bluuebunny/crossref_metadata_2025 huggingface dataset:
BRONCHOPULMONARY AMYLOIDOSIS—MULTIPLE TISSUE INVOLVEMENT AND LONG FOLLOW‐UP
Authors: YOUNG W. A.
Published: March 2008

Abstract A 59‐year‐old man developed a large asymptomatic left hilar mass due to amyloidosis of bronchial lymph nodes. Nodular involvement of the left lung and infiltration of the mucosa of the left lower lobe bronchus followed very gradually and a monoclonal gammopathy (IgA—Type Kappa) was demonstrated. Despite slowly progressive radiologic changes, the disease has had no effect on his health during a 20‐year period of observation.
CEREBRAL NOCARDIOSIS – CLINICAL AND PATHOLOGICAL FINDINGS IN THREE PATIENTS
Authors: HERKES G. K. , PRITCHARD R. , FRYER J. , WILSON R. McL. , RUSHWORTH R. , JOFFE R.
Published: March 2008

Abstract Cerebral nocardiosis is an uncommon but increasingly diagnosed infection in Australia. We report three cases. One occurred in an immunosuppressed male in whom the diagnosis was made at autopsy, one in an otherwise healthy elderly woman with subcutaneous nocardiosis, and the third was a posterior fossa nocardial abscess without systemic involvement occurring in a previously healthy woman after surgical excision of a meningioma. Primary cerebral nocardiosis is rare, with only two cases of primary posterior fossa nocardiosis reported. The cases highlight the difficulty of diagnosis and the need for aggressive treatment with a combined approach of surgical drainage and antibiotic therapy. The antibiotic regime of choice is the subject of controversy. Rifampicin, cephalosporins, imipenem, sulphonamides and other agents were used with varying success in our patients. Cerebral nocardiosis should be considered in any patient with a cerebral space occupying lesion.
TWO DIMENSIONAL ECHOCARDIOGRAPHY AND LEFT VENTRICULOGRAPHY IN CARDIAC SARCOIDOSIS
Authors: BOWER S.P.C. , THOMSON A.
Published: March 2008

A 48‐year‐old woman with histologically proven pulmonary sarcoidosis presented with congestive heart failure. Two dimensional echocardiography showed a peculiarly ragged appearance at the left ventricular apex which was confirmed on left ventriculography. This echocardiographic finding has not been previously described in cardiac sarcoidosis.
DANAZOL AND HEPATIC NEOPLASIA: A CASE REPORT
Authors: MIDDLETON C. , McCAUGHAN G. W. , PAINTER D. M. , STEPHEN M. S. , BEALE M. , FRASER I.
Published: March 2008

Although hepatic side‐effects of danazol are well known, the occurrence of hepatic tumours is not well documented. We report a case of hepatocellular adenoma occurring in a 35‐year‐old woman with endometriosis who had been taking danazol over a three year period.
CARDIOMYOPATHY. Edited by: Thomas D. Giles. Gary E. Sander.
Authors: Ikram H.
Published: March 2008

CARDIOMYOPATHY. Edited by: Thomas D. Giles. Gary E. Sander.
Mucor cerebral abscess associated with intravenous drug abuse
Authors: Fong K. M. , Seneviratne E. M. E. , McCormack J. G.
Published: March 2008

We report on a case of a 26‐year‐old intravenous narcotic abuser with a primary cerebral mucormycotic abscess caused by Rhizopus oryzae. He was treated with a combination of intravenous and intraventricular amphotericin B and surgical drainage with a successful outcome. There was no evidence that his infection was acquired by the rhinocerebral route, it seems likely that he injected himself with a contaminated batch of narcotic or amphetamine. Mucormycosis presenting in this way has been described previously but this is only the second such case to survive. Early diagnosis and treatment is essential for a favourable outcome in this condition.
Selective inhibition of platelet cyclooxygenase with controlled release, low‐dose aspirin
Authors: Vial J. H. , McLeod L. J. , Roberts M. S. , Seville P. R.
Published: March 2008

The hypothesis that slow administration of low doses of aspirin may selectively inhibit platelet cyclooxygenase and thromboxane A2 formation was evaluated using controlled release aspirin formulations. In the first study, doses of either 50, 100, 325 and 1,300 mg of these formulations and 300 mg soluble aspirin were ingested daily by healthy volunteers for one week. In the second study, doses of 5, 10, 25 and 50 mg controlled release aspirin, 50 mg soluble aspirin and 100 mg aspirin and glycine formulation were ingested daily for ten days. Platelet function and urinary prostaglandin production were assessed immediately before and on the seventh day of dosing in both studies and in the second study, repeated on the tenth day of dosing.

