Influence of Obesity on Plasma Fructosamine Concentration

The influence of obesity on plasma fructosamine concentration was studied in 68 diabetic and 1335 nondiabetic subjects from a Chinese community. Obese nondiabetic men (body mass index > 25 kg/m2) had lower fructosamine concentrations than nonobese nondiabetic men (body mass index < or = 25 kg/m2); the pattern was similar for diabetic women. Stepwise multiple-regression analysis showed that, apart from known factors (total protein, albumin, and indices of glycemic control), fructosamine was also associated with body mass index and plasma fasting triglycerides. However, the contribution of these were small except in diabetic women. We conclude that the effect of obesity on fructosamine is small.

A perinatal perspective on South Australia in the 1980s

OBJECTIVE

To assess changes in sociodemographic characteristics of mothers, their obstetric management and perinatal outcomes in the 1980s.

DESIGN

A survey of data recorded in the South Australian perinatal data collection. For singleton births, we compared risks of stillbirth, neonatal death and perinatal death by year of birth, after adjusting for risk factors.

SUBJECTS

There were 176,637 births of at least 400 g birthweight (or at least 20 weeks' gestation) notified to the perinatal data collection between 1981 and 1989.

MAIN OUTCOME MEASURES

Frequency of risk factors and relative risks of stillbirth, neonatal death and perinatal death by year of birth.

RESULTS

There have been changes in the sociodemographic characteristics of mothers, their obstetric management and perinatal outcomes during the 1980s. Crude perinatal mortality rates have not increased, despite increases in the frequency of low birthweight, preterm births, mothers aged 35 years and over, and some other risk factors. After adjusting for risk factors, the risks of stillbirth, neonatal death and perinatal death were lower among singletons in 1987-1989 than in the 1981-1982 reference period.

CONCLUSION

Advances in clinical management may be preventing increases in stillbirths, neonatal deaths and perinatal deaths in response to increased numbers of births with low birthweight, preterm delivery and some other risk factors in South Australia.

Association between insulin and blood pressure in a community population with normal glucose tolerance

The purpose of this study was to examine the relationship between insulin and BP in patients with normal glucose tolerance. The associations between systolic and diastolic BP, age, body mass index, waist/hip ratio, fasting glucose, insulin, fructosamine, glycosylated haemoglobin, lipid profile, and glucose and insulin two hours after 75 g oral glucose were examined in 1,520 employees of a public utility company and non-medical staff of a district hospital. Patients with impaired glucose tolerance or diabetes mellitus (using WHO criteria) were excluded. In men (mean age 35.6 +/- 8.7 years, n = 769), both systolic and diastolic BP were positively associated with age, body mass index, waist/hip ratio, fasting and 2h glucose and insulin, triglycerides and apolipoprotein B, and were negatively associated with glucose/insulin ration, and high density lipoprotein and cholesterol and its subfractions. However, in multivariate analysis only body mass index, age, fasting glucose and insulin were independent predictors of systolic BP, while only body mass index and age predicted diastolic BP. In women, age, glycosylated haemoglobin, 2h glucose/insulin ratio, 2h glucose, fructosamine and triglycerides were predictors of systolic BP. Fasting or 2h insulin, and glucose/insulin ratios did not predict diastolic BP. The results are compatible with the hypothesis that systolic hypertension may reflect a hyper-insulinaemic state even in those with normal glucose tolerance, independent of age and obesity. The association between plasma lipids and blood pressure is probably mediated by insulin and obesity.

Ventricular tachycardia after surgical repair of tetralogy of Fallot: results of intraoperative mapping studies

OBJECTIVES

Four patients with previous repair of tetralogy of Fallot and ventricular tachycardia underwent map-guided surgery to ablate the arrhythmias.

BACKGROUND

Although patients with repaired tetralogy of Fallot are at increased risk of sudden death due to ventricular tachycardia, little is known of the origin and mechanism of this arrhythmia.

