Lack of association of the caspase-12 long allele with community-acquired pneumonia in people of African descent

Community-acquired pneumonia (CAP) is a common cause of sepsis. Active full-length caspase-12 (CASP12L), confined to the people of African descent, has been associated with increased susceptibility to and mortality from severe sepsis. The objective of this study was to determine whether CASP12L was a marker for susceptibility and/or severity of CAP. We examined three CAP cohorts and two control populations: 241 adult Memphis African American CAP patients, 443 pediatric African American CAP patients, 90 adult South African CAP patients, 120 Memphis healthy adult African American controls and 405 adult Chicago African American controls. Clinical outcomes including mortality, acute respiratory distress syndrome (ARDS), septic shock or severe sepsis, need for mechanical ventilation, and S. pneumoniae bacteremia. Neither in the three individual CAP cohorts nor in the combined CAP cohorts, was mortality in CASP12L carriers significantly different from that in non-CASP12L carriers. No statistically significant association between genotype and any measures of CAP severity was found in any cohort. We conclude that the functional CASP12L allele is not a marker for susceptibility and/or severity of CAP.

The influence of esmolol on the dose of propofol required for induction of anaesthesia

Cardiac output may be an important determinant of the induction dose of intravenous anaesthetic. Esmolol is known to reduce cardiac output, and we examined its effect on the propofol dose required for induction of anaesthesia. The size of the effect seen with esmolol was compared with midazolam co-induction. Sixty patients were randomly allocated to placebo (saline), esmolol (1mg x kg(-1) bolus, followed by an infusion at 250 microg x kg(-1)min(-1)) or midazolam (0.04 mg x kg(-1)) groups. Induction of anaesthesia commenced 3 min following the administration of the study drug, using a Diprifusor set to achieve plasma propofol concentrations of 10 microg x ml(-1) at 5 min. The primary end point used was the propofol dose per kg at loss of response to command. The mean (SD) propofol dose for each group was 2.38 (0.48) mg x kg(-1) for placebo, 1.79 (0.36) mg x kg(-1) for esmolol and 1.34 (0.35) mg x kg(-1) for midazolam (all means significantly different; p < 0.0005). We found that predosing with esmolol reduces the propofol requirements for induction of anaesthesia by 25%.

Prolonged length of stay and reduced functional improvement rate in malnourished stroke rehabilitation patients

OBJECTIVE

To determine associations between the nutritional status of inpatient rehabilitation (rehab) unit stroke patients and (1) length of stay (LOS) and (2) functional outcome using Modified Barthel Index (MBI). Secondary objective-to determine whether hypoalbuminemia was equally related to outcome measures. A priori hypothesis-LOS and MRI are adversely related to malnutrition.

DESIGN

inception cohort study.

SETTING

Tertiary care center.

PATIENTS

49 consecutive "middle-band" patients (4 declined).

MAIN OUTCOME MEASURES

LOS and MRI at admission (T1), 1 month (T2), and discharge (T3).

RESULTS

LOS was significantly related to overall malnutrition, T1 and T2MBI scores, T1 dysphagia, T1 enteral feeding (all p<.01), T1 malnutrition, peripheral vascular disease (negative relationship), and diabetes mellitus history (all p<.05). In analysis of covariance, adjusting for T1 MBI, overall rehab malnutrition was related to LOS (p=.011). Other covariates were not significant. T1 malnutrition was related to lower T2 MBI scores(p=.038). Lower T1 MBI scores was related to T2 malnutrition (p=.032). Diabetics (p=.005) and right hemispheric lesion patients(p=.015) had lower T1 MBI scores. Hypoalbuminemia was unrelated to LOS and MBI scores. Although malnourished and adequately nourished functionally dependent patients improved equally in MBI scores by discharge, prolonged LOS in the malnourished lowered their functional improvement rate ([T3 MBI - T1 MBI]/LOS) (p=.047).

CONCLUSIONS

Malnutrition was the most potentially modifiable variable relating to LOS and functional outcome. Close attention to nutrition status may help to optimize stroke patients' rehab potential and use of health care resources.

Carpentier-Edwards supra-annular bioprosthesis in the aortic position. Has altered design affected performance?

BACKGROUND AND AIM OF THE STUDY

The Carpentier-Edwards supra-annular valve was introduced in 1982 and was designed to incorporate the perceived benefits of low pressure fixation and supra-annular configuration. We report an eleven year experience with the valve, concentrating on its use for single valve replacement in the aortic position.

METHODS

The prosthesis was implanted in 395 patients at 399 operations between January 1984 and October 1993. Myocardial revascularization was additionally performed in 122 (31%) patients. The mean age of the patient population was 65.4 years (range 22-84 years). Sex distribution was predominantly male (62%). Three hundred and seventy-two patients left hospital (30 days operative mortality 5.8%). The mean follow up extended to 3.4 years per patient, and the cumulative follow up for the series was 1264.3 patient years.

RESULTS

Overall actuarial survival at six years was 75.8% +/- 4.1%. The incidence of valve-related complications expressed in terms of actuarial freedom from complication at six years resulted in a freedom from reoperation of 95.1% +/- 1.8%, from prosthetic endocarditis of 97.2% +/- 1.0%, from thromboembolism and anticoagulant-related hemorrhage of 95.9% +/- 1.3% and 95.8% +/- 1.6%, respectively. Freedom from periprosthetic leak was 99.1% +/- 0.7%, whilst freedom from structural valve deterioration was 97.6% +/- 1.5%.

