Secondary injury in traumatic brain injury patients--a prospective study.

OBJECTIVE: Secondary insults of hypotension and hypoxia significantly impact on outcome in patients with traumatic brain injury (TBI). More than 4 hours' delay in evacuation of intracranial haematomas has been demonstrated to have an additional impact on outcome. The objective of this study was to document the incidence of these preventable secondary insults in patients admitted with moderate or severe brain injury. METHODOLOGY: All moderate and severe head injury patients admitted to Groote Schuur Hospital over a 3-month period were studied prospectively. Data were obtained from ambulance dockets, referral letters, patient charts and attending medical staff. Preventable secondary insults (hypotension, hypoxia) and time delay to assessment and surgery were documented. Outcome was assessed using the Glasgow outcome scale (GOS) at discharge or outpatient follow-up. RESULTS: Ninety-six patients were studied. Forty-nine patients experienced at least one recorded preventable event of hypoxia or hypotension. Seventeen had an intracranial haematoma requiring evacuation. The mean time interval between injury and surgery was 455 minutes. No haematoma was evacuated within 4 hours of injury. Patients referred via a primary or secondary care facility experienced a mean additional delay of 70 minutes. These results demonstrated a significant incidence of secondary injury and delay to assessment and surgery. We believe that education and a raised awareness of the impact of secondary insults may have a positive impact on TBI outcome in our referral area.     

Sequential fractures of both hips in elderly patients--a prospective study.

Thirty-five patients with sequential fractures of both hips were studied prospectively. The second hip fractures occurred more commonly if the patients were institutionalized, if they suffered from concomitant neurologic diseases such as previous stroke or Parkinsonism, or if there was biochemical evidence of osteomalacia. Twelve patients sustained the contralateral hip fracture within 12 months of the first one. There was a significant correlation between biochemical evidence of osteomalacia and early occurrence of the second hip fracture. Although rehabilitation was difficult for such patients, it was possible with a longer period of intensive physiotherapy; only three patients were not able to walk upon discharge from the hospital after the second hip fracture.     

Effect of radio contrast media on residual renal function in peritoneal dialysis patients--a prospective study.

BACKGROUND: Residual renal function is an independent predictor of survival in peritoneal dialysis patients. Systemic administration of radio contrast media (CM) may increase the risk of acute renal failure in patients with impaired renal function not on dialysis. There are few data on the influence of CM administration in dialysis patients. METHODS: We investigated residual renal function in 10 continuous ambulatory peritoneal dialysis (CAPD) patients who underwent elective diagnostic intravenous or intra-arterial administration of CM (study group). Iopromide (a iodinated, non-ionic hypo-osmolar CM) was used for all interventions. The median dose of CM given was 107.5 ml/patient. Residual renal function (calculated as the average of renal creatinine and renal urea clearance) was measured on the day before the intervention (baseline), on days 1-7, day 10 and day 30 after intervention. Eight CAPD patients without exposure to CM acted as the control group. RESULTS: There was no significant difference between the two groups in age, gender, diabetes, duration of dialysis and renal clearance at baseline. In the study group, we observed a temporary decline of residual renal clearance after administration of CM (P<0.05; Friedman test). On day 30, clearances were not significantly different from baseline. In the control group, there was no significant change of residual clearance during the observation period. Repeated measures ANOVA revealed no significant difference in the course of residual renal function between study and control groups. The decline of residual renal clearance between baseline and a routine visit after 4 months was comparable between groups. CONCLUSION: Administration of iopromide did not lead to a persistent decline of residual renal function in CAPD patients. Nevertheless, non-ionic hypo-osmolar CM should be given to these patients with the lowest possible dose and only if there is a real clinical indication.     

Bacterial prostatitis: treatment with trimethoprim-sulfamethoxazole.

Fifteen patients with chronic bacterial prostatitis were treated with trimethoprim-sulfamethoxazole for three months. In 60 per cent of the patients a recurrence of chronic bacterial prostatitis developed during a follow-up period of from one to two and one-half years. It appears that factors other than a diffusion barrier to effective antimicrobial agents into the prostatic gland are responsible for the persistence of chronic bacterial infections of the prostate.     

