Alcohol and the accident and emergency department: a current review

Alcohol misuse constitutes a major problem in our modern society and both physical and mental alcohol-related harm result in a large number of Accident and Emergency (A&E) attendances, thus imposing a significant burden on the workload and financial resources of the department. The current management of problem drinking by most A&E departments could be further improved. The introduction of a holistic approach that includes efficient screening instruments and effective brief, anti-alcoholic interventions, for the management of these patients must be considered. This should strengthen the preventive role of A&E departments, and, in the long term, may result in a decrease in the number of cases of alcohol misuse and in alcohol-related attendances.     

Prostate cancer presenting as a solitary cerebellar metastasis. A case report and review of the literature

We describe a case of a 70-year-old patient with sudden onset of gait ataxia, headache, dizziness and dysarthria. Magnetic resonance imaging revealed a solitary lesion in the left cerebellar hemisphere with strong and irregular enhancement of the contrast medium, surrounded by extensive edema. Rectal examination revealed an abnormally enlarged and stiff left prostate lobe, and ultrasound-guided transrectal biopsies showed prostate adenocarcinoma of mild differentiation. Neurosurgical intervention and histopathologic examination revealed metastatic prostate adenocarcinoma. The patient underwent orchiectomy and was given antiandrogens. He is still alive and closely followed. According to the literature, prostate cancer presenting as a solitary cerebellar metastasis is an extremely rare clinical problem.     

The effects of strength training, cardiovascular training and their combination on flexibility of inactive older adults

The purpose of this study was to investigate the effects of aerobic training, strength training and their combination on joint range of motion of inactive older individuals. Thirty-two inactive older men (65 - 78 yr) were assigned to one of four groups (n = 8 per group): control (C), strength training (ST), cardiovascular training (CT), and combination of strength and aerobic training (SA). Subjects in the S, A, and SA trained three times a week for 16 weeks. ST included 10 resistance exercises for the major muscle groups at an intensity of 55 - 80% of 1-RM and CT included walking/jogging at 50 - 80 % of maximal heart rate. Body weight and height, physical activity level and maximal oxygen uptake (.VO(2)max) were measured before the training period. Isokinetic (60 and 180 deg x sec(-1)) and concentric strength (1-RM in bench and leg press) were assessed prior to and at the end of the training period. Hip flexion, extension, abduction, and adduction, shoulder extension, flexion, and adduction, knee flexion, elbow flexion and sit-and-reach score were determined before and at 8 and 16 weeks of training. There were no differences between groups in .VO(2)max, body weight, and height (p < 0.05). ST and SA but not CT and C increased isokinetic and concentric strength at the end of the training period (p < 0.05). ST and SA increased significantly (p < 0.05) sit-and-reach performance, elbow flexion, knee flexion, shoulder flexion and extension and hip flexion and extension both at mid- and post-training. CT increased (p < 0.05) only hip flexion and extension at post training. Results indicate that resistance training may be able to increase range of motion of a number of joints of inactive older individuals possibly due to an improvement in muscle strength.     

Recombinant factor VIII SQ--the influence of formulation parameters on structure and surface adsorption

The main aim of this paper was to investigate the influence of temperature, pH and ionic interactions on the structural stability and surface adsorption of a recombinant factor VIII product, r-VIII SQ. The interaction of r-VIII SQ with glass and air interfaces, and possible means of increasing the stability of the formulation, were also investigated. The stability of r-VIII SQ was followed by measuring the biological activity (VIII:C), by circular dichroism (CD) studies and by the measurement of surface tension using the pendant drop method. The results show that the surface tension decreased exponentially with time; this decrease was more pronounced above 20 degrees C, indicating increased conformational flexibility of the protein with increased temperatures. Far UV CD spectra were not influenced in the range 5-55 degrees C and near UV CD measurements did not indicate structural changes below 45 degrees C. During agitation at 25 degrees C, VIII:C was lost rapidly in formulations without a macromolecular additive. Nonionic surfactants such as polysorbate 80 and polysorbate 20 protected VIII:C to an equally high degree against surface adsorption. Albumin was less effective, but it is possible that this is because it is a protein itself and may have been affected by the agitation. The addition of 300 mg/ml of sucrose improved the long term stability of VIII:C, a finding most likely explained by the theory of preferential hydration. Near UV CD spectra at acidic or basic pH mainly indicated changes around 242 nm, especially at low ionic strength. Addition of 10 mM EDTA at pH 7 resulted in similar changes. This effect was completely reversed by the addition of an excess of Ca(2+), Sr(2+) or Mg(2+) ions. In conclusion, CD spectra and surface tension measurements of r-VIII SQ did not reveal any temperature-induced conformational changes in the temperature range 5-20 degrees C; changes were first noted at elevated temperatures. Surface adsorption of r-VIII SQ during agitation was prevented by the addition of a nonionic surfactant. Preferential hydration improved the storage stability of the protein but did not directly prevent its surface adsorption. The structural integrity of the molecule was preserved at pH 7, at an increased ionic strength and in the presence of some divalent metal ions (Ca(2+), Sr(2+) or Mg(2+)).     

