Effect of alcohol on the lactate/pyruvate ratio of recently injured adults

OBJECTIVE: To compare the ability of plasma (lactate) and the plasma lactate/pyruvate (L/P) ratio to predict shock-related outcome after injury and also to examine the influence of plasma ethanol on any relationships found. DESIGN: Prospective observational study. SETTING: Emergency departments in the UK and the Republic of South Africa. PATIENTS: Blood samples were taken at presentation from 232 adult patients 1-23 hrs (median, 3.5 hrs) after sustaining an injury or injuries deemed sufficiently severe to require inpatient care. MEASUREMENTS: Plasma concentrations of lactate, pyruvate, and ethanol, anatomical severity of injury, development of multiple organ failure, and 30-day survival were determined. RESULTS: At 90% specificity for predicting subsequent mortality and/or multiple organ failure, plasma lactate >or=3.85 mmol/L was 23% (5% to 41%) more sensitive than an L/P ratio of >or=42.76. At 90% sensitivity for ruling out morbidity, plasma lactate <1.6 mmol/L is 6% (-1% to 13%) more specific than an L/P ratio of <14.08. High L/P ratios were noted to be associated with a detectable plasma alcohol level. A post hoc regression analysis showed that alcohol-positive/-negative status was a much stronger predictor of the L/P ratio than was anatomical severity of injury, shock, or time after injury. CONCLUSIONS: Plasma lactate alone is a better predictor than the L/P ratio of shock-related outcome after injury. The interpretation of L/P ratios after injury is confounded in the presence of elevated plasma ethanol.     

Aerobic exercise capacity in patients with juvenile dermatomyositis

OBJECTIVE: To examine the feasibility of maximum exercise testing in patients with juvenile dermatomyositis (JDM), characterize the maximum oxygen consumption (VO2peak) of these patients, and determine if exercise time could be used as an surrogate index for VO2peak. METHODS: Fifteen patients diagnosed with JDM (age 5-14) performed a graded, maximum exercise test using a motor driven treadmill and metabolic cart to volitional exhaustion conforming to the Bruce protocol. RESULTS: All patients were able to perform the exercise test. Ten of the 15 patients performed a maximal effort (heart rate > 180 beats/min or respiratory exchange ratio > 1.0). The patients who had a maximal exercise performance, the mean absolute VO2peak, relative VO2peak (related to body mass), and exercise time were respectively -1.82 (+/- 1.5), -2.83 (+/- 1.9), and -3.65 (+/- 1.9) standard deviations lower compared to age and sex matched reference values (p < 0.05). Z scores for exercise time were significantly lower compared to Z scores for absolute and relative VO2peak, an indication of reduced muscular economy. When exercise time was converted to VO2peak using the equation: VO2peak = 0.1583 (exercise time) + 0.0828, the VO2peak values were not significantly different from the measured VO2peak values. CONCLUSION: Aerobic exercise testing on a treadmill was possible in patients with JDM and revealed an impairment in their maximal aerobic exercise capacity. Exercise time can be used as an indicator of VO2peak, when converted to VO2peak using a regression equation. VO2peak, measured or estimated, has the potential to be a good indicator of muscle function in patients with JDM.     

Behavioral surveillance: current perspectives,and its role in catalyzing action

In the age of 2nd generation surveillance, behavioral surveillance systems form one of the central components of national HIV monitoring systems. Different approaches to behavioral monitoring and the comparative role of behavioral surveillance are discussed, followed by an exploration of some of the practical issues that arise in the implementation of behavioral surveillance systems. This article concludes by stressing the importance of ensuring that the results of behavioral surveillance work are translated into actions that improve the national response to HIV.     

Both body and arm position significantly influence blood pressure measurement

The position of both the body and the arm during indirect blood pressure (BP) measurement is often neglected. The aim of the present study was to test the influence of the position of the patient on BP readings: (1) sitting with the arms supported precisely at the right atrium level and (2) supine: (a) with the arms precisely at the right atrium level and (b) with the arms on the examination bed. In a first group of 57 hypertensive patients, two sessions of BP and heart rate (HR) measurements were performed in two positions: sitting and supine with the arms supported precisely at right atrium level in both positions. BP was measured simultaneously at both arms, with a Hawksley Random Zero sphygmomanometer at the right arm, and with an automated oscillometric device (Bosomat) at the left arm. BP and HR readings obtained in the two positions were then compared. In a second group of 25 normo- and hypertensive persons, two sessions of BP and HR readings were performed in supine with the arms in two different arm positions: (a) the arm placed precisely at right atrium level and (b) the other arm on the examination bed. The measurements were performed at both arms with two automated devices (Bosomat). The readings taken in the two positions were compared. Both systolic BP (SBP; by 9.5 +/- 9.0 (standard deviation, s.d.); right arm) and diastolic BP (DBP; by 4.8 +/- 6.0 mmHg; right arm) were significantly higher in the supine than in the sitting position. When the two different arm positions (body continously supine) were compared in the second part of the study, significantly higher SBP (by 4.6 +/- 6.1 mmHg) and DBP (by 3.9 +/- 2.8 mmHg) were obtained when the arm of the patient was placed on the bed (below the right atrium level), than when the arm was placed at the level of the right atrium. BP readings in sitting and supine positions are not the same. When according to guidelines the arm of the patient is meticulously placed at the right atrium level in both positions, the difference is even greater than when the arm rests on the desk or on the arm support of the chair. Moreover, in the supine position small but significant differences in BP are measured between arm on a 5 cm-high pillow and arm on the bed. In every study reporting BP values, the position of both the body and especially the arm should be precisely mentioned.     

Kayser-Fleischer like rings in alcoholic liver disease: a case report

Kayser-Fleischer rings are brown pigmented rings that run along the periphery of the cornea. Situated in Descemet's membrane and being comprised of granules of deposited copper they have traditionally been thought of as pathognomic of Wilson's disease. However, they can also be seen in other forms of liver disease. We document a case of Kayser-Fleischer like rings occurring in alcoholic liver disease--a previously unreported association.     

Acute rheumatic fever in a patient with glycogen storage disease type Ib: causal or coincidental simultaneous occurrence?

We report a Caucasian female who was diagnosed with glycogen storage disease type Ib (GSD-Ib) at the age of 4 months and whose clinical course was complicated by neutropenia and very frequent episodes of infection, including tonsillopharyngitis. Recurrent group A streptococcal infections resulted in multiple episodes of extremely high serum levels of antibodies to streptolysin O (5,000 IU/ml) and DNAse B (6,000 IU/ ml). At the age of 14 years she presented with carditis, migratory arthritis, fever, elevated erythrocyte sedimentation rate as well as serological evidence for recent streptococcal infection providing a diagnosis of acute rheumatic fever. CONCLUSION: the occurrence of these two very rare disorders in our patient may indicate that this association is not coincidental because neutrophil dysfunction in glycogen storage disease type Ib may have predisposed this patient to acute rheumatic fever due to increased susceptibility to group A streptococcal infections. aberrant glycogenolysis and gluconeogenesis, neutropenia and neutrophil dysfunction are regular findings in GSD-Ib. Neutropenia and neutrophil dysfunction in patients with GSD-Ib are due to defects in myeloid maturation, impaired neutrophil motility, defective chemotaxis and phagocytosis and diminished bactericidal activity resulting in recurrent bacterial infections.