METHODS

A customized right ventricular balloon with 112 electrodes was used to record endocardial activation and, where possible, simultaneous epicardial recordings were obtained with a sock electrode array. Three patients had an aneurysm of the right ventricular outflow tract and one had a septal aneurysm. All had moderate to severe pulmonary valve insufficiency. Preoperative electrophysiologic study demonstrated inducible rapid (cycle length 180 to 300 ms) hemodynamically unstable monoform ventricular tachycardias.

RESULTS

Intraoperatively, five different tachycardias (two in one patient) were induced and mapped. The sites of earliest activation were located in the subendocardium of the right ventricular outflow tract in all, but they varied widely among the septum, free wall and parietal band and could not be identified by visible scar. All were due to a macroreentrant circuit initiated by a critical delay in activation beyond a functional arc of block. Two patients treated by cryoablation while the heart was beating and perfused at normal temperature had inducible ventricular tachycardia postoperatively. In the two subsequent patients, the application of cryoablation under anoxic cardiac arrest resulted in noninducibility of arrhythmia.

CONCLUSIONS

Ventricular tachycardia in tetralogy of Fallot in these four patients was caused by macroreentry in the right ventricular outflow tract. Surgical success depends on detailed mapping and cryoablation under anoxic cardiac arrest. In patients at risk of sudden death, map-directed surgery may offer distinct advantages over either implantable devices or drug therapy.

The association of low socio-economic status in metropolitan Adelaide with maternal demographic and obstetric characteristics and pregnancy outcome

The South Australian perinatal statistics collection for 1988 was used to consider the association of low socio-economic status in metropolitan Adelaide (South Australia) with maternal demographic and obstetric characteristics and pregnancy outcome in 12047 singleton births. Socio-economic status--low, middle or high--was inferred from the socio-economic rating of the postcode of residence. Chi-squared analyses were carried out to test for significant trends in proportions of pregnancy and pregnancy outcome variables across the socio-economic groupings. There was trend for the proportions of adverse obstetric and perinatal outcomes to decrease with increasing level of socio-economic status. Logistic regression analysis, adjusted for maternal age, marital status, race, parity and gestational age, confirmed the findings of the trend analyses, namely that mothers from the poor socio-economic areas were at a greater risk for poor pregnancy outcome. These poor outcomes included Apgar scores of less that 7 at both 1 and 5 minutes after birth, delay in onset of regular breathing of 5 minutes or longer; the need for intubation; the use of narcotic antagonists; low birthweight of under 2500 g; the need for special nursey care; and neonatal death.

Blood pressure and urinary cations in a Chinese population

The prevalence of hypertension and the relationship between blood pressure, age, body mass index (BMI) and urinary cations from casual urine specimens were examined in 1,513 Chinese employees of a public utility company and non-medical personnel of a district hospital. The prevalence of hypertension, defined as systolic blood pressure greater than or equal to 140 or a diastolic blood pressure greater than or equal to 90 mmHg, or a past history of hypertension, was 17% in men and 5% in women. After excluding subjects who were on antihypertensive medication, age, body mass index, and urinary sodium/potassium ratio were independently and positively associated with blood pressure, while urinary potassium/creatinine ratio was inversely related to blood pressure. No association with urinary sodium or sodium/creatinine ratio was found. Higher mean blood pressure in men was accompanied by lower urinary potassium/creatinine and potassium concentration and higher sodium/potassium ratio, even though men had the same mean BMI when compared with women. A difference in potassium intake between the sexes may partly account for this finding. We conclude that in this Chinese population, whose dietary intake is more influenced by the West compared with Chinese in the Peoples' Republic of China, age and BMI are important determinants of blood pressure, together with potassium intake as reflected by urinary potassium excretion. No association of blood pressure with sodium excretion was demonstrated.

