QJM - Advance Access

'Hospital at Night' improves outcomes: does the evidence support opinions?

Cappuccio, F.P. — 2009-07-01

Resistance exercise plus to aerobic activities is associated with better lipids' profile among healthy individuals: the ATTICA study

2009-07-01

Background: The influence of different types of exercise on risk factors for cardiovascular diseases has rarely been investigated. The aim of the present work was to evaluate the effect of adding resistance exercise to aerobic activities on lipid–lipoprotein profile, in a representative sample of men and women from the province of Attica, Greece.

Methods: We randomly enrolled 1514 and 1528 healthy men and women, respectively, stratified by city, age and gender distribution. Participants were classified as inactive (INA), sufficiently active (SA) and highly active for either aerobic activities (HAA) alone or a combination of aerobic plus resistance exercise (HAC). The main outcome measures are lipid–lipoprotein profile [total, high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, triglycerides, apolipoprotein-A1, apolipoprotein-B] and anthropometric indices.

Results: From those participating in aerobic activities, 480 (31.7%) men and 502 (32.9%) women were classified as SA, 100 men (6.6%) and 93 women (6.1%) as HAA and 90 men (5.9%) and 49 women (3.2%) as HAC. After various adjustments were made, men from the HAC group had an average of 23% lower plasma triacylglycerol concentration (P = 0.04) and 10% lower LDL-cholesterol (P = 0.01) when compared with the HAA group. Moreover, women from the HAC group had 13% lower LDL-cholesterol when compared with HAA group (P = 0.051).

Conclusions: These data suggest that combining aerobic and resistance-type activities may confer a better effect on lipoprotein profile in healthy individuals than aerobic activities alone.

Failure of antivenom to improve recovery in Australian snakebite coagulopathy

Isbister, G.K., Duffull, S.B., Brown, S.G.A., for the ASP Investigators — 2009-07-01

Background: Venom-induced consumption coagulopathy (VICC) is an important feature of snake envenoming.

Aim: To investigate the effect of antivenom and fresh frozen plasma (FFP) on recovery of VICC in Australian elapid snake envenoming.

Design: Prospective cohort study.

Methods: Patients with VICC were included from the Australian Snakebite Project (ASP). Time to recovery of VICC (defined as time until INR <2) was investigated using a time to event analysis in WinBUGS. The model considered the effects of age, sex, snake type, time of antivenom after bite, antivenom dose and use of FFP within 4 h.

Results: The study included 167 cases of VICC, median age being 41 [interquartile range (IQR): 28–53) years, and 130 (78%) were males. Antivenom was administered at a median of 3.6 (IQR: 2.2–5.6) h after the bite at a median dose of four vials (IQR: 2–6 vials). Thirteen patients received FFP within 4 h. Recovery of VICC occurred after a median of 14.4 (IQR: 11.5–17.5) h, and only the use of FFP within 4 h influenced the time to recovery. Neither antivenom dose nor time of antivenom administration had an effect on recovery of VICC. In patients administered with FFP, 12% [credible interval (CrI): 6–21%] and 81% (CrI: 61–94%) had recovered at 6 and 12 h, respectively, vs 2.5% (CrI: 1.5–4%) and 28% (CrI: 22–34%) not receiving FFP.

Discussion: Antivenom did not appear to be effective for the coagulopathy in snake envenoming in Australia. FFP appeared to shorten the time of VICC recovery.

When I use a word ... Declarative titles

Aronson, J. — 2009-06-29

Incomplete Carney triad--a review of two cases

Sawhney, S.A., Chapman, A.D., Carney, J.A., Gomersall, L.N., Dempsey, O.J. — 2009-06-26

A curious association of three rare tumours was described by Carney in 1977. ‘Carney's triad’ characteristically includes multifocal pulmonary chondroma, gastric stromal sarcoma and extra-adrenal paraganglioma. Patients may exhibit complete or incomplete expression of the triad. Carney acknowledged that, of 79 patients, only 17 possessed all three tumours. We report here two patients with incomplete expression of Carney's triad.