Management of 150 flail chest injuries: analysis of risk factors affecting outcome.

OBJECTIVE: Flail chest continues to be an important injury with significant complications. The records of 150 patients presenting with flail chest injury were reviewed to determine risk factors affecting morbidity and mortality. MATERIAL AND METHOD: During a 7-year period 150 patients with a flail chest injury were admitted to our trauma center. There were 111 men (74%) and 39 women (26%) ranging in age from 18 to 88 years with a mean age of 56.9. Only 66 (44%) had an isolated flail chest injury on admission. The majority of patients were older than 55 years (n = 89, 59.3%), 80 (53.3%) presented with an hemo-, or/and pneumothorax, 36 (24%) sustained a head injury and 25 (16.7%) needed ICU monitoring. The mean ISS score was 38. Age, concomitant diseases, presence of pneumothorax and/or hemothorax, Severity Score (ISS), the need for mechanical support, length of stay and deaths were evaluated by using the t-test and chi2 test where appropriate. RESULTS: Sixty-seven patients (44.6%) were conservatively treated, while 80 (53.3%) needed thoracic drainage. Only in 6 cases (4%) thoracotomy was required, while in 9 (6%) laparotomy was performed. Mortality rate reached 5.3%. The main factors correlated with an adverse outcome were: ISS and the presence of associated injuries, while age, hemopneumothorax and mechanical support affected the length of hospitalization but not the mortality. CONCLUSIONS: (1) Age and hemopneumothorax did not affect mortality. (2) ISS was found to a strong predictor on outcome concerning morbidity and prolonged hospitalization but did not influence mortality rate. (3) Mechanical support was not considered a necessity for the treatment of flail chest.     

Production and clearance of lactate from brain tissue, cerebrospinal fluid, and serum following experimental brain injury

Lactate dynamics in the brain, cerebrospinal fluid (CSF), and serum were studied in 20 chloralose-anesthetized cats following fluid-percussion trauma. Brain lactate and brain tissue pH were measured by hydrogen-1 and phophorus-31 magnetic resonance spectroscopy. The CSF, arterial, and cerebrovenous serum lactate levels as well as serum glucose concentration were quantified. In the six sham-operated control animals, brain, CSF, cerebrovenous, and arterial lactate levels as well as brain pH remained at normal values. In the five animals in the mild-trauma group (1.6 atm), brain and CSF lactate levels were moderately elevated, although the brain pH and serum lactate content remained at control values. Severe trauma (3.1 atm) in nine cats produced an 82% increase in the brain lactate index and a reduction in brain tissue pH (7.02 +/- 0.02 to 6.95 +/- 0.02; mean +/- standard error of the mean), indicating brain tissue acidosis caused by excessive lactate accumulation. Brain lactate levels reached a peak 1 1/2 hours after severe trauma, then steadily decreased to normal levels by 8 hours posttrauma. Maximum increases of CSF and arterial lactate levels (from 1.4 +/- 0.2 to 4.1 +/- 0.4 and from 1.6 +/- 0.2 to 4.1 to 0.6 mmol/liter, respectively) were observed 15 minutes after trauma, and the values decreased during the next 2 hours. The response was biphasic, with a secondary rise observed in both CSF and serum lactate levels during the remaining 4 hours of the experiment. The difference between the arterial and venous lactate levels (A-Vlact) gradually increased and reached a peak 2 hours postinjury (from -0.05 +/- 0.10 to -0.41 +/- 0.09 mmol/liter). The results of this study show that the production of lactate in brain tissue, CSF, and blood increased in proportion to the severity of the injury. The observation that lactate levels in blood and CSF are maximum immediately following impact while brain lactate and A-Vlact are gradually increasing suggests that the brain-tissue production of lactate fails to account for the rapid appearance of lactate in CSF and blood. It is speculated that the initial elevation of CSF lactate values reflects the systemic response of trauma, and the secondary rise of CSF lactate levels following severe trauma is due to slow seepage of lactate produced by brain tissue into the CSF space. These studies are the first to describe the temporal profile of brain lactate production and eventual clearance by CSF and blood in fluid-percussion injury.(ABSTRACT TRUNCATED AT 400 WORDS)     

