Repetition of overdose: a retrospective 5-year study

This study investigated the number, timing and disposal (admission or discharge) of patients repeating an overdose who attended the accident and emergency department of a district general hospital during a 5-year period. There was a total of 1958 overdoses by 1597 individuals over the 5-year period. Overdoses were repeated by 12% (n = 191) of patients and accounted for 552 of the total overdoses (representing 361 repeats). First repeats were found to occur more frequently in the 3 months following the original overdose for 43% of patients, 70% of repetitions occurring within a year. The distribution of first repeats showed a similar pattern for males and females. During the 5-year period 49% of all repetitions occurred within 3 months. Almost one-fifth of repeaters were discharged, irrespective of whether it was the patient's 'index' (first overdose within the study period) or a repeat overdose. Within the repeater population, 31% of overdoses occurred on a Friday, Saturday and on, or immediately prior to, a Bank Holiday. Since there was no on-site psychiatric service available at such times, those patients had to wait until the next working day for assessment. The study recommends that all overdose patients should receive psychiatric assessment, and therefore on-site psychiatric services should be available for accident and emergency patients.     

"Spoon bowl" deformity of proximal femoral bypass vein graft: a cause of late graft failure on four occasions

Six patients with specific pulmonary diseases had pulmonary tissue surgically resected for diagnostic purposes. All six cases were characterized by space-occupying lesions surrounded by a peculiar reaction of the pulmonary parenchyma indistinguishable from desquamative interstitial pneumonia. If small biopsies from these areas had been taken, a diagnosis of desquamative interstitial pneumonia would have been made, and the underlying process would have gone undetected. These cases corroborate even further the concept that desquamative interstitial pneumonia is a pattern of pulmonary reaction, rather than a well-defined disease entity. Furthermore, it seems advisable to make the dianosis of desquamative interstitial pneumonia only when other conditions have been carefully ruled out by thorough clinical and pathologic investigations.     

Aortocoronary bypass grafting with expanded polytetrafluoroethylene: 12-year patency

The size of CAG repeats was compared in lymphocytes and skeletal muscle from nine patients with Huntington disease (HD) and two patients with Kennedy disease (KD). In HD, the number of CAG repeats did not differ between lymphocytes and skeletal muscle. In the two KD patients, however, the CAG expansion was larger in muscle than in lymphocytes. The difference in trinucleotide expansion between lymphocytes and muscle cells is not a universal phenomenon in trinucleotide repeat disorders, but seems to occur in disorders primarily affecting the neuromuscular system.     

Adenocarcinoma of the uterine cervix associated with pregnancy: a retrospective 10-year investigative study

Plasma proteins, especially albumin, account for much of the normal anion gap. The relationship between globulins and the anion gap has not received much attention except for reports of a narrowing of the gap associated with certain monoclonal immunoglobulin G gammopathies. The author presents a patient with polyclonal gammopathy, the magnitude of which correlated strongly and positively with the anion gap, along with data from 400 patients attending a renal hypertension clinic, which show a significant positive correlation between the anion gap and total globulins. These results indicate that both albumin and globulin concentrations should be taken into account when attempting to explain abnormalities or changes in the magnitude of the gap.     

Salmonella typhi infections. A 10-year retrospective study

Enteric fever is still a common health problem in many countries, especially in children. Thus a ten-year retrospective study was carried out to evaluate the clinical and laboratory properties of enteric fever and the incidence of antimicrobial resistance in children. Throughout the past 10 years, Salmonella was isolated in 105 patients by blood culturing, 27 of which were Salmonella typhi. Most of the patients were above the age of two. Besides the typical symptoms and signs of enteric fever, 29.2% of the patients had some neurologic findings. Besides, 68.5% had elevated liver enzymes while only 44.4% had hepatomegaly with or without splenomegaly. Anemia was present in 44%, leukopenia in 16% and leukocytosis in 11.1% of the cases. The emergence of antimicrobial resistance during the last five years against ampicillin, chloramphenicol and trimetoprim-sulfamethoxazole has created a challenge in treating these infections.     

