Phaeochromocytoma in Pregnancy

Summary: An unusual case of phaeochromocytoma in pregnancy is reported. The patient had a history of recurrent hypertension and abruptio placentae with fetal death before the diagnosis was made. Another pregnancy complicated by 'toxaemia' followed excision of the tumour. General principles concerning diagnosis and management of phaeochromocytoma during pregnancy are discussed.     

Revascularization for foot salvage in diabetic critical foot ischaemia

A consecutive series of 32 diabetic patients, 16 male and 16 female, who presented to the authors with critical limb ischaemia was reviewed over a two-year period. Atherosclerotic risk factors and co-morbidities were present in 56% of these patients. Diagnostic angiography was performed in all patients. Revascularization was achieved in 91% of the cases with three perioperative deaths. Ten bypasses were anastomosed distally to one of the crural or ankle arteries at the foot. Major amputations were required in five patients who had had revascularization and in 4 of these gross sepsis was the main factor responsible for limb loss despite patent grafts. The primary graft patency rates at one month and one year were 96% and 90% respectively. Surgical reconstruction was possible in the majority of diabetic patients with critical ischaemia and should be offered to patients preferably before the establishment of gross sepsis to improve limb salvage.     

The electrical-respiratory analogy when gas density is high

The respiratory system can be considered analogous to a remarkably simple alternating-current electrical system with a resistor, an inductor, and a capacitor in series. This communication extrapolates the analogy from normal to hyperbaric environments with reference to information from experiments involving high-frequency, low-amplitude breaths (forced oscillations) in humans and various animals. Although the natural frequency, where inertial forces balance elastic recoil forces, is decreased by high density, the natural frequency does not become so low that it will be below the frequencies expected in exercising men; it falls from the normal 5 to around 1.5 breaths/s when density is increased 10-fold, but changes little more when density is increased further. When density is normal, total pressure for transporting gas through airways during forced oscillations is little more than pressure for overcoming airflow resistance over a range of frequencies from 1 to more than 15 breaths/s; this range of resistance domination shrinks when gas inertance increases, but the effect of high inertance tends to be countered by the increase of flow resistance that accompanies high gas density.     

Children's over‐the‐counter medicines pharmacoepidemiological (COPE) study

Objective To quantify the extent and types of minor ailments in children that were presented at community pharmacies and the types of over‐the‐counter (OTC) medicines purchased in response to these ailments. Method Data on all requests and sales of OTC medicines for children (aged 16 years and under) and consultations for minor ailments in children were recorded in eight community pharmacies for one week every month over a 12‐month period. Participants were members of the public who consulted the pharmacists or other pharmacy staff in the community pharmacies. Key findings A total of 976 consultations was recorded with 61.5% requesting an OTC medicine by name and 38.5% by symptom presentation. An average of 10.2 consultations was made per pharmacy per week. Requests for treatment were usually made within five days of symptom occurrence (86%). Most of the consultations were made by mothers (75%), although 17% were by fathers. The most commonly purchased OTC medicine was paracetamol. There were five requests for aspirin and one was for a 2‐year old child. A total of 62 cases (6%) was referred back to the child's primary care physician (general practitioner). Conclusions Symptoms related to cough and cold were the most common problems in children presenting to community pharmacies for treatment. Paracetamol was the most widely used OTC medicine in children. Pharmacy staff do question the request for OTC medicines such as aspirin, to ensure its safe use. Community pharmacies play an important role as the first port of call for advice on minor ailments in children and have an opportunity to provide health promotion to carers of children.     

Cost-effectiveness of prescribing statins according to pharmaceutical benefits scheme criteria.

OBJECTIVES: (i) To analyse how well Pharmaceutical Benefits Scheme (PBS) criteria for prescribing lipid-lowering therapy identify people most at risk of coronary heart disease (CHD); and (ii) to determine the cost-effectiveness of primary prevention therapy with pravastatin according to these criteria in Australia. DESIGN: (i) Analysis of targeting of CHD risk according to PBS criteria; (ii) cost-effectiveness analysis for pravastatin as primary preventive therapy (40 mg/day), with a 20-year projection from 1999. PARTICIPANTS: (i) Men and women aged 25-69 years from the 1989 National Heart Foundation Risk Factor Prevalence Survey; (ii) Australian men and women, aged 25-85 years, excluding those with diabetes and existing CHD. MAIN OUTCOME MEASURES: (i) Proportion eligible for lipid lowering treatment according to PBS criteria within 15-year risk of CHD mortality groups; (ii) average net cost in Australian dollars ($) per year of life saved (YOLS), with 80% uncertainty ranges (UR). RESULTS: (i) PBS criteria do not adequately identify those most at risk of CHD, as only 61% of Australians (aged 25-69 years) with a greater than 10% 15-year risk of CHD mortality were eligible for treatment; and 11% of those at low risk of CHD mortality (< 2.5% over 15 years) were eligible for treatment. (ii) Cost-effectiveness of treatment according to PBS criteria was estimated at $110,000 (80% UR, $96,000-$150,000) per YOLS for men and $87,000 (80% UR, $80,000-$130,000) per YOLS for women. As an indicator of the likely recurrent annual costs, total first-year treatment costs (excluding the costs of non-compliers) were estimated at $940 million. Assuming compliance of 50%, cost-effectiveness of treatment was markedly improved using 32.5% 15-year risk of CHD mortality as a cut-off, with ratios of $31,000 (80% UR, $27,000-$40,000) per YOLS for men and $39,000 (80% UR, $33,000-$53,000) per YOLS for women. First-year treatment costs of $940 million were the same as treating according to PBS criteria, but absolute health impact in terms of deaths averted and years of life saved was more than doubled. CONCLUSIONS: While PBS criteria do target patients at risk of CHD, there is room for improvement in identifying those most at risk of CHD, and treatment according to PBS criteria is not likely to be the most cost-effective. For optimal cost-effectiveness, targeting of therapy for primary CHD prevention needs to be based on population-specific, multivariable risk.     

