Arrhythmias in general practice: diagnostic value of patient characteristics, medical history and symptoms

BACKGROUND: Complaints possibly caused by arrhythmias are frequently seen in general practice. It is unclear to what extent such complaints can differentiate between arrhythmias and other pathology in general practice. OBJECTIVES: We aimed to assess the value of symptoms (a) in diagnosing arrhythmias in general practice and (b) in identifying patients with clinically relevant arrhythmias. METHOD: During a 2-year period, a structured history from 762 patients with new complaints possibly related to an arrhythmia was taken by the GP, and a transtelephonic electrocardiogram (ECG) was made. RESULTS: In 28.3% of the patients, arrhythmias were detected and 8.8% were clinically relevant. Several patient characteristics, symptoms and medical history findings have high predictive values in diagnosing arrhythmias. In the logistic regression analysis, age and, to a lesser extent, male gender, palpitations and dyspnoea during consultation and the use of cardiovascular drugs are associated with the presence of arrhythmias. In detecting clinically relevant arrhythmias the same parameters apart from gender are important, as well as a history of arrhythmias. The use of central nervous system medication and frequent psychosomatic complaints are negatively associated with the presence of clinically relevant arrhythmias. CONCLUSIONS: In general practice, patient characteristics, symptoms and medical history findings can be used in the detection of arrhythmias and the assessment of their severity. They can help in the decision of whether to make an ECG recording.      

The effect of the antimycotic itraconazole on the pharmacokinetics and pharmacodynamics of diazepam

Summary— The azole antimycotic itraconazole is a potent and relatively unspecific inhibitor of cytochrome P450 enzymes and has a potentially dangerous interaction with midazolam and triazolam. The possible interaction between itraconazole and diazepam was investigated in a double-blind, randomized, cross-over study. Ten healthy volunteers were given orally placebo or itraconazole 200 mg a day for 4 days. The challenge dose of 5 mg of diazepam was ingested on the fourth day, after which plasma samples were collected and psychomotor performance tests were carried out for 42 h. Despite a statistically significant small increase in the area under the plasma diazepam concentration-time curve and the elimination half-life of diazepam, there was no clinically significant interaction as determined by the psychomotor performance tests. The lack of significant first-pass metabolism and the different metabolic pathways of diazepam explain the smaller interaction potential of diazepam compared with midazolam and triazolam. Diazepam, unlike midazolam and triazolam, can be prescribed in usual doses for patients receiving itraconazole and probably other inhibitors of P4503A4, at least when diazepam is used as single doses.     

Digital gastrointestinal imaging: the effect of pixel size on detection of subtle mucosal abnormalities

Five radiographs of double-contrast colon examinations demonstrating subtle mucosal changes of inflammatory bowel disease and five radiographs of healthy colonic mucosa were selected and digitized to four levels of resolution. Pixel sizes of 0.1 mm, 0.2 mm, 0.4 mm, and 0.8 mm were used. Ten radiologists interpreted the images, which were displayed on laser-printed film. Analysis of variance with repeated measures was performed and receiver operator characteristic curves were determined. The results demonstrate that the sensitivity in detecting subtle mucosal abnormalities improved as the resolution improved, with the best sensitivity at the highest resolution; more experienced readers detected details well even at the poorer levels of resolution; the resolution necessary for successfully evaluating the colonic mucosa was lower than expected; and given low noise levels, the matrix size used in conventional television fluoroscopy would be adequate for mucosal evaluation.     

Primary and secondary histiocytic lymphoma of the brain: CT features

The authors examined 19 patients with diffuse histiocytic lymphoma of the brain, including 8 with primary disease and 11 with secondary disease. Both primary disease and secondary disease involving the brainstem and deep nuclei exhibited the characteristic CT appearance, consisting of a large, solid, homogeneously enhanced mass with varying amounts of edema. However, most secondary lymphomas outside the brainstem and basal ganglia contained large areas of low attenuation consistent with necrosis. Multifocal lesions were seen only in patients with secondary lymphoma. Systemic chemotherapy for extracranial lymphoma had no effect on the CT appearance of intracranial lesions. The authors suggest that these "unusual" CT patterns are actually typical of a distinct subset of histiocytic lymphomas.     

