Dr Scrooge's casebook

‘Dear Doctor,’ I wrote to the medical registrar,‘This woman appears to have surgical emphysema extendingfrom her chest into her neck and face ... ’ I saw the patient three days before Christmas. I had just completedmy last surgery before going off for two weeks’ breakwith my family. There was one home visit to do, then Christmaslunch with the team, and my work would be finished for the year. I set off in the car to do the visit, but the Christmas trafficwas backed up for nearly a mile,     

Infection of the Central Nervous System by Listeria monocytogenes: a Review of 54 Adult and Juvenile Cases

The clinical features in 54 juvenile and adult patients withListeria monocytogenes infection of the central nervous systemare described. Thirty-one of the patients had pre-existing chronicdisease; the remainder were previously healthy. Twenty of thepatients, the ‘meningo-encephalitic group’ developedfocal neurological signs. The remaining 34, the ‘meningiticgroup’ exhibited no focal signs other than those causedby increased intracranial pressure. The ‘meningitic group’ differed from the ‘meningo-encephaliticgroup’ in that the cerebro spinal fluid white cell count,protein and glucose levels were markedly more abnormal and theprognosis worse. Evidence of septicaemia was found only in the‘meningitic group’. Meningo-encephalitis may represent a modified response to listerialinfection typified by granulomatous rather than a suppurativeresponse. The predominance of this response that was demonstratedin females may indicate partial immunity, the result of previousListeria monocytogenes colonisation of the female genital tract. Listeria monocyrogenes infection is treatable and should beconsidered in patients with meningitic or encephalitic illness.Repeated blood cultures may be required to establish the diagnosis.     

Insulin and C-peptide secretion in non-insulin-dependent diabetes mellitus and its response to dietary therapy

We studied insulin and C-peptide levels in patients with non-insulin-dependentdiabetes mellitus (NIDDM) during standard oral or intravenousglucose tolerance tests (GTT) at the time of diagnosis and after3 months dietary therapy. On the second occasion they also hadan ‘augmented’ GTT, in which slow intravenous infusionof glucose raised basal plasma glucose to a level similar tothat at the time of diagnosis. Eight patients had oral tests,and seven patients intravenous tests. In both groups, dietarytherapy significantly reduced fasting and peak plasma glucose(p<0.05 for oral; p<0.01 for intravenous GTT). Serum insulinlevels during conventional oral GTT were not significantly differentafter dietary therapy compared to diagnosis, but were significantlyhigher during the ‘augmented’ oral GTT (p<0.05).In those patients who underwent intravenous GTT, there was asignificant increase in both the total amount of insulin secreted(0–60 min) and in first-phase insulin secretion (0–10min) during the ‘augmented’ test compared to diagnosis(p<0.01), but first-phase insulin secretion during the conventionalintravenous GTT was unchanged. Serum C-peptide responses werealso greater during ‘augmented’ tests (p<0.05),similar in pattern to serum insulin. There is a relative deficiencyin insulin secretion in untreated NIDDM, which can be reversedby dietary therapy. It is essential to study insulin and C-peptidesecretion in controlled ‘fasting’ glucose conditions.     

Jellyfish responsible for Irukandji syndrome

Sir, A recent letter from Little et al.¹ makes several doubtful claimsto be the first to describe the Irukandji syndrome in severalspecies of cubozoans that have been described previously. The ‘fire jelly’ they mention is more commonly knownas the ‘Morbakka’ in     

Cigarette smoking and bone mineral density in older men

Cigarette smoking is cited as having a detrimental effect onbone mineral density (BMD), with associated increased fracturerisk. Most of the data are from studies of women, with few studiesof men. We examined the relationship between BMD and cigarette-smokinghabit in a population-based study of men who were categorizedby self-report as ‘never smokers’, ‘currentsmokers’ and ‘ex-smokers’. BMD was measuredusing dual X-ray absorptiometry (DXA). We examined 453 men aged65–76 years (mean 69.1). Non-smokers (‘never’and ‘ex’ smokers) were heavier than current smokers(p = 0.05). There was no significant relationship between BMDand smoking habit at any site except the trochanter, where currentsmokers had significantly lower BMD than did non-smokers. However,after adjusting for age and weight there was no longer a significantrelationship. BMD did not relate to pack-years of cigarettesmoking. Current smokers consumed significantly more alcoholthan non-smokers (p=0.031), but adjusting for alcohol intakedid not alter the BMD-smoking relationship. Cigarette smokingappears not to affect BMD in this group of older men.     

