced metabolic acidosis and hyperkalaemia.

A patient who developed significant metabolic acidosis and severe hyperkalaemia while taking Moduretic (amiloride and hydrochlorothiazide) is reported. During the period of hyperkalaemia (maximum potassium 7-6 mmol/l) the patient''s whole body potassium content was normal. His acid-base balance and serum potassium returned to normal some 10 days after stopping the drug. The possible mechanism of acidosis and hyperkalaemia in this patient is discussed.     

Rhabdomyolysis associated with hypokalaemic periodic paralysis of renal tubular acidosis

Two cases of hypokalaemia with serum potassium levels of 1.4 mmol/L and 1.9 mmol/L causing severe periodic paralysis since childhood are presented. There were associated with muscular aches and markedly raised muscle enzymes suggesting massive rhabdomyolysis. These abnormalities were due to renal tubular acidosis with markedly acidic arterial pH. The hypokalaemia and rhabdomyolysis responded to potassium and bicarbonate replacement. We postulate these patients had sporadic distal type of renal tubular acidosis and that the hypokalaemia and acidosis had caused the rhabdomyolysis.     

Lysozyme and hypokalaemia

Serum potassium, lysozyme and urinary lysozyme measurements were made in 98 patients with tuberculosis, 18 with sarcoidosis and 30 with acute myeloid leukaemia. Serum K concentration fell below 3·5 mmol/l in 17 of the 30 leukaemic patients and only 7 of these had raised serum lysozyme concentrations. None of the patients in the tuberculosis-sarcoidosis group with lysozymaemia or lysozymuria developed hypokalaemia. This study suggests that raised lysozyme concentrations are not causally related to hypokalaemia.     

兔脑创伤后早期血清β淀粉样前体蛋白动态变化的实验研究

 目的探讨兔脑创伤后血清β淀粉样前体蛋白(β-APP)含量与损伤程度及其时间动态变化相关性。方法将24只大白兔随机分为对照组和轻、中、重度脑损伤组,各组于不同时间点(0.5h、2h、6h、24h)采集标本,检测血清β-APP的含量。结果采用完全随机设计多因素重复测量方差分析和组间两两比较的LSD检验进行统计学分析。结果脑损伤后血清β-APP均升高。中、重度损伤组各时间点血清β-APP含量较对照组和轻度损伤组升高(P<0.05),重度损伤组血清β-APP含量各时间点均高于同时间点的中度损伤组,但差异无统计学意义(P>0.05);轻度损伤组血清β-APP含量与对照组相比在统计学上无显著性差异(P>0.05)。结论脑损伤后血清β-APP含量升高,且损伤越重血清β-APP含量越高。血清β-APP含量可作为早期判断颅脑损伤程度指标之一。     

The pathophysiological and molecular basis of Bartter's and Gitelman's syndromes

Molecular defects affecting the transport of sodium, potassium and chloride in the nephron through the ROMK K⁺ channel, Na⁺/K⁺/2Cl^- cotransporter, the Na⁺/Cl^- cotransporter and chloride channel have been identified in patients with Bartter''s and Gitelman''s syndromes. Defects of the angiotensin II type I receptor and CFTR have also being described. These defects are simple (ie, most are single amino acid substitutions) but affect key elements in tubular transport. The simplicity of the genetic defects may explain why the inheritance of these conditions remains unclear in most kindreds (ie, not just recessive or dominant) and emphasises the crucial importance of the conformational structure of these channels. Application of this molecular information will allow the early genetic identification of patients with these syndromes and enable us to differentiate between the various disorders at a functional level. It may also identify a sub-group in which the heterozygous form may make patients potentially exquisitely sensitive to diuretics.