Oral fish oil supplementation raises blood omega-3 levels and lowers C-reactive protein in haemodialysis patients--a pilot study.

BACKGROUND: We previously reported that haemodialysis patients have suboptimal blood levels of the cardioprotective omega-3 polyunsaturated fatty acids (n-3 PUFA) eicosapentaenoic (EPA) and docosahexaenoic (DHA) acids. In the present pilot study, we tested the hypothesis that supplementing haemodialysis patients for 12 weeks with the American Heart Association (AHA)-recommended fish oil dose would be well tolerated and efficacious in boosting blood n-3 PUFA levels and improving cardiovascular risk biomarkers. METHODS: Twenty-seven subjects were randomized in a 2 : 1 ratio to either 1.3 g of EPA + DHA daily or placebo. RESULTS: At baseline, 83% of subjects consumed inadequate dietary fish and had the following erythrocyte n-3 PUFA levels (mean +/- SD,% weight)-EPA: 0.3 +/- 0.2, DHA: 2.9 +/- 2.0, and ratio of n-6/n-3 PUFA: 4.2 +/- 1.3. Supplementation induced large increases in mean blood EPA and DHA levels (% increase, P-value vs placebo group): erythrocyte-EPA: +400%, P = 0.0018, DHA: +205%, P < 0.0001; plasma-EPA: +275%, P = 0.0003, DHA: +69%, P = 0.0352. Levels in the placebo group remained relatively unchanged. The omega-3 index, a value correlating with the level of cardioprotection, increased significantly in the fish oil group. A reduction in mean C-reactive protein levels (-3.3 +/- 8.1 mg/l, P = 0.0282) and a trend towards lower triglyceride levels (-24 +/- 74 mg/dl, P = 0.0783) were also observed in the active vs placebo group. Minimal side effects were noted. CONCLUSIONS: Our preliminary observations that the AHA-recommended fish oil dose is well tolerated, efficacious and may improve surrogate markers of cardiovascular disease in haemodialysis patients paves the way for larger clinical trials to confirm a clinical benefit.     

Problems in the optimal management of myasthenia gravis patients--a prospective clinical survey at Kalafong Hospital.

OBJECTIVES: This study forms part of a clinical survey of problems in the optimal management of patients with inherited neuromuscular diseases seen at Kalafong Hospital in Pretoria. Our objectives were to determine the problems associated with providing patients with optimal management until true remission (cure), and to apply the findings to ongoing improvement of optimal management. This is the first report of the series. METHODS: Twenty-six patients were studied prospectively from 1986 to 1998. Early sternal-splitting thymectomy on class II-V patients as well as anticholinesterases, corticosteroids, azathioprine, plasma exchange, intensive care and various combinations of these constituted part of the optimal management. An assessment of the total monthly income and distance from hospital was done for each patient. RESULTS: Five of the 15 thymectomised patients (33.3%) were lost to follow-up after reaching remission. Of the remaining 10 patients, 6 (40%) are in true remission and the remaining 4 (26.7%) are in pharmacological remission. Four of the 11 patients (36%) treated non-surgically were lost to follow-up. Of the remaining patients, 1 (9.1%) is in true remission and the remaining 6 (54.5%) are in pharmacological remission. The average monthly income of patients lost to follow-up in the thymectomised group was lower than that of patients who continued follow-up, and their homes were further away from hospital. In the non-surgical group the average monthly income of patients lost to follow-up was higher than that of patients who continued follow-up and their homes were nearer to the hospital. CONCLUSION: Early thymectomy (the aggressive approach) resulted in 40% cures, 26.7% pharmacological remissions, no mortality, minimal morbidity, and early discharge. Loss to follow-up was one of the biggest problems in providing optimal management for these patients. We modified optimal management in response to our patients' concerns without sacrificing excellence, and found that poverty and poor access to tertiary hospitals were possible contributory factors to loss to follow-up. Suggestions are made with regard to tackling the problems. Myasthenia gravis (MG) is a disorder of neuromuscular function resulting from an immunologically based premature destruction of acetylcholine receptors.     