Intravenous Glucose Tolerance and Mortality in Non-insulin-dependent Diabetes Mellitus

Two hundred and forty-nine patients with non-insulin-dependentdiabetes were entered into a prospective study at diagnosisand examined at presentation and one, three, and five yearslater. Ten years after diagnosis, 34 patients were known tobe dead and 214 alive. A number of factors were significantlyassociated with survival on univariate analysis and appearedto form two independent intra-related groups: a ‘metabolic’group and a ‘degenerative condition’ group. Multivariateanalysis of these two groups showed that glucose tolerance (therate constant K_G for decrease in plasma glucose concentrationafter its intravenous injection) was significantly related tosurvival in the ‘metabolic’ group, and age, bloodpressure and anti-hypertensive therapy were significant in the‘degenerative’ group of factors. A low K_G valuewas more strongly associated with prognosis than any other factor.Values from the one year review were prognostically more usefulthan initial or later values. Indices of insulin secretion weresimilar irrespective of whether patients survived or died, andso we believe the lower K_G values of dead patients were dueto impaired insulin sensitivity. A regression, equation usingthe above factors correctly allocated survival outcome in 81%of subjects.     

How not to be a doctor

‘How can I help you?’ I asked. It isn't the wayI always open consultations but I was making a teaching video,so I thought I would be conventional for a change. As it turnedout, it was a fortunate move. ‘I’m not sure if youreally can help me’, the patient answered. ‘I’veseen lots of specialists, and none of them have managed to helpme so far. You see, I keep having these funny turns ...’Two weeks later, when showing the video to a group of seniorhouse officers, I stopped the recording at this     

Reinfection or recrudescence after apparently successful eradication of Helicobacter pylori infection: implications for treatment of patients with duodenal ulcer disease

Helicobacter pyloris is considered to be aetiologically implicatedin gastritis and peptic ulceration, since if H. pyloris infectioncan be eradicated the risk of subsequent ulcer relapse is markedlyreduced. The rate of ‘reinfection’ following treatment rangesfrom 0% to 45%, but its origin remains controversial (reappearanceof uneradicated original infection or a fresh infection). Todistinguish temporary suppression of H. pylori from fresh infectionwe conducted a retrospective analysis of the criteria used toestablish eradication of the original infection in 304 patients.We used the [¹⁴C]urea breath test, in which an integrated areaunder the curve (AUC) value of < 40 in 2 h is consideredto indicate eradication of H. pylori in patients tested 1 monthafter treatment. The results suggest that relapsed infection with H. pylori usuallyrepresents recrudescence of the original infection rather thana fresh infection; there was a higher relapse rate in patientswith a breath test AUC > 20 < 40, compared with thosewith an AUC < 20. All ‘reinfections’ occurredwithin 24 months of the original treatment. ‘Reinfection’was uncommon in patients receiving powerful therapeutic regimens(e.g. triple therapy) compared with those receiving monotherapyor relatively ineffective dual therapy combinations. In patientswhose urea breath test remains negative 12 months after treatmentthe subsequent reinfection rate is only 0.44%/ year. This supportsthe strategy of eradicating H. pylori infection from suitablepeptic ulcer patients.     

Percutaneous Transluminal Angioplasty for Atheromatous Renal Artery Stenosis - Blood Pressure Response and Discriminant Analysis of Outcome Predictors

Percutaneous transluminal angioplasty was performed in 39 consectivepatients with atheromatous renal artery stenosis associatedwith hypertension. The mean blood pressure before angioplastywas 191/107 mm Hg and this had dropped to a mean of 167/90 mmHG at the patient's most recent visit, representing a significantfall in both systolic (p<0.01) and diastolic pressures (p<0.001).The mean serum creatinine was 166.7 µmol/l before percutaneoustransluminal angioplasty and 155.3 µmol/1 at the mostrecent visit (not statistically significant. The mean numberof anti-hypertensive drugs fell from 2.4 to1.9 after percutaneoustransluminal angioplasty (p<0.05). Three patients (eightper cent) were ‘cured’ (diastolic blood pressure<90 mm Hg without medication), 25 (64 per cent) had ‘improved’(diastolic blood pressure <109 mmHg, with a fall of morethan 15 per cent) and 11 (28 per cent) had not improved. Logisticdiscriminant analysis showed that pre-percutaneous transluminalangioplasty diastolic blood pressure, age, serum creatinineand smoking habit together correctly predicted the outcome ofpercutaneous transluminal angioplasty in 90 per cent of patients,with four ‘false positives’ and no ‘falsenegatives’. Ten patients suffered, a total of 12 seriouscomplications related to the procedure: one death in acute renalfailure, one myocardial infarction, one severe hypotension,just after the procedure, one deep vein thrombosis, one episodeof transient ischaemia of the toes and seven groin haematomas.Thus percutaneous transluminal angioplasty for atheromatousrenal artery stenosis rarely ‘cures’ hypertension,but improved blood pressure control is often achieved, albeitat the expense of troublesome complications. A prospective,randomized trial is needed to establish whether or not the improvementis due directly to percutaneous transluminal angioplasty.     