Q fever: persistence of antigenic non-viable cell residues of Coxiella burnetii in the host--implications for post Q fever infection fatigue syndrome and other chronic sequelae

2009-06-25

Background: Our previous studies of persistence of Coxiella burnetii in humans after an initial acute Q fever infection revealed raised, maintained antibody levels and low levels of coxiella genomic DNA at the age of 5 years from onset in Australian patients and at 12 years in patients in the 1989 Birmingham UK Q fever outbreak. Attempts to isolate the coxiella in standard cell culture and susceptible mice by serial passage of PCR positive PBMC and bone marrow were negative.

Aim: To retest PCR positive patient samples by more sensitive methods for viable coxiellas and for the coxiella cell components of antigen and specific lipopolysaccharide (LPS). To re-interpret the previous results in the light of the new information. To review the pertinent literature for a concept of an immuno-modulatory complex generated by the current studies.

Design: Laboratory case study.

Methods: Stored patient samples were inoculated into SCID mice that were followed for 60 days. Mouse spleen and liver samples were then examined by PCR assay for targets in the COM1 and IS1111a sequences and for antigens by IFA with a polyclonal rabbit antiserum to C. burnetii Phase 1 and a monoclonal antiserum to Phase 1 LPS (details; O. Sukocheva et al., unpublished data).

Results: All specimens, including a recently excised heart valve from a Birmingham patient with late developing endocarditis, were infection negative in SCID mice. Dilutions of SCID mouse spleen and liver homogenates titrated in PCR assays were negative at dilutions attained by control mice inoculated with an endpoint dilution of a viable prototype strain of C. burnetii. Sections of the spleens from all specimens showed a complex of coxiella antigen-LPS by IFA.

Discussion/Review: We advance a concept of long-term persistence of a non-infective, non-biodegraded complex of coxiella cell components with its antigens and specific LPS [so called Immunomodulatory complex (IMC)] associated with traces of genomic DNA that signalled its presence in our earlier studies. The IMC's survival in patients for at least 12 years, and in one patient for 70 years implies a capacity for serial passage in macrophages with effective down-regulation of their biodegrading functions. The review assesses the compatibility of the IMC concept in relation to cogent literature on C. burnetii interactions with macrophage and cell-mediated immunity. Some remaining gaps in our knowledge of the organ sites and duration of carriage of viable coxiellas after initial infection are also identified.

The non-invasive biopsy--will urinary proteomics make the renal tissue biopsy redundant?

Bramham, K., Mistry, H.D., Poston, L., Chappell, L.C., Thompson, A.J. — 2009-06-24

Proteomics is a rapidly advancing technique which gives functional insight into gene expression in living organisms. Urine is an ideal medium for study as it is readily available, easily obtained and less complex than other bodily fluids. Considerable progress has been made over the last 5 years in the study of urinary proteomics as a diagnostic tool for renal disease. Advantages over the traditional renal biopsy include accessibility, safety, the possibility of serial sampling and the potential for non-invasive prognostic and diagnostic monitoring of disease and an individual's response to treatment. Urinary proteomics is now moving from a discovery phase in small studies to a validation phase in much larger numbers of patients with renal disease. Whilst there are still some limitations in methodology, which are assessed in this review, the possibility of urinary proteomics replacing the invasive tissue biopsy for diagnosis of renal disease is becoming an increasingly realistic option.

