PARENTERAL THIAMINE AND WERNICKE'S ENCEPHALOPATHY: THE BALANCE OF RISKS AND PERCEPTION OF CONCERN

Wernicke's encephalopathy, a disorder with significant mortalityand high morbidity, is common amongst alcohol-dependent patients.Thiamine deficiency appears to play a key role in its aetiology,and parenteral high-dose thiamine is effective in prophylaxisand treatment. Unfortunately, reports of rare anaphylactoidreactions have led to a dramatic reduction in the use of parenteralthiamine, and it is possible that this change in treatment hasled, or will lead, to an increase in morbidity and mortality.There is a need for education of doctors who treat alcohol-dependentpatients, in order to ensure appropriate use of parenteral thiaminein prophylaxis and treatment of this disorder.     

Enteral versus parenteral nutritional support in acute pancreatitis: A clinical review

Abstract   A critical analysis of the trials comparing enteral with parenteral nutritional support in acute pancreatitis is presented with particular scrutiny of the clinical endpoints in each trial. The heterogeneity of the trials and the discrepancies in caloric intake between enterally and parenterally fed patients are discussed. The hazards of each route of nutritional support are highlighted and the concept of 'nutritional bioavailability' in the context of acute pancreatitis is introduced. It is concluded that although there is evidence to support enteral feeding as the preferred option, both routes have a role.     

A survey of forensic psychologists’ work with sex offenders in England and Wales

This paper describes the results of a survey of the extent and variety of work with sex offenders by psychologists working in different forensic settings in England and Wales. A postal questionnaire was sent out to all 199 psychologists in the special hospitals, regional forensic psychiatry services, prisons and youth treatment service requesting details about their work with sex offenders during the year June 1991 to July 1992. The results are described under the headings of assessment and treatment; supervision, consultation, teaching and training; research and evaluation. The discussion highlights some of the patterns and trends of the work of forensic psychologists with sex offenders, together with the range of psychological interventions. There are also patterns within services. Results of the survey highlight the links psychologists have with other disciplines in working with sex offenders and raise questions about the most appropriate model of psychology practice, given the limited resources.     

Effect of inhaled atrial natriuretic peptide on methacholine bronchoconstriction in asthma

We have previously demonstrated that intravenous and inhaled atrial natriuretic peptide (ANP) significantly inhibits histamine induced bronchoconstriction in asthmatic patients. The current study was designed to determine whether inhaled ANP was also able to inhibit the effects of methacholine. Eight atopic asthmatic patients (five women) were studied: mean (SD) age 38.2 (8.3) years flow expiratory volume per second (FEV₁) 2.97 (0.60) litres, equivalent to 92 (13) % of the predicted. Each had demonstrated at least mild bronchial hyperreactivity to inhaled methacholine at screening (geometric mean PC20 l.02mg/ml; range 0.1l–6.54mg/ml). Patients attended for 3 study days and after baseline spirometry received 3.5 ml saline (placebo), 0.1 mg ANP or 1 mg ANP (ANP dissolved in 3.5ml saline) in a randomized, double-blind manner via a Mizer aerosol conservation device. Aerosolization took approximately 9 min and FEV₁ was repeated at 0.5, 1.5 and 3 min after completion. Immediately thereafter each patient received a 2 min inhalation of methacholine at a dose individually calculated to give a 25% fall in FEV₁ (as extrapolated at their initial screening visit) and the FEY₁ was followed over the next 20 min. Mean (SEM)% FEV₁ did not change significantly after ANP being -4.3 (1.7), -3.2 (2.7) and -2.4 (1.2) after placebo, 0.1 mg ANP and 1 mg ANP respectively. The mean (SEM) maximum fall in FEV₁ after methacholine was as follows: placebo 26.9 (5.7)%, 0-1 mg ANP 18.2 (4.3)% and 1.0mg 11.2(2 7)%, (P < 0.05 placebo vs 1 mg ANP). These results demonstrate that ANP offers significant protection against methacholine induced bronchoconstriction in asthmatic patients.     

COMPARISON OF PIROXICAM WITH PLACEBO IN THE MANAGEMENT OF PAIN AFTER TOTAL HIP REPLACEMENT

A randomized double-blind controlled study was undertaken toassess the analgesic efficacy of piroxicam. Twenty-four patientsunderwent total hip replacement under spinal anaesthetic; afteroperation, they received a 3-day course of either placebo (n= 12) or piroxicam (n = 12). Adequate analgesia was providedfor 48 h by a patient-controlled analgesia system deliveringmorphine. Patients receiving piroxicam required 50% less morphinethan the control group (38 mg compared with 76 mg (P < 0.002)).This technique was tolerated well and there were no significantside effects.     

Can communication skills be assessed independently of their context?