Enalapril and renal injury in spontaneously hypertensive rats

Rats of the spontaneously hypertensive strain develop kidney damage that resembles the nephropathy seen in some cases of human essential hypertension. Previous studies with a triple drug antihypertensive regimen indicated that proteinuria and glomerular histopathology in spontaneously hypertensive rats might develop despite long-term effective control of systemic blood pressure. To investigate further the relation between hypertension and kidney disease, a group of spontaneously hypertensive rats were treated with enalapril at 15 weeks of age. Blood pressure, protein excretion, and kidney function were measured in those rats at regular intervals during the next year and a half and were compared with untreated spontaneously hypertensive rats and the normotensive Wistar-Kyoto parent strain. Kidney tissue samples from all three groups, collected at autopsy, were stained by immunohistochemical and conventional methods to assess the relative severity and nature of kidney damage. Although enalapril therapy was completely effective in controlling the blood pressure of spontaneously hypertensive rats, it only postponed the onset of kidney disease. Enalapril-treated spontaneously hypertensive rats eventually exhibited albuminuria as severe as that found in hypertensive rats. Kidney vessel pathology was completely prevented with enalapril, but the abnormal accumulation of mononuclear cells in tubulointerstitial and periglomerular sites was the same as in untreated spontaneously hypertensive rats. We have concluded that elevated protein excretion in rats of the spontaneously hypertensive rat strain is not a secondary consequence of systemic hypertension. Structural abnormalities of renal vessels also do not appear to contribute significantly to the pathogenesis of albuminuria in spontaneously hypertensive rats. Other explanations must be sought to account for the close link between spontaneous hypertension and kidney damage in this animal model. The clear dissociation of kidney disease from systemic hypertension exhibited by spontaneously hypertensive rats may also be relevant for human disease.     

Cisapride in the treatment of post-operative ileus

The effect of cisapride on duration of post-operative ileus after surgery was investigated in a randomized, double-blind, placebo-controlled study. Patients undergoing elective upper gastrointestinal (n = 47) or colonic (n = 22) surgery were pre-operatively randomly allocated to treatment with either cisapride 30 mg t.d.s., by rectal administration, or placebo. Treatment started exactly 48 h after surgery if the patient at this time had not passed stool. Time to passage of first stool after surgery was estimated. Mean time to passage of stool was 85 (32) h (s.d.) for cisapride-treated and 91 (43) h for placebo-treated patients. No difference between the treatment groups was noted. Treatment with cisapride did not shorten the duration of postoperative ileus after either upper gastrointestinal or colonic surgery.     

Factors associated with proteinuria in renal transplant recipients treated with sirolimus

Although sirolimus (SRL) use in renal allograft recipients (RTX) is associated with improved renal function, proteinuria develops in a significant proportion. 48 SRL-treated RTX were evaluated for development of proteinuria and stratified by level of proteinuria after SRL therapy. The Proteinuria Group ( n  = 25, 52.1%) had new-onset proteinuria or >25% increase in proteinuria following SRL conversion; the Nonproteinuria Group had stable proteinuria <0.5 g/day throughout. There was a higher proportion of male RTX and female donors to male recipients in the Proteinuria Group, (24% vs. 10%, P  = 0.008). Calcineurin inhibitor- and statin usage were significantly higher in the Nonproteinuria Group (8% vs. 17%, P  = 0.046; 28% vs. 83%, P  < 0.001 respectively) whereas biopsy-proven acute rejection was higher in the Proteinuria Group (68% vs. 33%, P  = 0.037). SDS-PAGE analysis of urine from 23 RTX in the Proteinuria Group demonstrated glomerular proteinuria in 100% and tubular proteinuria in 87%. While male gender and gender mismatch may impact on glomerular proteinuria through inadequate nephron dose and subsequent hyperfiltration, concurrent cyclosporine use may mitigate the development of proteinuria in SRL-treated patients, through afferent arteriolar vasoconstriction. Glomerular injury occurring following acute rejection may further contribute to glomerular proteinuria. Statins, through their anti-inflammatory and anti-fibrotic effects, may protect against development of proteinuria.     

Pushed to the margins and pushing back: a case study of one adult's reflections on social interactions after a traumatic brain injury sustained as an adolescent

Traumatic brain injury (TBI) is a worldwide chronic health problem. Current empirical approaches to defining factors that contribute to a meaningful life after TBI have been limited to the biomedical perspective. Such a limited paradigm fails to address how people with TBI find meaning and act on and are acted on by the world in which they live. Between 2005 and 2007 an in-depth qualitative case study was conducted. The primary data source was a man's retrospective journal writings about his life after sustaining a severe TBI. The qualitative perspective of symbolic interactionism framed this case study analysis. Meaning is strongly influenced by the ways in which the social world interacts with the injured person. Despite an accumulation of negative social experiences, a traumatically brain-injured person can also assign positive meanings to the quality of his or her life. This has been ignored or explained away as a defense mechanism in previous investigations. More studies that include unbiased methods able to capture subjective experiences and what they mean to individuals with TBI are needed. This information will lead to more relevant interventions and better outcome instruments for use with this population.