Intestinal obstruction in patients with widespread intraabdominal malignancy

The clinical course of 28 patients with surgically documented widespread intraabdominal malignancy who developed intestinal obstruction was reviewed. Of 26 patients, 13 responded to initial conservative management. In the ten patients treated surgically, there was significant morbidity in 80% and a postoperative mortality of 40%. Reobstruction occurred in 11 patients, responded poorly to therapy, and was associated with a short life expectancy. These results support the use of conservative therapy in the management of intestinal obstruction due to widespread intraabdominal malignancy, with emphasis on the palliation of symptoms and maintenance of quality of life.

Primary hyperparathyroidism in younger and older patients: symptoms and outcome of surgery

Two-hundred and fifty patients undergoing initial exploration for primary hyperparathyroidism were analyzed for differences in clinical presentation, biochemical status, pathology, and outcome of surgery. In patients less than 60 years of age (younger patients, n = 119) the most common preoperative symptoms and signs were fatigue (40.3%), bone pain (33.6%), renal stones (31.0%), hypertension (27.7%), and psychiatric illness (27.7%). In patients greater than or equal to 60 years of age (older patients, n = 131) the most frequent symptoms and signs were hypertension (46.6%), fatigue (35.1%), bone pain (30.5%), muscle weakness (28.2%), and joint pain (22.9%). Renal stones were 2.6 times more common (p less than 0.001, chi 2) in younger patients and hypertension 1.7 times more common (p less than 0.05, chi 2) in older patients. There was no significant difference in the preoperative and postoperative laboratory values typically associated with primary hyperparathyroidism. Double adenomas were more common in older (9.2%) than in younger patients (2.5%, p less than 0.05, chi 2). Surgical cure was obtained in 98.8% of patients, and after parathyroidectomy 83% of the younger and 82% of the older patients experienced substantial relief of pre-operative symptoms. Specific questioning revealed most patients to be symptomatic and older patients appear to receive the same clinical and metabolic benefits from parathyroidectomy as younger patients.

Complications and failure of anticoagulation therapy in the treatment of venous thromboembolism in patients with disseminated malignancy

Thirty-one patients with malignancy, anticoagulated for the treatment of venous thromboembolism (VTE) are reported. Complications of treatment included major bleeding (35%), redevelopment of VTE whilst on therapeutic levels of anticoagulants (13%) and recurrent VTE following cessation of anticoagulant (42%). Forty-two per cent of patients died within three months of initiating anticoagulant therapy. The cause of death was progressive malignancy, except in one patient who died of anticoagulant-related bleeding. The high incidence of bleeding is frequently associated with over-anticoagulation and indicates the need for improved monitoring. The frequent recurrence of VTE is associated with chronic disseminated intravascular coagulation, for which warfarin is ineffective and heparin is indicated.

Neonatal Campylobacter fetus meningitis: a report of an unusual case

Campylobacter fetus is a rare cause of meningitis in the pediatric age group and, in particular, among neonates. The clinical presentation of campylobacter meningitis in high-risk neonates is not well-described. A review of campylobacter meningitis by Lee et al in 1985 reported nine cases occurring in neonates, of which only one case was caused by C. fetus. In the ensuing six years only three more confirmed cases of neonatal meningitis caused by C. fetus have been reported. We here report another confirmed case of C. fetus meningitis in a neonate.

Free triiodothyronine in sera of acutely ill general medical patients: a prognostic indicator?

We measured free triiodothyronine (FT3), thyrotropin (TSH), and C-reactive protein (CRP) in sera of 39 acutely ill medical patients who died within three months of admission and 39 age- and sex-matched control patients selected at random from a total of 294 acute medical admissions. Serum FT3 in nonsurvivors (1.91 +/- 1.51 pmol/L) was significantly lower than that in survivors (3.01 +/- 1.3 pmol/L, P less than 0.01) and the CRP in nonsurvivors (54.6 +/- 59.2 mg/L) was significantly higher than in survivors (43.6 +/- 59.5 mg/L, P less than 0.05). There was no difference in plasma TSH between the two groups. The estimated odds ratio relating death to a plasma FT3 value less than 1.0 pmol/L on admission was 17 (highly significant: P less than 0.001). We conclude that plasma FT3 may be a useful prognostic indicator in acutely ill patients.