Platelet function and serum thromboxane B2 production were fully inhibited by all formulations of 50 mg aspirin and above, but not by doses of controlled release aspirin below 50 mg doses. The excretion of urinary 6‐keto‐PGF1α (a major metabolite of prostacyclin) was significantly reduced at controlled release aspirin doses above 100 mg and at all doses of rapidly absorbed aspirin tested. As no significant reduction in the urinary 6‐keto‐PGF1α production was observed at doses of controlled release aspirin of 50 and 100 mg and below, it appeared that these doses did not inhibit the systemic vascular cyclooxygenase. These data are consistent with a selective inhibition of platelet function by daily doses of 50 and 100 mg of the controlled release formulation of aspirin.
Brief upper airway (laryngeal) dysfunction
Authors: Campbell A. H. , Mestitz H. , Pierce R.
Published: March 2008

We describe in six men, recurrent episodes recurring over months or years, of sudden, brief complete obstruction to respiration followed by dyspnoea with loud inspiratory stridor lasting two to five minutes. Attacks occurred during wakefulness and/or sleep. In one patient an episode was witnessed endoscopically: the initial obstruction was seen to be caused by complete laryngeal closure. The false vocal cords then opened, but the vocal cords remained adducted and caused inspiratory stridor. The similarity of the attacks described by the other patients suggests that they were all caused by laryngeal closure. Furthermore, they could simulate the episodes by voluntarily adducting their vocal cords. The symptoms were usually preceded by a sensation of throat irritation and in four cases symptoms of upper respiratory infection were present. Associated features present in some of the patients included post‐nasal discharge, snoring, sleep apnoea and gastro‐oesophageal reflux. None was hypocalcaemic. Although stimulation of laryngeal receptors is known to produce reflex laryngeal closure, cough is the usual response during wakefulness. Treatment aimed at reducing upper airway irritation and voluntary inhibition of coughing appeared successful in reducing the incidence and severity of the episodes. Recognition of the condition is important as it may be confused with other causes of acute dyspnoea and it appears to respond to specific management.
Streptococcus Pyogenes Pneumonia with Abscess Formation
Authors: McIntyre H. D. , Armstrong J. G. , Mitchell C. A.
Published: March 2008

A 30‐year‐old female with mild asthma presented with high fever, hypotension, pleuritic chest pain, vomiting and diarrhoea. Chest radiograph showed consolidation of the right upper lobe, and S. pyogenes was cultured from blood and sputum. Following initial rapid recovery the patient relapsed ten days after antiobiotics were ceased, with rapid development of a large abscess cavity. Clinical improvement occurred following reinstitution of treatment including intravenous penicillin. Progressive radiological resolution eventuated during outpatient follow‐up. This case demonstrates that S. pyogenes pneumonia may occur without an antecedent viral infection or major predisposing condition, cause rapid cavitation despite antibiotic therapy and resolve satisfactorily with prolonged penicillin therapy.
Myocardial and skeletal muscle injuries following adenine arabinoside therapy
Authors: Mak K. H. , Boey M. L. , Wan S. H. , Lee Y. S.
Published: March 2008

A healthy young male with chronic persistent hepatitis associated with positive HBsAg and HBeAg and without any predisposing factors for coronary artery disease was treated with a course of prednisolone and adenine arabinoside. At the end of therapy, he developed myocardial and skeletal muscle injuries. The temporal relationship between the administration of the drug and the monophasic nature of the myotoxic injuries strongly suggests that adenine arabinoside induced the clinical manifestations in the patient.
Long‐term cardiopulmonary function after human heart‐lung transplantation
Authors: Glanville A. R. , Baldwin J. C. , Hunt S. A. , Theodore J.
Published: March 2008

We present cardiac and pulmonary function data obtained at serial annual reviews in 21 heart‐lung transplant (HLT) recipients followed for up to four years postoperatively, reflecting the entire Stanford experience as of June 1987. A total of 50 cardiac catheterisation procedures and endomyocardial biopsies yielded the following results: rejection on biopsy (0/50) (0% of patients), angiographic coronary artery disease (1/50) (5%), pulmonary hypertension (2/50) (10%), elevated pulmonary vascular resistance (PVR) (1/50) (5%), and low cardiac index (CI) (4/50) (14%). Systemic hypertension was common, with an elevated systemic vascular resistance (SVR) (26/44) (76%) and an elevated mean aortic pressure (MAP) (22/44) (67%). Pulmonary function testing frequently revealed abnormalities. Airflow limitation was manifested by a reduction in both FEV,/FVC ratio (17/50) (52%) and FEF25–75 (30/50) (71%), and was often associated with arterial hypoxaemia (13/50) (52%). Subsequently, five patients with these findings have died with obliterative bronchiolitis (OB), one underwent retransplantation for OB, six have stable OB, and one has progressive OB. Length of survival was highly correlated with the resting Pa02 at the first annual review (r = 0.99) (p < 0.001), and, to a lesser degree, on the reduction in FEF25–75 (r = 0.73) (p<0.05) and FEV1/FVC ratio (r = 0.77) (p<0.05). Resting Pa02 was determined by ventilatory (r = 0.80) (p< 0.001) rather than circulatory factors and all patients with airflow limitation who died had OB at post‐mortem examination.

These results support the continued study of HLT as a therapeutic modality for selected patients with irreversible pulmonary hypertension. They demonstrate that, in the absence of severe OB, haemodynamics, cardiac function, and coronary patency are preserved for several years after HLT. Whereas the value of regular pulmonary function testing has become evident, there does not appear to be a clinical need for annual surveillance with invasive cardiac procedures in long‐term survivors of HLT.
Flucloxacillin induced delayed cholestatic hepatitis
Authors: Miros M. , Kerlin P. , Walker N. , Harris O.
Published: March 2008