Bilateral adrenal haemorrhage and coeliac disease

Sir, Granel et al.¹ describe an interesting case of bilateral adrenalhaemorrage in a patient with an hypocoagulability state dueto coeliac disease. The CT image presented in their report reveals:‘asymmetrically enlarged adrenal glands ... with a heterogeneousappearance typical of adrenal haemorrhage’. This caseis quite atypical,     

Familial juvenile hyperuricaemic nephropathy

Sir, In their letter to the Editor, Drs Bleyer and Hart¹ raised severalaspects concerning familial juvenile hyperuricaemic nephropathy(FJHN). First, they state that in QJM letter of February 2003,²we wrote that ‘ ... an unresolved aspect of FJHN is thegene defect’, despite their having reported     

Assessing chronic fatigue

Sir, Naschitz et al.¹ studied patients with chronic fatigue syndrome(CFS) in comparison with some controls ‘exhibiting sharedclinical features with CFS’,     

Temporal artery biopsy in ophthalmology: a useful investigation

Sir, We read with interest the article by Lenton et al. entitled‘Does temporal artery biopsy influence the managementof temporal arteritis?’.¹ An audit of     

The Amazing Science Behind Nature's ‘Miracle From The Sea’

Georges Halpern. The Amazing Science Behind Nature's ‘MiracleFrom the Sea’. Bioprospecting is a relatively new term that seems to prevailin early pages of eCAM and it may be considered now a definitecomponent of eCAM, giving opportunities to discover new andeffective compounds, especially those derived from marine andterrestrial animals. Bioprospecting sets out to discover newhealing agents in a field dominated by molecules derived fromplants. Now eCAM is taking the initiative by focusing on     

CORRECTION

In the paper on The Genetics of Pseudoxanthoma Elasticum byG. M. Berlyne, M. G. Bulmer, and R. Platt, the following correctionshould be made. The second sentence under the heading FamilyHe should read ‘he has previously been reported by Edwards(1958) who excised a small piece of the stomach because of gastrointestinalbleeding.’     

A Simple and Rational Twice Daily Insulin Regime: DISTINCTION BETWEEN BASAL AND MEAL INSULIN REQUIREMENTS

A new insulin regime is described, in which the primary aimis to attain normal basal plasma glucose concentrations by meansof a constant insulin delivery rate from the long-acting Ultratardinsulin. Additional twice daily Actrapid insulin is given tocover meals, and we have investigated this regime in 29 insulindependent diabetics, with control assessed by admission for24 hour profiles. Patients with low insulin requirements onlyneed a basal insulin supplement with Ultratard insulin. Withincreasing insulin requirements the dose of short-acting insulinincreases more than the basal insulin supplement. Thus fixedcombinations of short- and long-acting insulins cannot producegood control in all patients. Twenty-one patients were deemed‘well controlled’ in that they had no symptomatichypoglycaemia, an overnight plasma glucose concentration of<5·5 mmol/l and a mean late post-prandial glucoseconcentration of <6·5 mmol/l. Their average ‘meanexcess glycaemic exposure’ (mean incremental plasma glucoseabove 5 mmol/l) was 0·7 mmol/l (normal range 0–0·5mmol/l), which is considerably less than that found in manymaturity-onset diabetics. The distinction between basal andmeal insulin requirements simplifies rules of insulin therapy.     

Metabolic Studies in Kidney Stone Disease

Patients with kidney stones (n=59) and healthy controls (n=31)collected a 24-hour urine sample and later underwent a 6-hour‘fast and load’ test in which an oral calcium loadwas taken after 2 hours. In the 24-hour urine sample, mean calciumexcretion was higher in patients than controls, while mean urate,oxalate and citrate levels were similar. The patients had higherlevels of fasting plasma calcium, serum calcitriol and fastingurinary calcium, and lower levels of plasma phosphate than didthe controls. Following the calcium load, plasma and urinarycalcium increased similarly in both groups. Serum parathyroidhormone (PTH) levels were similar in both groups and decreasedsimilarly following the calcium load. Multiple linear regression, relating the presence or absenceof stone formation to all variable, found the only variablessignificantly related to stone formation to be plasma levelsof calcium (p<0.001) and phosphate (p=0.001) and fastingurinary area (p<0.001), and 24-hour urinary calcium excretion(p<0.05). Urinary oxalate and citrate were not related tostone formation. The data do not support the hypothesis thatprimary stimulation by calcitriol produces a normal fastingplasma calcium level, with an exaggerated increase after anoral calcium load. The findings instead suggest an abnormalityof parathyroid cell ‘set point’, such that PTH secretioncontinues until the plasma calcium level is a little higherand the phosphate a little lower than in controls.     

Serratia Marcescens in a General Hospital

Fourteen patients with infections caused by Serratia marcescenswere seen over an eight-month period in a large general hospital.Predisposing factors suggested an ‘opportunistic’pattern similar to that previously described in the United States.S. marcescens is an important pathogen which may be increasingin significance in the United Kingdom. Multiple resistance ofthe organism to antibiotics other than gentamicin makes thefinding of apparent sensitivity to co-trimoxazole of potentialtherapeutic value.