Free Triiodothyronine in Sera of Acutely Ill General Medical Patients: a Prognostic Indicator

We measured free triiodothyronine (FT3), thyrotropin (TSH), and C-reactive protein (CRP) in sera of 39 acutely ill medical patients who died within three months of admission and 39 age- and sex-matched control patients selected at random from a total of 294 acute medical admissions. Serum FT3 in nonsurvivors (1.91 +/- 1.51 pmol/L) was significantly lower than that in survivors (3.01 +/- 1.3 pmol/L, P less than 0.01) and the CRP in nonsurvivors (54.6 +/- 59.2 mg/L) was significantly higher than in survivors (43.6 +/- 59.5 mg/L, P less than 0.05). There was no difference in plasma TSH between the two groups. The estimated odds ratio relating death to a plasma FT3 value less than 1.0 pmol/L on admission was 17 (highly significant: P less than 0.001). We conclude that plasma FT3 may be a useful prognostic indicator in acutely ill patients.

The association of maternal and socioeconomic characteristics in metropolitan Adelaide with medical, obstetric and labour complications and pregnancy outcomes

Multiple regression analysis was used to measure associations of maternal age, race, gravidity, marital status and socioeconomic status with medical problems and pregnancy outcomes. The study population comprised all singleton births to residents of metropolitan Adelaide (in South Australia) during 1988 that were included in the State's perinatal statistics collection. The results indicate that in metropolitan Adelaide, low socioeconomic status is related to a higher risk profile of mothers and babies. It also highlights that there is a strong association of divorce and separation with medical problems and an adverse pregnancy outcome. Poorer outcomes are also seen in never married women, teenage women, older women, non-Caucasian women and primigravid women. These poorer outcomes in older women and primigravidas include higher risks of low birth-weight and prematurity of their babies. The study also demonstrates that groups that are less likely to have choice of obstetric care, eg. teenage women, non-Caucasian women, and women of low socioeconomic status, have a lower odds of obstetric intervention as characterized by nonspontaneous labour and elective Caesarean section.

Palliative care in a general teaching hospital. 2. Establishment of a service

OBJECTIVE

To assess the first year of operation of a palliative care service in a general teaching hospital.

DESIGN, SETTING, PATIENTS

A retrospective analysis of 241 terminally ill patients referred to the Austin Hospital Palliative Care Service during its first year of operation.

MAIN OUTCOME MEASURES

The occurrence and relief of pain, the occurrence and management of social and psychological problems, involvement of allied health services and the place of death.

MAIN RESULTS

Unrelieved pain was the most frequent medical problem but, with appropriate medical management as well as input from other members of the multidisciplinary team, all patients achieved satisfactory pain control. The occurrence and severity of social and psychological problems was greater than expected. Most of the patients were discharged home and referred to domiciliary palliative care services; one-quarter of patients were able to die at home, one-third died in an inpatient hospice, and the remainder died in hospital.

CONCLUSIONS

The Service was able to achieve most of its stated aims and has generated a much improved appreciation of the palliative care needs of patients with terminal illness and their families within the Hospital. A multidisciplinary approach to the management of terminally ill patients is crucial, and this Service has been successful despite limited staffing because of the willing involvement of other Units and Services in the Hospital. The difficulties inherent in the evaluation of a palliative care program (quality of life, cost-effectiveness) are discussed.

Palliative care in a general teaching hospital. 1. Assessment of needs

OBJECTIVE

To assess the palliative care needs and the results of treatment of patients with terminal cancer admitted to a general teaching hospital.

