An outpatient anticoagulation protocol managed by a vascular nurse-clinician

Lifetime anticoagulation has become a therapeutic option for surgical patients with hypercoagulable states or prosthetic arterial bypass grafts. However, physicians may not achieve optimal anticoagulation or may attempt to limit the length of the therapy period because of the perceived morbidity from hemorrhagic complications of Coumadin therapy. A protocol for anticoagulant therapy monitored and regulated by a vascular nurse-clinician was reviewed. Coumadin was prescribed for 1,891 patient-months to 93 patients to maintain their prothrombin time 1.5 to 2 times control (range: 18 to 24 seconds). The mean (+/- SD) prothrombin time for the study population was 19.8 +/- 1.8 seconds. During follow-up, 472 (14%) of 3,479 prothrombin times measured were below the therapeutic range (n = 232) or prolonged (n = 240), prompting an adjustment in the Coumadin dose in 82 (88%) patients. Four patients developed recurrent vascular graft thrombosis while receiving anticoagulation. There were 6 major and 11 minor hemorrhagic complications. Patients with a chronic risk for arterial or venous thrombosis can have out-patient anticoagulant therapy administered at optimal intensity and regulated safely with a low incidence of hemorrhagic and thrombotic events.     

Prenatal diagnosis by isoenzymic differentiation of Treacher Collins' syndrome induced by retinoids in rats

A series of branchial arch malformations was induced in 618 embryos from 72 pregnant rats by a single intraperitoneal injection of 10 mg/kg etretinate at 8.5 days of gestation. The litters developed several malformations, including microtia, low set and dorsally placed outer ears, defective middle ear ossicles, short cochleas, defectively differentiated Meckel's cartilages, micrognathia, rudimentary malar bones, lateral facial clefts, fistulas and skin tags, all of which were similar to Treacher Collins' syndrome in man. The defects were accompanied by a pathological differentiation pattern of various isoenzymes in maxillary and mandibular processes. These isoenzymes could be detected in amniotic fluid from the 9th to the 20th days of pregnancy and showed a pathological differentiation pattern here as well. We conclude that a teratogenically induced syndrome affecting the first and second branchial arches is accompanied by a pathological differentiation pattern that can be traced by determinations of isoenzymes in the branchial arches as well as in amniotic fluid.     

Acute idiopathic scrotal oedema: Rare disorder or difficult diagnosis?

This study reports our experience in 6 cases of acute idiopathic scrotal oedema. Although children were the primary targets, this pathologic condition was also encountered in adults. Specific diagnosis of acute idiopathic scrotal oedema, opposed to other causes of scrotal swelling, is based on history, an objective examination, velocimetric Doppler exam and echography. Correct diagnosis is important in order to avoid unnecessary surgery. We are inclined to consider acute idiopathic scrotal oedema as an allergic disorder and recommend a follow-up within two days.     

Brightness discrimination and contrast sensitivity in chronic glaucoma--a clinical study.

The visual acuity, the difference in sensitivity of the two eyes to light (brightness ratio), and contrast sensitivity were assessed in 28 patients with chronic open angle glaucoma and compared with those of 41 normal controls of similar ages and visual acuity. The results obtained were related to the results of Tübingen visual field analysis in patients with glaucoma. Twenty-four of the 28 glaucoma patients (86%) had a significant disparity in brightness ratio between the two eyes. This was found to match the frequency of visual field loss. Moreover, there was a significant relationship between the interocular differences in brightness sense and the difference in the degree of visual field loss between the two eyes. Of the glaucoma patients 39% had sum contrast sensitivities outside the normal range for age-matched normal controls. No significant correlation was found between the interocular difference in brightness sense and the visual acuity or the interocular difference in sum contrast sensitivity. It is concluded that, in the presence of a normal visual acuity, the brightness ratio test warrants evaluation as a potential screening test for chronic open angle glaucoma.     