In many examinations, communication skills tend to be treated as if they are a single attribute independent of the context of the communication. However, it is clear that such assessments are confounded by candidates' knowledge or lack of knowledge of the medical issues about which they are communicating. In the 1990 Part One examination for Membership of the Royal New Zealand College of General Practitioners candidates were provided with all the essential knowledge relevant to the problem they were to communicate about. Despite this, performance was still seen to be context specific, demonstrating that such specificity is not purely knowledge related. Candidates completing the examination were observed to share information about the cases with candidates about to commerce. There was no evidence that performance was enhanced by such breaches in examination security.     

Dendritic cells and tolerance induction

We isolated a 27-kD protein using cation exchange chromatography from an acid extract of neutrophil granules. N-terminal amino acid sequence analysis of the first 10 residues showed that this protein is azurocidin, a member of the family of neutral serine proteinase found in the neutrophil, which shares amino acid sequence homology with the three other neutral serine proteinases, elastase, proteinase 3 (PR3) and cathepsin G, but unlike them is without proteolytic activity. To test whether, in addition to these proteases, azurocidin might be a target for the humoral autoimmune responses associated with human vasculitis, 185 indirect immunofluorescence (IIF)-positive ANCA sera, made up of four groups of sera with specificities for PR3 (n = 37), myeloperoxidase (MPO; n = 50), bactericidal/permeability-increasing protein (BPI; n = 41) and sera that recognized none of them (triple negative, n = 57), and 46 normal sera were screened for IgG anti-azurocidin antibodies using an ELISA incorporating purified azurocidin. Twenty of the 185 IIF-positive sera and 2/46 normal sera displayed reactivity with azurocidin. Positive sera could blot the 27-kD band by Western blot analysis. Further study of the 20 positive sera revealed that: (i) 10 also had autoreactivity for MPO, of which six additionally recognized lactoferrin; (ii) two had reactivity with BPI; (iii) the remaining eight sera were positive only for azurocidin. All 20 sera were from patients with systemic vasculitis, and four of the six sera with triple reactivity (for azurocidin, MPO and lactoferrin) were from patients with hydralazine-induced vasculitis. We concluded that: (i) azurocidin is a novel ANCA antigen; (ii) anti-azurocidin antibodies from a subgroup of patients might represent the consequence of a drug-induced multi-clone activation.     

The affected sib method. V. Testing the assumptions

The affected sib methods, which are used to make inferences about the genetic components of HLA associated diseases, have many underlying assumptions which may not always be realistic. These include no selective disadvantage of affected individuals, little or no recombination between the marker loci and the 'disease' locus, a single panmictic population, Mendelian segregation of the disease locus alleles and random distribution of individuals over environments. The effects of breaking these assumptions have been investigated. We have explicitly derived the haplotype sharing identity by descent (IBD) expectations for the cases of selection against affected individuals and recombination between the HLA marker loci and the 'disease' predisposing locus for affected sib trios (as was previously done for affected sib pairs). We have also derived, for both affected sib pairs and trios, the haplotype sharing expectations for non-random mating (positive assortative), admixture, meiotic drive (of disease allele carrying haplotypes), and a random versus shared environmental component for sibs. In order to assess the sensitivity of the affected sib methods to perturbations in the assumptions, the expectation spaces of haplotype sharing in affected sib pairs and sib trios under the single diallelic locus model with varying penetrances and allele frequencies are fully described. The effects on haplotype sharing and subsequent disease parameter estimation are different for each of the factors we have considered. The affected sib methods are found to be robust in many situations.     

Effect of nedocromil sodium on histamine airway responsiveness in grass-pollen sensitive asthmatics during the pollen season

We examined the effect of nedocromil sodium on histamine airway responsiveness in twelve grass-pollen sensitive patients during the 1984 pollen season. The study was a randomized double-blind crossover comparison of nedocromil sodium administered by a pressurized aerosol (4 mg b.d.) with placebo. Crossovers were made at 14-day intervals throughout 8 weeks of the grass pollen season. Histamine airway responsiveness was assessed twice before the pollen season and at the end of each 14-day treatment period. Results were expressed as the provocation concentration (PC) producing a 10% fall in FEV₁ (PC₁₀ FEV₁) and a 40% fall in flow at 30% of the vital capacity (PC₄₀V?_30(P)). During the pollen season all patients developed hay fever and seven had symptoms of asthma. The observed lowest values of PC₁₀ FEV₁ and PC₄₀V?_30(P) during the placebo treatment periods were significantly lower than mean preseasonal values although not significantly lower than theoretical expected values. Geometric means PC₁₀ FEV₁ and PC₄₀V?_30(P) were significantly higher during nedocromil sodium treatment compared with placebo. These results indicate that nedocromil sodium has a small but statistically significant effect reducing histamine airway responsiveness in grass-pollen sensitive patients during the pollen season.