Growth hormone treatment in hemodialysis patients--a randomized, double-blind, placebo-controlled study

OBJECTIVE: Renal failure and hemodialysis (HD) affect the anabolic growth hormone (GH)-insulin-like growth factor (IGF) axis. A positive correlation between serum IGF-I and normalized protein catabolic rate (PCRn) in HD patients has been reported, and the aim of this study was to assess the metabolic impact of recombinant human (rh)GH in these patients. MATERIAL AND METHODS: In a randomized, double-blind, placebo-controlled study, rhGH was given to 35 HD patients for 8 weeks: 0.025 IU/kg/day for 1 week, increasing to 0.05 IU/kg/day. Patients with diabetes, malignancy or clinical signs of infection and those receiving steroid treatment were excluded. RESULTS: All patients completed the study. Side-effects were rare and equally distributed between the two groups. Post-treatment, serum IGF-I and IGF-I standard deviation score (IGF-I SD) increased in the rhGH group compared to the placebo group: 283+/-33 vs 151+/-16 mg/l (p = 0.001) and 1.8+/-0.6 vs -0.2+/-0.6 (p = 0.002), respectively. IGF binding protein-3 was higher in the rhGH group compared to the placebo group: 5859+/-285 vs 4369+/-321 mg/l (p = 0.002). PCRn was significantly higher in the rhGH group compared to the placebo group: 1.09+/-0.06 vs 0.90+/-0.06 g/kg/day (p = 0.029). No differences were found in body weight, serum albumin or leptin between the two groups. There was no change in C-reactive protein (CRP) in the rhGH group compared to the placebo group: 17.4+/-9.0 vs 12.3+/-4.6 mg/l (p = NS). When the patients were subgrouped according to the CRP level (< or > 10 mg/1), the effect on PCRn persisted only in rhGH-treated subjects with a normal CRP level: 1.10+/-0.08 vs 0.81+/-0.09 g/kg/day (p = 0.025). CONCLUSION: Treatment of HD patients with rhGH at a moderate dose causes augmentation of PCRn which is considered to indicate a higher dietary protein intake. The anabolic effect of rhGH seems to be abolished by subclinical inflammation.     

Electron microscopic diagnosis of cerebral toxoplasmosis. Case report

Rapid and specific diagnosis of infections involving patients with acquired immunodeficiency syndrome (AIDS) is imperative. Toxoplasmosis is one of the most frequent causes of central nervous system disease in these patients. The authors present a case of cerebral toxoplasmosis in an AIDS patient, diagnosed by electron microscopy of brain biopsy tissue using rapid techniques.     

Serum antibody titers in treatment with trimethoprim-sulfamethoxazole for chronic prostatitis.

A comparative study of the clinical, bacteriologic, and serum antibody titer response of 22 men who received therapy with trimethoprim-sulfamethoxazole for chronic prostatitis due to various strains of Escherichia coli was done. Of the 7 patients who were cured by therapy on the basis of clinical and bacteriologic data, 6 of 6 patients who had elevated serum antibody titers prior to treatment demonstrated a decrease to normal range of serum titers during follow-up, confirming disappearance of the bacterial antigen. Of the 15 patients who were not cured on the basis of clinical and bacteriologic data, 12 of 12 patients who had elevated serum antibody titers prior to treatment demonstrated no change in serum titers throughout the study, confirming persistence of the bacterial antigen.     

