Surprise at over 75s referral rate

I read with interest the letter from a practice SEN (Assessing the Over 75s, Nursing Standard, September 12).

Metabolic effects of reducing rate of glucose ingestion by single bolus versus continuous sipping

Modifying the rate of absorption has been proposed as a therapeutic principle of specific relevance to diabetes. To demonstrate clearly the metabolic benefits that might result from reducing the rate of nutrient delivery, nine healthy volunteers took 50 g glucose in 700 ml water on two occasions: over 5-10 min (bolus) and at a constant rate over 3.5 h (sipping). Despite similar 4-h blood glucose areas, large reductions were seen in serum insulin (54 +/- 10%, P less than 0.001) and C-peptide (47 +/- 12%, P less than 0.01) areas after sipping, together with lower gastric inhibitory polypeptide and enteroglucagon levels and urinary catecholamine output. There was also prolonged suppression of plasma glucagon, growth hormone, and free-fatty acid (FFA) levels after sipping, whereas these levels rose 3-4 h after the glucose bolus. An intravenous glucose tolerance test at 4 h demonstrated a 48 +/- 10% (P less than 0.01) more rapid decline in blood glucose (Kg) after sipping than after the bolus. Furthermore, FFA and total branched-chain amino acid levels as additional markers of insulin action were lower over this period despite similar absolute levels of insulin and C-peptide. These findings indicate that prolonging the rate of glucose absorption enhances insulin economy and glucose disposal.

Differential effects of three enteral dietary regimens on selected outcome variables in burn patients

A modular tube feeding recipe (MTF) was designed to meet the unique nutritional needs of burn patients, applying principles previously documented in our burned guinea pig model. MTF, a high-protein, low-fat, linoleic acid-restricted formulation is enriched with omega-3 fatty acids, arginine, cysteine, histidine, vitamin A, zinc, and ascorbic acid. Fifty patients, 3 to 76 years of age with burns ranging from 10 to 89% total body surface area were prospectively randomized into three groups which blindly compared MTF to two enteral regimens widely utilized in the nutritional support of burns. Age, percent total and third-degree burn, resting energy expenditure, and calorie and protein intake were similar in all groups. Data analysis demonstrated significant superiority of MTF in the reduction of wound infection (p less than 0.03) and length of stay/percent burn (p less than 0.02). MTF was also associated with a decreased incidence of diarrhea, improved glucose tolerance, lower serum triglycerides, reduced total number of infectious episodes and trends toward improved preservation of muscle mass, although statistical significance was not achieved. Seventy percent of deaths occurred in the group supported with an inherently large dose of fat and linoleic acid. Combining these observations, it is believed that MTF is effective in modulating an improved response to burn injury.

Photobiological properties of a novel, naturally occurring furoisocoumarin, coriandrin

The photobiological properties of a novel, naturally occurring furoisocoumarin isolated from coriander and named coriandrin are described. Photosensitized lethal and mutagenic effects in bacteria indicate that it is more active than psoralen. It is a weak frameshift mutagen in the dark. Mammalian cells in tissue culture are photosensitized more actively with coriandrin than with psoralen even though preliminary evidence from interrupted radiation experiments and DNA analysis suggest that coriandrin does not form DNA interstrand crosslinks. Sister chromatid exchanges were induced with a unit dose of 1.1 x 10(-2) with coriandrin; the value for psoralen is 3 x 10(-3). Coriandrin appears to be metabolized more rapidly than furocoumarins by liver mixed function oxidases. Skin photosensitizing activity is very weak compared with psoralen, a surprising observation considering its potency in biological test systems.

