Phaeochromocytoma with myocarditis managed with alpha-methyl-p-tyrosine

A case of bilateral phaeochromocytoma with catecholamine-induced myocarditis is described. The two operations needed allowed comparison of the use of alpha-methyl-p-tyrosine alone and in conjunction with adrenergic blocks in the management of the patient. The combination of both drugs was particularly successful in the relief of symptoms and reduction of catecholamine metabolism as monitored by 4-hydroxy-3-methoxymandelic acid (HMMA) excretion. As myocarditis is a potentially fatal complication, further investigation of the combined use of alpha-methyl-p-tyrosine and adrenergic blocking drugs is suggested in the pre-operative management of patients with phaeochromocytoma.     

Factors related with compliance with tuberculosis chemoprophylaxis

OBJECTIVES: To determine therapeutic tolerance and compliance level with antituberculous chemoprophylaxis. PATIENTS AND METHODS: 587 patients were proposed for antituberculous chemoprophylaxis with isoniazid from January 1995 to June 1996 in Murcia (Spain). RESULTS: 3.6% of the patients gave up treatment because of hepatic intolerance and 73% completed the prophylaxis. Non-compliance related factors were: social risk factors (odds ratio [OR] = 9.31), previous history of allergies (OR = 2.87), previous personal history of tuberculosis-related events (OR = 0.49) and interaction between sex and age. CONCLUSIONS: Support and intervention measures directed to risk groups of a social origin deem to be needed. Control measures and information provided to middle-aged males, with particular emphasis to the first weeks of prophylaxis, should also be implemented.     

Communication with parents of children with cancer

The authors summarize the results of recent work evidencing the existence of latent merozoites during the course of the erythrocytic cycle of the rodent Plasmodia. These merozoites, unlike the majority of merozoites released at schizogony, do not penetrate immediately into the erythrocytes and remain latent for a variable length of time. The merozoites of each of the species or subspecies show marked peculiarities which are responsible for the characteristics of their cycle. The presence of latent merozoites free in the blood, the asynchronous development, and the resistance to chloroquine, are three closely related factors. Knowing that the merozoite is so far drug resistant, and that latent merozoites can maintain the infection for any length of time, it appears important to take into account these purely biological data, when studying the drug resistance of the human falciparum malaria.     

Surgical outcome in patients with epilepsy with occult vascular malformations treated with lesionectomy

PURPOSE: This retrospective study reports the long-term surgical outcome of patients with medically refractory epilepsy and vascular malformations who were treated with lesionectomy. A detailed analysis of surgical failures had been performed in an attempt to define predictors of surgical success and failure. METHODS: Fifteen patients with medically intractable epilepsy and angiographically occult vascular malformations (AOVMs) were treated surgically with lesionectomy at Duke University Medical Center. Lesionectomy consisted of removal of the AOVM and surrounding hemosiderin-stained brain only, without the use of electrocorticography (ECoG) to guide resection. RESULTS: Eleven (73%) patients are seizure free after lesionectomy. Three showed no significant improvement, and one patient died, presumably after a seizure. Age of onset, duration of seizures, age at resection, and gender did not affect outcome. All patients with neocortical AOVMs in whom EEG findings correlated with the site of the lesion were seizure free after lesional resection. Treatment failures were associated with the presence of multiple intracranial lesions, poorly localized or diffuse EEG findings, discordant positron emission tomography (PET) imaging, or with a lesion in close proximity to the limbic system. CONCLUSIONS: Lesionectomy, with removal of surrounding hemosiderin-stained brain, can be considered the procedure of choice in carefully selected patients with epilepsy with occult vascular malformations.     

Women's satisfaction with medical abortion with RU486

The combination of RU486 (mifepristone) and prostaglandin analogues has been used for medical abortion in several European centres. We surveyed 41 Australian women who successfully used this method of abortion in a World Health Organization-sponsored trial. Overall, the women were satisfied with the method and found the associated pain level acceptable.     

Patients with malignant meningitis presenting with neuropsychiatric manifestations

BACKGROUND: Malignant meningitis is often thought of as a late event in the course of cancer. At one time, it was thought to be rare, but it has been recognized more frequently in recent times. Clinical suspicion of malignant meningitis is prompted by neurologic symptoms and signs in patients at risk for this oncologic complication. Neuropsychiatric symptoms previously were not considered as presenting symptoms of malignant meningitis. METHODS: Three patients with cancer with no neurologic symptoms were examined for malignant meningitis based on neuropsychiatric symptoms. Cerebrospinal fluid was examined for malignant cells to confirm the diagnosis of malignant meningitis. RESULTS: The clinical presentation of malignant meningitis for three patients was neuropsychiatric. None of the patients had delirium during their initial presentation. CONCLUSIONS: It is important that clinicians recognize that psychiatric symptoms without neurologic findings may indicate malignant meningitis and that malignant meningitis needs to be included in the differential diagnosis of neuropsychiatric disorders in patients with cancer.     

