Sleep disordered breathing – a new component of syndrome x?

Sleep disordered breathing (SDB) is a complication of obesity estimated to occur in about 4–6% of overweight individuals. These respiratory disturbances during sleep incorporate a number of conditions including snoring, upper airway resistance syndrome and obstructive sleep apnoea syndrome (OSAS). It is thought that as well as having deleterious effects on sleep quality these conditions may also promote cardiovascular and hormonal changes leading to an elevated blood pressure and an increased incidence of cardiovascular morbidity. Evidence reviewed here points to an alteration in sympathovagal balance, baroreceptor sensitivity, insulin resistance and leptin, growth hormone and lipid levels. Whether these changes are a consequence of the associated obesity or the SDB itself remains to be proven.     

HYPOTHALAMO-PITUITARY-ADRENAL AXIS SUPPRESSION IN ASTHMATIC ADULTS TAKING HIGH DOSE BECLOMETHASONE DIPROPIONATE

Inhaled corticosteroids control symptoms of chronic asthma in most patients. Use of drugs such as beclomethasone dipropionate (BDP) and budesonide is being encouraged as the importance of airways inflammation in asthma is increasingly appreciated. Beclomethasone dipropionate is used in doses of up to 2000 μg daily (equivalent to eight puffs of Beclorforte inhaler) and the Data Sheet warns that systemic absorption sufficient to cause suppression of the hypothalamo-pituitary-adrenal (HPA) axis may occur in some patients taking 2000 μg. HPA suppression to an extent which is clinically relevant has not been reported in asthmatic adults taking lower doses of BDP. We report six cases of HPA hypofunction occurring in patients on long-term treatment with BDP, in a dose of 1500 μg daily. Patients taking BDP in a dose of 1500 μg daily might be at risk of adrenal crisis and should carry steroid cards unless HPA function has been assessed and found normal.     

Patient and Primary Care Physician Satisfaction with Chest Pain Unit and Routine Care

OBJECTIVES: The chest pain unit (CPU) has been developed to improve care for patients with acute, undifferentiated chest pain. The authors aimed to measure patient and primary care physician (PCP) satisfaction with CPU care and routine care and to determine whether patient satisfaction predicted PCP satisfaction. METHODS: A CPU was established, and 442 days were randomly allocated to either CPU care or routine care. Consenting patients presenting with acute, undifferentiated chest pain were recruited and followed at two days and one month. All were given a self-completed patient satisfaction questionnaire two days after attendance (N = 972). Each patient's PCP was sent a self-completed satisfaction questionnaire during days 171-442 of the trial (N = 601). Analysis determined whether CPU care was associated with improved patient or PCP satisfaction and whether patient satisfaction predicted PCP satisfaction for three questions relating to diagnosis, treatment, and overall care. RESULTS: CPU care was consistently associated with higher scores across all patient satisfaction questions, from the perceived thoroughness of examination to care received to an overall assessment of the service received. However, CPU care achieved small improvements in only two of ten PCP satisfaction questions, concerning overall management of the patient and the amount of information about investigations performed. Furthermore, patient satisfaction did not predict PCP satisfaction in relation to diagnosis (p = 0.456), treatment (p = 0.256), or overall care (p = 0.085). CONCLUSIONS: CPU care is associated with substantial improvements in all dimensions of patient satisfaction but only minimal improvements in PCP satisfaction. Patient satisfaction was not a strong predictor of PCP satisfaction with emergency care.     

Problem Drinkers in Medical Wards: consumption patterns and disabilities in newly identified male cases

One hundred and sixty-one male medical inpatients were identified as problem drinkers according to criteria previously defined. This paper describes the pattern of their drinking and the associated medical and psychosocial problems. Over half had been admitted with an illness not typically related to alcohol and a similar proportion reported levels of consumption which have previously been considered safe. Classical symptoms of dependence were uncommon but specific enquiry revealed a broad range of social problems related to alcohol. Recognition of this profile is necessary if problem drinkers are to be identified at an early stage and to benefit from counselling.     

Opioid-induced Delay in Gastric Emptying: A Peripheral Mechanism in Humans

Background: Opioids delay gastric emptying, which in turn may increase the risk of vomiting and pulmonary aspiration. Naloxone reverses this opiate action on gastric emptying, but it is not known whether this effect in humans is mediated by central or peripheral opiate antagonism. The importance of peripheral opioid receptor antagonism in modulating opioid-induced delay in gastric emptying was evaluated using methylnaltrexone, a quaternary derivative of the opiate antagonist naltrexone, which does not cross the blood-brain barrier.

Methods: In a randomized, double-blind, crossover placebo-controlled study, 11 healthy volunteers were given either placebo (saline), 0.09 mg/kg morphine, or 0.09 mg/kg morphine plus 0.3 mg/kg methylnaltrexone on three separate occasions before ingesting 500 ml deionized water. The rate of gastric emptying was measured by two methods: a noninvasive epigastric bioimpedance technique and the acetaminophen absorption test.

Results: The epigastric bioimpedance technique was sufficiently sensitive to detect opioid-induced changes in the rate of gastric emptying. The mean +/- SD time taken for the gastric volume to decrease to 50% (t0.5) after placebo was 5.5 +/- 2.1 min. Morphine prolonged gastric emptying to (t0.5) of 21 +/- 9.0 min (P < 0.03). Methylnaltrexone given concomitantly with morphine reversed the morphine-induced delay in gastric emptying to a t0.5 of 7.4 +/- 3.0 (P < 0.04). Maximum concentrations and area under the concentration curve from 0 to 90 min of serum acetaminophen concentrations after morphine were significantly different from placebo and morphine administered concomitantly with methylnaltrexone (P < 0.05). No difference in maximum concentration or area under the concentration curve from 0 to 90 min was noted between placebo and methylnaltrexone coadministered with morphine.     

Prognostic factors in upper gastrointestinal bleeding

In this study we examined factors of possible prognostic value about outcome in a consecutive series of 2217 patients with hematemesis and melena. Death occurred in 189 (8.5%) patients, and 243 (11%) patients experienced rebleeding. Death was significantly associated with rebleeding, age over 60 years, and the finding of blood in the stomach at endoscopy. Rebleeding was significantly associated with melena, identification of a gastric or duodenal ulcer, endoscopic stigmata of hemorrhage such as blood, clot, and active bleeding, and the finding of shock at admission. However, female gender, previous history of ulceration, or indigestion of ulcerogenic drugs, especially nonsteroidal antiinflammatory drugs, were poor predictors of either death or rebleeding. We conclude that the identification of patients at a high risk could contribute to improved management of patients with gastrointestinal bleeding, including early therapeutic intervention.