Comparison of Antibiotic Use between the First Two Waves of COVID-19 in an Intensive Care Unit at a London Tertiary Centre: reducing broad-spectrum antimicrobial use did not adversely affect mortality

BACKGROUND

The COVID-19 pandemic increased the use of broad-spectrum antibiotics due to diagnostic uncertainty, particularly in critical care. Multiprofessional communication became more difficult, weakening stewardship activities.

AIM

To determine changes in bacterial co-/secondary infections and antibiotics used in COVID-19 patients in critical care, and mortality rates, between the first and second waves.

METHODS

Prospective audit comparing bacterial co-/secondary infections and their treatment during the first two waves of the pandemic in a single centre teaching hospital ICU. Data on demographics, daily antibiotic use, clinical outcomes, and culture results in patients diagnosed with COVID-19 infection were collected over 11 months.

FINDINGS

From 9/3/20 to 2/9/20 (Wave 1), there were 156 patients and between 3/9/20 and 1/2/21 (Wave 2) there were 235 patients with COVID-19 infection admitted to intensive care. No significant difference was seen in mortality or positive blood culture rates between the two waves. The proportion of patients receiving antimicrobial therapy (93.0% vs 81.7%; p<0.01), and the duration of meropenem use (median (interquartile range): 5 (2-7) vs 3 (2-5) days; p=0.01) was lower in Wave 2. However, the number of patients with respiratory isolates of Pseudomonas aeruginosa (4/156 vs 21/235; p<0.01) and bacteraemia from a respiratory source (3/156 vs 20/235 p<0.01) increased in Wave 2, associated with an outbreak of infection. There was no significant difference between waves with respect to isolation of other pathogens.

CONCLUSIONS

Reduced broad spectrum antimicrobial use in the second wave of COVID-19 compared with the first wave was not associated with significant change in mortality.

Investigating LMNA-Related Dilated Cardiomyopathy Using Human Induced Pluripotent Stem Cell-Derived Cardiomyocytes

LMNA-related dilated cardiomyopathy is an inherited heart disease caused by mutations in the LMNA gene encoding for lamin A/C. The disease is characterized by left ventricular enlargement and impaired systolic function associated with conduction defects and ventricular arrhythmias. We hypothesized that LMNA-mutated patients' induced Pluripotent Stem Cell-derived cardiomyocytes (iPSC-CMs) display electrophysiological abnormalities, thus constituting a suitable tool for deciphering the arrhythmogenic mechanisms of the disease, and possibly for developing novel therapeutic modalities. iPSC-CMs were generated from two related patients (father and son) carrying the same E342K mutation in the LMNA gene. Compared to control iPSC-CMs, LMNA-mutated iPSC-CMs exhibited the following electrophysiological abnormalities: (1) decreased spontaneous action potential beat rate and decreased pacemaker current (I_f) density; (2) prolonged action potential duration and increased L-type Ca²⁺ current (I_Ca,L) density; (3) delayed afterdepolarizations (DADs), arrhythmias and increased beat rate variability; (4) DADs, arrhythmias and cessation of spontaneous firing in response to β-adrenergic stimulation and rapid pacing. Additionally, compared to healthy control, LMNA-mutated iPSC-CMs displayed nuclear morphological irregularities and gene expression alterations. Notably, KB-R7943, a selective inhibitor of the reverse-mode of the Na⁺/Ca²⁺ exchanger, blocked the DADs in LMNA-mutated iPSC-CMs. Our findings demonstrate cellular electrophysiological mechanisms underlying the arrhythmias in LMNA-related dilated cardiomyopathy.

