Prevalence of chronic kidney disease stages 3-5 among acute medical admissions: another opportunity for screening

Background: Early identification of chronic kidney disease (CKD)can help delay or prevent its progression, but the opportunitiesfor systematic screening of patients are not well defined. Aim: To define the prevalence of CKD Stages 3–5 and relatedanaemia among acute medical admissions. Design: Retrospective analysis. Methods: We studied all acute medical admissions to a majorLondon teaching hospital during one year. The lowest creatinine,highest haemoglobin (Hb) and average mean corpuscular volume(MCV) were determined for 3 months before and after admission.Patients were categorized as CKD Stages 3–5 if the highestestimated GFR (eGFR) was <60 ml/min/1.73 m². CKD-relatedanaemia was diagnosed if these patients had Hb <11 g/dl withnormal MCV. Results: A total of 6073 patients were studied: male 49.0%,age 65.4 ± 19.6 years (mean ± SD), creatinine82.7 ± 46.7 µmol/l, eGFR 89.1 ± 32.5 ml/min/1.73m², Hb 13.6 ± 1.73 g/dl, MCV 87.7 ± 7.2 fl. Therewas an inverse correlation between eGFR and age (r² = 0.5; P< 0.001). Males were younger than females (63.5 ±18.4 years vs. 67.3 ± 20.5) and had higher eGFR (93.6± 34.1 vs. 84.7 ± 30.2 ml/min/1.73 m²; P <0.001). A total of 743 patients (12.2%) had raised creatinine>110 µmol/l, however using eGFR <60 ml/min/1.73m², 1075 patients (17.7%) were identified. The patients werecategorized as follows: Stage 3: 950 (15.6%), Stage 4: 100 (1.7%),Stage 5: 25 (0.4%). Ninety-nine (9.2%) of the 1075 patientshad normocytic anaemia. Conclusions: We have found a high prevalence of CKD Stages 3–5(17.7%) among acute medical admissions, of whom 9.2% had a relatedanaemia. Our findings highlight an important opportunity (amongstthe 1.9 million acute medical admissions annually in England)for detecting patients with CKD.     

Association of severe haemophilia A with osteoporosis: a densitometric and biochemical study

Following a femoral neck fracture and vertebral compressionfractures in two patients with severe haemophilia A, bone densityand turnover were measured in 19 males with severe haemophiliaA (all HIV negative, 18/19 hepatitis C antibody positive) andin 19 age/sex matched controls. Bone density at the lumbar spine(L2–4), measured by dual energy X-ray absorptiometry,was significantly lower in the haemophiliac patients (HPs) at(mean ± SEM) 1.109 ± 0.042 g/cm² vs. 1.234 ±0.027 in controls; p = 0.018. Femoral neck density was alsolower at 0.877 ± 0.034 g/cm² (HPs) vs. 1.067 ±0.032; p< 0.0005. No significant differences were evidentbetween the groups for serum calcium, parathyroid hormone, luteinizinghormone, follicle-stimulating hormone or 1,25 dihydroxyvitaminD3, nor for fasting urinary hydroxyproline, pyridinoline ordeoxy-pyridinoline excretion. Serum total alkaline phos-phatasewas elevated in HPs at 200 ±10 U/l vs. 158 ± 8;p = 0.004. Similarly, -glutamyl transferase was elevated at42 ±7 U/l (HPs) vs. 20 ±2; p = 0.007. Serum totaltestosterone and sex-hormone-binding globulin (SHBG) were higherin HPs at 26 ± 2.5 nmol/l vs. 17.4 ± 1.6 (p =0.009) and 56 ±6 nmol/l vs. 27 ± 3 (p = 0.0005),respectively. Free androgen index, however, was lower in HPsat 44 ± 5 vs 69 ± 7; p = 0.008. These resultssuggest significant osteopenia associated with haemophilia A.This may be partly due to liver dysfunction in HPs, but otherfactors, e.g. relative immobilization, may also be relevant.     

