Rapid diagnosis of early ectopic pregnancy in an emergency gynaecology service--are measurements of progesterone, intact and free {beta} human chorionic gonadotrophin helpful?

The clinical usefulness of measuring serum concentrations ofprogesterone, human chorionic gonadotrophin (HCG) and the free-subunit of HCG in distinguishing between early viable and non-viablepregnancy, before an accurate ultrasound diagnosis is possible,was evaluated in a prospective study of patients presentingto our emergency gynaecology service with a clinical suspicionof ectopic pregnancy. Patients were selected on the basis ofinitial HCG concentrations; samples with HCG 25–10 000IU/I were later analysed for progesterone and free HCG. Of the181 patients studied, 38 (21%) had an ectopic pregnancy, 108(60%) had a spontaneous abortion and 35 (19%) had a viable intra-uterinepregnancy. Concentrations of HCG and free HCG in the group withviable pregnancies were significantly higher than in the groupwith ectopic pregnancy (P < 0.001) and than those destinedto miscarry (P < 0.01). Progesterone concentrations werealso significantly higher in the viable versus the ectopic andthe spontaneous abortion groups (P < 0.001 in each case).Despite these highly significant differences there was a degreeof overlap such that it was impossible to devise a cut-off levelfor any hormone analysed, either singly or in combination, whichwould offer a clinically useful predictor of outcome.     

Communicating health

Routine production of communication materials without paying attention to utilization, field test, and impact analysis is ineffective. The concept of information, education, and communication (IEC) should encompass voluntary activity of health education in a tradition of innovation. One seminal factor may be the communication technologies developed by the National Technology Missions. The missions were participatory by seeking solutions among communities and analyzing health issues from the perspective of those directly involved, rather than from the top down. The prime focus of the national drinking water mission was convenience, hence messages concentrating on health advantages were ignored. At this juncture, influencing health behavior required decentralization reflecting local cultures. Thus community-based partners became the foundation of a strategy of communicating safe water. As national strategies emerged in each of the technology missions, communication addressed advocacy of the need for political will, dissemination of technical information, and influencing patterns of behavior. Despite learning a new understanding, the danger exists that IEC remains just another label of mass communication with posters, advertisements, brochures, radio, and television. Decisions on contraceptive choice and use requires more than just accurate information; it requires the power to make such a decision. A new approach demands a priority for communication skills taking into account people's aspirations. The HIV-AIDS crisis underlines the urgency with which communication has to respond to health challenges. A series of experiments facilitated by the World Conservation Union helped build communication capabilities among environmental groups working in Latin America, Africa, and India. The International Reference Center on Water and Sanitation initiated pilot communication projects in West Africa for community health.     

Preventing syphilis: lessons from a survey of two inner-city communities in Houston, Texas.

To develop a relevant, community-based prevention campaign, the authors examined, using street-intercept interviews, syphilis-related knowledge, circulation of information, and screening and treatment practices among four hundred residents of two inner-city communities in Houston, Texas, where syphilis case rates exceed city, county, and national averages. Although awareness of syphilis was near universal, one-fourth of the respondents thought syphilis was incurable, and a large proportion confused syphilis with other sexually transmitted diseases (STDs), mentioning discharge and burning or itching in the genital area as symptoms. Almost four out of five respondents were aware of free treatment and screening facilities in the local area, yet, less than two of five expressed the intention to get tested within the next month. Only 22 percent had seen or heard anything about syphilis in the past twelve months. The resultant prevention campaign is discussed along with implications for the development of comprehensive STD prevention and control campaigns in similar poor and underserved communities.     