     

A survey of the dose of ACE inhibitors prescribed by general physicians for patients with heart failure

AIM—To describe the pattern of angiotensin converting enzyme (ACE) inhibitor doses prescribed by general physicians for patients with chronic heart failure and to review the current evidence favouring the use of higher doses.
DESIGN—A retrospective survey of the medications of 125 patients with chronic heart failure (in both inpatient and outpatient settings) was carried out between December 1999 and February 2000.
RESULTS—Altogether 18.4% of patients surveyed were receiving no ACE inhibitor, the majority of these (65%) having a contraindication to such an agent. Of those patients who were prescribed an ACE inhibitor, 65% were receiving a high dose. The majority of patients who were prescribed a low dose of ACE inhibitor had no identifiable contraindication to receiving a higher dose. Of all patients with chronic heart failure studied, 25% were receiving either no ACE inhibitor or only a low dose in the absence of contraindication.
CONCLUSION—Since no objectively measurable variable has been shown to share a clear relationship with the outcome benefits of ACE inhibitors, no convenient and reliable assessment exists for determining when an adequate dose has been reached for each patient. There is an abundance of evidence favouring high dose ACE inhibitors in heart failure; evidence for the role of low doses is much less clear. The fact that only half of the patients with chronic heart failure were found to be receiving a high dose of ACE inhibitor is probably testimony to inaccurate perceptions and unreliable assumptions among physicians. It is likely that a change in current prescribing patterns would benefit patients with chronic heart failure.


     

随意皮瓣修复眶周软组织缺损的体会

 目的总结随意皮瓣修复眶周软组织缺损的临床经验。方法对65例患者应用随意皮瓣修复眶周软组织缺损,皮瓣设计蒂宽1.0～2.5cm,长度根据缺损范围确定,为1.0～3.5cm,长宽比例不超过2.5∶1。充分考虑到眶周各部位创口愈合后对眼睑运动功能的影响,设计尽量短小的附加切口且沿皮纹走行,同时结合患者的个性化要求,作皮瓣的合理设计和选择。结果3例术后有不同程度的皮瓣远端或边缘出现表皮暗红及水泡现象,经积极处理后皮瓣完全恢复;其余病例皮瓣完全成活。随访8个月～2年,创口无明显瘢痕,皮瓣与周围色泽协调一致,质地柔软,弹性良好,功能理想。结论随意皮瓣是修复眶周软组织缺损的理想方法之一。     

Lemierre's syndrome (necrobacillosis)

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.


     

儿童过敏性紫癜124例临床分析

 目的研究儿童过敏性紫癜(HSP)的临床特征。方法对124例HSP患儿的临床资料进行回顾性分析。结果54.84%(68/124)的患儿起病前有明确的上呼吸道感染史。紫癜性肾炎组中63.83%(30/47)的患儿出现皮肤紫癜反复,非紫癜性肾炎组中28.57%(22/77)的患儿出现皮肤紫癜反复,差异显著(P<0.05)。同时具有皮肤紫癜、消化道症状及关节症状的患儿肾脏受累发生率高于单纯皮肤紫癜患儿(P<0.05)。67.35%的患儿血清IgA升高,39.39%的患儿C反应蛋白水平升高。结论上呼吸道感染为主要发病诱因,皮肤紫癜反复出现的HSP患儿及同时具有皮肤紫癜、消化道症状和关节症状的HSP患儿肾脏受累几率明显升高。     

A large pelvic arteriovenous malformation in an adult patient with cystic fibrosis

We present a prepubertal male cystic fibrosis patient with high circulating oestrogen levels (as a consequence of severe cystic-fibrosis-related hepatobiliary disease) who subsequently developed a large pelvic arteriovenous malformation. This has not previously been described in patients with cystic fibrosis, despite the association between high oestrogen levels and arteriovenous malformations. The aetiology and treatment options of arteriovenous malformations are discussed.


     

Drug related medical emergencies in the elderly: role of adverse drug reactions and non-compliance

BACKGROUND—Adverse drug reactions and non-compliance are important causes of admissions in the elderly to medical clinics. The contribution of adverse drug reactions and non-compliance to admission by the medical emergency department was analysed.
METHODS—A total of 578 consecutive elderly patients admitted to the medical emergency department were interviewed to determine the percentage of admissions due to adverse drug reactions or non-compliance with medication regimens, their causes, consequences, and predictors.
RESULTS—Eighty three (14.4%) of the 578 admissions were drug related: 39 (6.7%) caused by adverse drug reactions and 44 (7.6%) caused by non-compliance with medication. One hundred ninety two (33.2%) patients had a history of non-compliance. Factors associated with an increased risk of admission because of an adverse drug reaction were patients with diabetes or neoplasms, and patients using numerous different medications. Factors associated with a higher risk of hospitalisation because of non-compliance were poor recall of the medication regimen, seeing numerous physicians, female sex, polypharmacy, drug costs, and switching over to non-conventional forms of treatment.
CONCLUSION—Many elderly admissions are drug related, with non-compliance accounting for a substantial fraction of these. Elderly people at high risk of suffering a drug related medical emergency are identified and suitable interventions may be planned by the healthcare policymakers to target them.


