Failure of repeated blood patch in the treatment of spinal headache

The management of a persistent, incapacitating postdural puncture headache that required four consecutive autologous epidural blood patches is presented. Inadequate blood volumes, early patching and steroid in the epidural space are considered as possible causes of failure. Other associated problems and interventions are briefly discussed.     

Linear IgA disease in adults

A multi-centre study is described in which thirty-five adult patients with papillary IgA dermatitis herpetiformis (DH) were compared with forty-two patients with linear IgA deposits, of whom thirty-four had homogeneous-linear (HL) and eight had granular-linear (GL) IgA deposits. The three groups were similar with regard to age of onset, presence of circulating immune complexes and auto-antibodies, incidence of spontaneous remission, histology of lesional skin and response to dapsone. There was a female predominance in the HL group in contrast to the male predominance in the other two. It was not possible to diagnose the HL group clinically. Some patients had a rash typical of DH whilst others resembled pemphigoid. In the majority, however, no specific diagnosis could be made with confidence. The GL group clinically resembled the DH group. The incidence of positive potassium iodide patch tests was greater in the DH group than in the other two. An associated enteropathy was found in 24% of patients in the HL group, 30% of patients in the GL group and 85 % of patients in the DH group. Fifty-six percent of HL patients had HLA-B8 compared with 50% in the GL group and 88% in the DH group.     

Effect of Chronic Ethanol Ingestion on the Structure and Function of Liver, Adrenals and Testes of Male Rats

Ethanol was given as a 15% (v/v) solution in the drinking waterto male rats for 58–108 weeks. There was no evidence oftrue induction of hepatic microsomal enzyme activity nor offatty liver. Biphenyl- and aniline-4-hydroxylase activitieswere increased, however, probably due to enzyme activation resultingfrom removal of bound endogenous substrate by ethanol ratherthan to new enzyme protein synthesis. Treated animals had markedlyenlarged adrenal glands but adrenal histology and serum corticosteronelevels were unaffected. The testes were increased in size andweight but their histological appearance was normal. Plasmatestosterone levels were lower than in controls and plasma LHlevels were markedly elevated. Plasma testosterone protein bindingcapacity was normal. It is postulated that an early effect ofethanol on the testis is to inhibit testosterone synthesis leadingto a compensatory increase in plasma LH secretion and secondarytesticular hypertrophy. The findings are discussed in relationto other experimental studies and their possible relevance tohuman alcoholism.     

The symptomatology of the climacteric in relation to hormonal and cytological factors

Summary. Climacteric symptomatology was investigated in a group of non-selected women aged between 54 and 56 years of age, Vasomotor complaints and dyspareunia, in particular, were noted and related to plasma hormone levels and vaginal cytology. Only 33% of those women who were within 5 years of the menopause had symptoms of a magnitude that might require hormone replacement therapy. Neither the vasomotor complaints nor dyspareunia correlated with the hormone levels or cytology findings to such an extent as to be helpful in planning treatment. Aarently only a minority of women in their middle 50s demonstrate a symptomatic need for hormone replacement therapy and laboratory investigations are of little use in their identification.     

Evaluation of Electrocardiographic Leads for Detection of Atrial Activity (P Wave) in Ambulatory EGG Monitoring: A Pilot Study

The usual lead systems for ambulatory ECG monitoring (AECG) used in the evaluation of arrhythmias is a modified bipolar V-1 and V-5. A comparison of various lead systems to enhance the detection of atrial activity (p waves) has not been reported. We evaluated various surface lead systems in 12 subjects comparing p waves recorded at 20 mm/mV and 50 mm/sec. We compared p wave area, amplitude, and duration from modified bipolar V1 and V5 as well as seven nonstandard leads recorded on a AECG monitor. Of the seven nonstandard leads, a vertical sternal lead, with the negative pole just below the suprasternal notch and the positive pole at the xiphoid process, had the largest area (1.46 +/- 0.65 mm2), and also had a greater area than the standard V1 (0.88 +/- 0.45 mm) and V5 (1.06 +/- 0.49 mm2) lead system (P less than 0.01). We conclude that the bipolar vertical sternal lead system provides a larger p wave area than seven nonstandard bipolar lead systems and the two standard lead systems currently used in AECG monitoring. Replacement of the modified bipolar V1 lead with a vertical sternal lead should improve the recognition of atrial activity and, therefore, enhance the diagnosis of cardiac arrhythmias.     

