MÜNCHAUSEN'S SYNDROME (HIV INFECTION): A TRAP FOR THE UNWARY

SUMMARY A case of Münchausen's syndrome with AIDS illustrates the need for a high index of caution when dealing with individuals whose histories are inconsistent and suspicious, particularly when they have moved area.     

Randomised trial of targeted chemotherapy with lipiodol and 5-epidoxorubicin compared with symptomatic treatment for hepatoma.

Lipiodol injected into the hepatic artery is selectively retained in hepatomas so has been used as a vehicle for cytotoxic drugs. This study compared treatment with 5-epidoxorubicin emulsified in lipiodol and infused into the hepatic artery with symptomatic treatment alone in a randomised trial. Of 136 patients with hepatoma 78 (57%) were not eligible, eight (6%) refused to take part, and 50 entered the trial (chemotherapy: n = 25, symptomatic treatment: n = 25). The two groups had similar prognostic indices. Seven of 25 patients allocated to chemotherapy were unable to receive it. The slight survival disadvantage associated with chemotherapy was not significant (median survival 48 days compared with 51 days, log rank chi 2 = 0.07, p > 0.05). Patients given chemotherapy spent significantly longer in hospital, however (median three days compared with one, p = 0.0008). Changes in symptoms and indices of tumour growth did not differ significantly between the two groups. It is concluded that infusion of 5-epidoxorubicin emulsified in lipiodol for hepatoma increased morbidity but did not affect survival. In addition, most patients were unsuitable for this treatment because of advanced disease. The patients in the trial had a short median survival time so the conclusions may not be valid for other patients with hepatoma.     

正相-反相两步高效液相色谱法制备毫克量级维生素D3异构体

利用正相半制备柱和反相分析柱的两步高效液相色谱法,在实验室规模制备了毫克是级维生素D₃的三个重要异构体——维生素D₃前体、光甾醇₃和速甾醇₃·维生素D₃原体,7-去氢胆固醇的光照是在一个装有UVB荧光灯的光治疗室中进行。采用紫外分光光度法和高效液相色谱法对制得的三个异构体进行了定性定量分析。在这三个异构体检测极限下,除了维生素D₃前体中有不超过0.25%的维生素D₃杂质外,三个产品中均没有发现任何除它本身之外的其他异构体杂质。     

RECTOPERINEAL FISTULA: AN UNUSUAL CAUSE OF ANOGENITAL DISCHARGE

SUMMARY The serendipitous presentation of a rectoperineal fistula in a 34-year-old nulliparous woman is described. This surgically correctable cause of an anogenital discharge posed a risk (if unrecognised) of producing a rectovaginal fistula at the time of vaginal delivery.     

A study of a new osmotic purgative for colonoscopy

An osmotic laxative containing polyethylene glycol and sodium sulfate (Golytely^® Braintree Laboratories, Inc., Braintree, MA) is widely used to clean the colon for colonoscopy. However, its salty taste makes the mixture unpalatable. We therefore tested the claim that a similar solution but without sodium sulfate (Golytely-RSS^® Braintree Laboratories, Inc., Braintree, MA) makes preparation of the colon more acceptable to patients in a double-blinded randomized controlled trial. Colonic preparation using polyethylene glycol with or without sodium sulfate was randomized in 100 patients due to undergo colonoscopy. The overall acceptability of the regimen was measured on a linear analogue scale and an estimate of symptoms was obtained. Body weight and serum electrolytes, urea, creatinine, hemoglobin and hematocrit were determined before and after preparation in order to assess fluid absorption. The efficacy of colonic cleansing was graded by the colonoscopist. Four patients did not complete the protocol, 47 received the regimen containing sodium sulfate and 49 received the regimen without it. The two groups did not differ in age or body mass. There was no statistical difference in the overall acceptability of the two regimens to the patients (median acceptability rating 74 for regimen with sodium sulfate, range 4–100 compared with 77 for regimen without, range 3–100, p=0.32, Mann-Whitney test). Nor was there any difference in taste, nausea, vomiting, cramping or perianal discomfort or in the endoscopists' rating of the cleanliness of the colon. The serum sodium concentration rose slightly (mean 1.6 mmol/L) when the regimen with sodium sulfate was used. Moreover, prescribing the laxative regimen without sodium sulfate increased the cost of the regimen by 65 percent. In preparing the colon for colonoscopy, omitting sodium sulfate from the conventional mixture of polyethylene glycol and sodium sulfate does not make the preparation more acceptable to patients, does not affect the cleanliness of the colon and increases the cost of the laxative substantially. Golytely^® is therefore preferable to Golytely-RSS^®.Presented in part at the South African Gastroenterology Society Meeting in 1991 and published as an abstract in S A Med J 1991: 80: 51     