Natural history of in situ breast cancer in a defined population

The entire experience of in situ breast cancer in Alberta from 1953 to 1984 was examined. Of 243 patients coded, 226 were available for review by a panel of three pathologists. In 149 cases the diagnosis of in situ disease was confirmed. One hundred and eight patients had 109 ductal carcinomas in situ, 38 patients had lobular carcinomas in situ, with 3 patients having both. A multitude of treatments was used, ranging from local excision to radical mastectomy. Survival at a mean of 6 years follow-up was equal in all groups, with only two patients with a confirmed diagnosis of ductal carcinoma in situ dying from clinically suspected systemic disease. In patients treated by local excision, ipsilateral cancers were seen in 12% of ductal carcinoma in situ patients who had local excision and 13% of patients with lobular carcinoma in situ. Contralateral metachronous invasive cancers were seen in 6% of ductal carcinoma in situ patients and 3% of lobular carcinoma in situ patients. No lymph node involvement was seen in any of these patients, either with prophylactic dissection or in follow-up. The conclusion reached was that both in situ lesions are similar in their clinical course. Lymph node dissection is not necessary. Pathologic review is critical for accurate studies, with a change in diagnosis of 36% of diagnoses. Treatment does not appear to affect prognosis. The most appropriate treatment needs to be determined in prospective randomized trials.

Myocardial infarction complicating cardiovascular stress testing with normal coronary arteriography

A patient with normal coronary arteriography who experienced a non-Q myocardial infarction is described. The temporal relationship of ischemic symptoms, ECG changes, and rise in creatine phosphokinase (CPK) support a relationship to an exercise treadmill test.

Diminished antigen processing by endosomal acidification mutant antigen-presenting cells

The role of acidified endosomes in Ag processing was investigated using mutant Chinese hamster ovary cells that express temperature sensitive defects in their acidification mechanism. These cells were transfected with MHC class II genes to convert them to APC. When such mutant cells were incubated at the nonpermissive temperature, losing early endosomal but not lysosomal acidification, their ability to process several native protein Ag was impaired. The nonpermissive temperature did not affect Ag processing by transfected wild type parental cells. Furthermore, T cells were stimulated normally under these conditions when the mutant cells presented antigenic peptide fragments, which do not require processing. The mutant cells were also not defective in the uptake and overall degradation of native antigen. The elimination of Ag processing by paraformaldehyde and chloroquine treatment of the Chinese hamster ovary cells indicates that these cells do not use a different process than physiologic APC. These results suggest that acidification of early endosomes is an important event in Ag processing.

Diminished antigen processing by endosomal acidification mutant antigen-presenting cells

The role of acidified endosomes in Ag processing was investigated using mutant Chinese hamster ovary cells that express temperature sensitive defects in their acidification mechanism. These cells were transfected with MHC class II genes to convert them to APC. When such mutant cells were incubated at the nonpermissive temperature, losing early endosomal but not lysosomal acidification, their ability to process several native protein Ag was impaired. The nonpermissive temperature did not affect Ag processing by transfected wild type parental cells. Furthermore, T cells were stimulated normally under these conditions when the mutant cells presented antigenic peptide fragments, which do not require processing. The mutant cells were also not defective in the uptake and overall degradation of native antigen. The elimination of Ag processing by paraformaldehyde and chloroquine treatment of the Chinese hamster ovary cells indicates that these cells do not use a different process than physiologic APC. These results suggest that acidification of early endosomes is an important event in Ag processing.

Nutritional and pathological changes in male and female rats fed modifications of the AIN-76A diet

Male and female weanling Sprague-Dawley rats were fed either an AIN-76A diet or a modification of the AIN-76A diet containing no added DL-methionine but with higher levels of vitamins, fluoride and magnesium than in the AIN-76A diet. Both diets were fed, to groups of ten rats of each sex, at 18% protein or a reduced protein level of 13% for 12 wk. Within each sex, all diets produced comparable weight gains in rats at the end of 12 wk, except that the reduced-protein modified AIN-76A diet was associated with a reduction in weight gain in male rats. Both diet and protein level had statistically significant effects on the relative weights of some organs, particularly the kidney. The AIN-76A and the reduced-protein AIN-76A diets significantly increased the relative kidney weights (% body weights) of female rats, when compared with the effects of both modified AIN-76A diets (18 and 13% protein). Male rats fed both of the diets containing 18% protein had higher relative kidney weights than did those consuming both 13% protein diets. Females fed the modified diet containing 13% protein had significantly lower liver weights than the other groups. In both sexes, the two diets containing 18% protein caused significantly higher plasma urea nitrogen concentrations than did the lower protein diets. Kidney calcium concentrations varied with the diet, with dietary protein level, and with the sex of the animal. All diets caused small mineral (calcific) concretions of minimal to mild severity in the lumina of scattered renal tubules in the cortex and/or medulla of male rats. All female rats fed the AIN-76A and the reduced-protein AIN-76A diet had large, moderate or severe mineral concretions in the tubules at the corticomedullary junction and this was associated with increased renal calcium levels. The higher concentration of renal calcium at the lower dietary protein level (13%) was associated with severe corticomedullary junction mineralization. The higher protein diets were associated with an increased incidence of hyaline droplets in the cytoplasm of kidney cortical tubules in male rats.