Non-infective colitis in infancy: evidence in favour of minor immunodeficiency in its pathogenesis

Forty two infants below the age of 2 years presenting with chronic non-infective diarrhoea and shown to have histologically proved colitis were investigated over a five year period. Allergic colitis was the most common cause of colitis, accounting for 62% of the cases. Other colitides diagnosed included: non-specific colitis, autoimmune enterocolitis, and ulcerative colitis accounting for 10% each; severe combined immunodeficiency 7%, and Crohn's disease 3%. A positive family history and a personal history of atopy were obtained in 48% and 29% of the cases respectively. Serum immunoglobulin A, IgG2, and IgG4 were very low in over 50% of the entire cohort of infants with colitis; 66% of those with severe combined immunodeficiency, autoimmune enterocolitis, and ulcerative colitis (n = 11) had low CD3 and CD4 T lymphocytes with an accompanying increase in CD8 in two thirds of those with severe combined immunodeficiency. T lymphocytes were normal in those with allergic colitis. Thus infants with proved non-infective colitis as a group show a high prevalence of IgA, IgG2, and IgG4 deficiency. It is likely that this minor deficiency of mucosa associated immunoglobulin production has a role in the pathogenesis of the colitic process.     

The angiogenic switch in hamster buccal pouch keratinocytes is dependent on TGFbeta-1 and is unaffected by ras activation

This study was undertaken to investigate the mechanisms by which Syrian hamster buccal pouch keratinocytes treated in vivo with 7,12- dimethylbenz[a]anthracene (DMBA), switch from an angio-inhibitory to an angiogenic phenotype. Cells were cultured from pouches at various times after exposure to carcinogen and their angiogenic activity assessed. The angio-inhibitory activity present in conditioned media from normal cells was lost as early as 3 weeks after carcinogen treatment, resulting in weak expression of angiogenic activity. By 5 weeks, cells had become strongly angiogenic due to the secretion of high levels of TGFbeta-1, a potent angiogenic factor. Because the switch to high levels of secreted TGFbeta-1 occurred at the same time as the activation of the H-ras oncogene, non-angiogenic cell lines lacking an activated H-ras oncogene were stably transfected with mutant H-ras and their transformed and angiogenic phenotypes were evaluated. Although ras transfection drove two of the three cultured cell lines to anchorage independence and modestly increased their ability to clone in low serum, it had no effect on the angiogenic phenotype or on the level of secreted active TGFbeta-1. These results demonstrate that the angiogenic phenotype in the hamster buccal pouch model of oral carcinogenesis develops in a step-wise fashion with an early decrease in the production of an inhibitor of angiogenesis and a subsequent marked increase in the secretion of the inducer TGFbeta-1. Although the activation of the H-ras oncogene contributed to anchorage independence, it did not affect the expression of the angiogenic phenotype in this model system.      

The mini-micro-epididymal sperm aspiration for sperm retrieval: a study of urological outcomes

Epididymal sperm aspiration and in-vitro fertilization (IVF) with intracytoplasmic sperm injection is an established treatment for obstructive azoospermia. Sperm aspiration is performed with either an incision or percutaneously. To control costs, minimize morbidity and retain the advantages of both approaches, we developed a mini-incision technique for epididymal aspiration and here report sperm retrieval and procedure-related outcomes. Twenty-six consecutive patients with obstructive azoospermia underwent epididymal sperm retrieval through a 1 cm incision with local anaesthesia to provide spermatozoa for concurrent IVF cycles. The quality of retrieved spermatozoa, the quantity of spermatozoa cryopreserved as well as anaesthetic requirement, recovery time and patient satisfaction were evaluated. Fresh epididymal spermatozoa were retrieved in 25 of 26 (96%) patients. In one patient, testicular sperm extraction was necessary. Excess motile spermatozoa were cryopreserved in 24 of 26 (92%) patients; a mean total motile count of 4.8x10(6) motile spermatozoa were banked. The procedure was performed with 62% of patients receiving minimal i.v. sedation. Post-procedure recovery was rapid, with a median time to return to work of 2.0 days with a median of 2.0 pain pills taken. Procedure-related satisfaction was high. The mini-micro-epididymal sperm aspiration achieves the goals of reliable retrieval of abundant epididymal spermatozoa with a single, minimally morbid procedure. It appears to combine the advantages of the incision and percutaneous approaches.