Depressed β-adrenergic inotropic responsiveness and intracellular calcium handling abnormalities in Duchenne Muscular Dystrophy patients' induced pluripotent stem cell-derived cardiomyocytes

Duchenne muscular dystrophy (DMD), caused by mutations in the dystrophin gene, is an X-linked disease affecting male and rarely adult heterozygous females, resulting in death by the late 20s to early 30s. Previous studies reported depressed left ventricular function in DMD patients which may result from deranged intracellular Ca2+ -handling. To decipher the mechanism(s) underlying the depressed LV function, we tested the hypothesis that iPSC-CMs generated from DMD patients feature blunted positive inotropic response to β-adrenergic stimulation. To test the hypothesis, [Ca2+ ]i transients and contractions were recorded from healthy and DMD-CMs. While in healthy CMs (HC) isoproterenol caused a prominent positive inotropic effect, DMD-CMs displayed a blunted inotropic response. Next, we tested the functionality of the sarcoplasmic reticulum (SR) by measuring caffeine-induced Ca2+ release. In contrast to HC, DMD-CMs exhibited reduced caffeine-induced Ca2+ signal amplitude and recovery time. In support of the depleted SR Ca2+ stores hypothesis, in DMD-CMs the negative inotropic effects of ryanodine and cyclopiazonic acid were smaller than in HC. RNA-seq analyses demonstrated that in DMD CMs the RNA-expression levels of specific subunits of the L-type calcium channel, the β1-adrenergic receptor (ADRβ1) and adenylate cyclase were down-regulated by 3.5-, 2.8- and 3-fold, respectively, which collectively contribute to the depressed β-adrenergic responsiveness.

Diabetes transition care and adverse events: a population-based cohort study in Ontario, Canada

AIMS

To describe patterns of primary and diabetes care during transition age (17 to < 19 years) into early adulthood (age 19 to 26 years), and to evaluate the association of primary and diabetes care patterns during transition age with the risk of adverse events in early adulthood.

METHODS

We conducted a population-based cohort study of individuals in Ontario, Canada who were diagnosed with diabetes aged < 15 years and who turned 17 between November 2006 and March 2011, followed until March 2015 (n = 2525). Using linked administrative databases, we examined healthcare use during: 'pre-transition-age' (15 to < 17 years), 'transition-age' (17 to < 19 years), and 'early adulthood' (19 to 26 years). The main outcomes were time to death or ketoacidosis and rate of diabetes-related admissions. The main exposures were the gap in diabetes care and primary care visits during transition age.

RESULTS

There were < 6 deaths and 446 individuals (17.7%) had at least one admission for ketoacidosis during early adulthood. In all, 1188 individuals (47.0%) had a > 12-month gap in diabetes care and 241 (9.5%) had no primary care visits during transition age. A gap in diabetes care of > 12 months and no primary care visits during transition age were associated with an increased risk of ketoacidosis or death (adjusted hazard ratio 1.31, 95% CI 1.04-1.66 and adjusted hazard ratio 1.42, 95% CI 1.02-1.97, respectively).

CONCLUSIONS

In Ontario, Canada, where physician and hospital-based services are universally covered, a high proportion of young adults with diabetes have insufficient care during transition age and this is associated with a higher risk of important adverse outcomes in early adulthood. Ensuring primary care involvement during transition may be a strategy to reduce morbidity.

Functional abnormalities in induced Pluripotent Stem Cell-derived cardiomyocytes generated from titin-mutated patients with dilated cardiomyopathy

Aims

Dilated cardiomyopathy (DCM), a myocardial disorder that can result in progressive heart failure and arrhythmias, is defined by ventricular chamber enlargement and dilatation, and systolic dysfunction. Despite extensive research, the pathological mechanisms of DCM are unclear mainly due to numerous mutations in different gene families resulting in the same outcome—decreased ventricular function. Titin (TTN)—a giant protein, expressed in cardiac and skeletal muscles, is an important part of the sarcomere, and thus TTN mutations are the most common cause of adult DCM. To decipher the basis for the cardiac pathology in titin-mutated patients, we investigated the hypothesis that induced Pluripotent Stem Cell (iPSC)-derived cardiomyocytes (iPSC-CM) generated from patients, recapitulate the disease phenotype. The hypothesis was tested by 3 Aims: (1) Investigate key features of the excitation-contraction-coupling machinery; (2) Investigate the responsiveness to positive inotropic interventions; (3) Investigate the proteome profile of the AuP cardiomyocytes using mass-spectrometry (MS).