     

Record linkage study of hypokalaemia in hospitalized patients.

Retrospective analysis of biochemical data from 58,167 hospital inpatients revealed that 21% developed hypokalaemia during hospitalization-in 5.2% the serum potassium was less than 3.0 mmol/l. Subsequent evaluation showed a positive correlation between hypokalaemia and both female sex and hospital mortality. Patients with leukaemia and lymphoid tumours, especially when receiving antibiotic or cytotoxic therapy, and patients with gastro-intestinal malignancy were amongst those most frequently experiencing hypokalaemia. There was no significant association with cardiovascular disease. Drug and intravenous fluid administration accounted for the hypokalaemia in 56% of patients. While drug-related hypokalaemia was most commonly seen with diuretics, it was also apparent following use of steroids, insulin and haematinics.     

科技论文的中英文作者信息不对称现象

为了解我国科技期刊论文作者信息中,包括作者姓名、单位名称、邮编等大量中英文信息不对称现象,随机抽查20种医药卫生类高影响力科技期刊论文共计400篇论文,进行了分析,发现其中34％存在中英文作者信息不对称,并对其产生原因与改进措施进行了初步探讨。     

Hyperkalaemia in diabetes: prevalence and associations.

Hyperkalaemia is associated with diabetes, but there are no recent reports of its prevalence and associations. Serum potassium concentrations were measured in all 1764 patients attending a diabetic clinic over a 12-month period and found to be > 5.0 mmol/l in 270 (15%), and > 5.4 mmol/l in 67 (4%). There was no other evident cause of hyperkalaemia in 41 of these 67 patients. These data serve to highlight the risk of dangerous hyperkalaemia in diabetic patients, particularly with concurrent administration of angiotensin-converting-enzyme inhibitors and potassium-sparing diuretics.     

大鼠神经干细胞中MAPKK/MEK-MAPK/ERK信号转导通路的实验研究

 目的应用丝裂原激活的蛋白激酶激酶(MAPKK/MEK)特异性阻滞剂PD98059孵育大鼠神经干细胞(NSC),探讨MAPKK/MEK-MAPK/ERK信号通路在NSC中的作用。方法体外分离、培养大鼠NSC,应用不同浓度的PD98059孵育NSC后进行WTS-8、Nestin,BrdU、β-tubulin-Ⅲ、Western
      blot检测。结果PD98059对NSC的存活、增殖和分化的影响呈剂量依赖性,在PD98059较高浓度时NSC的存活率明显下降(P<0.05),BrdU和β-tubulin-Ⅲ的阳性细胞数明显少于正常对照组(P<0.05)。PD98059阻断ERK表达的作用呈剂量依赖性。结论MAPKK/MEK-MAPK/ERK信号通路对大鼠NSC的存活、增殖、分化起重要作用。     

Simultaneous onset of idiopathic dilated cardiomyopathy in identical middle-aged twins

Idiopathic dilated cardiomyopathy is a primary myocardial disease which is characterised by left ventricular, or biventricular, dilatation and impaired contractility. The precise aetiology is unknown and the relative contribution of genetic and environmental factors is debated. We report two identical male twins of Caucasian origin with idiopathic dilated cardiomyopathy who presented within a few months of each other.


     

Parathyroid crisis in a 20 year old—an unusual cause of hypercalcaemic crisis

Since the advent of automated serum analysis, patients with primary hyperparathyroidism (PHPT) are often asymptomatic at presentation or have mild symptoms attributable to the disease. Parathyroid crisis is a rare and potentially fatal complication of PHPT in which patients develop severe hypercalcaemia with signs and symptoms of multiple organ dysfunction. A case of parathyroid crisis in a 20 year old man who presented with brown tumours and renal stones is described.