DESIGN, SETTING, PATIENTS

A retrospective analysis of 110 consecutive patients with terminal cancer admitted to the Austin Hospital.

MAIN OUTCOME MEASURES

The occurrence and relief of pain, the use of allied health services and the place of death.

MAIN RESULTS

Pain was the most common symptom and was satisfactorily improved in only two-thirds of the patients. Allied health services were used sporadically and appeared to be underused. Psychological problems were documented in very few patients. Only seven patients died at home, the remainder dying in hospital (82) or in a hospice (21).

CONCLUSIONS

One-third of patients with terminal cancer in a general teaching hospital received inadequate pain relief; the reasons for this included lack of medical expertise in the use of analgesics for chronic cancer pain and the frequent use of analgesia given only "as required". The underuse of allied health services, the infrequent documentation of psychological issues and the observation that only a small proportion of patients were able to die outside hospital all underline the need for a coordinated multidisciplinary approach to the management of patients with terminal cancer.

In vivo and in vitro sodium pump activity in subjects with thyrotoxic periodic paralysis

OBJECTIVE

To examine whether sodium pump activity plays a part in the pathogenesis of thyrotoxic periodic paralysis.

DESIGN

Measurement of platelet sodium-potassium ATPase and in vivo sodium pump activities in healthy subjects and thyrotoxic subjects with and without paralysis.

SETTING

University hospital in Hong Kong.

SUBJECTS

21 healthy subjects, 23 untreated thyrotoxic subjects, 13 untreated men with periodic paralysis, seven treated thyrotoxic subjects, and six treated men with periodic paralysis.

MAIN OUTCOME MEASURES

Platelet Na+, K(+)-ATPase activity and plasma rubidium concentration after oral loading.

RESULTS

Median (range) platelet Na+, K(+)-ATPase activity in thyrotoxic subjects was 253 (169-821) mumol inorganic phosphate/h/g protein--significantly higher than that in healthy subjects (134 (81-180) mumol/h/g protein; p less than 0.001). Na+, K(+)-ATPase activity in those with periodic paralysis was 374 (195-1196) mumol/h/g protein, again significantly higher than that in healthy subjects (p less than 0.001) and that in other thyrotoxic subjects (p less than 0.01) despite similar degrees of hyperthyroidism. Activities in treated thyrotoxic subjects with and without periodic paralysis were 148 (110-234) and 131 (86-173) mumol/h/g protein respectively. Mean (95% confidence interval) plasma rubidium concentration five hours after oral administration in thyrotoxic subjects (7.0 (6.6 to 7.5) mumol/l) was significantly lower than in healthy subjects (10.2 (9.5 to 10.9) mumol/l; p less than 0.001) and higher than in those with periodic paralysis (6.0 (5.7 to 6.3) mumol/l; p less than 0.01).

CONCLUSIONS

Sodium pump activity in untreated subjects with periodic paralysis is higher than in other thyrotoxic subjects, and this may be responsible for the hypokalaemia.

Teenage pregnancy in South Australia, 1986-1988

Teenage pregnancies accounted for 6.0% of confinements and 24.8% of legal abortions in South Australia in 1986-1988. The teenage pregnancy rate has declined by 28.5% since the early 1970s, associated with a 52.6% decline in the confinement rate. The abortion rate rose in the 1970s but fell slightly in the 1980s; nearly half the teenage pregnancies now end in legal abortion: abortion was a more likely pregnancy outcome for younger teenagers and for teenagers resident in metropolitan areas. Compared with women confined in their twenties, confined teenagers were more likely to be single, primigravid and Aboriginal, to have few antenatal visits and to have a medical or obstetric complication during their pregnancy. They were less likely to have an induction of labour or an elective Caesarean section. They had higher frequencies of preterm deliveries (8.9%) and low birth-weight babies (9.3%). The youngest teenagers had the most risk factors and the worst outcomes. In the small group of Aboriginal teenagers aged 16 years and under, about a third of the babies were low birth-weight or premature and one in 12 babies was a perinatal death. Comparison of singleton pregnancies of teenagers with women in their twenties all of whom were single, Caucasian and primigravid, with 7 or more antenatal visits, showed similarity in outcomes. This suggests that being teenage is not in itself a risk factor. Continued support and extension of teenage counselling and antenatal care services is essential.