Ectopic thyroid tissue in the lower neck with a coexisting normally located multinodular goiter and brief literature review

Ectopic thyroid tissue in the lower neck with a coexisting normally located multinodular goiter is a rare entity. We present a 27-year old asymptomatic woman with a recent history of a painless mass in the left side of her lower neck. Thyroid function tests were normal. An ultrasound of her neck showed a multinodular goiter and a 3.4 cm solid mass in the left lower cervical area. These findings were confirmed by an MRI scan of her neck. The Tc99m Pertechnetate scan showed the presence of a functioning area under the left lobe of the thyroid gland. The patient underwent surgery. The cervical mass was identified as a structure separate from the left lobe of the thyroid, without any attachments to the body of the gland and was uniformly resected. A subtotal thyroidectomy was also performed. The histology revealed that the separate structure represented ectopic thyroid tissue. The patient had an uneventful postoperative recovery, subsequent to which she was euthyroid and had normal calcium levels.     

Comparison of DXA, QCT and trabecular structure in beta-thalassaemia

Osteopathy, as a major feature of homozygous beta-thalassaemia, is a multifactorial disorder, not fully understood. We studied the lumbar vertebrae of 48 patients using Dual-Energy X-ray Absorptiometry (DXA) and Quantitative Computed Tomography (QCT), and we focused on structural properties, assessed by High Resolution Computed Tomography (HRCT). Bone Mineral Density (BMD) values were expressed as Z-scores and the results were correlated. The effect of age, sex, and type of thalassaemia and hormonal factors on BMD was assessed. We estimated, with HRCT, the cortex integrity and the number and thickness of trabeculae; the latter were classified to a three-grade scale. Our results showed the overall prevalence of osteoporosis to be 44% with DXA and 6% with QCT. Both techniques revealed an inverse correlation between age and BMD, whereas hormonal factors demonstrated associations with QCT and DXA measurements. The correlation coefficient between DXA's BMD and QCT's trabecular BMD was 0.545 (P < 0.001) whereas the corresponding value for Z-scores was r = 0.491 (P < 0.001). The classification of the patients into normal, osteopenic and osteoporotic categories, using QCT's Z, was in better agreement with the assignment based on trabecular number (K = 0.209, P = 0.053) than the classification using DXA's Z (K = 0.145, P = 0.120). Cortex evaluation by HRCT showed discontinuity in 15 patients. Both methods indicate a progression of osteoporosis with age. Hormonal deficiency is associated with thalassaemic osteoporosis whereas the visual estimation of cortex indicates that Thalassaemia Intermedia (TI) patients could be more affected than Thalassaemia Major (TM). Using the trabecular number as an indicator of osteoporosis, it seems that QCT may evaluate osteopathy better than DXA. Since the former has the ability to measure trabecular and cortical BMD separately, it could give early indication of which changes more rapidly and to what degree.     

Retinol-binding protein, acute phase reactants and Helicobacter pylori infection in patients with gastric adenocarcinoma

AIM: To determine the serum levels of c-reactive protein (CRP), transferrin (TRF), a2-macroglobulin (A2M), ceruloplasmin (CER), a1-acid glycoprotein (AAG), pre-albumin (P-ALB) and retinol-binding protein (RBP) in gastric carcinoma patients and to explore their possible correlation with underlying Helicobacter pylori (H pylori) infection. METHODS: We measured the serum levels of CRP, TRF, A2M, CER, AAG, P-ALB, and RBP in 153 preoperative patients (93 males; mean age: 63.1±11.3 years) with non-cardia gastric adenocarcinoma and 19 healthy subjects. RESULTS: The levels of CRP, CER, RBP, and AAG in cancer patients were significantly higher than those in healthy controls (P<0.0001), while no difference was found regarding the TRF, P-ALB, and A2M levels. Cancer patients with H pylori infection had significantly lower RBP values compared to non-infected ones (P<0.0001) and also higher values of CRP and AAG (P=0.09 and P=0.08, respectively). CONCLUSION: High serum levels of CRP, CER and AAG in cancer patients do not seem to be related to H pylori infection. Retinol-binding protein seems to discriminate between infected and non-infected patients with gastric carcinoma. Further studies are needed to explore if it is directly involved in the pathogenesis of the disease or is merely an epiphenomenon.