Would that we had the energy

Seaton, A. — 2009-06-22

Abdominal wall hernia during peritoneal dialysis

Chung, S., Chang, Y.S., Park, C.W. — 2009-06-17

Commissioned article: management of exotic snakebites

Warrell, D.A. — 2009-06-17

Exotic (foreign or non-native) snakes, including venomous species, are becoming increasingly popular pets in Western countries. Some of them are kept illegally (as defined by the UK Dangerous Wild Animals Act of 1976). There is a large international market for such animals, with contraventions of the Convention on International Trade in Endangered Species of Wild Fauna and Flora (CITES). In the UK, several other European countries and the USA the reported numbers of bites by venomous exotic snakes, although small, are increasing but still underestimate the occurrence of these occasionally fatal events because of the victims’ reluctance to seek medical care. Victims are predominantly young men who have been drinking alcohol. Bites may be intentionally provoked. In Europe, the species most often involved are cobras, green mambas, American pit vipers particularly rattlesnakes, African adders, vipers and Asian green pit vipers. To illustrate the special problems involved, case histories are presented of bites by exotic species in the UK and of bites abroad, where patients were repatriated for treatment. In view of the relative rarity and diversity of these cases, expert advice must usually be sought. These requests should include information about the species thought to have been responsible and the history and timing of the evolution of envenoming. Sources of advice and antivenom are discussed together with recommendations for appropriate first aid and emergency treatment while this is being awaited. Respiratory and cardiovascular resuscitation may be required and when systemic or severe local envenoming develops, specific (equine or ovine) antivenom is indicated.

Conservatively managed patients with stage 5 chronic kidney disease--outcomes from a single center experience

Ellam, T., El-Kossi, M., Prasanth, K.C., El-Nahas, M., Khwaja, A. — 2009-06-17

Background: Limited survival data are available on chronic kidney disease stage 5 (CKD 5) patients who opt for conservative management rather than dialysis.

Aim: To measure survival in such patients and investigate potential factors predicting survival.

Design: Retrospective survival analysis of a cohort of conservatively managed CKD 5 patients from a single center.

Methods: Survival was measured in 69 conservatively managed patients from the time they were first known to have CKD 5. Comorbidities, residual renal function and other laboratory parameters (calcium, phosphate, parathyroid hormone, albumin and hemoglobin) and blood pressure were recorded.

Results: Overall median patient survival from the time of first known CKD 5 was 21 months. Patients known to a nephrologist before reaching CKD 5 survived longer (median 32 months) than those presenting with CKD 5 (15 months, P = 0.025). Serum albumin >35 g/l was associated with greater survival, but other biochemical parameters, comorbidity grade and age did not predict survival.

Conclusions: These survival data provide useful information for nephrologists counseling CKD 5 patients considering whether to pursue dialysis or conservative management. Risk factors that correlate with survival in the dialysis population may not predict survival in conservatively managed CKD 5 patients.

Steroid responsive metastatic epidural nerve root infiltration with chronic lymphocytic leukaemia

Agarwal, S., Gabriel, C.M., Campbell, V.L., Marks, S. — 2009-06-16

Megaoesophagus: an unusual cause of stridor

Thomas, J.D., Monaghan, T.M., Latief, K. — 2009-06-16

Randomized control trial investigating the influence of coffee on heart rate variability in patients with ST-segment elevation myocardial infarction

Richardson, T., Baker, J., Thomas, P.W., Meckes, C., Rozkovec, A., Kerr, D. — 2009-06-16

Background: Cardiac autonomic dysfunction post ST-segment elevation myocardial infarction (STEMI) has been linked to an excess risk of premature cardiovascular morbidity and mortality above those with normal autonomic function post-STEMI.

Aim: The aim of this study was to evaluate the effect of acute ingestion of coffee on autonomic function and cardiovascular outcomes in patients with acute STEMI.

Design: Randomized control trial.

Methods: We randomized 103 patients with acute STEMI, admitted to our Coronary Care Unit, to receive regular coffee (caffeinated) or de-caffeinated coffee using a randomized controlled double-blinded design. Heart rate variability was assessed 5 days post-STEMI to assess the effect of caffeine on autonomic function.

Results: In the group randomized to regular coffee, parasympathetic activity increased by up to 96% (P = 0.04) after 5 days. There was no detrimental effect of regular coffee on cardiac rhythm post-STEMI.