We report four cases of severe delayed cholestatic hepatitis induced by flucloxacillin. All patients presented with deep jaundice and pruritus which developed soon after ceasing flucloxacillin. Liver function tests were abnormal in all patients with markedly elevated serum bilirubin concentration, alkaline phosphatase and aspartate transaminase levels. Extrahepatic biliary obstruction and infective hepatitis were excluded in all cases. Liver biopsies showed centrilobular cholestasis with portal and lobular inflammation and eosinophil infiltration. Although symptoms resolved within six weeks in all patients, cholestatic liver function tests have persisted in two patients for more than six months. With the increasing usage of this drug and the delayed presentation of cholestasis, flucloxacillin needs to be considered in the differential diagnosis of all patients presenting with cholestatic jaundice.
Proarrhythmic actions of antiarrhythmic drugs: a review
Authors: Campbell TJ.
Published: March 2008

The ability of antiarrhythmic drugs to aggravate and even cause arrhythmias is now well‐established. The incidence of such effects for a wide range of agents is of the order of 3–15%. The two major mechanisms are facilitation of reentry circuits and the production of triggered activity due to early afterdepolarisations. This latter effect probably underlies the drug‐induced long QT syndromes and associated arrhythmias including ‘torsade de pointes’ and is more likely to occur in association with bradycardia, hypokalaemia, or concomitant digitalis therapy. While some or all of these mechanisms are capable of producing or aggravating both supraventricular and ventricular arrhythmias, this review deals only with ‘proarrhythmic’ effects in the ventricles. These are known to be more likely in the presence of poor ventricular function (left ventricular rejection fraction < 35%). Optimal management may include withdrawal of antiarrhythmic agents, replacement of potassium, infusion of magnesium and overdrive pacing.
Late (one month) reversible ischaemia after primary coronary occlusion treated with recombinant tissue plasminogen activator (rTPA)
Authors: Wilkes N. P. F. , Magee M. , Hoschl R. , Nelson G. I. C.
Published: March 2008

Abstract The incidence of reversible ischaemia was assessed four weeks after primary coronary occlusion in 36 patients who had not required earlier revascularisation after randomisation to receive rTPA (n= 19) or placebo (n= 17). Coronary arteriography was performed at three weeks and thallium scintigraphy with dynamic stress testing at four weeks. Patients were followed for one year without planned intervention in the absence of symptoms. Managing physicians remained blinded to thrombolytic therapy.

Patency rate of the infarct related artery at three weeks was greater after rTPA (rTPA 16, placebo 9; p= 0.04). Reversible perfusion defects within infarct related artery territory occurred with similar frequency in both treatment groups (rTPA 7, placebo 8). Multivessel disease was frequent (rTPA 11, placebo 12) but associated with a low incidence of reversible perfusion defects outside infarct related artery territory (rTPA 3, placebo 2). Thallium scintigraphy identified six of seven patients requiring subsequent revascularisation (sensitivity 86%, specificity 59%, negative predictive value 94%). Dynamic stress testing was positive for reversible ischaemia in 28% (rTPA 6, placebo 4) and identified two patients requiring revascularisation (sensitivity 29%, specificity 72%, negative predictive value 81%).

The greater patency rate achieved with rTPA at three weeks after primary coronary occlusion was not associated with a significantly greater incidence of reversible perfusion defects at four weeks in patients who had not required prior revascularisation. The absence of reversible perfusion defects at four weeks was associated with a low incidence of revascularisation procedures during one year follow‐up.
Benign recurrent unilateral abducens nerve palsy
Authors: Hankey G. J.
Published: March 2008

Abstract The recurrence of an isolated unilateral left abducens nerve palsy on five occasions over five years is described in an adult. No evidence of any systemic or intracranial disorder has been identified. The aetiology remains uncertain and the clinical course is benign. The diagnosis of ‘benign’ abducens nerve palsy is one of exclusion and is made retrospectively after an adequate period of serial evaluations.
A randomised study of outcomes in a defined group of acutely ill elderly patients managed in a geriatric assessment unit or a general medical unit
Authors: Harris R. D. , Chalmers J. P. , Henschke P. J. , Tonkin A. , Popplewell P. Y. , Stewart A. M. , Radford A. J. , O'Brien K. P. , Bond M. J. , Harris M. G. , Turnbull R. J. , Champion G. , Hobbin E. R. , Andrews G. R.
Published: March 2008

The aim of this study was to identify differences in the medical management and clinical outcome in a group of elderly patients admitted to a designated geriatric assessment unit (GAU) or to two general medical units (GMUs). A prospective randomised controlled trial was undertaken in 267 patients aged 70 years and over (mean age = 78.3 years). Following discharge from hospital, patients were followed up at three monthly intervals for a total of 12 months. At the time of discharge, no significant differences were found in inpatient management, length of stay, mortality rates, discharge rates to institutional care or utilisation of community services in patients admitted to the GAU and the GMUs. Similarly, no significant differences were found at three, six, nine, and 12 month follow up in case fatality, activities of daily living indices, mental health status, rates of institutional referral and the level of community service support in patients admitted to the GAU and the GMUs studied.

These findings do not show any advantage for the unselected 70 + acutely ill elderly patient who is admitted to a designated geriatric assessment unit rather than to a general medical unit. Therefore, an admission policy to GAU, based solely on age 70 + is medically inappropriate and cost‐inefficient. Evidence from other sources suggests that an age cohort of acutely admitted patients beyond 80 years may well have returned more optimistic findings for the GAU. In future, GAUs will require a more selective admission policy to maximise the benefits of their rehabilitative and interdisciplinary approach. (Aust NZ J Med 1991; 21: 230–234.)
Physician response to screening for hypercholesterolaemia in a coronary care unit
Authors: Cox S. V. , Woodhouse S.
Published: March 2008

Abstract Hypercholesterolaemia is a known risk factor for coronary artery disease. This study describes a retrospective analysis of 176 patients admitted to the Coronary Care Unit (CCU) in a six month period with an admission fasting serum cholesterol of greater than 5.5 millimoles per litre (mmols/L). The patient records were examined at least six months after hospital discharge to determine what action, if any, was instituted in response to their hypercholesterolaemia.