Diarrhea in tube-fed burn patients: incidence, etiology, nutritional impact, and prevention

The hypermetabolic state observed in thermally injured patients warrants aggressive nutritional management. Enteral support is the preferred route of nutrient delivery, however diarrhea is reported to be a persistent complication of continuous nasogastric or nasoduodenal hyperalimentation. Diarrhea adds to problems in patient care, disturbs fluid and electrolyte balance, and worsens nutritional status. There has been the impression that tube feeding hyperosmolality, antibiotics, and low serum albumin induce diarrhea. However, in view of the sparsity of published work, a prospective study was undertaken to determine the incidence of diarrhea and to define factors associated with its cause. Of the 50 patients studied, 16 (32%) developed diarrhea. Stool cultures were negative for pathogenic organisms. Although the risk of diarrhea was associated with antibiotics (p less than 0.005), several nutrients also had an impact. Results demonstrated a significant relationship between dietary lipid content (p less than 0.05) or vitamin A intake (p less than 0.001) and diarrhea. Implementation of tube feeding within 48 hrs postburn was also associated with a decreased incidence of diarrhea (p less than 0.001). This paper describes a modular tube feeding program in which diarrheal frequency is lessened (p less than 0.0001). Surprisingly, tube feeding osmolality, drugs used to prevent stress ulcers, or hypoalbuminemia did not have an adverse effect on intestinal absorption. The cause of diarrhea in burn patients is obviously multifactorial. It is concluded that a low fat (less than 20% of caloric intake), vitamin A enriched (greater than 10,000 IU/day), early enteral support program maximizes conditions which promote tube feeding tolerance while minimizing nutrient malabsorption during the nutritional rehabilitation of thermal injury.

Hematuria in the burned child

Hematuria is a frequent complication in burn patients, but its clinical significance has not been reported. The incidence, etiologies, treatment, and outcome of hematuria in 1,785 burn patients treated from 1964 to 1983, have been reviewed. Ninety-one patients had hematuria (greater than 15 RBC/HPF with unspun urine). There were five main causes: urinary infections (UTI), 50 cases; renal calculi (RC), 14 cases, including 3% and 5% total body surface area burn patients; catheter trauma, 7 cases; renal vein thrombosis (RVT), 5 cases; and acute renal failure (ATN), 4 cases. Ten patients died in the UTI group, five with Candida as the infecting organism. No RC patients died, but two required surgical extraction of their stones. This incidence of RC may be due to large intake of dairy products and antacids and to prolonged immobilization. The catheter trauma group had no deaths and was the youngest group. One RVT patient was diagnosed clinically and successfully treated surgically. The other three were diagnosed at necropsy. The ATN patients all developed renal failure late as part of multiple organ system failure and all died. We conclude hematuria is a serious finding in burn patients and prompt diagnosis of its etiology and treatment are essential for maintaining renal function and patient survival.

Efficacy and safety of flecainide acetate for atrial tachycardia or fibrillation

Thirty-nine patients with symptomatic ectopic atrial tachycardia (9 paroxysmal, of which 5 were incessant) and atrial fibrillation (AF) (25 paroxysmal, 5 chronic) were treated with oral flecainide acetate (100 to 400 mg/day). Thirty-two patients had organic heart disease (16 coronary artery disease, 6 valvular, 10 cardiomyopathy, 7 primary electrical abnormality). Previous antiarrhythmic trials consisted of 0 to 5 drugs (mean 2.2). Of 39 patients with atrial tachycardia or AF, a complete response (no recurrent symptomatic atrial arrhythmia) was achieved in 22 (56%), a partial response (more than 95% reduction in arrhythmia occurrence) in 3 (8%) and no response in 14 (36%). Left atrial size, ejection fraction, underlying heart disease, duration of symptoms before treatment and drug levels were not useful for predicting clinical response. Therefore, during the follow-up period of 5.4 +/- 6.7 months (range 4 weeks to 2.5 years), flecainide had a complete or partial effect in 25 patients (64%). Complete or partial responses were noted in 8 of 9 patients (90%) with ectopic atrial tachycardia and 17 of 30 (57%) with AF. In 14 patients with concurrent ventricular arrhythmias, a significant reduction in episodes of nonsustained ventricular tachycardia was also achieved. Treatment was discontinued in 8 patients (20%) because of cardiac adverse reactions, including pulmonary edema and ventricular or atrial proarrhythmic response. Thus, oral flecainide acetate is effective therapy for some patients with ectopic atrial tachycardia or AF.