Nutritional status of pavement dweller children of Calcutta City

Pavement dwelling is likely to aggravate malnutrition among its residents due to extreme poverty, lack of dwelling and access to food and their exposure to polluted environment. Paucity of information about nutritional status of street children compared to that among urban slum dwellers, squatters or rural/tribal population is quite evident. The present study revealed the magnitude of Protein Energy Malnutrition (PEM) and few associated factors among a sample of 435 underfives belonging to pavement dweller families and selected randomly from clusters of such families, from each of the five geographical sectors of Calcutta city. Overall prevalence of PEM was found almost similar (about 70%) to that among other 'urban poor' children viz. slum dwellers etc., but about 16% of them were found severely undernourished (Grade III & V of IAP classification of PEM). About 35% and 70% of street dweller children had wasting and stunting respectively. Severe PEM (Grade III & IV) was more prevalent among 12-23 months old, girl child, those belonged to illiterate parents and housewife mothers rather than wage earners. It also did increase with increase of birth rate of decrease of birth interval.     

Relationship between corneal thickness and measured intraocular pressure in a general ophthalmology clinic

OBJECTIVE: To assess whether central corneal thickness (CCT) is a confounding factor in the classification of patients attending for glaucoma assessment in a district general hospital. DESIGN: Cross-sectional study by a single observer. PARTICIPANTS: Patients attending a general ophthalmic clinic: 235 clinically normal eyes, 52 eyes with normal-tension glaucoma (NTG), 335 eyes with primary open-angle glaucoma (POAG), 12 eyes with pseudoexfoliative glaucoma (PXE), 42 eyes with chronic angle closure glaucoma (CACG), and 232 glaucoma suspect (GS) eyes. INTERVENTION: Central corneal thickness was measured using ultrasonic pachymetry. MAIN OUTCOME MEASURE: Correlation of CCT and diagnosis. RESULTS: Mean CCT was 553.9 microm (95% confidence intervals [CI] for the mean, 549.0-558.8 microm) in the clinically normal eyes, 550.1 microm (95% CI, 546.6-553.7 microm) in the POAG eyes, 514.0 microm (95% CI, 504.8-523.3 microm) in the NTG eyes, 530.7 microm (95% CI, 511.2-550.1 microm) in the PXE eyes, 559.9 microm (95% CI, 546.8-573.0 microm) in the CACG eyes, and 579.5 microm (95% CI, 574.8-584.1 microm) in the GS eyes. The differences of mean CCT between the groups were highly significant (P< 0.001 analysis of variance). Eighty-five percent of eyes with NTG and only 36% of eyes with POAG had a mean CCT of 540 microm or less. Thirteen percent of eyes with POAG and 42% of GS eyes had a mean CCT greater than 585 microm. CONCLUSIONS: The CCT measurement is desirable in patients attending for glaucoma assessment in a district general hospital to avoid misclassification resulting from the relationship between CCT and tonometric pressure. Central corneal thickness alone is not an accurate predictor for the clinical diagnosis in this group of eyes. However, many eyes diagnosed as having NTG have thin corneas, which would tend to lower the tonometrically recorded intraocular pressure (IOP), so the finding of a less-than-normal thickness cornea introduces some doubt as to the diagnosis of NTG. For the GS eyes, most eyes had thick corneas, which would tend to increase the tonometrically recorded IOP. Thus, GS eyes with modest elevation of IOP and a thick cornea may be at low risk of progressing to POAG. Thus, many patients with "high IOPs" and a thick CCT do not necessarily have high IOPs and may not need to be followed as GS eyes.     

Pharmacokinetics of trimetrexate and dapsone in AIDS patients with Pneumocystis carinii pneumonia