Thrombocytopenia in septic shock patients--a prospective observational study of incidence, risk factors and correlation with clinical outcome

The objectives of the study were to study the incidence of various degrees of severity of thrombocytopenia in septic shock, the risk factors for its development and the correlation with clinical outcome. Complete blood counts, chemistry panel, arterial lactate, serum cortisol, APACHE II score, logistic organ dysfunction score and SOFA score were determined in 69 septic shock patients within 24 hours of admission or onset of septic shock. We followed the patients until they died or for six months to determine the mortality rate. The incidence of thrombocytopenia in our study group was 55%. Patients with thrombocytopenia had significantly higher serum creatinine, SOFA score, vasopressor requirement, lower PaO2/FiO2 ratio and higher mortality than those without thrombocytopenia (P < 0.05). Higher SOFA score, low P(a)O2/FiO2 ratio and high vasopressor dose were independent risk factors for development of thrombocytopenia. The presence of thrombocytopenia had significant correlation with SOFA score (P = 0.008). On receiver-operator characteristic curve analysis, platelet count was found to be predictive of increased mortality (area under curve = 0.56). Thrombocytopenic patients had 1.4 times the risk of mortality and lower survival probability at six months (log rank test P = 0.03). In conclusion, thrombocytopenia is common in septic shock and is associated with worse clinical outcome. Higher SOFA score, low P(a)Os/FiO2 ratio and high vasopressor dose are independent risk factors for development of thrombocytopenia in septic shock.     

Life threatening hyperkalemia and acidosis secondary to trimethoprim-sulfamethoxazole treatment.

We present a 77-year-old male with moderate chronic renal insufficiency from diabetic nephropathy who developed severe metabolic acidosis and life threatening hyperkalemia on treatment with regular dose of trimethoprim-sulfamethoxazole (TMP-SMZ) for urinary tract infection. The metabolic acidosis and hyperkalemia resolved upon appropriate medical intervention and discontinuation of TMP-SMZ. While hyperkalemia has commonly been reported with high dose of TMP-SMZ, severe metabolic acidosis is quite uncommon with regular dose TMP-SMZ. We emphasize that patients with renal tubular acidosis (RTA), renal insufficiency, aldosterone deficiency, old age with reduced renal mass and function, and angiotensin converting enzyme (ACE)-inhibitor therapy are at high risk of developing these severe and potentially life threatening complications.     

Standardized treatment of colorectal cancer. A prospective study

304 patients with colorectal adenocarcinoma underwent standardized, aggressive treatment which included wide resection, adjuvant radio- or chemotherapy and management of advanced disease. The mean age of the patients was 68 years; 50% were older than 70 years, and 17% above 80 years. The resectability rate was 86.2%. Overall postoperative mortality was 7.3%, in patients operated on for cure 5.7%, and in patients more than 80 years 16.3%. The highest postoperative mortality was seen following right hemicolectomy and deaths were mainly caused by anastomotic leakage and myocardial infarction. In patients with primarily inoperable rectal cancer treated with irradiation and followed by attempted curative surgery, the estimated 5-year survival was 38%. In patients with operable rectal cancer treated with preoperative irradiation followed by surgery the 5 year survival was 69% as compared to 45% for those treated with surgery only. Adjuvant cytostatic therapy in patients with colonic tumours of Dukes B and C stages did not improve survival.     

Prophylactic antibiotics in the treatment of penetrating chest wounds. A prospective double-blind study.

Considerable controversy exists as to whether or not antibiotics should be administered "prophylactically" to patients with penetrating chest trauma. No prospective study of this problem has been reported. Therefore, 75 patients with isolated, penetrating chest injury were randomized prospectively in a double-blind study. Group A patients (38 patients) were given 300 mg. of clindamycin phosphate every 6 hours, beginning with admission and lasting until 1 day following chest tube removal or for 5 days, whichever was shorter. Group B patients (37 patients) were given a placebo on the same schedule. The patients' hospital course, fever, white blood count, culture data, and roentgenograms were recorded serially. Clindamycin-treated patients had a significantly lower incidence of radiographic pneumonia, less fever, and a lower incidence of positive pleural and wound cultures. They acquired empyema less frequently, required fewer operations, and had a shorter period of hospitalization. Antibiotics may be useful, therefore, as adjunctive therapy in the management of penetrating chest trauma.