A prospective study of thymopentin in severely burned patients

A randomized prospective double-blind study of thymopentin was performed upon 24 severely burned patients to evaluate its efficacy in correcting postburn immunologic abnormalities and preventing infectious morbidity and mortality. Patients in the treated group received 50 milligrams of thymopentin daily for the first two weeks after injury and three times weekly thereafter until the patient was no longer at risk for having infections develop. The placebo group received saline solution intravenously. The rate of infectious complications was recorded. Immunologic tests used at least weekly were: white blood cell counts, OKT4 to OKT8 ratios, lymphocyte blastogenesis and neutrophil bactericidal index. There were no differences noted in patient mortality, infectious complications or antibiotic use. There were two significant differences noted among the immunologic tests. First, there was a decreased lymphocyte blastogenic response in the treated group at two weeks after injury without a difference in T4 to T8 ratios. Second, there was less leukopenia during the first week after injury in the treated group.

An evaluation of Aquaphor Gauze dressing in burned children

Aquaphor Gauze was evaluated as a dressing for skin graft donor sites, for partial thickness burn injuries and for split thickness skin grafts. Control dressings consisted of: fine mesh gauze for skin graft donor sites. silver sulphadiazine (Silvadene) on coarse mesh gauze for the partial thickness burns, and nitrofurazone cream (Furacin) on fine mesh gauze for the skin grafts. The Aquaphor Gauze was found to be inferior to the fine mesh gauze for donor site dressings. No statistically significant difference was identified between Aquaphor Gauze and controls for the treatment of partial thickness burns. As a dressing for skin grafts the Aquaphor Gauze was significantly superior to the control dressing as measured by graft take and reduced patient pain. We would recommend that Aquaphor Gauze be used as a dressing for skin grafts where the risk of infection is not excessive.

Failure of topical steroids and vitamin E to reduce postoperative scar formation following reconstructive surgery

One hundred fifty-nine operative procedures for postburn contractures of interdigital webs (96), the axilla (46), or the neck (17) were prospectively randomized to be treated postoperatively for four months with a topical steroid (Aristocort A), topical vitamin E, or the base cream carrier for these drugs. The nature of the medication was blinded both to the patient and to the evaluator. Patients were followed for one year. Observations were made for range of motion, scar thickness, change in graft size, and ultimate cosmetic appearance. No beneficial effect of either vitamin E or topical steroid could be demonstrated. However, adverse reactions occurred in 16.4% of patients receiving active drug, compared to 5.9% treated only with base cream. Interestingly, the grafts initially contracted and subsequently grew to be a size larger (about 20%) than the original graft by one year. It is concluded that neither topical steroid nor topical vitamin E is effective in reducing scar formation after grafting procedures for reconstruction for postburn contractures.

Controlled trial of homoeopathic treatment of osteoarthritis

In a double-blind, placebo-controlled crossover study to compare the homoeopathic remedy Rhus tox. 6X with fenoprofen in osteoarthritis of the hip and knee, fenoprofen was shown to have beneficial analgesic and anti-inflammatory effects which differed significantly from those of placebo. The effects of Rhus tox. 6X and placebo did not differ significantly. Patient preference was for fenoprofen. Side-effects were not severe but were seen more frequently with fenoprofen. Similar results were seen in all patients regardless of whether they had been referred to and assessed by a homoeopathic physician or a rheumatologist.

Teaching with audiovisual recordings of consultations

The experience gained from two years' teaching with audiovisual recordings of consultations of both undergraduates and postgraduates is presented. Some basic teaching rules are suggested and further applications of the technique are discussed.