One hundred and thirty‐four (76%) patients had a discharge diagnosis of myocardial ischaemia or infarction. Of the 176 patients, 73 were referred to a dietitian, 31 were given dietary advice by a medical officer, 13 were commenced on lipid‐lowering drugs with nine continuing lipid‐lowering drugs and only 13 patients were referred to this hospital's lipid clinic. Sixty‐nine (39%) received no response to their hypercholesterolaemia.

It is likely that our experience is not unique and greater attention to CCU measured lipid results and risk factor modification should be instituted by physicians. (Aust NZ J Med 1991; 21: 401–404.)
Targeted‐immunosuppression with vincristine infusion in the treatment of immune thrombocytopenia
Authors: Manoharan A.
Published: March 2008

Abstract Twenty‐four patients with immune thrombocytopenia (ITP) were treated with vincristine (VCR) 1.0–2.0mg given as 4‐hr I.V. infusions at weekly intervals for four‐six weeks; four patients received further infusions, as maintenance therapy, at increasing intervals for up to 12 months. Eight often patients with recent‐onset (< 6 months) ITP showed an excellent and sustained response, 7/8 without maintenance therapy. Among the 14 patients with ITP of >6 months' duration, seven showed a good or excellent but only transient response; sustained responses (two good, one partial) were seen only in the three patients who received maintenance therapy. The collective global experience with this novel therapeutic approach of targeted‐immunosuppression for ITP is still small, but results to date suggest a promising role for this approach, especially in patients with recent‐onset ITP. (Aust NZ J Med 1991; 21: 405–407.)
Autoantibodies in systemic vasculitis
Authors: Savige J. A. , Gallicchio M. , Chang L. , Parkin J. D.
Published: March 2008

Abstract We have studied 495 sera that were referred to us from patients suspected on clinical and/or histological grounds to have a small vessel vasculitis. These sera were tested for antibodies against neutrophil cytoplasm antigens (anti‐neutrophil cytoplasm antibodies, ANCA) using assays based on neutrophil acid extract, myeloperoxidase and elastase. Such antibodies are commonly found in Wegener's granulomatosis (WG) and microscopic polyarteritis (MPA), and sometimes in other small vessel vasculitides.

One hundred and twenty‐six of these sera (25%) were positive in the acid extract ELISA, 68 (14%) in the assay for anti‐myeloperoxidase antibodies and 35 (16%) in the assay for anti‐elastase antibodies. A total of 166 sera (34%) were positive for antibodies against neutrophil cytoplasm constituents.

No ANCA, anti‐myeloperoxidase or anti‐elastase antibodies were detected in 26 convalescent sera from patients either with WG or MPA, or who had previously been positive. The mean time between positive and negative sera was eight weeks (range three weeks to six months) and three out of three who relapsed again developed ANCA of the same specificity as the original sera.

Of the 228 sera also tested for anti‐GBM antibodies, 13 (5.7%) were positive. All these contained antibodies against neutrophil cytoplasm constituents (three against the acid extract, eight against myeloperoxidase and two against elastase).

Forty‐nine of the 74 sera (66%) tested for ANA were positive. Twenty‐nine (39%) had a speckled and 20 (27%) had a homogeneous pattern. Twenty of these were positive for ANCA or anti‐myeloperoxidase or anti‐elastase antibodies and 29 were negative.

ANCA, anti‐myeloperoxidase and anti‐elastase antibodies are common in patients in whom a vasculitis is suspected on clinical and/or histological grounds. The presence of these antibodies correlates with disease activity. Anti‐GBM antibodies and ANA are not uncommon in this group. A single ELISA for ANCA is insufficient to detect all antibodies directed against neutrophil cytoplasm constituents. (Aust NZ J Med 1991; 21: 433–437.)
Cryofibrinogenaemia: a case report
Authors: Young G. D. , Cleland L. G. , McNeil J. D.
Published: March 2008

Abstract A case of chronic acral ulceration is described in a 54‐year‐old man with cryofibrinogenaemia. Initial management with prednisolone and azathioprine was unsuccessful in controlling the disease. Introduction of a programme of plasmapheresis in addition to treatment with cyclophosphamide and prednisolone has brought about marked improvement. (Aust NZ J Med 1991; 21: 444–446.)
Miliary spread of malignant pleural mesothelioma without a clinically identifiable pleural tumour
Authors: Musk A. W. , Dewar J. , Shilkin K. B. , Whitaker D.
Published: March 2008

Abstract :A 44‐year‐old man with past minor exposure to blue asbestos presented with supraclavicular lymphadenopathy and miliary shadowing on his chest radiograph. Cytology and electronmicroscopy on material obtained by fine needle aspiration from his cervical lymph node revealed malignant mesothelioma. Malignant mesothelioma cells were also present in bronchoalveolar lavage fluid and on transbronchial lung biopsy. At autopsy the right pleural cavity was studded with small tumour nodules. This case demonstrates that malignant mesothelioma may present as metastatic disease and without evidence on conventional investigations of a primary pleural tumour. (Aust NZ J Med 1991; 21: 460–462)
Neural transplantation for Parkinson's disease: a critical appraisal
Authors: Rosenfeld J. V. , Kilpatrick T. J. , Bartlett P. F.
Published: March 2008