Predominant rearrangements of the T cell receptor beta-chain gene in blood lymphocyte populations stimulated with autologous tumor cells suggest clonal T cell expansion in two of fourteen cases

T cell responses against autologous tumors with samples from patients with a variety of tumors were examined. The abilities of T lymphocytes to lyse the autologous tumor cells were analyzed after short-term mixed lymphocyte/tumor cell cultures (MLTC). Southern blot analysis was used to evaluate whether particular rearrangements of the TCR beta-chain gene predominate in these cultures. Tumor specific lysis could be induced in a proportion of the mixed cultures. In two cases enrichment of T lymphocytes with similar TCR beta-chain gene rearrangements was detected after repeated stimulations with autologous tumor cells.

Subxiphoid partial pericardiectomy with or without sclerosant instillation in the treatment of symptomatic pericardial effusions in patients with malignancy

Twenty-two patients with malignant pericardial effusions were treated with subxiphoid partial pericardiectomy between 1984 and 1989. Thirteen patients also had a sclerosing agent instilled intrapericardially. Tamponade was relieved by pericardiocentesis before administration of general anesthesia. In 18 patients (82%), the effusions were controlled for longer than 30 days, and two patients died before 30 days without effusion. There were two recurrences at 1.5 and 7 months. There was one death due to hemorrhage from a laceration in a heavily infiltrated pericardium, and one patient had persistent dyspnea after the procedure. Complications included transient atrial arrhythmias (two patients), chest pain after sclerosant instillation (three patients), and fever greater than 37.5 degrees C after sclerosant (five patients). The survival range was 0.1 to 18 months (median, 5 months). Subxiphoid partial pericardiectomy with or without intrapericardial sclerosant is a safe and efficacious treatment for malignant pericardial effusions.

Early and late surgical complications of subtotal oesophagectomy for squamous carcinoma of the oesophagus

The use of stapling devices in oesophagogastric anastomosis has markedly reduced the incidence of anastomotic leakage, but may be associated with a higher incidence of stricture formation. The purpose of this study was to review the incidence, morbidity, management and outcome of leakage and stricture in patients undergoing subtotal oesophagectomy. Seventy-two consecutive patients with proven squamous carcinoma of the thoracic oesophagus who underwent subtotal oesophagectomy and gastric pull-up with stapled anastomosis were studied. Thirty-six patients had the anastomosis constructed using the EEA size 25 mm circular stapler (group 1). Thirty-six patients had oesophagogastric reconstruction using the EEA size 28 mm circular stapler (group 2). Data were collected prospectively, but the groups were not randomized. One clinical/radiological anastomotic leak (3%) occurred using the 25 mm gun (group 1), but no dehiscence was demonstrated in group 2. There was no 30-day mortality, but two patients died before leaving hospital (overall hospital mortality rate, 3%). Early complications included anastomotic bleed, respiratory failure, chylothorax, transient bilateral recurrent laryngeal nerve palsy, and severe chest infections. After surgery, the patients were followed up at 1 month, at 3 months and then at 3-monthly intervals up to 1 year. Stricture formation occurred in 11 patients in group 1 and only four patients in group 2 (chi 2 test P less than 0.05). All benign strictures presented within 6 months of surgery. These strictures were satisfactorily treated by endoscopic dilatation. Two patients (one from each group) suffered anastomotic recurrence of their tumour at 8 and 10 months respectively.(ABSTRACT TRUNCATED AT 250 WORDS)