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     

Immunological and Psychological Benefits of Aromatherapy Massage

This preliminary investigation compares peripheral blood cellcounts including red blood cells (RBCs), white blood cells (WBCs),neutrophils, peripheral blood lymphocytes (PBLs), CD4⁺, CD8⁺and CD16⁺ lymphocytes, CD4⁺/CD8⁺ ratio, hematocrit, humoralparameters including serum interferon- and interleukin-6, salivarysecretory immunoglobulin A (IgA). Psychological measures includingthe State–Trait Anxiety Inventory (STAI) questionnaireand the Self-rating Depression Scale (SDS) between recipients(n = 11) of carrier oil massage and aromatherapy massage, whichincludes sweet almond oil, lavender oil, cypress oil and sweetmarjoram oil. Though both STAI and SDS showed a significantreduction (P < 0.01) after treatment with aromatherapy andcarrier massage, no difference between the aromatherapy andcontrol massage was observed for STAI and SDS. Aromatherapy,in contrast to control massage, did not significantly reduceRBC count or hematocrit. However, aromatherapy massage showeda significant (P > 0.05) increase in PBLs, possibly due toan increase in CD8⁺ and CD16⁺ lymphocytes, which had significantlyincreased post-treatment (P < 0.01). Consequently, the CD4⁺/CD8⁺ratio decreased significantly (P < 0.01). The paucity ofsuch differences after carrier oil massage suggests that aromatherapymassage could be beneficial in disease states that require augmentationof CD8⁺ lymphocytes. While this study identifies the immunologicalbenefits of aromatherapy massage, there is a need to validatethe findings prospectively in a larger cohort of patients.     

Apolipoprotein E genotypes in Chinese patients with Wilson's disease

Sir, The name Wilson’s disease (WD) derives from great workof the English specialist Wilson (1912).¹ On the Chinese mainland,approximately 3000 WD in-patients have been institutionalizedat the Anhui College of TCM.² WD is due to mutations in theATP7B gene, whose various defects cause accumulation of copperin the liver, brain, kidney, etc.³ ApoE genotypes     

Pharmacokinetics and Clinical Toxicity of Quinine Overdosage: Lack of Efficacy of Techniques Intended to Enhance Elimination

We report clinical details in 16 cases of quinine poisoning.Plasma quinine concentrations above 15 mg/l were associatedwith increased risks of permanent visual damage and of cardiacarrhythmias from which one of our patients died. The rate ofquinine elimination was not significantly altered by forcedacid diuresis in five patients(t^1/2 25.1±SEM 4.6 h) ascompared to eight patients treated conservatively (t^1/226.5±SEM5.78 h). Neither urinary pH or flow rate correlated consistentlywith urinary quinine clearance. In three other patients charcoalcolumn haemoperfusion, haemodialysis and exchange transfusionwere performed. These were also ineffective in increasing quinineelimination. It is concluded that techniques advocated to increasequinine elimination are ineffective in the management of quininepoisoning.     

Comparative Electropharmacological Actions of Some Constituents from Ginkgo biloba Extract in Guinea-pig Ventricular Cardiomyocytes

Effects of the constituents from Ginkgo biloba extract (GBE)on the action potentials and the ionic currents in guinea pigventricular cardiomyocytes were investigated using whole-celland current-clamp techniques. The constituents, ginkgolidesA, B, C and quercetin, had depressant effects at 0.1–3µMon the action potential configuration. Ginkgolide A (1–3µM) prolonged the action potential (action potential duration:APD) at 75% and 90% repolarizations (APD₇₅ and APD₉₀). However,ginkgolides B and C at low concentrations prolonged APD, butat higher concentrations (>1 µM) shortened APD. Quercetinat 3 µM prolonged the APD, but not at the lower concentrations.These constituents also inhibited the V_max. The resting potentialwas unaffected. In voltage-clamp experiments, ginkgolides Aand B (0.1–3 µM) markedly and concentration-dependentlyincreased the Ca²⁺ current (I_Ca) and the delayed rectifier K⁺current (I_K), and decreased the inwardly rectifying K⁺ current(I_K1). On the other hand, ginkgolide C failed to affect theI_Ca but increased the I_K by 14.0 ± 2.3% (n = 6, P <0.05) at 1 µM. Quercetin inhibited I_Ca, and enhanced I_Kbut decreased I_K1. These responses to the constituents werealmost reversible (80–90% of control) after a 10- to 20-minwashout. These results indicate that even at acute administrations,these constituents produce the effective actions on the APDand the underlying ionic currents in cardiomyocytes. Each constituentdoes not exhibit a uniform response, although GBE acts as anet.     