Abstract :The medical treatment of severe Parkinson's disease is presently problematical and neural transplantation has been proposed as an additional therapy. While functional improvement in animal models of Parkinson's disease has been reported following neural grafting, the treatment of human Parkinsonian patients by adrenal medulla autografting into the neostriatum has produced little clinical improvement overall, and is associated with significant morbidity. Although recent grafting of human foetal dopaminergic neurons has shown more promise, many of the case reports lack rigorous assessment and long term follow‐up. Further laboratory experimentation in animal models, particularly primates, to ascertain the mechanism of action of the grafts, the optimal sites for grafting, and the immunological responses to grafting, is essential. The future success of neural transplantation for Parkinson's disease may depend on the development of novel strategies such as the use of growth factors to aid cell survival, regulate neurotransmitter levels and promote connectivity. However, at present, the clinical application of neural transplantation for Parkinson's disease is premature. (Aust NZ J Med 1991; 21: 477–484.)
A prospective randomised trial of cyclosporin and methotrexate versus cyclosporin, methotrexate and prednisolone for prevention of graft‐versus‐host disease after HLA‐identical sibling marrow transplantation for haematological malignancy
Authors: Atkinson K. , Biggs J. , Concannon A. , Dodds A. , Young S. , Wilson F. , Ashby M. , Downs K.
Published: March 2008

Abstract A prospective randomised trial was performed in patients given HLA‐identical sibling bone marrow transplants for haematological malignancy comparing the combination of cyclosporin and methotrexate (CM) (n = 20) with the combination of cyclosporin, methotrexate and prednisolone (CMP) (n = 21) as prophylaxis for graft‐versus‐host disease (GVHD). There was no significant differences between the two arms for the incidence of acute GVHD grades I‐IV, acute GVHD grades II‐IV, chronic GVHD, interstitial pneumonitis, relapse, survival and disease‐free survival. The actuarial incidence of acute GVHD grades II‐IV in the CMP group was 10% and in the CM group 15% (ns). The incidence of leukaemic relapse in good risk patients was 42% in the CMP group and 40% in the CM group (ns), although the majority of these relapses were cytogenetic relapses only in patients with chronic myeloid leukaemia. The incidence of acute GVHD grades II‐IV in both arms of the current trial was significantly lower than in our previous trial comparing cyclosporin and methotrexate as single agents. Leukaemic relapse is now the principal cause of treatment failure in this patient population. We conclude that prednisolone should not be included as part of the prophylactic GVHD regime and that further improvement in therapeutic outcome is dependent upon better control of the underlying malignancy. (Aust NZ J Med 1991; 21: 850–856.)
Allergic bronchopulmonary fungal disease caused by Bipolaris and Curvularia
Authors: Lake F. R. , Froudist J. H. , McAleer R. , Gillon R. L. , Tribe A. E. , Thompson P. J.
Published: March 2008

Abstract Allergic bronchopulmonary fungal disease (ABPFD) usually manifests in asthmatics as allergic bronchopulmonary aspergillosis. In a few instances other fungi have been implicated. Serological testing in Western Australia between 1979 and 1986 revealed precipitins to Bipolaris and Curvularia species in 40 of 503 patients tested. Eight of these were patients with ABPFD due to Bipolaris and/or Curvularia and are reported here.

Geographical location appeared to be significant as seven of eight of those with ABPFD (and at least 18 of 40 with positive serology) were living in the more remote and sub‐tropical northern part of the state.

ABPFD due to fungi other than Aspergillus species may be more common than previously recognised and further epidemiological assessment is warranted. (Aust NZ J Med 1991; 21: 871–874.)
Pulmonary actinomycosis complicated by effusive constrictive pericarditis
Authors: O'Sullivan R. A. , Armstrong J. G. , Rivers J. T. , Mitchell C. A.
Published: March 2008

Abstract A case of pulmonary actinomycosis presenting with a right calf abscess and complicated by effusive constrictive pericarditis is discussed. Clinical improvement occurred with antibiotic therapy and pericardiectomy. There was no evidence of recurrence after 18 months. (Aust NZ J Med 1991; 21: 879–880.)
Hepatic metastasis from a meningeal haemangiopericytoma
Authors: Chakravarty B. J. , Munn S. , Lane M. R.
Published: March 2008

Abstract Intracranial tumours rarely metastasise outside the central nervous system (CNS). Meningeal haemangiopericytoma is an exception. We report the case of a 41‐year‐old female who initially presented in 1984 with what was thought to be a posterior fossa meningioma which was excised, as were two subsequent recurrences in 1987 and 1988. In October 1990 she represented, having discovered a mass in her abdomen. This proved to be a metastatic haemangiopericytoma in the liver which had similar histology to the original intracranial tumour. This metastasis; and another found at operation, have been excised, and at the time of this report, she is alive and well seven months after surgery without any evidence of other metastasis or recurrence. Haemangiopericytomas are unusual in their propensity to metastasise outside the CNS and successful resection of hepatic metastases from this tumour has not been reported before. (Aust NZ J Med 1991; 21: 884–885.)
Inability to detect circulating anti‐idiotypic antibodies in human anti‐GBM antibody‐mediated disease using a splenic PFC assay
Authors: Savige J. A. , Lockwood C. M.
Published: March 2008

Anti‐idiotypic antibodies are antibodies that are directed against the variable region of the corresponding antibody molecule and have been postulated to have a regulatory role in the immune response. Circulating anti‐idiotypic antibodies have been reported in several antibody‐mediated autoimmune diseases.

