An audit of 24-hour creatinine clearance measurements at Tygerberg Hospital and comparison with prediction equations.

BACKGROUND: Internationally, clinical guidelines recommend the use of creatinine-based equations to estimate glomerular filtration rate (GFR) for assessment and follow-up of kidney disease. The routine use of 24-hour creatinine clearances (CrCl) is no longer advocated. OBJECTIVES: To examine the indications for requesting CrCl at Tygerberg Hospital, identify problems associated with the procedure, and evaluate the utility of the Cockcroft-Gault (CG) and Modification of Diet in Renal Disease (MDRD) equations with different levels of renal dysfunction in the ethnic groups of the Western Cape. METHODS: A clinical audit of CrCl was performed. The estimated GFR as predicted by the modified CG and MDRD formulae was compared with CrCl in 252 patients, representing three local ethnic groups. MDRD formulae with and without the correction factor for black ethnic group (MDRD-B) were evaluated. RESULTS: Problems with urine collection or data supplied were identified in one-third of CrCl requests, leading to unreliable results. The CG correlated best with CrCl in the group as a whole. The average absolute and percentage differences from CrCl in the different ethnic groups were as follows: coloured (mixed ethnicity) (N = 186) - CG 13.4 ml/min/1.73 m(2) (18%), MDRD 16.8 ml/min/1.73 m(2) (23%) and MDRD-B 27.9 ml/ min/1.73 m(2) (38%); black (N = 21) - CG 14.8 ml/min/1.73 m(2) (19%), MDRD 12.9 ml/min/1.73 m(2) (17%) and MDRD-B 25.1 ml/min/1.73 m(2) (33%); white (N = 45) CG 13.5 ml/min/1.73 m2 (19%), MDRD 15.3 ml/min/1.73 m(2) (21%) and MDRD-B 24.8 ml/min/1.73 m(2) (35%). Throughout the renal function levels (chronic kidney disease stages 1 - 5) CG correlated better with CrCl than MDRD. CONCLUSIONS: Possible reasons for poor correlations include a high prevalence of obesity, underweight and normal GFR in the study population. There is a need for further research, using a gold standard, into the accuracy of these prediction equations in our unique patient populations before firm recommendations can be made regarding their use. Until then CrCl will continue to be widely used. Greater efforts at patient and health care worker education are required to ensure proper collections.     

Long-term hypertransaminasemia disclosing a muscular disease

Prolonged increase in serum transaminase activity is usually seen in chronic liver disease. Evaluation in one patient with such a prolonged increase having no evidence of liver disease including histological examination, revealed a limb girdle muscular dystrophy. This case suggests that a muscular disease should be suspected in all children with persistent increase in serum transaminase activity when the liver is apparently normal.     

Evaluation of the end-expiratory lung volume as an indirect index of bronchial constriction in asthma

The purpose of this study was to evaluate the merits of the end expiratory lung volume as an indirect ventilatory index of bronchial obstruction and to show an application of continuous monitoring of lung volume in asthmatic patients. The accuracy of the external measurements (IS) of functional residual capacity (FRC) was controlled by comparing them with the helium measurements (DS) obtained during nine methacholine tests (IS = 0.06 + 1.065 DS in litres: R2 = 0.99). Seven asthmatics (18-48 yr) were monitored by measuring rib cage and abdominal perimeter variations. This was done in basal condition, after methacholine-induced bronchoconstriction and after bronchodilation by either salbutamol or oxytropium bromide inhalation. All the subjects were investigated on two separate days and were their own control. Bronchoconstriction produced a significant increase (p less than 0.01) of tidal volume (VT: + 67%), external minute ventilation (VE: + 58%), mean inspiratory flow (VT/TI: + 78%) and FRC (+ 26.5%) while frequency (f) and fractional inspiratory time (TI/TT) fluctuated non significantly. In the group of seven tested subjects, there was a significant correlation (p less than 0.01) between forced expiratory volume in one second (FEV1) and VE, FEV1 and VT/TI, FEV1 and FRC. However, the individual regression line showed a significant relationship only between FEV1 and FRC (R2 = 0.80 +/- 0.04). We therefore conclude that the variation of the end expiratory level can be chosen as an indirect index of bronchoconstriction.(ABSTRACT TRUNCATED AT 250 WORDS)     