Patient satisfaction with time spent with their physician

AIMS: The aim of the study was to compare the effects of meloxicam and piroxicam on the gastroduodenal mucosa in healthy adults. METHODS: Forty-four healthy volunteers were given a 28 day course of either meloxicam 15 mg, piroxicam 20 mg or placebo. Damage to the oesophageal, gastric and duodenal mucosa was assessed, mucosal blood flow (MBF) measured at endoscopy and biopsies taken for prostaglandin content and microscopic assessment of damage before NSAID administration and during days 1, 7 and 28 of continued intake. RESULTS: Maximal macroscopic gastric mucosal damage (median grade+IQR) occurred within 24 h of piroxicam administration, the damage score increasing from 0 to 2.5 (0-3) (P=0.02) at day 1 before falling to 2.0 (0-2) at day 7 and 0 (0-1) at day 28 with resolution of damage observed in six out of the seven subjects who sustained acute injury. No significant macroscopic gastric damage occurred in either of the two other groups although some minor damage was observed in seven subjects taking placebo and five taking meloxicam. There was a trend towards piroxicam causing more acute gastric damage than meloxicam (P=0.06). Baseline antral, body and duodenal MBF were similar in all three groups. No significant changes occurred in any of the groups on any of the visits. There were also no changes in gastric mucosal prostaglandin content in any group. CONCLUSIONS: These observations suggest that meloxicam causes little acute damage to the upper gastrointestinal tract and piroxicam causes some acute gastric injury but such damage resolves in most subjects by 28 days.     

以质量求生存以特色求发展--关于新建本科院校发展问题的思考

近几年来，新建本科院校从数量和规模上得到了较大发展。本文从新建本科院校的办学定位、人才培养质量、办学特色等方面进行了一些有益的探讨，提出了可以借鉴的方法和思路。     

Non-union of the scaphoid. Treatment with cannulated screws compared with treatment with Herbert screws

We retrospectively reviewed the results for thirty-four patients in whom a non-union of the scaphoid had been treated with bone-grafting and internal fixation with use of one of two types of screws as well as the temporary placement of Kirschner wires parallel to the screw to prevent rotation. The patients were divided into two groups: Group 1 contained sixteen patients who had been managed with a Herbert screw from 1986 through 1989 and Group 2, eighteen patients who had been managed with a 3.5-millimeter cannulated AO/ASIF screw from 1990 through 1992. There were no clinical or radiographic differences between the two groups. The time to union, confirmed with tomography, was 7.6 +/- 3.6 months for Group 1 and 3.6 +/- 1.2 months for Group 2. This difference was significant (p < 0.01). Both screws significantly improved the alignment of the scaphoid and decreased carpal collapse (p < 0.05). Regardless of the type of screw used, the time to union was significantly shorter when the screw had been placed in the central one-third of the scaphoid (p < 0.05). Seventeen of the eighteen cannulated screws had been placed centrally, compared with seven of the sixteen Herbert screws (p < 0.01).     

Echocardiography with dobutamine in hypertensive patients with chest pain

INTRODUCTION: The exercise stress test shows limited diagnostic accuracy for the detection of coronary artery disease in hypertensive patients. Echocardiography with dobutamine is a useful tool in the assessment of coronary artery disease. PURPOSE: Our purpose has been to compare dobutamine stress echocardiography and exercise stress test for diagnosing coronary disease in hypertensive patients. MATERIAL AND METHODS: Dobutamine stress echocardiography (administered up to 40 micrograms/kg/min, and atropine when necessary), exercise stress test and coronary arteriography were performed on 74 hypertensive patients with chest pain and no previous history of coronary artery disease. RESULTS: Forty-eight (65%) patients underwent a diagnostic exercise stress test and 66 (89%) a diagnostic dobutamine stress echocardiography. Coronary artery disease (> or = 70% stenosis in, at least, one major vessel) was demonstrated in 28 (58%) patients who underwent a diagnostic exercise stress test, and in 39 (59%) patients who completed a dobutamine stress echocardiography. Sensitivity for exercise stress test was 82%, and 79% for dobutamine stress echocardiography (p = NS). Specificity was higher for dobutamine stress echocardiography (100% vs 60%; p < 0.005). CONCLUSIONS: Dobutamine stress echocardiography has high sensitivity and specificity for the detection of coronary artery disease in hypertensive patients. Dobutamine stress echocardiography has higher feasibility and specificity than exercise stress test in this group of patients.     

Treatment with beta-blockers in patients with acute coronary syndrome

BACKGROUND: Immunosuppressive treatment with cyclosporin A (CsA) improves the survival of renal allografts, but is associated with renal vasoconstriction and hypertension. Previous reports suggest that the calcium-channel blockers nifedipine and amlodipine may improve graft function in CsA-treated patients. We have compared the effects of amlodipine (5-10 mg once daily) and nifedipine retard (10-40 mg twice daily) on renal function and blood pressure in renal transplant recipients treated with CsA. METHODS: This was a multicentre, two-way, crossover study in 27 evaluable hypertensive patients with renal insufficiency following renal transplantation, who were maintained on a stable dose of CsA. Patients received either amlodipine (5-10 mg once daily) or nifedipine retard (10-40 mg twice daily) for 8 weeks, and were then crossed over to the other treatment for a further 8 weeks. RESULTS: Trends were seen during amlodipine treatment towards larger improvements, in serum creatinine (by 8% of baseline on amlodipine vs 4% on nifedipine), lithium clearance (13% vs 2%), and glomerular filtration rate 11% vs 7%). Effective renal plasma flow was increased by 11% of baseline on nifedipine vs 9% on amlodipine. There were no significant differences between treatments. Amlodipine and nifedipine lowered systolic blood pressure to a similar extent (21 mmHg vs 15 mmHg respectively, P=0.25), but amlodipine was more effective than nifedipine in lowering diastolic blood pressure (13 mmHg vs 8 mmHg, P=0.006). Both treatments were well tolerated. CONCLUSION: Once-daily amlodipine is at least as effective as twice-daily nifedipine retard in controlling blood pressure and does not adversely affect graft function in hypertensive renal allograft recipients.