We have established the following detection system for anti‐idiotypic antibodies in human anti‐glomerular basement membrane (GBM) disease. Spleen cells harvested from BALB/c mice immunised with human GBM were incubated with GBM‐coated sheep red blood cells in the presence of guinea pig complement. Each spleen cell that produced anti‐GBM antibodies resulted in a surrounding plaque where antibodies lysed the GBM‐coated RBC. The number of plaques could be inhibited by the addition of heterologous anti‐idiotypic antibodies to the plaquing mixture. Anti‐idiotypic antibodies were then sought in both acute and convalescent phase sera from patients with anti‐GBM disease and in laboratory staff who repeatedly handled GBM and sera containing anti‐GBM antibodies. Anti‐GBM antibodies were removed from all material before testing and affinity‐purified preparations contained concentrations of IgG corresponding to the range that resulted in inhibition when affinity‐purified rabbit anti‐idiotypic antibody was examined.

No anti‐idiotypic antibodies could be demonstrated in any of the sera or IgG preparations examined. We conclude that if circulating anti‐idiotypic antibodies are present in patients with anti‐GBM disease, they must be infrequent, or at concentrations below the limits of detection of this assay (< 1 mcg/mL). The observations of anti‐idiotypic antibodies in other antibody‐mediated diseases need to be confirmed.
Sino‐atrial arrest due to temporal lobe epilepsy
Authors: Joske D. J. L. , Davis M. J. E.
Published: March 2008

A case of sino‐atrial arrest due to temporal lobe epilepsy is described and compared with previously documented such cases in the literature. The rarity of bradycardias and sinus arrest due to arrhythmogenic seizures is discussed, as is the role of prospective ambulatory electroencephalographic and electrocardiographic studies in evaluating this association.
Epidemiological characteristics of Legionella infection in South Australia: implications for disease control
Authors: Cameron S. , Roder D. , Walker C. , Feldheim J.
Published: March 2008

About one third of adults surveyed in South Australia have shown evidence of past silent infection with Legionella pneumophila serogroup 1. However, the annual notification rate for symptomatic disease is only about 0.5 per 100,000 residents in non‐epidemic years. The male to female ratio is 2.5 to one and approximately 50% of cases are at least 60 years of age. Cases have presented more in summer and in the metropolitan areas.

Twenty cases of Legionnaires' disease occurred during the summer of 1985‐86. A cooling tower was held to be the principal source with aerosols being dispersed up to three kilometres away during an atmospheric thermal inversion.

A subsequent outbreak of 22 L. longbeachae serogroup 1 infections had no marked geographic clustering. The outbreak commenced in spring and cases were distinguished as active gardeners. L. longbeachae was found in garden soil and it is hypothesised that this soil inhabitant can become aerosolised and inhaled during gardening.

The potential for primary prevention of Legionnaires' disease is discussed in relation to water‐handling equipment and the need for early precautionary treatment of all community‐acquired pneumonia as suspect Legionnaires' disease is emphasised.
High density lipoproteins, genetic polymorphism for apo A‐I and coronary artery disease
Authors: Simons L. A. , Balasubramaniam S. , Szanto A. , Simons J. , Friedlander Y. , Hickie J. B. , Shine J.
Published: March 2008

HDL cholesterol and apolipoprotein A‐I are associated with the development of coronary artery‐disease (CAD). The presence of a PstI site polymorphism adjacent to the gene encoding apo A‐I (known as P2) has also been shown to be associated with CAD but this relationship is controversial. A case control study was conducted in an Australian population to re‐examine whether the rare P2 allele is associated with CAD. Data were derived from 159 cases of angiographically confirmed CAD and 99 healthy controls. The proportion of CAD cases carrying the P2 allele did not differ significantly from controls (11% versus 9%). In a multiple logistic regression model controlling for the effects of age, country of birth, hypertension and hypotensive drugs, body mass index and lipid variables, the P2 allele failed to predict significantly the presence of CAD (odds ratio 1.83; 95% confidence interval 0.65–5.19).
Survival from pentamidine induced pancreatitis and diabetes mellitus
Authors: Wood G. , Wetzig N. , Hogan P. , Whitby M.
Published: March 2008

Serious and occasionally fatal reactions to pentamidine have been reported and with the increased use of the drug in immunocompromised patients they are likely to become more frequent. We report the development of acute pancreatitis and permanent diabetes mellitus in an AIDS patient treated with intravenous pentamidine for Pneumocystis pneumonia. The literature on pentamidine induced pancreatic damage is reviewed.
Giant cell arteritis associated with pericarditis and large vessel disease
Authors: Stanley D. , Henderson D. , Harris S.
Published: March 2008

Giant cell arteritis is well recognised to affect branches of the external carotid artery and to cause systemic symptoms, but may also involve branches of the aorta producing a clinical syndrome that may be difficult to diagnose. A patient is described who presented with limb ischaemia, pericarditis and systemic symptoms. Treatment with corticosteroids improved the systemic manifestations but not the ischaemia. The patient died of bowel infarction four months after treatment was commenced.
Digital echocardiography in myocardial infarction
Authors: Feigenbaum Harvey
Published: March 2008

Probably the most under‐utilised application of echocardiography is in patients with coronary artery disease (CAD). This under‐utilisation is striking since echocardiography can be very valuable in evaluating the natural history and therapy of CAD.