Value and limits of "critical auscultation" of neck bruits

Within a group of 2,000 patients evaluated, most of them with symptoms of cerebrovascular insufficiency, 441 had a monolateral or bilateral cervical bruit. The 627 sides with an audible bruit were divided into main groups (A) symptomatic (TIA and/or stroke homolateral to the bruit), (B) possibly symptomatic (non-side-related symptoms), (C) asymptomatic (C1, in totally asymptomatic patients; C2, in patients with symptoms dependent on the hemisphere contralateral to the cervical bruit). Each patient was studied by means of clinical (history, blood pressure in both upper limbs, phonoendoscopic auscultation at various levels) and noninvasive instrumental examinations (CW Doppler spectrum analysis). An apparently primitive cervical bruit corresponded to a lesion of the carotid bifurcation in 61% of the cases (positive predictive value) whereas a normal bifurcation was detected in 70% of the cases in which the cervical bruit was considered as secondary (negative predictive value); the diagnostic accuracy of the "critical auscultation" has a value therefore of 63%, with a sensitivity of 84% and a specificity of 40%. The results obtained in the different groups of patients (symptomatic or asymptomatic) were not significantly different (chi-square). Even though maintaining the value of a cervical bruit as a sign of carotid stenosis or occlusion and consequently confirming the importance of neck auscultation, the authors conclude that the critical auscultation as commonly performed is not capable of excluding the presence of a carotid lesion with sufficient reliability, even in totally asymptomatic patients.     

Revisiting the oddball paradigm. Non-target vs neutral stimuli and the evaluation of ERP attentional effects.

We recorded topographic mapping of auditory evoked potentials (AEPs) to homogeneous series of tones delivered in the absence of any cognitive task ("neutral condition") and compared them with responses to identical stimuli when they acted as non-targets in an oddball paradigm. With respect to the neutral condition, non-target responses showed an increase in N100 amplitude which was found to depend on two different, but partially overlapping effects. The "early effect" had similar latency and topography as exogenous N100 and may reflect changes in the overall state of alertness since its amplitude declined at the end of the test. The "late effect" affected the N100s descending slope and had features consistent with those of a processing negativity. It was frontally distributed, and topographic mapping revealed a right-sided predominance. Finally, non-target responses exhibited a central positivity (P250) which did not appear in neutral AEPs. P250 shares several features, including latency, amplitude and scalp topography, with the endogenous ERP component commonly labelled "P3a". Non-target P250 could be the result of an attentional shift towards the stimuli, and reflect some aspects of the classification process. We suggest that non-target responses in simple oddball paradigms should be routinely studied along with target responses in order to improve the diagnostic capabilities of cognitive ERPs. Notably, non-target responses may help to decide whether an abnormal target-P300 is related or not to a deficit in the mobilization of attentional resources.     

Connectedness: some skills for spiritual health

Abstract This article explores the relationship between connectedness and spiritual health. Three forms of connectedness are discussed: connecting with oneself, with others, and with a larger meaning or purpose. Eight connectedness skills are suggested. Combined, these skills may lead to an enhanced sense of spiritual well-being.     

Iridoids from Scaevola racemigera1

Five iridoids have been isolated from the aerial parts of SCAEVOLA RACEMIGERA D?niker, namely, loganin, loganic acid, sylvestroside III, cantleyoside, and scaevoloside. This latter is a novel compound whose structure 1 has been elucidated on the basis of its spectral data, mainly (1)H- and (13)C-NMR.     

Is the auditory sensory memory sensitive to visual information?

The mismatch negativity (MMN) component of auditory event-related brain potentials can be used as a probe to study the representation of sounds in auditory sensory memory (ASM). Yet it has been shown that an auditory MMN can also be elicited by an illusory auditory deviance induced by visual changes. This suggests that some visual information may be encoded in ASM and is accessible to the auditory MMN process. It is not known, however, whether visual information affects ASM representation for any audiovisual event or whether this phenomenon is limited to specific domains in which strong audiovisual illusions occur. To highlight this issue, we have compared the topographies of MMNs elicited by non-speech audiovisual stimuli deviating from audiovisual standards on the visual, the auditory, or both dimensions. Contrary to what occurs with audiovisual illusions, each unimodal deviant elicited sensory-specific MMNs, and the MMN to audiovisual deviants included both sensory components. The visual MMN was, however, different from a genuine visual MMN obtained in a visual-only control oddball paradigm, suggesting that auditory and visual information interacts before the MMN process occurs. Furthermore, the MMN to audiovisual deviants was significantly different from the sum of the two sensory-specific MMNs, showing that the processes of visual and auditory change detection are not completely independent.