A case of Lambert-Eaton myasthenic syndrome with possible myasthenia gravis

Lambert-Eaton myasthenic syndrome (LEMS) is a rare autoimmune disorder of neuromuscular transmission (NMJ) that shares many clinical features with myasthenia gravis (MG). We report a 73 year-old lady who presented 10 years previously with stiffness of both calves, dry mouth, fatigue, proximal weakness and areflexia in lower limbs. Neurophysiological studies were consistent with LEMS. Her work up for an underlying neoplasm was negative. She recently developed unilateral ptosis and diplopia which dramatically improved with pyridostigmine suggesting concomitant MG.

Characteristics of AZD9708, a novel, selective β2-adrenoceptor agonist with rapid onset and long duration of action

Here we describe the pre-clinical pharmacological profile of AZD9708, a novel long-acting β(2)-adrenoceptor agonist that has potential as a once-daily therapy for asthma and chronic obstructive pulmonary disease (COPD). AZD9708 is a potent and selective agonist at the human β(2)-adrenoceptor, with selectivity over human β(1)- and β(3)-adrenoceptors of >500 and >24 fold, respectively. AZD9708 relaxes carbachol-induced contraction of human bronchial rings with a time to 90% of maximal relaxation of 13-20 min, similar to that seen with formoterol and quicker than salmeterol. In anesthetized guinea pigs, AZD9708 provides significant protection against histamine-induced airway constriction at 24 h after intratracheal and nebulized doses. This is longer than with intratracheal salmeterol, which is bronchoprotective for approximately 8 h, and formoterol, which is bronchoprotective for 8 and 12 h following nebulized and intratracheal dosing, respectively. AZD9708 also shows the potential for a greater therapeutic margin than widely used β(2)-adrenoceptor agonists such as formoterol. At a defined efficacy dose that provides 80% bronchoprotection (ED(80)), formoterol leads to a decrease in blood potassium levels in guinea pigs, whilst AZD9708 is not associated with significant reductions in potassium levels at doses up to 7 times the ED(80). [(14)C]AZD9708 is associated with extensive protein binding in both human (mean 1.0% free) and rat (mean 2.6% free) plasma. This pharmacological profile indicates the potential of AZD9708 to become an important addition to the range of bronchodilators available for the treatment of patients with obstructive airways disease.

A review of major trauma admissions to a tertiary adult referral hospital over a ten year period: fewer patients, similar survival

BACKGROUND

Trauma is an important cause for presentation to the emergency department, representing a significant number of emergency surgical admissions. Societal changes result in alterations in the epidemiology of trauma.

OBJECTIVES

This study aimed to review patients admitted to a tertiary referral hospital as a result of traumatic injuries, assessing for changes in admission epidemiology.

METHODS

Trauma admissions over two year-long periods a decade apart were reviewed. The Trauma Audit and Research Network (TARN) audit system identified admissions and transfers between June 2006 and May 2007. The Hospital In-Patient Enquiry (HIPE) system identified those fulfilling TARN criteria a decade earlier. Comparative analysis was performed on the dataset.

RESULTS

There were 367 trauma admissions between June 2006 and May 2007: 88 road traffic accidents (RTAs), 201 falls and 77 other injuries, with 627 admissions a decade earlier: 286 RTAs, 247 falls and 94 others. Males comprised 72% and 69% of RTA admissions in both periods respectively. Firearm-related injuries increased significantly (p = 0.015). Neurosurgical transfers decreased from 256 to 150 with a slight increase in unadjusted overall mortality from 8.5% to 10.9%. Admissions of patients aged less than 19 reduced from 150 to 59 (p = 0.0031) with a similar trend in those aged between 20 and 29 years from 149 to 78.

CONCLUSION

Admissions resulting from RTAs and of patients aged under 30 reduced significantly, however, young males remain the most affected sub-group. Firearm injuries increased significantly, a worrying trend in view of the severity of injury sustained by these victims.

Long-term neurotoxicity of chemotherapy in adolescents and young adults treated for bone and soft tissue sarcomas

Purpose. To study the long-term neurotoxicity of chemotherapy in adolescents and young adults treated for bone and soft tissue sarcomas.

Patients and Methods. Thirty-six adolescents and young adults (median age 17 years) were examined following chemotherapy for bone and soft tissue sarcomas. Twenty-nine (29/36) had received cisplatin (median 400 mg/m²), 15/36 ifosfamide (median 20 g/m²), and 12/36 vincristine (median 16 mg). Neurotoxicity was assessed at a median of 8 months (range, 1–54 months) after completion of chemotherapy by clinical examination, nerve conduction studies, audiograms and autonomic function tests. The same nerve conduction studies were carried out in 20 normal volunteers to define normal ranges in this age group.