Methods and results

iPSC were generated from the patients' skin fibroblasts. The major findings were: (1) Sarcomeric organization analysis in mutated iPSC-CM showed defects in assembly and maintenance of sarcomeric structure. (2) Mutated iPSC-CM exhibited diminished inotropic and lusitropic responses to β-adrenergic stimulation with isoproterenol, increased [Ca²⁺]_out and angiotensin-II. Additionally, mutated iPSC-CM displayed prolonged recovery in response to caffeine. These findings may result from defective or lack of interactions of the sarcomeric components with titin through its kinase domain which is absent in the mutated cells.

Conclusions

These findings show that the mutated cardiomyocytes from DCM patients recapitulate abnormalities of the inherited cardiomyopathies, expressed as blunted inotropic response.

Mental health visits and low socio-economic status in adolescence are associated with complications of Type 1 diabetes in early adulthood: a population-based cohort study

AIM

To determine the association of mental health visits and socio-economic status in late adolescence with the risk of mortality and acute and chronic diabetes complications in early adulthood.

METHODS

We conducted a population-based cohort study of individuals in Ontario, Canada, who had their 20th birthday between January 1999 and March 2015 and a diagnosis of diabetes prior to their 15^th birthday, using linked administrative databases (n=8491). The main outcome was death; other outcomes were hypoglycaemia or hyperglycaemia-related hospitalizations and emergency department visits and chronic diabetes complications (dialysis, ophthalmological and macrovascular complications).

RESULTS

Over the course of 59 361 person-years there were 127 deaths.. Low socio-economic status and mental health visits were both associated with a higher risk of death [hazard ratio 2.03, (95% CI 1.13 to 3.64) and 2.45 (95% CI 1.71 to 3.51), respectively]. Those with the lowest socio-economic status and a mental health visit had a higher rate of diabetes-related hospitalizations (rate ratio 4.84, 95% CI 3.64 to 6.44) and emergency department visits (rate ratio 3.15, 95% CI 1.79 to 5.54). Low socio-economic status and mental health visits were both associated with an increased risk of any chronic complication [hazard ratio 1.54 (95% CI 1.21 to 1.96) and 1.57 (95% CI 1.35 to 1.81), respectively].

CONCLUSION

We identified significant socio-economic and mental health disparities in the risk of death and acute and chronic complications in early adulthood for people with childhood-onset diabetes. Targeted interventions to prevent adverse events for these adolescents at highest risk should be evaluated.

Pharmacist's review and outcomes: Treatment-enhancing contributions tallied, evaluated, and documented (PROTECTED-UK)

PURPOSE

The purpose was to describe clinical pharmacist interventions across a range of critical care units (CCUs) throughout the United Kingdom, to identify CCU medication error rate and prescription optimization, and to identify the type and impact of each intervention in the prevention of harm and improvement of patient therapy.

MATERIALS AND METHODS

A prospective observational study was undertaken in 21 UK CCUs from November 5 to 18, 2012. A data collection web portal was designed where the specialist critical care pharmacist reported all interventions at their site. Each intervention was classified as medication error, optimization, or consult. In addition, a clinical impact scale was used to code the interventions. Interventions were scored as low impact, moderate impact, high impact, and life saving. The final coding was moderated by blinded independent multidisciplinary trialists.

RESULTS

A total of 20517 prescriptions were reviewed with 3294 interventions recorded during the weekdays. This resulted in an overall intervention rate of 16.1%: 6.8% were classified as medication errors, 8.3% optimizations, and 1.0% consults. The interventions were classified as low impact (34.0%), moderate impact (46.7%), and high impact (19.3%); and 1 case was life saving. Almost three quarters of interventions were to optimize the effectiveness of and improve safety of pharmacotherapy.

CONCLUSIONS

This observational study demonstrated that both medication error resolution and pharmacist-led optimization rates were substantial. Almost 1 in 6 prescriptions required an intervention from the clinical pharmacist. The error rate was slightly lower than an earlier UK prescribing error study (EQUIP). Two thirds of the interventions were of moderate to high impact.

Treatment of pulmonary hypertension in the general adult intensive care unit: a role for oral sildenafil?