Plasmodium falciparum Hyperparasitaemia: use of Exchange Transfusion in Seven Patients and a Review of the Literature

During the last 15 years, at least 35 patients with severe falciparummalaria or babesiosis have recovered following treatment byexchange of up to 10 1 of blood. In a patient treated in Manchester,a parasitaemia of 2.10 x 10⁶ µl (42 per cent) was virtuallyeliminated over eight hours by a 3.5 litre exchange blood transfusion.However, the equipment and amounts of compatible blood requiredfor total exchange are rarely available in areas endemic formalaria and the risks of the procedure, including transfusion-relatedinfections, are high. Partial exchange transfusion with oneto two litres of blood carried out over two to seven hours,reduced Plasmodium falciparum parasitaemias of 0.33–1.48x 10⁶/µl (13–38 per cent) to 0.11–0.81 x 10⁶(4–17 per cent) in six Thai patients who were receivingintravenous quinine. The reduction in parasitaemia ranged from0.13–0.67 x 10⁶ µl (9–12 per cent) withinsix hours. During the same period, parasitaemia in 13 patientswith cerebral malaria treated with chemotherapy alone showedlittle reduction from initial levels of 0.20–1.74 x 10⁶/µl(11–42 per cent). One of the patients who were treatedwith exchange transfusion died with intractable hypotensionbefore the procedure could be completed and two others developedoliguric renal failure which was controlled by peritoneal dialysis.Partial exchange transfusion is a promising and practical alternativeto total exchange where facilities are limited. It deservesfurther assessment in the rural tropics.     

Patterns of Insulin Dependence in an African Diabetic Clinic

SUMMARY Analysis of the age of onset of diabetes amongst insulin-treatedpatients in a large African diabetic clinic revealed a bimodaltype of distribution, 23 per cent having an age of onset before30 years and 77 per cent with onset at 30 years of age. All66 of the young insulin-treated group (21.7±4.8 years(mean±1 SD)), and a random selection of 50 older insulin-treatedpatients (49.7±10 years), were studied. The older groupwere better controlled (HbA₁ 8.4±1.7 per cent vs. 10.8±2.6per cent, p<0.001), on lower doses of insulin (49±23vs. 71±23 u/day, p<0.001) and had higher body massindex (26.0±5.6 vs. 21.8±3.5, p<0.001). SerumC-peptide (0.24±0.15 vs. 0.07±0.10 nmol/l, p<0.0001),and C-peptide/glucose ratio (2.57±2.65 vs. 0.56+0.98nmol/mmolx 10², p<0.001) were very significantly higher inolder patients. Patients with later onset disease thus had betterpreservation of pancreatic function, higher body mass indexand better glycaemic control on lower doses of insulin. Thesefeatures suggest that older insulin-treated patients could infact be ‘Type 2’ or non-insulin dependent patients,and the condition may be controllable with diet and/or oralhypoglycaemic agents, at least in some.     

Haematological changes and infectious complications in anorexia nervosa: a case-control study

To determine the prevalence of haematological abnormalitiesin patients with anorexia nervosa (AN), and assess the relationshipsbetween these changes, the severity of AN and the propensityto infections, we retrospectively studied 67 patients who metthe DSM-III-R diagnostic criteria for AN. We recorded physicalfindings and routine haematological data on admission, and infectiousevents during hospitalization. The patients were compared with67 normal controls matched for age and sex. Mean haemoglobin(Hb) was normal but lower in AN patients than in controls (131± 1 9 vs. 137 + 11 g/l, p=0.03) and the prevalence ofanaemia (Hb<120 g/l) was higher in the AN group (27% vs.1.5%, p<0.0001). Patients had a lower leucocyte count (4.94+ 1.9 vs. 6.78 + 2.4 x10⁹/ l , p< 0.0001), and increasedprevalence of leucopenia ( < 4 x 10 ⁹ cells/l)(36% vs. 1.5%,p<0.0001), neutropenia (<1500x10⁶ cells/l)(17% vs. 0%,p=0.0015)and thrombocytopenia (<150x109 / l ) (10% vs. 0%, p = 0.03).Only 2 patients (3%) had pancytopenia, but 9/17 patients withanaemia (53%) also had leucopenia. There was a slight but significantcorrelation between body-mass index (BMI) and total leucocyte,neutrophil and red blood cell counts. Severe infectious complicationsoccurred in 9% of AN patients vs. 0% in controls (p = 0.01);they were more frequent with neutropenia (relative risk, 15.1:95% Cl, 10–20.2) or low (<12) BMI (relative risk, 11.6:95% Cl, 6.6–16.6) on admission. Compared with controls,AN patients thus had an increased prevalence of anaemia, leucopeniaand thrombocytopenia. The severity of AN, as assessed by BMI,correlated with leucocyte, neutrophil and red blood cell countsbut not with platelet count The risk for subsequently developingsevere infections was significantly increased when low BMI orneutropenia was found on admission.     