Conclusion: Coffee ingestion is associated with an increase in parasympathetic autonomic function immediately post-STEMI. Coffee was found to be safe and not associated with any adverse cardiovascular outcomes in the short term.

Whitish thickening of the tongue

Guarneri, C., Vaccaro, M., Barbuzza, O. — 2009-06-15

An unusual cause of bone marrow 18-fluorodeoxyglucose uptake

Chetty, M., Denison, A.R., Currie, G.P. — 2009-06-11

European Working Time Directive in a stroke unit: hidden deficits

McCarroon, M.O., Armstrong, M., McCarron, P. — 2009-06-10

Dyslipidemia and cardiovascular risk: the importance of early prevention

Miller, M. — 2009-06-04

Strategies aimed at primary prevention provide an outstanding opportunity for reducing the onset and burden of cardiovascular (CV) disease. Lipid abnormalities, including high levels of low-density lipoprotein cholesterol (LDL-C), elevated triglycerides and low levels of high-density lipoprotein cholesterol (HDL-C), are associated with an increased risk of CV events, thereby serving as contributors to this process. By consensus, lowering LDL-C, generally with statin therapy, is the primary target of lipid-lowering therapy. However, statin therapy may be insufficient for patients with mixed dyslipidemia, especially those with insulin resistance syndromes. While the addition of niacin, fibrate or omega-3 fatty acids may be useful in this setting, outcomes data are lacking. Therefore, data from ongoing prospective studies will hopefully resolve this issue and facilitate identification of optimal strategies to augment CV risk reduction.

Gas-forming pyogenic liver abscess

Huang, C.-Y., Chou, W.-K., Lin, M.-S., Tsai, K.-C., Sun, J.-Tang. — 2009-05-21

Improvement in out-of-hours outcomes following the implementation of Hospital at Night

2009-05-21

Background: Hospital at Night (H@N) is a Department of Health (England) driven programme being widely implemented across UK. It aims to redefine how medical cover is provided in hospitals during the out-of-hours period.

Aim: To investigate whether the implementation of H@N is associated with significant change in system or clinical outcomes.

Design: An observational study for 14 consecutive nights before, and 14 consecutive nights after the implementation of H@N. Data were collected from the Combined surgical and medical Assessment Unit (CAU), the 18 medical/surgical wards (The Ward Arc) and the four High Dependency Units (The Critical Care corridor) within the Royal Infirmary of Edinburgh.

Methods: Following an overnight episode of clinical concern, data were gathered on response time, seniority of reviewing staff, patient outcome and the use of Standardized Early Warning Score (SEWS).

Results: Two hundred and nine episodes of clinical concern were recorded before the implementation of H@N and 216 episodes afterwards. There was no significant change in response time in the CAU, Ward Arc or Critical Care corridor. However, significant inter-speciality differences in response time were eradicated, particularly in the Critical Care corridor. Following the implementation of H@N, patients were reviewed more frequently by senior medical staff in CAU (28% vs. 4%, P < 0.05) and the Critical Care corridor (50% vs. 22%, P < 0.001). Finally there was a reduction in adverse outcome (defined as unplanned transfer to critical care/cardiac arrest) in the Ward Arc and CAU from 17% to 6% of patients reviewed overnight (P < 0.01). SEWS was more frequently and accurately recorded in CAU.

Conclusion: This is the first study that we are aware of directly comparing out-of-hours performance before and after the implementation of H@N. Significant improvements in both patient and system outcomes were observed, with no adverse effects noted.