Use of inhaled nitric oxide for treatment of pulmonary hypertension in adult critical illness is limited by its mode of delivery and high costs, prompting evaluation of alternative therapies. We report the use of oral sildenafil in a patient with severe secondary pulmonary hypertension and right ventricular dysfunction. Following reduction in mean pulmonary artery pressure and pulmonary vascular resistance with inhaled nitric oxide, crossover to sildenafil therapy maintained control of pulmonary hypertension, facilitating discontinuation of respiratory and cardiovascular organ support. The relative pulmonary vascular specificity of oral sildenafil, and its low cost, makes it an attractive therapeutic alternative to inhaled nitric oxide, and warrants further study.

Linkage study of polymorphisms in the gene for myelin oligodendrocyte glycoprotein located on chromosome 6p and attention deficit hyperactivity disorder

Family and twin studies have shown that there is a substantial genetic contribution to both reading disabilities (RD) and attention deficit hyperactivity disorder (ADHD), and recent twin studies have suggested that the overlap between these phenotypes is largely due to common genetic influences. Studies using a linkage approach to search for genes for susceptibility to RD and ADHD have identified regions linked to each of these phenotypes separately, with recent studies suggesting that some chromosomal regions may contribute to both. Linkage to the human leukocyte antigen (HLA) region has been targeted in particular for RD and ADHD, as both of these disorders have been suggested to be autoimmune. Linkage to the HLA region of 6p for RD has now been reported by several groups. Alleles at two genes in the HLA (C4B and DRB1) have also been reported to be associated with ADHD, prompting one investigator to suggest a possible connection between the linkage of RD and ADHD to this region. The location of the gene for myelin oligodendrocyte glycoprotein (MOG), in the region of 6p with the strongest evidence for linkage to RD, and its proposed role as a minor component of myelin in the central nervous system suggest that it may be a factor in neuronal functioning and therefore a candidate for RD and ADHD. In this study, we tested the gene for linkage to ADHD by genotyping two polymorphisms in the MOG gene-a dinucleotide repeat located upstream from the MOG transcription start site and a Val145Ile substitution in exon 3-in a sample of 104 nuclear families identified through a proband with ADHD. We examined the transmission of the alleles of the Val145Ile and the dinucleotide repeat polymorphisms using the transmission disequilibrium test. We did not observe biased transmission of the alleles at either polymorphism to ADHD probands or siblings. Our findings using this sample do not support the role of the MOG gene in ADHD.

Splenosis presenting as occult gastrointestinal bleeding

A 48-year-old man presented with recurrent gastrointestinal bleeding and anemia. Routine endoscopic evaluation was nondiagnostic. Angiography demonstrated multiple apparent arteriovenous malformations. Exploratory laparotomy revealed numerous splenic implants along the small and large bowels, some of which had apparently eroded through the bowel mucosa and bled. Excision of these penetrating lesions prevented further bleeding. An incidentally noted renal cell cancer was also resected. The patient's splenosis was the result of childhood trauma that caused splenic rupture and precipitated splenectomy. Splenosis develops frequently following traumatic splenic rupture. Experimental evidence suggests that the presence of an intact spleen suppresses the growth and development of splenic implants. Following splenectomy, splenules may replace some of the "housekeeping" and immunologic functions of the spleen, but even patients with documented splenosis should be considered functionally hyposplenic. While in most cases splenules cause no symptoms, splenosis must be considered in the differential diagnosis of previously splenectomized patients who present with unexplained masses or occult bleeding.

Splenosis presenting as occult gastrointestinal bleeding

A 48-year-old man presented with recurrent gastrointestinal bleeding and anemia. Routine endoscopic evaluation was nondiagnostic. Angiography demonstrated multiple apparent arteriovenous malformations. Exploratory laparotomy revealed numerous splenic implants along the small and large bowels, some of which had apparently eroded through the bowel mucosa and bled. Excision of these penetrating lesions prevented further bleeding. An incidentally noted renal cell cancer was also resected. The patient's splenosis was the result of childhood trauma that caused splenic rupture and precipitated splenectomy. Splenosis develops frequently following traumatic splenic rupture. Experimental evidence suggests that the presence of an intact spleen suppresses the growth and development of splenic implants. Following splenectomy, splenules may replace some of the "housekeeping" and immunologic functions of the spleen, but even patients with documented splenosis should be considered functionally hyposplenic. While in most cases splenules cause no symptoms, splenosis must be considered in the differential diagnosis of previously splenectomized patients who present with unexplained masses or occult bleeding.