Prolonged survival by 'early' salvage treatment of breast cancer patients: a retrospective 6-year study

Between 1977 and 1993, 384 breast cancer patients were followed up post-operatively every 4 or 6 months with a serum tumour marker panel (CEA-TPA-CA15-3) and the usual imaging techniques. Twenty-eight patients were treated 13.5 +/- 10 months (mean +/- s.d.) before the clinical and/or radiological occurrence of distant metastases that were suspected because of an increase in the tumour markers (patients treated 'early'). Their outcome was compared with that of 22 similar patients who were treated only after a definite radiological diagnosis was achieved (patients treated 'not early'). The median survivals from mastectomy and salvage treatment were also compared for the two groups. The groups were similar for all the major prognostic factors (menopause, staging, hormone dependency). In the group treated 'early', the lead time from the tumour marker increase to the clinical and radiological signs of metastases was significantly longer than that of the group not treated 'early' (13.5 +/- 10 vs 3.4 +/- 2.8 months respectively; P < 0.001 by unpaired t-test). For patients treated 'early', the survival curves up to 30 months after salvage treatment and up to 72 months after mastectomy showed greater survival than those for the patients treated later (42.9% vs 13.6% and 42.9% vs 22.7% respectively; P = 0.04 in both instances). These data suggest that treatment triggered by rising tumour markers before clinical and/or radiological appearance of distant metastases can be useful in prolonging both the asymptomatic interval and the duration of response of some relapsed patients. Randomized prospective trials must be encouraged to confirm these data and to better evaluate the effect on the disease-free survival (DFS) and overall survival (OS) of 'early' salvage treatment protocols.     

The effect of surface coating of femoral prostheses implanted without cement: a 2- to 4-year follow-up study

The complement system covalently attaches C3d to microbial antigens which binds to CR2 on B lymphocytes, leading to a markedly enhanced adaptive immune response to that antigen. The enhancement is mediated by the cross-linking of the CR2-CD19 complex to mIg which augments the activation of several intracellular signalling pathways. Two additional receptors of the B lymphocyte, FcgammaRIIB and CD22, have opposing effects when cross-linked to mIg, the former suppressing signalling by recruiting the inositol phosphatase, SHIP, and the latter by activating the phosphotyrosine phosphatase, SHP-1. Two principles emerge from these studies: innate immunity guides the adaptive immune response, and activation of the B lymphocyte is determined by co-receptors which evaluate the biological characteristics of antigen.     

The growth and development of the Annals of Human Biology: a 25-year retrospective

Several fundamental questions relating to the biochemical basis of megaloblastic hemopoiesis in vitamin B12 (B12) and folate deficiency and neurological damage in B12 deficiency remain to be answered. Among them is the explanation underlying (1) the failure of B12-deficient animals to develop megaloblastic hemopoiesis despite indirect evidence of impaired thymidylate synthesis and (2) the inverse relationship between the extent of hematologic and neurological damage in B12 deficiency. Diagnostic advances have led to the awareness that many patients with B12 or folate deficiency are hematologically normal and that subtle hematologic or neuropsychiatric manifestations may be found at a fairly early stage of developing B12 deficiency. Studies of the mechanism of absorption of B12 in food have identified the syndrome of food B12 malabsorption in which the degree of B12 deficiency is commonly, although not invariably, mild. Folate intake influences the prevalence of neural tube defects (NTDs) and a suboptimal folate status may be associated with an increased risk for dysplasia and cancer. The latter may be at least partly the result of uracil misincorporation into DNA and consequent DNA strand breaks. Folate status has also been linked to arteriosclerotic vascular disease through its effect on serum homocysteine levels. Uracil misincorporation into DNA and increased serum homocysteine levels may also be found in B12 deficiency. These adverse associations form the basis of a case for improving B12 or folate status in individuals with a mild degree of deficiency. Because inadequate folate intake is relatively common, especially in the elderly and the poor, the fortification of staple foods with folate is currently under active consideration.     

Granulomatous hepatitis: a retrospective study

51 cases of granulomatous hepatitis were seen among 1234 liver biopsies over a 10 year period. Tuberculosis was the commonest cause seen in 55 percent of cases. Other causes included leprosy, sarcoidosis, histoplasmosis, brucellosis, amoebic liver abscess, lymphoma and malignant granuloma. 12 percent of cases remained undiagnosed. Clinically these patients presented with pyrexia and hepatosplenomegaly. Jaundice was uncommon. Many showed elevated alkaline phosphatase levels, anaemia and raised ESR Granulomatous hepatitis of unknown aetiology with FUO was seen in 6 percent cases only.     