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.     

In vitro anti-Candida Activity of Zataria multiflora Boiss

Zataria multiflora Boiss known as Avishan Shirazi (in Iran)is one of the valuable Iranian medicinal plants. The aim ofstudy was to evaluate anti-Candida activity of Z. multifloraagainst different species of Candida in vitro. Anti-Candidaactivity of the aqueous, ethanolic and methanolic macerationextract of the aerial parts of Z. multiflora Boiss was studiedin vitro. Anti-Candida activity against Candida species wasdone using serial dilutions of extracts in Sabouraud's dextroseagar. Minimal inhibitory concentration (MIC) of the methanolicand ethanolic extracts was 70.7 and 127 mg l^–1, respectively.Aqueous extract showed no remarkable activity against Candidaspecies. We conclude that methanolic extract of the aerial partsof Z. multiflora Boiss has more anti-Candida effect at 70.7mg l^–1 compared to ethanolic extract 127 mg l^–1.In addition, the isolates of Candida parapsilosis were moresusceptible to methanolic extract than other tested species.     

Isolated microscopic haematuria

Sir, I read with interest the paper by Chow et al.¹ (‘Long-termfollow-up of patients with asymptomatic     

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,     

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     

Prognostic significance of the neutrophil count in immunocompetent patients with bacteraemia

To examine the prevalence of neutropaenia in immunocompetent,bacteraemic patients, and whether it carries an independentrisk for mortality, we surveyed 2096 bacteraemic patients withoutmalignant diseases, and who were not receiving cytotoxic drugs.The granulocyte count on the day of the first positive bloodculture was < 1 x10⁹ cells/l in 33 patients (1.7%, group1); 1.0–4.0 x 10⁹ cells/l in 154 patients (7.9%, group2); 4.0–8.0 x 10⁹ cells/l in 564 patients (29%, group3); 8.0–;20.0x10⁹ cells/; in 1034 patients (53%, group4); and >20.0x10⁹ cells/l in 163 patients (8.4%, group 5).The mortality rates in the five groups were 39.4%, 18.8%, 18.1%,25.7% and 25.8%, respectively (p=0.0001). The main pathogensin group 1 were Staphylococcus aureus in 25% of patients andPseudomonas sp. in 23%. Mortality in group 1 patients was higherthan in the other patients (odds ratio 1.4, 95% Cl 1.1–1.9).Mortality was also significantly higher in group 2 patientswith high blood urea nitrogen. The percentage of neutropaenic,septic patients without known risk factors for neutropaeniais small, but their mortality is high. Overall mortality inpatients with relative neutropaenia (1.0–4.0x10⁹ cells/l)is low, but a subgroup of patients with high blood urea nitrogenis at considerable risk for a fatal outcome. High leucocytecounts are also a marker of increased risk for mortality, butthis association is not an independent prognostic factor.     

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     

Cold agglutinin disease revealing mediastinal seminoma

Sir, Cold agglutinin disease (CAD) is an autoimmune haemolytic anaemiain which cold-reactive auto-antibodies bind to erythrocyte carbohydrateantigens, causing hemagglutination and complement-mediated haemolysis.^1–4It is associated with various conditions, including infections(Mycoplasma pneumoniae, hepatitis C), autoimmune diseases (especiallysystemic lupus erythematosus) and lymphoproliferative disorders(mainly lymphoma.^1–8 However, it has rarely been described