Results. Sixteen patients (44%) had a significant reduction in deep tendon reflexes, and this clinical parameter correlated well with abnormalities detected in nerve conduction studies. Vibration perception threshold (VPT) was raised in 20/36 patients (55%) and this was the most sensitive single test in the assessment of neuropathy. There was a significant correlation between VPT and cumulative cisplatin dose received in mg/m^-2 (r=0.607, p<0.01). Ten of 29 patients (35%) had abnormal nerve conduction studies with a pattern characteristic of sensory axonal neuropathy. No patient complained of auditory symptoms, but minor high tone hearing loss was detected by audiograms in 5/28 patients who had received cisplatin. No patients had symptoms of autonomic neuropathy, but autonomic function tests showed minor abnormalities in 4/22 patients tested, and all had received cisplatin.

Conclusions. This study demonstrates significant, although asymptomatic, long-term neurotoxicity of cisplatin in adolescents and young adults receiving chemotherapy for bone and soft tissue sarcomas. Follow-up studies are planned to assess whether these neurological deficits improve with time.

Impact of pharmacotherapy on the incidence of transurethral prostatectomy for benign prostatic hyperplasia and the implications for surgical training

Medical therapy has become first line treatment for Benign Prostatic Hypertrophy (BPH) and in many cases TURP may no longer be required. Proof and quantification of this evolution in practice has been somewhat elusive and provided the principle impetus for this study. This is a retrospective study of BPH management in Republic of Ireland from 1995 to 2008. National treatment databases were sourced for numbers undergoing TURP and pharmacotherapy prescribing data was obtained from individual pharmaceutical companies. A total of 28,240 TURP's were performed nationally between 1995 and 2008. TURP's performed annually, decreased by 1,494 (51%), alpha-blocker prescriptions increased from 8,710 to 302,159 units and the number of urology trainees increased by 10 (60%). Clear association between decreases in TURP's and increases in pharmacotherapy for BPH is demonstrated. Implications on training likely exist and will require proper evaluation in order to maintain future standards in this surgical practice.

Out-patient management and non-attendance in the current economic climate. How best to manage our resources?

Outpatient non-attendance is a considerable source of inefficiency in the health service, wasting time, resources and potentially lengthening waiting lists, Given the current economic climate, methods need to be employed to reduce non-attendance. The aim was to analyse outpatient non-attendance and determine what factors influence attendance. A prospective audit over a two-month period to a tertiary-referral Urological service was performed to determine the clinical and demographic profile of non-attendees. Of 737 appointments, 148 (20%) patients did not attend (DNA). A benign urological condition was evident in 116 cases (78%). This group of patients also accounted for the majority of new patients not attending 40/47, returning patients not attending 101/148 and the majority of patients who missed multiple appointments 43/49. Patients with benign conditions make up the majority of clinic non-attendance. Consideration may be given to discharging such patients back to their general practitioner after one unexplained non-attendance until other alternatives of follow up are available.

Acid soil indicators in forest soils of the Cherry River Watershed, West Virginia

Declining forest health has been observed during the past several decades in several areas of the eastern USA, and some of this decline is attributed to acid deposition. Decreases in soil pH and increases in soil acidity are indicators of potential impacts on tree growth due to acid inputs and Al toxicity. The Cherry River watershed, which lies within the Monongahela National Forest in West Virginia, has some of the highest rates of acid deposition in Appalachia. East and West areas within the watershed, which showed differences in precipitation, stream chemistry, and vegetation composition, were compared to evaluate soil acidity conditions and to assess their degree of risk on tree growth. Thirty-one soil pits in the West area and 36 pits in the East area were dug and described, and soil samples from each horizon were analyzed for chemical parameters. In A horizons, East area soils averaged 3.7 pH with 9.4 cmol(c) kg(-1) of acidity compared to pH 4.0 and 6.2 cmol(c) kg(-1) of acidity in West area soils. Extractable cations (Ca, Mg, and Al) were significantly higher in the A, transition, and upper B horizons of East versus West soils. However, even with differences in cation concentrations, Ca/Al molar ratios were similar for East and West soils. For both sites using the Ca/Al ratio, a 50% risk of impaired tree growth was found for A horizons, while a 75% risk was found for deeper horizons. Low concentrations of base cations and high extractable Al in these soils translate into a high degree of risk for forest regeneration and tree growth after conventional tree harvesting.

A pernicious leucoencephalopathy

Pernicious anaemia may manifest various neurological symptoms and signs ranging from the subtle to the dramatic. We describe a young man with cobalamin deficiency presenting with sensorimotor deficits, ataxia, dysarthria, mild cognitive deterioration and altered mood of insidious onset. The MRI brain findings were in keeping with a leucoencephalopathy without evidence of MRI changes in the spinal cord. This constellation of features has been reported rarely. His response to treatment as well as the marked improvement of the leucoencephalopathy on imaging suggests at least partial reversibility of the neurological deficits.