The effect of dental rehabilitation on the body weight of children with early childhood caries

PURPOSE

The purpose of this study was to determine the effect of comprehensive dental rehabilitation on the percentile weight and percentile growth velocity of children with early childhood caries (ECC).

METHODS

The percentile weight categories of children with noncontributory medical histories and ECC were compared to caries free comparison patients, before and after comprehensive dental treatment under general anesthesia.

RESULTS

Prior to dental rehabilitation, test subjects' percentile weight categories were significantly less than that of comparison counterparts (P < 0.001). Of the ECC patients, 13.7% weighed less than 80% of their ideal weight, thereby satisfying one of the criteria for the designation of failure to thrive, while none of the comparison patients did so (P < 0.05). Following therapeutic intervention, ECC children exhibited significantly increased growth velocities through the course of the follow-up period (P < 0.001), reflecting the phenomenon of catch up growth. The average length of follow-up for the test and comparison groups were 1.58 and 1.36 years, respectively. At the end of the follow-up period there were no longer any statistically significant differences noted in the percentile weight categories of the test and comparison groups.

CONCLUSION

Comprehensive dental rehabilitation resulted in catch-up growth, such that children with a history of nursing caries no longer differed in percentile weights from comparison patients.

The effect of dental rehabilitation on the body weight of children with failure to thrive: case reports

Four case reports of children with nursing caries and failure to thrive are presented. Without regard to the condition of the dentition, the various cases could be classified as organic, mixed, or nonorganic in etiology. After dental rehabilitation, all patients exhibited an acceleration of weight velocity that resulted in weights above the 5th percentile. During the period of observation, the weight velocity continued to increase with time, consistent with the "catch-up" phenomenon of growth that is observed in nutritionally deprived children.

Aerobic versus strength training for risk factor intervention in middle-aged men at high risk for coronary heart disease

To compare the effects of strength training (ST) to those of aerobic training (AT) for coronary heart disease (CHD) risk factor intervention, we studied 37 previously untrained males (aged 50 +/- 9 years, mean +/- SD) before and after 20 weeks of either ST (N = 14), AT (walk/jog, N = 13), or no exercise (inactive controls, N = 10). Lipoprotein and lipid profiles, blood pressure, and glucose and insulin responses to an oral glucose tolerance test (OGTT) were assessed before and after the training period in all three groups. The ST program produced significant reductions in plasma glucose levels at 60, 90, and 120 minutes (P < .05) after glucose ingestion, whereas the AT program resulted in significant reductions only at 90 and 120 minutes (P < .05). ST also decreased insulin levels during fasting (P < .05) and at 90 and 120 minutes (P < .01) after glucose ingestion. AT decreased insulin levels at 90 and 120 minutes (P < .01) after glucose ingestion. Both training programs reduced the total area under the glucose tolerance curve for glucose (both P < .05) and insulin (both P < .05), but there were no significant differences in these changes between the two groups. None of the glucose or insulin values were significantly altered in the control group. There were no significant changes in lipoprotein and lipid profiles or blood pressure in any of the three groups. These results suggest that ST and AT have comparable effects on risk factors for CHD.(ABSTRACT TRUNCATED AT 250 WORDS)

Multiple realities. Teaching rounds in an inpatient pediatric service

Teaching rounds are a mainstay of most educational programs for interns and residents, but little is known about how they are conducted and the role they play in house staff members' learning. We performed a qualitative study of teaching rounds in an inpatient adolescent service using five data sources: observations, interviews, house staff ratings, results of a house staff retreat, and documents outlining faculty responsibilities. Interns, senior residents, and faculty members expressed differing views regarding the purpose, process, and content of rounds; mutual roles and expectations; and time management. An interactive teaching format focused around the visit of a patient to the conference room stimulated house staff interest and learning to a greater extent than did more traditional case presentations and lectures. These results suggest a need to develop a consensus among faculty and house staff regarding the purpose, content, and process of rounds.