When I Use a word ... Changing your practice

Aronson, J. — 2009-05-21

Medication errors: what they are, how they happen, and how to avoid them

Aronson, J.K. — 2009-05-20

A medication error is a failure in the treatment process that leads to, or has the potential to lead to, harm to the patient. Medication errors can occur in deciding which medicine and dosage regimen to use (prescribing faults—irrational, inappropriate, and ineffective prescribing, underprescribing, overprescribing); writing the prescription (prescription errors); manufacturing the formulation (wrong strength, contaminants or adulterants, wrong or misleading packaging); dispensing the formulation (wrong drug, wrong formulation, wrong label); administering or taking the medicine (wrong dose, wrong route, wrong frequency, wrong duration); monitoring therapy (failing to alter therapy when required, erroneous alteration). They can be classified, using a psychological classification of errors, as knowledge-, rule-, action- and memory-based errors. Although medication errors can occasionally be serious, they are not commonly so and are often trivial. However, it is important to detect them, since system failures that result in minor errors can later lead to serious errors. Reporting of errors should be encouraged by creating a blame-free, non-punitive environment. Errors in prescribing include irrational, inappropriate, and ineffective prescribing, underprescribing and overprescribing (collectively called prescribing faults) and errors in writing the prescription (including illegibility). Avoiding medication errors is important in balanced prescribing, which is the use of a medicine that is appropriate to the patient's condition and, within the limits created by the uncertainty that attends therapeutic decisions, in a dosage regimen that optimizes the balance of benefit to harm. In balanced prescribing the mechanism of action of the drug should be married to the pathophysiology of the disease.

Small bowel volvulus and the whirl sign

Lin, C.-h., Kao, P.-C., Wang, H.-p., Lien, W.-C. — 2009-05-18

Thomas Addison's disease after 154 years: modern diagnostic perspectives on an old condition

Leelarathna, L., Powrie, J.K., Carroll, P.V. — 2009-05-06

Thomas Addison was first to describe adrenocortical failure in 1855. Despite advances in the treatment of this condition, the diagnosis is still often delayed and sometimes missed with potentially fatal consequences. From the same institution where Thomas Addison performed his original autopsy studies, we present four recent cases highlighting the wide clinical spectrum and discuss how modern biochemical and immunological tests could be utilized in early diagnosis and aetiological classification.

Towards a more inclusive vision of the medical sciences

Farrelly, C. — 2009-04-29

Progress in the medical sciences is largely determined by two things: (i) the questions we ask, and (ii) how rigorously and vigorously we attempt to answer them. How do we know which questions are the right questions to ask, and thus the correct questions to spend our time and energies trying to answer? Such evaluative concerns bring into sharper focus the question—‘What is medicine for?’ The international study of rosuvastatin is important not simply because of the health benefits it may confer, but because it inspires a more robust and inclusive vision of the medical sciences. A vision which recognizes that the primary goal of medicine is to promote health, and that includes the health of ‘normal’ people as well as those with illness and disease. This inclusive vision of the medical sciences is a transformative one, it departs from the ‘disease-model’ approach which has dominated distinct areas of medical research for decades.

Haemorrhagic cardiac tamponade: a rare complication of pneumonia

Natarajan, B., Stephens, J.W. — 2009-04-24

Severe back pain in a hemodialysis patient

Hsiao, P.-J., Diang, L.-K., Lin, S.-H. — 2009-04-21

When I use a word ... Is it inflammation? It is!

Aronson, J. — 2009-04-15

Isolated pulmonary Langerhans cell histiocytosis

Kasmani, R., Narwal-Chadha, R. — 2009-04-09

Lunch with Richard Asher

Seaton, A. — 2009-04-05

Oh no--it's Donald Hunter!

Seaton, A. — 2009-03-31

Red-green blindness

Seaton, A. — 2009-03-24

Did Darwin read Mendel?

Galton, D. — 2009-03-13

Life-threatening scrotal pain

Sun, J.-T., Tsai, K.-C., Wu, C.-J., Lien, W.-C., Wang, H.-P. — 2009-02-18

Spontaneous haemopericardium with subacute cardiac tamponade in a patient with lung cancer receiving coumadin

2009-02-07