Syncope: The Diagnostic Value of Head-Up Tilt Testing

To determine the usefulness of prolonged head-up tilt in the diagnosis of neurally mediated syncope, 201 patients with history of syncope of unknown cause and 102 age and gender matched control subjects underwent a 40 minute 60 degree head-up tilt test. Head-up tilt elicited syncope (i.e., was positive) in 74 of the 201 patients (37%) with a history of unexplained syncope and in only 6 of the 102 controls (6%). The specificity of the test was 100% in patients 60 years of age and older. Symptoms during tilt-induced syncope were identified by the patients as similar to those they had suffered during their spontaneous episodes. All 80 subjects who had tilt-induced syncope recovered without sequelae. The positive predictive value of a positive response to head-up tilt was 93% and the negative predictive value was 43%. The results indicate that the prolonged head-up tilt test is a very specific procedure of high diagnostic value in patients with a history of unexplained syncope. It is particularly useful in the elderly age groups who have a high incidence of syncope.     

Septicemia as a Complication of Liver Biopsy

Although bacteremia is a common accompaniment of needle liver biopsy, septicemia is an extremely rare complication and normally occurs within the first eight hours after the procedure. A case of late onset septicemia, caused by E. coli and B. fragilis , secondary to bowel perforation during liver biopsy, is presented with a brief review of the recent literature.     

IMPROVEMENT OF ADULT HEIGHT PROGNOSIS IN PRECOCIOUS PUBERTY BY CYPROTERONE ACETATE

Three girls and one boy with idiopathic precocious puberty and one boy with operated suprasellar hamartoma and progressing precocious puberty were treated with Cyproterone acetate for periods ranging from 15 months to 4 years and 6 months. In all children, the signs of puberty were reduced. Height velocity, as related to bone age, was increased, as was the ratio of height age increment to bone age increment. An improvement of adult height prognosis in precocious puberty has been achieved by Cyproterone acetate.     

EFFECTS OF ALCOHOL AND LIVER CIRRHOSIS ON THE GH-IGF-I AXIS

Decreased serum insulin-like growth factor (IGF-I) levels havebeen shown in malnutrition and liver diseases. To analyse whichof them is the main cause of GH-IGF-I axis alterations, serumlevels of growth hormone (GH), growth-hormone releasing factor(GHRH), IGF-I and its binding protein IGFBP-3 were measuredin 85 hospitalized alcoholics (51 without cirrhosis, 15 withcompensated cirrhosis and 19 with cirrhosis with ascites) andin 25 healthy controls. Liver function tests and objective nutritionalassessment were also performed. Serum IGF-I and IGFBP-3 levelswere lower in alcoholics, particularly in those with liver cirrhosis.Serum GH was raised in cirrhotics with ascites but GHRH levelswere not significantly altered. Although these patients werefrequently malnourished there was no relationship between dataderived from GH-IGF-I axis and nutritional parameters. However,there was a significant positive correlation between serum GHconcentrations and impaired liver function and a significantnegative correlation between serum IGF-I and IGFBP-3 and impairedliver function. This suggests that, in this population, serumIGF-I and IGFBP-3 levels reflect liver dysfunction rather thanmalnutrition.     

EVALUATION OF THE EFFECTIVENESS OF TREATMENT ON ADULT HEIGHT PROGNOSIS IN DISORDERS WITH ADVANCED AND RETARDED BONE AGE Height and Height Velocity related to Chronological or to Bone Age

Different growth parameters and their graphical presentation in disorders with advanced and retarded bone age are discussed. Their usefulness for the evaluation of the effect of treatment on growth and maturation is compared. In precocious puberty, more information is obtained when height is plotted against bone age instead of chronological age. It is more reasonable from a physiological standpoint to plot height velocity against bone age rather than chronological age. For the evaluation of the efficiency of treatment on adult height prognosis in precocious puberty, two possibilities are proposed: height velocity expressed as height increment per bone age year, or the quotient height age increment/bone age increment. However, where skeletal maturation is severely retarded, as in hypopituitary growth retardation, these growth parameters should be related in the conventional way to chronological age, rather than to bone age.     

Respiratory excretion of hydrogen and methane in Italian subjects after ingestion of lactose and milk

Lactose malabsorption, by the breath hydrogen test, and lactose intolerance (presence of symptoms) were studied in twenty healthy Italian subjects after intake of 12.5, 25 and 50 g lactose, whole milk and low-lactose milk. A rise in respiratory concentration of hydrogen (greater than 20 ppm) (malabsorption) was found in fifteen subjects after 50 g lactose, in thirteen after 25 g and in seven after 12.5 g. Symptoms generally occurred in subjects presenting a rise in respiratory hydrogen excretion, but such a rise was often observed without symptoms. Thirteen subjects presented symptoms after 50 g lactose, but only three after 25 g and one after 12.5 g. Whole milk (500 ml) gave a lower incidence of lactose malabsorption than 25 g lactose (7/20 versus 13/20, P less than 0.05) and more subjects developed symptoms (7/20 versus 3/20, NS). Low-lactose milk produced no malabsorbers and one intolerant. Breath methane was detected constantly in seven subjects and in three on some of the days of observation. Respiratory methane excretion generally appeared to be unrelated to lactose ingestion.     

Identification of factors associated with deficient immunization coverage: An instrument to manage preventive health services

One of the most important challenges in the management of childhoodimmunization programmes is the persistence of some populationgroups with deficient immunization coverage. In the presentstudy we identify some factors associated with deficient immunizationcoverage in pre-school populations living in Murcia (Spain).The main purpose is to develop some instruments to help managersof immunization programmes in developing strategies directedat high risk groups. Case-control study was designed on thebasis of pre-school population (8579 children) living in thecity during 1989 and 1990. All of the 380 cases and a similarnumber of randomly chosen controls were studied. Multivariatelogistic regression method was used for statistical analysis.Secondly, two nominal group techniques were conducted with healthand social professionals, and, lastly, one group interview wasconducted with some mothers of deficiently immunized children.Variables associated with a deficient immunization coverageincluded: a large number of children in the family, being bornat public hospitals, a greater age of the child, and livingin certain city zones. The most important problems detectedby professionals are lack of social and health services coordination,poor functioning of administrative registers, lack of strategiesto catch marginal groups, and missed opportunities for the immunizationof high-risk children. Mothers identified some problems in servicesaccessibility, inadequate information from health professionals,and special characteristics of marginal groups. Informationfrom registers (case-control study), professionals, and consumersproves some useful in the management of preventive services.Early identification of high-risk children with deficient immunizationcoverage would make it possible to assign more resources togroups with greater needs.