Hairy leukaemic cell influx into the cerebrospinal fluid secondary to encephalomyelitis.

A case report of a 53 year old male with hairy cell leukaemia is presented in whom encephalomyelitis caused by toxoplasmosis resulted in an influx of hairy cells into the cerebrospinal fluid following disruption of the blood-brain barrier. These cells subsequently disappeared as the barrier reformed. It is suggested that the presence of hairy cells in the cerebrospinal fluid is a secondary self-limiting phenomenon.     

Minimisation of aminoglycoside toxicity in patients with cystic fibrosis.

BACKGROUND: There is evidence that administration of higher doses of aminoglycosides given less frequently improves the bactericidal effect and reduces the potential to cause side effects. To investigate this, a prospectively randomised open label therapeutic trial was undertaken in stratified groups of patients with cystic fibrosis to examine the efficacy and toxic potential of an aminoglycoside dosing regimen designed to generate high peak drug concentrations at 12 hourly intervals compared with conventional dosing at eight hourly intervals. METHODS: Patients in group A received tobramycin eight hourly using a dose aimed at generating a peak concentration of 10 mg/l with trough concentrations below 2 mg/l, and those in group B received the total daily dose required to achieve eight hourly target concentrations administered as two equal 12 hourly doses. Clinical outcomes measured and assessed included vestibular symptoms, hearing and renal function, length of hospital stay, readmission rate, and mortality. RESULTS: Twenty nine patients were recruited during a six month period, 20 to group A and nine to group B. The average peak tobramycin level was higher in group B (12.5 (2.2) mg/l) than in group A (7.9 (1.9) mg/l), whilst the average trough level was higher in group A (0.8 (0.3) mg/l) than in group B (0.5 (0.2) mg/l). There was a difference in the number of ototoxic events between patients in group A (seven of 18, 38.9%) and group B (none of eight), but no difference was found in other outcome measures assessed. CONCLUSIONS: These results suggest that 12 hourly high peak aminoglycoside dosing may be less toxic than equivalent eight hourly dosing, without any apparent difference in efficacy.     

Benzodiazepine receptor binding activity of 6,9-disubstituted purines

A series of 6,9-disubstituted purines were tested for their ability to bind to the benzodiazepine receptor in rat brain tissue. One of the most active compounds was 9-(3-aminobenzyl)-6-(dimethylamino)-9H-purine (44) with an IC50 = 0.9 microM, which was only 4.5-fold higher than the IC50 for chlordiazepoxide. Substitution of a 3-aminobenzyl or 3-hydroxybenzyl group at the 9-position of 6-(dimethylamino)purine led to over a 50-fold increase in receptor affinity. Compound 44 did not exhibit significant anxiolytic activity, nor did anticonvulsant activity correlate with relative receptor binding affinity.     

TREATMENT OF PERSONALITY DISORDER: LIMIT SETTING AND THE USE OF BENIGN AUTHORITY

abstract    Personality disorders are an ill-defined group of psychopatholo-gical conditions that are increasingly seen as one of the main domains of NHS dynamic psychotherapy. The authors discuss some of the concepts that underlie the diagnosis though it can most easily be understood as severe non-psychotic pathology. Psychoanalytic theory has suggested several paradigms to understand and treat such conditions, and most of these rely on interpretation as the central therapeutic agent. The authors argue in this paper that therapists may need to consider the use of limit setting with patients with personality disorder where dangerous acting out may occur. This runs counter to the principles of therapeutic neutrality, and yet the limit setting may be a prerequisite to an effective therapeutic encounter.     

Economic impact of transluminal angioplasty

Using actual bills and follow-up records we attempted to determine the economic impact of percutaneous transluminal angioplasty. The patients selected included forty angioplasties performed early in our experience as well as forty comparable patients who had operations in the same period of time. Clinical follow-up was obtained over four years. The statistics obtained demonstrate the hospital bills for angioplasty were only 24% that of surgical treatment for femoral lesions ($1,329.00 versus $6,112.00) and 16% for iliac lesions ($1,353.00 versus $7,732.00). Using this patient sample and readily available statistical data, we calculated direct national savings for using angioplasty on all patients suitable and used a standard value of life analysis to estimate the value of lives saved by doing the less dangerous procedure. The sum total savings in the United States from using angioplasty in all suitable candidates as opposed to surgery would be $180 million per year for femoral lesions and $117 million for iliac lesions. This could produce a significant savings in medical costs over the coming years.     