Strength training does not improve lipoprotein-lipid profiles in men at risk for CHD

Sixteen untrained males, age 46 +/- 11 yr (mean +/- SD), were studied to determine the effects of 20 wk of strength training on lipoprotein-lipid profiles and post-heparin lipase activities. All subjects had abnormal lipoprotein-lipid profiles and at least two other risk factors for coronary heart disease (CHD). To control for day-to-day variations in blood lipoprotein levels, baseline values were established by taking at least two blood samples on separate days from the training and control groups. The training program resulted in a 50% increase in upper body strength (P less than 0.001) and a 37% increase in lower body strength (P less than 0.001) as measured by the one repetition maximum test (1-RM). No changes in the 1-RM test were observed in the control group. There were no significant changes in VO2max (34.5 +/- 6.4 vs 36.2 +/- 7.4 ml.kg-1.min-1 or percent fat (25.4 +/- 4.2 vs 24.9 +/- 4.1%) with training. There were also no significant changes in plasma concentrations of triglyceride (193 +/- 96 vs 171 +/- 101 mg.dl-1), total cholesterol (231 +/- 22 vs 210 +/- 22 mg.dl-1), and HDL-C (35 +/- 6 vs 36 +/- 8 mg.dl-1), or LDL-C (139 +/- 16 vs 139 +/- 21 mg.dl-1). Furthermore, the activities of post-heparin lipoprotein lipase (9 +/- 4 vs 13 +/- 5 moles.ml-1.h-1) and hepatic lipase (35 +/- 10 vs 35 +/- 9 moles.ml-1.h-1) did not change with training.(ABSTRACT TRUNCATED AT 250 WORDS)

Lactate rise detected by 1H NMR in human visual cortex during physiologic stimulation

Brain lactate concentration is usually assumed to be stable except when pathologic conditions cause a mismatch between glycolysis and respiration. Using newly developed 1H NMR spectroscopic techniques that allow measurement of lactate in vivo, we detected lactate elevations of 0.3-0.9 mM in human visual cortex during physiologic photic stimulation. The maximum rise appeared in the first few minutes; thereafter lactate concentration declined while stimulation continued. The results are consistent with a transient excess of glycolysis over respiration in the visual cortex, occurring as a normal response to stimulation in the physiologic range.

Biopsychosocial aspects of long-term survival on end-stage renal failure therapy

At ten-years follow-up of 64 haemodialysis patients, 43 had died and 21 were alive, twelve with cadaver renal transplants and nine on haemodialysis. Examination of the influence of psychological, demographic, physical and biochemical factors revealed the Beck Depression Inventory and age as the two most important predictors of survival. The behaviour of the patient was directly responsible for five (11.6%) of the deaths, by suicide in three cases and dietary non-compliance in two cases. Hypothetical mechanisms linking depression with reduced survival have been reviewed. As the impact of depression on survival was maximal in the first few years of dialysis, monitoring for depression should be incorporated into routine care from the start of dialysis together with evaluative interventions that might enhance survival.

The influence of fibronectin administration on the incidence of sepsis and septic mortality in severely injured patients. The Medical College of Georgia Fibronectin Research Group

Eighty-five trauma patients between the ages of 18 and 55, with American College of Surgeon's (ACOS) trauma scores greater than or equal to 7 were entered into a double-blind, randomized, placebo-controlled study to assess the efficacy of prophylactic fibronectin (Fn) administration on clinical course, sepsis development, and septic mortality. Patients were randomized on admission to receive purified human virus-inactivated Fn or placebo control (human serum albumin, HSA). Fn or HSA was administered on a daily basis if and when the patient was Fn deficient (less than 75% normal). When a Fn deficiency was not evident, the patient received saline. Seventy one patients developed Fn deficiencies during their initial clinical course: 36 received Fn, 35 received HSA. Fourteen patients did not develop a Fn deficiency after trauma and thus received only saline. Analysis of admission data demonstrated no significant differences between the three groups with respect to extent of injury (injury severity score, ACOS trauma score) or physiologic assessments of organ function (serum creatinine, bilirubin, lactic acid). On day 1 after trauma, Fn levels were shown to correlate with other plasma proteins and cellular components (range of r values, 0.24 to 0.75; all p less than 0.05), but not with organ function parameters. Eighteen of 85 patients became septic as judged by clinical criteria. Ten of these patients had received Fn (10 of 36), five had received HSA (5 of 35), and three had received only saline (3 of 14) before the development of sepsis (differences not significant). When septic, nine of 17 patients developed Fn deficiencies. Six patients received Fn while septic, three received albumin, and eight received saline. Seven patients died: 5 of 6 Fn patients, 1 saline, and 1 HSA recipient. Our data suggest that exogenous Fn repletion in states of deficiency does not alter clinical course, the development of sepsis, or septic mortality.