The objective of this study was to determine the pharmacokinetics of trimetrexate and dapsone in AIDS patients with moderate to severe pneumocystis pneumonia. Trimetrexate, leucovorin, and dapsone were administered for 21 +/- 3 days in the following doses: trimetrexate glucuronate, 45 mg/m2; leucovorin, 20 mg/m2; and dapsone, 100 mg daily. The pharmacokinetics of trimetrexate, dapsone, and dapsone's metabolite, monoacetyldapsone, were determined at three separate periods over the course of treatment. Serial blood samples were obtained over 24 hours after dosing and analyzed for trimetrexate, dapsone, and monoacetyldapsone, and pharmacokinetic parameters were determined. The mean parameters obtained for the early, mid-, and late collection periods were the following: trimetrexate: t1/2 = 8.29, 9.15, 10.00 hr; AUC = 16.85, 22.38, 24.49 mg.hr/l; CI = 5.58, 4.14, 3.96 l/hr, respectively. DDS: t1/2 = 14.99, 16.59, 15.13 hr; AUC = 30.60, 35.29, 36.08 mg.hr/l; CI = 3.82, 3.49, 3.01 l/hr, respectively. Monoacetyldapsone: t1/2 = 20.25, 18.66, 16.32 hr; AUC = 24.05, 24.06, 23.86 mg.hr/l, respectively. No statistically significant changes in pharmacokinetics for trimetrexate or dapsone were observed over the 21 +/- 3 day course of treatment. The results suggest that there are no major interactions between trimetrexate and dapsone when administered together in acutely ill patients.     

Therapeutic Drug Monitoring in the Elderly

Therapeutic drug monitoring (TDM) is defined as the strategy by which the dosing regimen for a patient is guided by repealed measurements of plasma drug concentrations. TDM is also used to confirm drug poisoning and toxicity, to diagnose adverse drug reactions, and to verify patient compliance with drug regimens. There is a scarcity of data about the use of TDM in treating the elderly, but general inferences can be made based on pharmacokinetic and pharmacodynamic studies in older populations and on investigations in younger individuals. Despite its important limitations TDM seems to be an important tool in drug therapy management in the elderly given the increased frequency of chronic medical conditions, polypharmacy, drug interactions, and the atypical presentation of adverse drug reactions in this population.     

Comparison of left ventricular performance in healthy young women and men during exercise

Background

Previous studies show sex-related differences in left ventricular (LV) response to exercise. It is not clear, however, whether these differences are also seen in younger healthy subjects.

Methods and Results

This study examined the changes in LV performance during dynamic upright exercise in 11 healthy men and 19 healthy young women according to the Bruce protocol and an individualized ramp protocol. There were no significant differences between the two protocols for either men or women in heart rate, blood pressure, LV ejection fraction (EF) (measured by ambulatory nuclear detector), and measured oxygen consumption. The peak oxygen consumption was higher in men than in women (44±13 vs 36±9 ml/kg/min; p<0.05), but the peak heart rate, systolic blood pressure, and EF were similar. The change in EF (from rest to exercise) was 19%±8% in men and 19%±11% in women with the Bruce protocol (difference not significant) and 26%±9% in men and 19%±6% in women with the ramp protocol (difference not significant). At peak exercise, both men and women showed an increase in end-diastolic volume (29%±14% vs 23%±11%; difference not significant) and a decrease in end-systolic volume (41%±15% vs 43%±21%) (difference not significant). The increase in cardiac output during exercise was due to an increase in heart rate and stroke volume in both men and women. At submaximal exercise, however, the decrease in end-systolic volume was less in women than in men (p<0.05).

Conclusions

There are no sex-related differences in compensatory mechanism during dynamic execise in healthy subjects. The changes in contractility and LV volume are not affected by the exercise protocol.     

The specificity of pyrophosphate myocardial scintigrams in patients with prior myocardial infarction: concise communication.

Fifty-five patients with old (9 days to 10 yr) transmural infarcts but with no evidence of recent infarction, were imaged with Tc-99m pyrophosphate. Discrete uptake was rare in the setting of an old infarct. Diffuse uptake was neither sensitive to, nor specific for, acute infarction. Prior infarction will rarely cause diagnostic error if the discrete pattern is required for a positive diagnosis.     

Adenoid Cystic Carcinoma of submandibular salivary gland

A case of Adenoid Cystic Carcinoma of the submandibular salivary gland of a long duration is being reported.