One reason why echocardiography is not being utilised to its fullest is because of the reliance on videotape to record and display echocardiograms. This medium is time consuming and inconvenient for clinicians to review studies, it is not ideal for detecting subtle wall motion abnormalities, and videotape is impractical for comparing serial studies. Recording and storing echocardiograms on a digital medium overcomes these difficulties. Digital cine loops of single cardiac cycles provide great versatility. Multiple views or studies can be displayed simultaneously, subtle changes in wall motion are more easily detected and different views, or serial studies, can be readily compared. Such images can be displayed on computers on the ward or in the coronary care unit (CCU) and be available 24 hours a day, seven days a week at the convenience of the clinician. One does not need to find a recording on a two hour videotape, which may be in the ultrasound instrument, and one can view the exam in 30 sec instead of 5 to 10 min.

Regional and global left ventricular function is one of the most important manifestations of CAD. With new therapeutic efforts at restoring myocardial function and limiting infant expansion, assessing LV function is more important than ever. Digital echocardiography is an extremely practical and convenient way for clinicians to obtain this information.
Echocardiography in the management of mitral valve prolapse
Authors: Feigenbaum Harvey
Published: March 2008

Echocardiography plays a major role in the management of patients with mitral valve prolapse (MVP). The technique has greatly enhanced our understanding of the pathophysiology, epidemiology and natural history. There are major and minor echocardiographic diagnostic criteria for prolapse. Major criteria involve the mitral leaflets and include late systolic posterior displacement on M‐mode, bulging into the left atrium on 2D long‐axis (LAX) view, and thickening and redundancy of the leaflets. Minor criteria include holosystolic posterior prolapse on M‐mode, bowing of the mitral leaflets into the left atrium (LA) in the apical 2D views, and late systolic mitral regurgitation on the Doppler echogram. Any of the major criteria should be sufficient to make the diagnosis. One or two minor criteria without a major sign would be questionable.

The degree of thickening and redundancy and the presence and quantitation of mitral regurgitation influence prognosis. Echocardiography is also helpful in identifying complications such as endocarditis and ruptured chordae.

An echocardiogram may not be necessary for the diagnosis, but it is helpful for prognosis and as a baseline for possible future changes. The frequency of follow‐up echocardiograms should be determined by clinical findings. When mitral regurgitation is present, then one should follow LA and left ventricular size and function. Transoesophageal echocardiography may be desirable for better definition of vegetations or flail leaflets and is frequently used to monitor surgical repair.
Aspects of active rheumatic carditis
Authors: Barlow John B.
Published: March 2008

Fulminating active rheumatic carditis has been observed for over 3 decades in this environment with no recent alteration in either the incidence or the pattern of presentation. Patients are black, seldom older than 20 years and are usually in their early teens but may occasionally be as young as five years. Heart failure is prevalent but occurs only when a haemodynamically important left‐sided valve lesion supervenes. Regurgitation is the predominant valve lesion and involves principally the mitral valve. Mitral annular dilatation is the initial pathology and predisposes to lengthening – or rupture – of chordae tendineae and prolapse of the anterior leaflet. The resultant cardiac work‐overload apparently perpetuates the rheumatic activity. Heart failure, whether caused by or associated with active rheumatic carditis, makes surgical management of the valve lesion mandatory as a life‐saving measure. Mitral valve repair, rather than replacement, is the surgical procedure of choice but is not always practicable when the rheumatic activity is fulminant, significant aortic regurgitation associated or the surgeon relatively inexperienced. Aggressive medical therapy for heart failure, which should include vasodilator drugs, provides temporary improvement only. Contrary to ongoing doctrine, treatment with steroid drugs is neither life‐saving nor beneficial. Varying degrees of left ventricular dysfunction are encountered pre‐operatively and may be a sequel of the severe regurgitant valve lesion rather than of a rheumatic ‘myocardial factor’.
Exercise, echocardiography
Authors: Feigenbaum Harvey
Published: March 2008

Exercise testing is an indispensable component of clinical cardiology. Latent disease or the full extent of a problem may not be apparent on a resting examination. Some form of stress is frequently necessary, especially in patients with coronary disease, to appreciate whether a patient has stress‐induced ischaemia as manifested by exercise‐induced chest discomfort, a drop in blood pressure or electrocardiographic changes of ischaemia. Unfortunately as with every test ECG and clinical monitoring have limitations. Patients may have ischaemia without pain, ECG changes may be non‐specific, a resting abnormal ECG has limited value, and the location and amount of ischaemic muscle is not directly assessed.

Monitoring the echocardiogram adds significant additional information to routine stress testing. By visualising the myocardium in the exercising individual, it is possible to assess a fundamental manifestation of ischaemia, regional wall motion abnormalities. This information kelps identify the vessels and the amount of muscle involved. In addition resting wall motion abnormalities may detect clinically silent infarction or hibernating myocardium. Direct visualisation of the exercising heart provides an improved understanding of a patient's cardiac status. The technique is particularly useful in evaluating revascularisation procedures.

Advances in instrumentation have reduced or eliminated many of the technical difficulties with obtaining and interpreting exercise echocardiograms. This examination has become an extremely useful adjunct to routine stress testing.
The automatic implantable defibrillator is the most realistic and cost‐effective way of preventing sudden cardiac death
Authors: Uther John F. B.
Published: March 2008

Judgement about cost‐effectiveness of medical treatments depends upon the criteria used to define effectiveness. The most rational single criterion is the Quality Adjusted Life Year gained (QALY).