Acute Renal Failure due to Bacterial Pyelonephritis

Five patients who presented with acute renal failure in associationwith urinary tract infection are reported. Renal function improvedrapidly on antibacterial therapy and no alternative cause foracute renal failure could be Identified. None had previouslybeen known to have renal disease but three of the five had takenconsiderable amounts of analgesics. The unusual severity of renal functional impairment resultingfrom urinary tract infection in these patients is unexplainedbut may relate to previous analgesic abuse and/or delay in treatment.Since acute non-obstructive pyelonephritis may result in severereversible renal failure, this diagnosis must be consideredin patients presenting with acute uraemia.     

The effect on plasma corticosteroid levels of the short term topical application of clobetasol propionate

Thirty-four patients with skin diseases which necessitated treatment with potent topical steroids at a hospital clinic were studied. All the patients received clobetasol propionate ointment (Dermovate) for a period of 2 weeks and sixteen of the patients continued with their treatment for 4 weeks, during which time their plasma corticosteroid levels were measured. Thirty patients had normal levels throughout the whole period of study (≥ 6 μg/100 ml) and five patients showed a depressed level at some stage during the investigation. Of six patients who were using a large amount of clobetasol ointment (more than 100 g/week) and who had a significant proportion of their body affected by disease (20-80%), two had lowered plasma corticosteroid levels and in four there was no evidence of adrenal suppression.     

Failure of intradermal skin testing with gluten to produce delayed hypersensitivity reactions in patients with dermatitis herpetiformis

Dermatitis herpetiformis (DH) is characterized by a rash and a gluten-sensitive enteropathy (GSE) indistinguishable from that of coeliac disease. T-cell-mediated mechanisms have been implicated in the pathogenesis of GSE. It seems feasible that intradermal injection of gluten, in patients known to have GSE, could lead to an influx of T cells sensitized to gluten, with subsequent development of a delayed hypersensitivity-type reaction. Six patients with DH and three normal subjects had intradermal injections of‘Frazer's fraction III’ (FFIII; the partial peptic tryptic digest of gluten which is known to be antigenic) and phosphate-buffered saline (PBS) as a control. Skin biopsies were taken at PBS and FFIII injection sites at 48 h. In addition, two of the patients with DH had biopsies taken of FFIII injection sites at 6 h. Monoclonal antibodies and the avidin-biotin-peroxidase technique were used to stain for T cells in the skin biopsies. A monoclonal antibody to a neoepitope exposed in the terminal complement complex and an immunofluorescent method were used to detect the presence of terminal complement component in biopsies taken from two of the control subjects and two of the patients. Both patients and control subjects developed a weal and flare within a few minutes of injecting the FFIII, and this persisted for up to 6 h. No skin reaction was present in either the patients or the control subjects at 48 h. No skin reaction was visible at any time following injection of PBS. There was no increase in T cells in biopsies taken at 6 or 48 h from the FFIII injection sites compared with the PBS injection sites. Terminal complement component was present in the biopsies taken from DH patients at both the PBS and FFIII injection sites (6 and 48 h), but was absent from the biopsies taken from the control subjects. Normal delayed hypersensitivity responses to a battery of common recall antigens showed that the lack of response to FFIII was antigen specific. Thus, this study suggests that the T cells sensitized to gluten in patients with GSE are unable to migrate to the skin.     

Dermatitis herpetiformis exacerbated by indomethacin

Thirteen adults with dermatitis herpetiformis (DH) controlled by dapsone or sulphamethoxypyridazine were given indomethacin or placebo in a double-blind cross-over study. In nine of the thirteen patients the rash and pruritus of DH were exacerbated more by indomethacin than by placebo. Dapsone and sulphamethoxypyridazine requirements were increased during the indomethacin period. The involvement of lipoxygenase products in the pathogenesis of the DH skin lesions is postulated.