CONCLUSIONS

We conclude that the Carpentier-Edwards supra-annular valve compares favorably with other similar bioprostheses and that changes in its design have not impaired its structural integrity.

Malnutrition in stroke patients on the rehabilitation service and at follow-up: prevalence and predictors

This prospective study presents the prevalence and risk factors of malnutrition in 49 consecutive stroke patients on the rehabilitation (Rehab) service and at 2- to 4-month follow-up. Malnutrition was diagnosed using biochemical and anthropometric data. Stroke patients, on admission to Rehab, have a very high prevalence of malnutrition. Malnutrition, 49% on admission, declined to 34%, 22%, and 19% at 1 month, 2 months, and follow-up, respectively. Dysphagia, 47% on admission, was associated with malnutrition (p = .032) and significantly declined over time. Using logistic regression, predictors of malnutrition on admission involved acute service tube feedings (p = .002) and histories of diabetes (p = .027) and prior stroke (p = .013). Tube feedings, associated with malnutrition on admission (p = .043), were more prevalent in brain stem lesion patients. Patients tube fed > or = 1 month during rehabilitation or at home were not malnourished. Malnutrition was associated with advanced (> 70 years) age at 1 month (p = .002) and weight loss (p = .011) and lack of community care (p = .006) at follow-up. Early and ongoing detection and treatment of malnutrition are recommended during rehabilitation of stroke patients both on the service and at follow-up.

Colposcopy in a family planning clinic: a future model?

The first year's experience of a satellite colposcopy clinic in the Glasgow Family Planning Centre was analysed. Establishment of the clinic was supervised by an experienced member of the colposcopy team at the department of gynaecology, Western Infirmary, Glasgow, who trained one of the family planning centre's staff. Close links were thus maintained with the hospital clinic to which patients were referred for treatment. The policy at the new colposcopy clinic was to study prospectively all women in the hospital catchment area whose cervical smears were reported as abnormal. In 58 of 162 such patients there was at least moderate dyskaryosis and the cytologist's recommendation had been referral for colposcopy. In 104 cases the changes were either atypia alone or mild dyskaryosis and a repeat smear was recommended within three to 12 months; 18 of these patients had grade II or III cervical intraepithelial neoplasia on biopsy, and relying on repeat smears would have resulted in an 11.7% false negative rate. If an atypical cytological picture is to be an indication for colposcopy clinics attached to family planning centres may have an important role, given satisfactory training and close links with central specialist colposcopy clinics.

A prospective controlled study of the effect on blood pressure of contraceptive preparations containing different types and dosages of progestogen

A prospective controlled study investigated the effects of oral contraceptives on blood pressure in 485 women who were between 17 and 46 years of age and had blood pressures of less than 140/90 mmHg at entry. The women were divided into seven groups depending on the chosen method of contraception: intrauterine device or barrier method (control group): ethinyl oestradiol 30 micrograms plus levonorgestrel 150 micrograms (Microgynon-30 or Ovranette); norethisterone 350 micrograms (Micronor); norgestrel 75 micrograms (Neogest); norethisterone oenanthate 200 mg intramuscularly every 2 months for the first 6 months, then every 3 months thereafter; ethinyl oestradiol 30 micrograms plus ethynodiol diacetate 2 mg (Conova-30); and ethynodiol diacetate 500 micrograms (Femulen). Blood pressures were measured every 3 months by the family planning clinic nurse under standardized conditions using an Elag-Köln automatic sphygmomanometer. After one year, blood pressure had risen significantly (P less than 0.05) in the 137 women taking ethinyl oestradiol plus levonorgestrel (mean systolic and diastolic rises 6.4 and 2.7 mmHg respectively) and in the 91 women taking ethinyl oestradiol plus ethynodiol diacetate (mean systolic and diastolic rises 6.2 and 3.0 mmHg respectively). The 94 women taking the progestogen-only preparations and the 143 women in the control group showed no increases in blood pressure. These data were confirmed after 2 years of follow-up.

Effects on blood pressure of low dose oestrogen and progestagen only oral contraceptives

Oral contraceptives containing at least 50 micrograms oestrogen and 1-4 mg progestagen can raise blood pressure [1,2]. However, there is controversy about the effect of lower doses of oestrogen [3-5] on blood pressure and especially the role of the progestagen component [6-9]. We describe the results of a prospective, controlled study of the effects on blood pressure of contraceptive preparations containing different types and dosages of oestrogen and of progestagen.

Spinal stenosis. The narrow lumbar spinal canal syndrome

This is a report of 7 cases of narrow lumbar spinal canal syndrome encountered in 7 patients in a community hospital in one year. Nerve compression occurred from pressure from enlarged posterior elements. Although the clinical manifestations were unspecific, the lumbar spine radiographs and myelographic features are quite characteristic. Supported by myelography and/or operative findings, surgical management consisted of decompression laminectomy at multiple levels, together with diskectomy at the appropriate levels. The interim results observed at one year follow-up examination were excellent.

Systemic to pulmonary venous communication in the superior vena caval syndrome

A case of superior vena caval obstruction due to bronchogenic carcinoma is presented. Upper extremity venography demonstrated shunting of contrast media from systemic veins to the right pulmonary veins. This collateral pathway has been previously described in the superior vena caval syndrome. A proposed mechanism for this flow pattern is discussed.

Radiolucent mediastinal lipoma

Intrathoracic lipomas are rare. A patient with a surgically proved mediastinal lipoma is described. The lesion presented as an asymptomatic radiolucent mass within the mediastinum and was detected on routine chest radiography.

Disseminated tuberculosis of bone

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