Comparisons of cost‐effectiveness of treatments may be made by comparing the dollar costs per QALY. Both the dollar and the QALY comparisons are subject to all errors of biological variable measurement and bias introduced by experimental design seen in other biological experiments. The proper methodology for comparison is the prospective randomised controlled clinical trial. Such trials using the automatic implantable defibrillator (AICD) as prophylaxis against sudden cardiac death (SCD) have not yet been performed.

The major underlying cause of SCD is coronary artery disease with previous myocardial infarction (MI) and provocative tests for ventricular arrhythmias are the most powerful predictors of SCD in infarction survivors. AICD implantation carries a mortality of about 2%, and survival after successful implantation is about 89% at one, and 84% at two years. By comparison, infarction survivors with left ventricular ejection fraction <0.4 and inducible slow monomorphic ventricular tachycardia have a survival rate of 70% at one, and 54% at two years, Antiarrhythmic drugs have not proven effective. There is an urgent need to confirm the advantage of the AICD by proper randomised controlled trial
Asthma under‐recognition and under‐treatment in an Australian community
Authors: Bauman A. , Young L. , Peat J. K. , Hunt J. , Larkin P.
Published: March 2008

In a study in south‐western Sydney, we examined asthma symptoms in a random sample of 4239 schoolchildren aged five‐12 years. The prevalence of current wheeze and cough was 17.1% (95% CI 16.0–18.2%). Interviews were conducted with the parents of all 214 symptomatic children from two of the six schools. Only 60% of these children had ever been labelled as asthma, and only 20% were using appropriate asthma treatment. Fewer than 6% had ever had their airway function assessed. There was a socio‐economic difference, with better levels of asthma recognition and management in children attending the school in the more aflluent region. The findings suggest that asthma recognition, assessment and management in the Australian community, as in New Zealand and the UK, may need to be improved. (Aust NZ J Med 1992; 22: 36–40.)
Human fascioliasis successfully treated with triclabendazole
Authors: Laird P. P. , Boray J. C.
Published: March 2008

Fascioliasis, caused by the common liver fluke Fusciolu hepatica, is an endemic infection in sheep and cattle in many parts of Australia. Infections in humans in Australia have been reported infrequently and the most appropriate therapy for human fascioliasis remains to be determined. This case report describes a patient with the infection unsuccessfully treated with multiple high doses of praziquantel, mebendazole or albendazole. The infection was successfully eliminated by the administration of triclabendazole in two single doses of 900 mg (12 mg/kg) two days apart. No side effects were observed after the treatment. Based on our experience and that recently reported in the literature, triclabendazole may be regarded as the drug of choice for the treatment of human fascioliasis. (Aust NZ J Med 1992; 22: 45–47.)
A comparison of Abrams and Raja pleural biopsy needles
Authors: O'Connor S. , Yung T.
Published: March 2008

The diagnostic yield of the recently developed Raja pleural biopsy needle was compared to that of the Abrams needle. Paired biopsies were obtained in 12 cases. In two cases the Raja yielded a diagnosis of malignancy when the Abrams was negative, and in two other cases (one TB and one leukaemia) the Raja provided more specific diagnostic material. There were no cases where the Abrams provided information not present in a Raja biopsy. In our hands, the Raja pleural biopsy needle gave a diagnostic yield superior to the Abrams needle.
Polymerase chain reaction in detection of CMV DNA in renal allograft recipients
Authors: Lee W. T. , Antoszewska H. , Powell K. F. , Collins J. , Doak P. B. , Williams L. C. , Munn S. , Verran D. , Croxson M. C.
Published: March 2008

This study investigates the w of polymerase chain reaction (PCR) in comparison with viral culture and serology for monitoring of cytomegalovirus (CMV) infection in 21 consecutive renal allograft recipients mated with a quadruple immunosuppression protocol. In addition, an attempt is made to explore the significance of quantitation of CMV signals obtained from peripheral blood leucocytes.

CMV infection developed in 16 patients with seven of the patients having organ involve mat. All of these 16 patients bad a fourfold rise in antibody as well as positive identification of CMV DNA in peripheral blood leucocytes by PCR. Blood viral cultures were negative in two of these patients. All five patients who remained PCR negative also remained culture negative with no antibody change. PCR detected CMV infection on average 15 days and 20 days earlier than viral culture and serology respectively. All except one of the patients with CMV organ involvement had an initial peak of CMV DNA followed by prolonged carriage of detectable CMV. The majority of patients with fever only or asymptomatic CMV infection had a transient peak of CMV DNA.

A high incidence of CMV disease with organ involvement occurred in seronegative recipients of kidneys from seropositive donors (3/5) and in seropositive recipients Of kidneys from seronegative donors (3/7). OKT3 was associated with a higher incidence of CMV organ involvement compared to Antilymphocytic globulin (3/5 v 4/16) but there was a higher incidence of CMV mismatched patients in the OKT3 created group.

This study confirmed the high incidence of CMV infection in renal allograft recipients on an aggressive immunosuppression regimen. The detection of CMV DNA in peripheral blood leucocytes by PCR is a sensitive and specific marker of CMV infection. It enables an earlier diagnosis of CMV infection. The precise role for monitoring of CMV DNA levels is yet to be fully defined.