Identification and localization of huntingtin in brain and human lymphoblastoid cell lines with anti-fusion protein antibodies.

The Huntington disease (HD) phenotype is associated with expansion of a trinucleotide repeat in the IT15 gene, which is predicted to encode a 348-kDa protein named huntington. We used polyclonal and monoclonal anti-fusion protein antibodies to identify native huntingtin in rat, monkey, and human. Western blots revealed a protein with the expected molecular weight which is present in the soluble fraction of rat and monkey brain tissues and lymphoblastoid cells from control cases. In lymphoblastoid cell lines from juvenile-onset heterozygote HD cases, both normal and mutant huntingtin are expressed, and increasing repeat expansion leads to lower levels of the mutant protein. Immunocytochemistry indicates that huntingtin is located in neurons throughout the brain, with the highest levels evident in larger neurons. In the human striatum, huntingtin is enriched in a patch-like distribution, potentially corresponding to the first areas affected in HD. Subcellular localization of huntingtin is consistent with a cytosolic protein primarily found in somatodendritic regions. Huntingtin appears to particularly associate with microtubules, although some is also associated with synaptic vesicles. On the basis of the localization of huntingtin in association with microtubules, we speculate that the mutation impairs the cytoskeletal anchoring or transport of mitochondria, vesicles, or other organelles or molecules.     

Tourniquet technique for reduced blood loss and wound assessment during excisions of burn wounds of the extremity

Our surgical technique incorporates the advantages of previous techniques with some additional advantages described herein. We have found it a safe and effective method to reduce intraoperative bleeding, allow for intraoperative inspection of excised wounds and prevent the need for massive transfusions during excisions of burn wounds of the extremity.     

Reduction of central nervous system ischemic injury in rabbits using leukocyte adhesion antibody treatment.

Activated leukocytes appear to be directly involved in ischemic central nervous system injury. A surface glycoprotein (CD18) on the leukocyte is required for endothelial adherence and subsequent function and can be blocked with leukocyte adhesion antibody treatment. We used two animal models to determine the efficacy of anti-CD18 antibody treatment in preserving neurologic function after central nervous system ischemia. We gave a dose of 1 mg/kg anti-CD18 to treatment rabbits 30 minutes before inducing irreversible ischemia in the brain with intraarterial microspheres or in the spinal cord using reversible aortic occlusion. Treatment with anti-CD18 produced a significant reduction in neurologic deficits in the reversible spinal cord model, but not in the irreversible microsphere model. This protective effect supports the active role of leukocytes in central nervous system reperfusion ischemic injury and offers potential for future therapy.     

Warfarin therapy initiated during pregnancy and phenotypic chondrodysplasia punctata.

An infant is described who has clinical manifestations and roentgenographic features consistent with the diagnosis of chondrodysplasia punctata. The mother of this infant received warfarin during pregnancy. Eight cases demonstrating an association between warfarin therapy during pregnancy and chondrodysplasia punctata in the child have been reported; in the present case therapy was initiated following conception (see following case report). Warfarin may be teratogenic, producing a phencopy of the heritable forms of chondrodysplasia punctata. Because of the evident association we suggest (1) warfarin is contraindicated in pregnancy and alternative anticoagulants should be used; (2) products of at-risk pregnancies should be screened for the characteristic radiologic findings; and (3) preconceptual counselling and antenatal diagnosis of the disease may be beneficial.