Brachial plexitis complicating disseminated gonococcal infection

A patient with brachial plexitis associated with disseminated gonococcal infection is presented. This is, to the best of our knowledge, the first case to be reported of this association.     

Measuring neuroleptic-induced akathisia by three-channel actometry

Three-channel actometry was used to study neuroleptic-induced akathisia (NIA), a common and often serious disorder in association of traditional neuroleptic therapy. The aim was to explore the diagnostic possibilities of actometry in NIA and to examine in detail the motor phenomenology of the disorder in detail. The actometers were attached to the ankles and waists of ten patients, suffering from NIA, and to ten matched healthy controls. Five of the patients were changed to olanzapine treatment, and these patients were re-examined during the no-NIA condition. NIA was associated with manyfold movement activity during controlled rest (sitting) but not with increased daily overall motor activity. Movement frequencies in NIA seemed to be pathognomonic. Actometry is promising for investigation and clinical assessment of NIA. Olanzapine proved to be an adequate treatment choice for NIA patients.     

Differential regulation of cyclooxygenase isoenzymes by cAMP-elevating agents.

Bovine aortic endothelial cells produce prostacyclin as their major arachidonic acid metabolite. cAMP, in turn, is the second messenger for prostacyclin. In the present study, we investigated the effects of cAMP-elevating agents on prostacyclin production by bovine aortic endothelial cells. Treatment of resting bovine aortic endothelial cells with cAMP-elevating agents inhibited prostacyclin production and cyclooxygenase activity, without affecting arachidonic acid release. No change was detected in cyclooxygenase-1 protein expression. The specific inhibitor of protein kinase A, Rp-cAMPS (adenosine 3',5'-cyclic monophosphorothioate, Rp-isomer, triethylammonium salt), and the phosphatase inhibitor, okadaic acid, both suppressed cAMP-induced inhibition, suggesting that this inhibition is mediated by a phosphorylation-dephosphorylation cascade, which is possibly protein kinase A-dependent. In lipopolysaccharide-treated cyclooxygenase-2 expressing bovine aortic endothelial cells, where cyclooxygenase-1 activity was selectively inhibited, dibutyryl cAMP failed to inhibit cyclooxygenase-2 activity. Cyclooxygenase-2 protein was induced upon treatment with dibutyryl cAMP and further induction of cyclooxygenase-2 protein was effected by IBMX (3-isobutyl-1-methyl-xanthine) and dibutyryl cAMP in bacterial lipopolysaccharide-stimulated cells. These results suggest that increased cellular cAMP selectively inhibits cyclooxygenase-1 activity without altering cyclooxygenase-1 protein expression, and at the same time, up-regulates cyclooxygenase-2 protein. This complex regulation of cyclooxygenase activity and protein expression by cAMP may represent a prostacyclin-induced autoregulatory mechanism in bovine aortic endothelial cells.     

Purification, characterization and anticoagulant activity of a proteolytic enzyme from Vespa orientalis venom.

The anticoagulant effect of Vespa orientalis venom sac extract (VSE) was attributed to a proteolytic process, involving mainly coagulation factors VIII and IX [Joshua, H., Ishay, J., 1975. Toxicon 13, 11-20; Korenberg et al., 1988. Toxicon 26, 1169-1176]. Preliminary purification of the proteolytic activity showed the presence of three separate proteases. One of which, protease I, was purified. The purified enzyme migrated as a double band on sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS PAGE). The molecular weights of the bands, under reduced conditions were 42 and 44 kD. Both bands retained activity after the electrophoretic run. The enzyme hydrolyses bovine factor IX (BFIX), factor X (BFX) and prothrombin. The pH optimum for the degradation of BFIX was 7.0 and its isoelectric point is above pH 10. The amino acid composition of the protease was determined.     

Candida sepsis during total parenteral nutrition: An endogenous infection indicating the severity of patients' disease state

Between 1986 and 1989 we encountered 33 episodes of candida sepsis among 1169 patients receiving TPN for a total of 23350 days (2.8% candida infection rate). Total hospital stay averaged 78 (range 10-230) days and patients received TPN for an average of 21.5 (range 3-83) days before developing candida sepsis. Candida sepsis developed in 8 patients (26.6%) hospitalised in an ICU; 6 patients (20%) receiving high doses of glucocorticoids, 5 patients (16.6%) treated by cytotoxic agents; 23 patients (76.6%) received various combinations of broad-spectrum antibiotics. The number of tubes going in or out numbered an average of 3.6/patient (peripheral and/or central I.V.; endotracheal; tracheostomy; urinary catheter; arterial line; abdominal or chest drains). 18 patients underwent 38 (2.1/patient) operative procedures. 20 patients (66%) suffered fron mono- or polymicrobial bacterial sepsis in addition to candida sepsis, 16 of them metachronously. Candida species isolated were C. albicans - 14 patients; C. tropicalis - 6 patients; C. parapsylosis - 6 patients; not specified - 4 patients. In addition to positive blood cultures we found positive candida cultures in urine, peritoneal cavity, chest cavity, wounds, respiratory tract, intravascular catheters, often in more than one site per patient. All patients were treated with Amphotericin at an average dose of 770 mg/patient. Mortality rate in patients with candida sepsis was 33%. TPN associated candida sepsis seems to be an endogenous self-infecting process in a select group of severely injured-infected-depleted-immunosuppressed patients and is thus completely different from the usual exogenous bacterial TPN associated sepsis. The major risk factors for fungaemia and candida sepsis are the combination of severe underlying disease state, multiple surgical interventions and intravascular lines, the use of broad spectrum antibiotics, TPN, injury and malnutrition associated immunosuppression, multiple tubes and catheters, and intra-abdominal or intra-thoracic infection.     