     

Delivery of surgical care in a district general hospital without high dependency unit facilities

BACKGROUND—Many hospitals lack the facilities for high dependency care, and patients requiring this level of care are nursed on the surgical ward. The aim of this study was to assess the extent of this problem in a district general hospital, looking at the impact of providing high dependency unit (HDU) care at ward level.
METHODS—A 28 bed surgical ward was studied for 39 consecutive days. Patients were assessed as being either appropriately placed (routine) or inappropriately placed (HDU). Nursing interventions and observations over each 24 hour period were recorded for the most dependent patient in each group.
RESULTS—Data were collected for a total of 1092 bed days. Median bed occupancy was 22 patients/day (78%). Inappropriately placed HDU patients accounted for 55 bed days (5%, mean 1.4 patients/day). These patients required more nursing intervention than routine patients.
HDU patients received more observations during a 24 hour period than routine patients (mean 11.3 and 4.2 respectively, p<0.005). The number of observations recorded for a routine patient in a 24 hour period fell when a HDU patient was nursed concurrently on the ward (mean 5.1/24 hours, falling to 3.8 /24 hours in the presence of an HDU patient, p<0.02 ).
CONCLUSIONS—HDU patients require more intensive nursing care than routine surgical patients, and the nursing of HDU patients on the ward adversely affects the quantity of care available for less dependent patients. High dependency care should therefore be provided in dedicated units.
HDU is an essential facility for all surgical patients, including those who require intensive nursing, and the routine surgical patient whose nursing is compromised by the failure to provide comprehensive postoperative care.


     

Non-hepatic hyperammonaemia: an important,potentially reversible cause of encephalopathy

The clinical syndrome of encephalopathy is most often encountered in the context of decompensated liver disease and the diagnosis is usually clear cut. Non-hepatic causes of encephalopathy are rarer and tend to present to a wide range of medical specialties with variable and episodic symptoms. Delay can result in the development of potentially life threatening complications, such as seizures and coma.
Early recognition is vital. A history of similar episodes or clinical risk factors and early assessment of blood ammonia levels help establish the diagnosis. In addition to adequate supportive care, investigation of the underlying cause of the hyperammonaemia is essential and its reversal, where possible, will often result in complete recovery. Detection of an unborn error of metabolism should lead to the initiation of appropriate maintenance therapy and genetic counselling.


     

Prognostic value of stress echocardiography in women with high (> or = 80%) probability of coronary artery disease

OBJECTIVE—To assess the prognostic significance of stress echocardiography in women with a high probability of coronary artery disease (CAD).
SETTING—Secondary and tertiary cardiology unit at a university teaching hospital.
PARTICIPANTS—A total of 135 women (mean (SD) age 63 (9) years) with pre-test probability of CAD ⩾80% were selected from a database of patients investigated by treadmill or dobutamine stress echocardiography between 1995 and 1998.
MAIN OUTCOME MEASURES—Patients were followed up for occurrence of subsequent cardiac events (cardiac death, myocardial infarction, admission with unstable angina, and revascularisation) using a structured telephone interview and case note review.
RESULTS—Each patient had between two and seven (mean 3.5) CAD risk factors and pre-test probability of CAD ⩾80%. Ninety three patients (68.9%) had negative stress echocardiography. Mean (SD) follow up was 20.1 (8.5) months. There were six events in the positive stress echocardiography group (two cardiac deaths, one unstable angina, three revascularisations), and one event in the negative stress echocardiography group. Cox regression analysis showed positive stress echocardiography (p=0.02) and age (p=0.03) to be the only univariate predictors and positive stress echocardiography to be the only independent predictor of future cardiac events (relative risk 8.9, confidence interval 1.0 to 76.5, p=0.04). Cumulative event free survival to 38 months was 98% in the negative stress echocardiography and 50.7% in the positive stress echocardiography groups.
CONCLUSION—In women with high pre-test likelihood of CAD: (1) negative stress echocardiography identifies a subgroup with low risk of cardiac events who do not require further invasive investigation and (2) positive stress echocardiography identifies a subgroup with increased risk of subsequent cardiac events.