Venous thrombectomy for iliofemoral vein thrombosis--10-year results of a prospective randomised study

In a longitudinal evaluation of 37 patients with severe depression who had undergone brain magnetic resonance imaging (MRI) 6 months-2 years (mean 14.1 months) previously, the degree of residual dysfunction was predicted by the extent of subcortical white matter hyperintensities (WMHS, p < .01), longer time elapsed since the MRI scan (p < .05), older age (p < .05), and older age at onset of affective disorder (p < .05). Ten (27%) patients developed "probable" dementia syndromes of the vascular type, with such syndromes being predicted by WMHS (p < .01) and older age of onset of affective disorder (p < .05). Institutionalization of patients was predicted largely by the combination of chronic depression, progressive cognitive decline, and advanced age. The study supports the notion that a subgroup of patients with late-onset depressive disorders, without a family history of depression, and with risk factors to cerebrovascular disease, have extensive WMHS on MRI, and that such structural brain changes predispose to chronic depression and progressive cognitive decline.     

Partial replacement of an infected arterial graft by a new prosthetic polytetrafluoroethylene segment: a new therapeutic option

PURPOSE: As the title suggests, this is an account of treating infected arterial grafts other than by the accepted methods of complete graft removal and revascularization with autogenous material or extraanatomic bypass. METHODS: Since 1973, 42 patients with infected arterial grafts (n = 35) or autogenous reconstructions (n = 7) were seen with false aneurysm, hemorrhage, or perigraft or perianastomotic pus and were treated by removal of the infected graft and immediate adjacent or in situ revascularization by polytetrafluoroethylene (PTFE) in 39 cases and Dacron in three cases. Management plan included (1) removal of only the obviously infected part of the original graft, (2) obliteration of the infected anastomotic site, and (3) placement of the new PTFE graft in an adjacent clean or debrided route. So treated were 15 aortic Dacron grafts, 20 PTFE grafts (2 iliofemoral, 3 femorofemoral, and 15 femorodistal), and 7 autogenous reconstructions with bleeding. Partial graft salvage was attempted in 10 of 15 Dacron and 19 of 20 PTFE grafts. RESULTS: Four patients required further removal of the original infected graft (three Dacron, one PTFE), giving an ultimate success rate of 7 of 15 Dacron and 18 of 20 PTFE grafts; two patients required further obliteration of the original adjacent infected arterial segment because of rebleeding. An additional PTFE segment was joined successfully to incorporated PTFE in all six repeat operations. Initial failure did not prejudice the outcome; direct arterial flow to at least midthigh level was preserved in 37 of the 42 patients for a mean period of 40 months (range 9 to 130 months). Three of the new PTFE grafts occluded and became infected, which led to amputation and one death at a secondary operation. Visceral complications caused the only two other deaths in the aortic group. Five late amputations (four below the knee and one above the knee) were required because of femorodistal graft occlusion. CONCLUSIONS: Partial removal of infected grafts with adjacent or in situ replacement by PTFE is possible, simplifies management, and permits maintenance of distal circulation with low morbidity and mortality rates.     

Tick-borne diseases in Texas: a 10-year retrospective examination of cases

The occurrence of Rocky Mountain spotted fever, human monocytotropic ehrlichiosis, tularemia, tick-borne relapsing fever, and a southern erythema migrans-like illness (Lyme/Lyme-like disease) is determined by the geographic distribution and seasonal activity of the particular vector tick(s). The flulike signs and symptoms early in the course of spotted fever rickettsiosis, ehrlichiosis, tularemia, and relapsing fever are nonspecific and do not readily suggest a particular diagnosis. Laboratory diagnosis, particularly during the acute stage of illness, often is elusive. Empiric treatment with doxycycline can be lifesaving for Rocky Mountain spotted fever and ehrlichiosis. This article provides insight into the significance of each of these tick-transmitted diseases in Texas.     