Formation of a stump after enucleation

Despite the progress achieved in the treatment of ocular diseases, removal of the eyeball still has to be resorted to rather often. The records of 12 hospitals of Moscow over a year evidence 678 enucleations and eviscerations, 248 (39 percent) of these for oncologic diseases, 189 (29.1 percent) because of injury aftereffects, 153 (24 percent) because of glaucoma, and 58 (8 percent) because of ocular inflammations. Common enucleation was carried out in 203 of +/- 400 patients (except oncologic ones) and enucleation with implantation of biological and synthetic drafts in 197 cases, i.e. in half of the patients who needed it; this is explained by the absence of the necessary implants in hospitals. A bank of grafts should be created for centralized provision of ocular hospitals.     

Immunogold localisation of laminin in normal and exfoliative iris.

Immunoelectron microscopic studies of exfoliative iris tissue (seven specimens) revealed the presence of laminin in the fibrillar component of exfoliation material. The immunogold label was uniformly distributed on the exfoliation fibres. Deposition of laminin labelled exfoliation material in the dilator muscle was a noteworthy feature, as was an apparent depletion of laminin in the basement membranes of ostensibly unaffected vessels. In control iris tissue (five enucleated eyes) laminin was identified in the basement membrane round vascular contractile cells, but not beneath the endothelium.     

Efficacy of diltiazem in the treatment of diffuse oesophageal spasm

Calcium antagonist relax smooth muscle, a possible useful concept in treatment of diffuse oesophageal spasm. Therefore the effects of oral diltiazem (60 mg t.d.s.) and placebo were compared in eight patients with diffuse oesophageal spasm in a 10-week double-blind crossover study. The patients recorded the severity of chest pain and/or dysphagia in daily pain diaries using visual analogue scales. Chest pain index and dysphagia index were calculated by multiplying frequency with daily intensity of each individual symptom. When compared to placebo, diltiazem did not significantly change the overall dysphagia index and chest pain index. An individual sizeable reduction of dysphagia was attained on diltiazem in four out of six patients and in six out of eight patients suffering from chestpain. Side effects were not seen during diltiazem therapy. Diltiazem, in our study, did not yield in a significant improvement of symptoms in diffuse oesophageal spasm. Diltiazem, however, can offer relief in selected individual patients suffering from diffuse oesophageal spasm.     

Increased prevalence of undernutrition in Parkinson's disease and its relationship to clinical disease parameters

Summary An anthropometric study was performed in 95 subjects (53 male, 42 female) with Parkinson's disease. Weight, height, triceps and biceps skin-fold thicknesses, and mid-arm circumference were recorded. A high incidence of undernutrition was found (23.6% of males and 22.5% of females, as defined by recent British guidelines). A subgroup of severely disabled patients with Parkinson's disease had a significantly lower mean body mass index than a similarly disabled control group with chronic pyramidal upper motor neuron lesions (males 20.6v 23.2 kg/m² p<0.05; females 20.6v 26.6 kg/m² p<0.01), suggesting that the undernutrition is not due to chronic illness or immobility alone. Correlation between anthropometric indices and clinical features of disease demonstrated that the presence of moderate or severe dyskinetic movements was the clinical parameter most strongly related to undernutrition. The reduction in anthropometric indices was most marked for skin fold thickness (related to percentage body fat) and least for arm muscle circumference (related to lean body mass); therefore the weight loss seen in Parkinson's disease is primarily due to fat loss rather than muscle loss.     

Survey of certification practices for patients admitted to Sterkfontein Hospital

The involuntary hospitalisation of psychiatric patients continues to be a controversial issue. All patients certified and admitted to Sterkfontein Hospital under Sections 9 and 12 of the Mental Health Act, No. 18 of 1973, over a 4-week period were surveyed. Almost 40% were admitted as urgent certifications. The majority of the patients in the sample were black, single, urban and had either primary or limited high school education. Most patients had been referred from academic/teaching and provincial hospitals. The average duration of hospital stay was 7.2 weeks, with only 1 patient eventually being transferred to a ward for chronic patients within the hospital, which suggests that Sterkfontein Hospital functions largely as an acute psychiatric facility. There was a discrepancy of approximately 30% between the assessments of the certifying and ward doctors, probably as a result of differing uses of terminology. Not only are more community psychiatric services needed, but communication between psychiatry and the other medical disciplines should be improved.