Detection and Management of Alcohol Related Problems in General Practice

Abstract: It has often been suggested that general practitioners (GPs) are in an ideal position to detect early signs of alcohol related problems amongst their patients. However it appears that GPs often do not recognize the signs and symptoms of excessive alcohol consumption, and even when they do suspect that their patients are drinking too much, they are uneasy about discussing the issue. There is a gap between what GPs say they should do, and what they actually do; they acknowledge that warning patients about alcohol and health is part of their role, but in practice they neglect opportunities to promote healthy drinking. Some possible explanations of the gap between rhetoric and practice are discussed. General practitioners have been successful in helping patients give up smoking and this work is seen as a model for alcohol related interventions. A kit to assist the GPs respond to their drinking patients is currently being developed and evaluated. Early indications are that GPs are still reluctant to raise the topic of alcohol with their patients, even though their reactions to the kit are favourable.     

Efficacy of feedback training in long-standing facial nerve paresis

An efficacious treatment has not been available to patients with aberrant regeneration of the facial nerve as a result of Bell's palsy or after acoustic neuroma excision. This prospective controlled trial examines the efficacy of electromyographic feedback versus mirror feedback as treatment strategies for patients suffering from long-standing (18 months minimum) facial nerve paresis. Twenty-five patients were randomly assigned to electromyography with mirror feedback or mirror feedback alone. Seven rural patients who did not undergo treatment served as controls. At 0,6, and 12 months, facial motor function was objectively quantified by linear measurement of facial movement, visual assessment of voluntary movement, and electrical measurement of facial nerve response to maximal stimulation. Statistically significant improvements were noted in both electromyography and mirror-feedback groups with respect to symmetry of voluntary movement (P < .03) and linear measurement of facial expression (P < .01). The positive results of this controlled trial demonstrate that feedback training in combination with a structured home rehabilitation program is a clinically efficacious treatment for patients with facial nerve paresis.     

Combination diuretic treatment in severe heart failure: a randomised controlled trial.

OBJECTIVES--(a) To test the hypothesis that a fixed 3 day course of the combination of a thiazide and loop diuretic is as effective as more prolonged treatment in the management of severe resistant cardiac failure. (b) To compare two thiazide diuretics (bendrofluazide and metolazone) in combination with loop diuretics in the treatment of severe resistant cardiac failure. DESIGN--Randomised study with a 2 x 2 factorial design. SETTING--Provincial teaching hospital. PATIENTS--33 consecutive patients (40 episodes) admitted with severe congestive cardiac failure (New York Heart Association class III or IV) unresponsive to intravenous loop diuretics for 48 hours. MAIN OUTCOME MEASURES--Change in daily weight and serum electrolytes and clinical improvement in heart failure. RESULTS--Diuresis was established during 37 of 40 episodes; of the rest two patients died in hospital. On 36 occasions improvement was sufficient to allow discharge from hospital. Median (range) maximal weight loss was -5.05 (-11.3 to 1.6) kg after the addition of bendrofluazide and -5.6 (-12.2 to 4.8) kg after the addition of metolazone (NS). Area under the body weight loss against time curves showed no significant difference between the two thiazide diuretics. Median (range) maximal weight loss after three days of treatment was -5.4 (-12.2 to 4.8) kg and -5.5 (-10.3 to 1) kg after a more prolonged course of median (range) 5.6 (1 to 13) days (NS). Area under the body weight loss time curves showed no significant difference between the two durations of treatment. Bendrofluazide was associated with fewer electrolyte disturbances. CONCLUSIONS--Bendrofluazide and metolazone were equally effective in establishing a diuresis in patients with severe congestive cardiac failure resistant to loop diuretics. A fixed three day course of the combination was as effective as a longer course.     

Role of computed tomography in evaluating asbestos related lung disease

To find how computed tomography (CT) may be effectively used in individuals with suspected asbestos related lung disease 30 men with a history of exposure to asbestos were studied. All subjects underwent high kilovoltage posteroanterior and left lateral chest radiographs and chest CT. Eighteen were randomly selected asbestos workers referred for routine surveillance. The remaining 12 were patients who had been referred for investigation of respiratory symptoms or abnormal routine chest radiograph, or both, and found to have chest radiographic changes compatible with asbestos related lung disease. In the group referred for routine surveillance both pleural shadowing and pulmonary shadowing were shown on CT but not chest radiographs in only one case. Five were thought to have pleural shadowing on chest radiographs but this was confirmed on CT in only one case. All 12 patients referred for investigation showed pleural shadowing on chest radiographs; this was confirmed in all cases on CT which also showed unsuspected pulmonary shadowing in five cases. These findings suggest that it is not appropriate to use chest CT routinely in all asbestos workers referred for routine surveillance. When CT is used selectively in those with pleural shadowing on plain chest radiography, however, it is helpful in refuting or confirming the presence of pleural disease and may show unsuspected pulmonary shadowing.