Aneurysm of a subclavian-vertebral artery saphenous vein bypass graft: case report

OBJECTIVE AND IMPORTANCE: Although an autogenous saphenous vein is frequently used as a bypass graft, an aneurysm of a venous graft is a rare complication, especially in the case of cerebrovascular revascularization. We report a case of a successfully treated aneurysmal change in a venous graft after short vein bypass grafting. CLINICAL PRESENTATION: A 60-year-old man underwent a left subclavian-to-vertebral artery bypass operation with an interposed saphenous vein graft because of severe stenosis of the vertebral artery bilaterally. Angiograms of the left subclavian artery, obtained 4 months later, showed good patency of the graft without any dilation or stenosis. One year after the bypass surgery, the patient became aware of a pulsating mass in the left supraclavicular region, which was regarded as the grafted vein itself. A giant aneurysm of the vein graft, which developed at the nonanastomotic site, was shown in the angiogram 4 years later. INTERVENTION: The aneurysm was resected, and patch grafting of the orifice of the aneurysmal neck covered with an artificial vessel as a reinforcement was performed. CONCLUSION: The aneurysm seemed to have developed in a curved segment because of hemodynamic stress.     

Dysautonomia in dogs: a retrospective study

Dysautonomia was diagnosed in 11 young (median age, 14-months), predominantly medium- to large-breed dogs from 1988 to 1995. Clinical signs caused by autonomic dysfunction of the urinary, alimentary, and ocular systems were most common. Dysuria, mydriasis, absence of pupillary light reflexes, decreased tear production, dry mucous membranes, weight loss, and decreased anal tone were present in over 75% of affected dogs. Ocular pharmacological testing with a dilute (0.1%) solution of pilocarpine was used to demonstrate iris sphincter receptor function in all dogs. A low-dose (0.0375 mg/kg s.c.) bethanechol test and pharmacological testing with phenylephrine and epinephrine also demonstrated cholinergic and adrenergic receptor function in 4 dogs. All dogs died or were euthanized as a results of autonomic dysfunction. Neuronal depletion, with associated gliosis and minimal inflammation were noted histologically in the autonomic ganglia of each dog. The pelvic, ciliary, celiac, cranial cervical, and cranial and caudal mesenteric ganglia were affected in all dogs. The cause of autonomic failure in these dogs was not determined.     

SLAP lesions: a retrospective multicenter study

This study was performed to assess the relationship between the level and extent of prostatic capsular invasion (PCI) by cancer and the clinical and pathological features and prognosis of early-stage prostate cancer. We conducted a retrospective analysis of the clinical (age, stage, grade, prostate specific antigen [PSA] level) and pathological (tumor volume, stage, grade, surgical margins) features of 688 patients treated with radical prostatectomy to determine the pathological features and probability of recurrence associated with various levels of PCI. Radical prostatectomy specimens were serially sectioned and examined by whole-mount technique. Progression-free probabilities (PFP) after radical prostatectomy were determined by Kaplan-Meier and Cox proportional hazards regression analysis. Progression was defined as a rising serum PSA < or = 0.4 ng/mL or clinical evidence of recurrent cancer. Increasing clinical stage, Gleason grade in the biopsy specimen, and pretreatment serum PSA levels were each associated with increasing levels of PCI (P < .001). In the radical prostatectomy specimen, increasing levels of PCI were significantly associated with increasing tumor volume (P < .001), Gleason grade (P < .0001), seminal vesicle involvement (SVI, P < .001) and lymph node metastases (+LN, P < .001). None of 138 patients without capsular invasion had SVI or lymph node metastases (+LN), and all remained free of progression, even though some had large volume (up to 6.26 cm3) or poorly differentiated (Gleason sum up to 8) cancers. Invasion into the capsule (n = 271) was occasionally associated with SVI (6%) or +LN (3%) and a significantly (log-rank test) lower PFP of 87% at 5 years. Focal and extensive extraprostatic extension (EPE) were associated with progressively increased risk of SVI and +LN and lower PFP (73% and 42%, respectively). In a multivariate analysis, the level of PCI was an independent prognostic factor (P < .001). There is a strong association between the level of invasion of cancer into or through the prostatic capsule and the volume, grade, pathological stage, and rate of recurrence after radical prostatectomy. Prostate cancer does not appear to metastasize in the absence of invasion into the capsule regardless of the volume or grade of the intracapsular tumor. Subclassification of patients according to the levels of PCI provides valuable prognostic information.