A carbon-13 breath test to characterize glucose absorption and utilization in children

After the administration of a 5% glucose-water solution that contained tracer amounts of the stable nonradioactive isotope 13C, breath samples were collected from five children with congenital glucose-galactose malabsorption and five with severe small bowel villous atrophy and chronic diarrhea. The 13CO2 breath test curves of the children with the congenital malabsorption and chronic diarrhea were compared with each other and with those from three healthy children and four infants with severe malnutrition but no diarrhea. The breath test curves from the children with glucose-galactose malabsorption and from those with diarrhea were significantly different from those of the other two groups, a finding consistent with impairment of glucose absorption. The [13C]glucose breath test clearly identified the children with severe glucose malabsorption. Further studies are required to determine whether less severe cases of carbohydrate malabsorption also can be identified using the parameters described in our study.

Psychiatric aspects of physical complaints

The physician may find it difficult to diagnose patients who present with a psychiatric illness that has physical symptoms, or those who have a physical illness that is accompanied by changes in behaviour or mood. In this paper the author sets out guidelines for investigating and diagnosing both types of patients.

What should be taught in psychogeriatrics: a personal viewpoint

Psychiatry is part of medicine. The goals of medical practice should endorse a biopsychosocial view of illness, and practitioners should accept responsibility for all phases of illness: from the acute stage through rehabilitation to recovery or chronicity. Bedside instruction should emphasize basic clinical skills in history taking and a standard examination that includes the mental state. Liaison psychiatry offers an opportunity for training in psychogeriatrics and for the psychiatrist to re-enter the medical setting in providing health care to the elderly.

Psychosomatic education: who teaches what and where at the University of British Columbia

For this enquiry psychosomatic education was defined as education in areas that encompass a psychological as well as biological view of illness. The scope of this activity, undergraduate and postgraduate, was assessed by a review of curriculum content, and by a questionnaire of the clinical faculty that examined their attitudes to psychiatry in Medicine, what they actually taught, and whom they relied on for help. Obstacles to psychosomatic education stemmed from a negative view of Psychiatry as well as the omission of instruction by prestigious role models. The facilitation of psychosomatic education required a greater accessibility of psychiatrists to medical peers, and an expanded role for consultation liaison services into medical student teaching. New programs in holistic and behavioural medicine represented an emerging thrust particularly at the postgraduate level. Psychosomatic education should focus on specific training objectives acceptable to medical colleagues, educators and health planners.

Echocardiographic features of an unruptured aneurysm of the right sinus of Valsalva

A 2-cm aneurysm of the right sinus of Valsalva was documented in a patient with a prosthetic aortic valve. The M-mode findings differed from prior reports and mimicked those of aortic root dissection or a catheter placed in the right ventricular outflow tract. Two-dimensional echocardiograms readily distinguished the aneurysm of the right sinus of Valsalva from the alternative possibilities.

Thalamic stimulation for neuropathic pain

Eighteen patients with neuropathic pain underwent thalamic electrode implantation. Satisfactory initial pain relief ensued in 14, and their electrode systems were internalized for long-term use. Twelve of the 14 continue to obtain either complete or partial pain relief by regular stimulation. One of the other two patients has had a complete remission of pain, apparently spontaneously, and the other had to have the electrodes removed after it retracted from his thalamus on two occasions. The electrodes have been placed in the sensory nucleus of the thalamus where stimulation evokes paresthesias in the painful part of the body. Technical problems consisting of our inability to locate the target in two patients and our failure to fix the electrode adequately in one prevented us from employing the treatment in three patients. The fourth patient had temperature dysesthesia which was not altered during 2 weeks of stimulation.