Feeding jejunostomy for post-operative nutritional support

Enteral feeding by tube jejunostomy, inserted during definitive surgery, was used in 19 adult patients operated upon in a 24 month period. Jejunostomy feeding was associated with a low rate of minor complications enabling delivery of adequate caloric and protein input shortly after major abdominal operations and up to 9 months later. We feel that the insertion of a regular size jejunostomy tube during surgery is a simple, brief and safe procedure which offers efficient and inexpensive nutritional support, and thus has an important role in the post-operative management of selected patients. It is also easily used in the home setting if needed.     

The effect of haloperidol on epinephrine-stimulated adenylate cyclase in humans

Administration of epinephrine in man has been shown previously to lead to a rise in plasma cyclic AMP levels by activation of the -adrenergic-stimulated adenylate cyclase. Therapeutic doses of lithium in humans block the epinephrine-induced rise in plasma cyclic AMP levels, suggesting that lithium inhibits -adrenergic adenylate cyclase. In contrast, ten subjects receiving haloperidol, a drug also effective in the treatment of mania, show a mean rise in plasma cyclic AMP levels after epinephrine administration and the magnitude of the response is the same as for non-drug treated individuals. These findings are discussed in relation to the possible pharmacological mechanisms of action of lithium and haloperidol in the control of mania.     

Akathisia masked by hypokinesia

Here, we will discuss the concept of subjective akathisia and present a patient case. Our patient was suffering from neuroleptic-induced hypokinesia and akathisia at the same time. The typical motor manifestations of akathisia were masked by hypokinesia, which made the diagnosis difficult. However, the subjective symptoms of akathisia were evident and distressing. Although not observable to bare eye, the pathognomonic pattern of motor activity detected in akathisia was demonstrated by actometric recording. Changing the conventional neuroleptic to an atypical one brought relief to the subjective symptoms of akathisia and hypokinesia, while the motor activity was clearly diminished in actometric recording. Actometric recording may be useful in diagnosing akathisia masked by hypokinesia, but the typical subjective symptoms of akathisia should not be ignored, even when actometry is not available to demonstrate the missing motor component of akathisia. Not only akathisia defined by DSM-IV but also subjective akathisia should be adequately treated to relieve the subjective distress, and to diminish the unfavorable effects on psychotic symptoms, behavior, and drug compliance.     

Diagnosis of iron deficiency anemia in the elderly by transferrin receptor-ferritin index

BACKGROUND: The diagnosis of iron deficiency anemia (IDA) in the elderly is difficult because of the prevalence of chronic diseases, which can cause anemia with high ferritin levels, even in the presence of iron deficiency. Therefore, we studied the sensitivity and specificity of a serum transferrin receptor assay, which is not affected by chronic diseases, in the diagnosis of IDA in elderly patients. METHODS: We performed a prospective controlled study of 49 consecutive male and female patients older than 80 years who were admitted to an acute geriatric department. Bone marrow aspirate confirmed IDA in all 49 patients. Fourteen additional patients, also older than 80 years, with anemia but without evidence of iron deficiency on results of bone marrow examination, served as a control group. All patients underwent evaluation by means of a detailed medical history and results of complete physical examination, routine blood tests, and specific tests for diagnosis and evaluation of anemia. Examination of bone marrow aspirate was performed for all patients. Levels of transferrin receptor in serum were determined by means of a specific enzyme-linked immunosorbent assay. The transferrin receptor-ferritin index (TR-F index) was defined as the ratio of serum transferrin receptor level to log ferritin level. RESULTS: Only 8 patients could be diagnosed as having IDA by means of routine blood test results (serum iron, ferritin, and transferrin saturation levels). In contrast, the TR-F index disclosed IDA in 43 of the 49 patients, thus increasing the sensitivity from 16% to 88%. CONCLUSIONS: The diagnosis of IDA in the elderly by means of routine blood tests has a very low sensitivity. The TR-F index is much more sensitive, and when results are positive, the TR-F index can eliminate the need for bone marrow examination.