bluuebunny/crossref_metadata_2025 huggingface dataset:
Medroxyprogesterone induced Cushing's syndrome
Authors: Learoyd Diana , McElduff Aidan
Published: March 2008

A 74‐year old female taking medroxyprogesterone acetate (MPA) presented with Cushing's syndrome together with low serum cortisol and plasma ACTH and an impaired response to synthetic ACTH (Synacthen, CIBA). When the medroxyprogesterone therapy was ceased the cushingoid features resolved and serum cortisol, ACTH and ACTH responsiveness all returned to normal. The MPA was acting as an exogenous glucocorticoid causing Cushing's syndrome.
Familial iron overload with possible autosomal dominant inheritance
Authors: Eason R. J. , Adams P. C. , Aston C. E. , Searle J.
Published: March 2008

A 96 member Melanesian kindred with 31 cases of iron overload is reported. Liver biopsies from 19 of these patients showed features similar to those of genetic haemochromatosis in Caucasians, but in contrast to the previous reported HLA‐linked autosomal recessive pattern of inheritance for haemochromatosis, this family shows a pattern that is most consistent with autosomal dominant inheritance. This is suggested by involvement of three and possibly four consecutive generations, with a high frequency of transmission from parents to children and equal gender distribution. Linkage and segregation analysis supported dominant inheritance, with no demonstrable HLA linkage.
Continuous arteriovenous haemodiafiltration: optimal therapy for acute renal failure in an intensive care setting?
Authors: Bellomo R. , Ernest D. , Love J. , Parkin G. , Boyce N.
Published: March 2008

We report the results of continuous arteriovenous haemodiafiltration (CAVHD) treatment in 12 critically ill intensive care patients with acute renal failure (eight males, four females ‐ mean age 60.9 years ‐ range 47 to 76) (APACHE II score 28.8, range 18–37). All patients were oligo‐anuric or had a rising creatinine ( 100 JμM/L per day). Vascular access was obtained by Scribner shunt or wide‐bore femoral arterial and venous cannulae. At the beginning of CAVHD therapy the mean plasma urea was 38 mM/L (SE 4.5, 95% confidence interval (CI) 25.1 to 75.6 mM/L) and the mean creatinine was 604 μM/L (SE 70, 95% CI 450–756 μM/L). After 72 hours of therapy, despite oligoanuria, urea concentration had fallen to a mean of 15.7 mM/L (SE 2.4, 95% CI 12.5–22.9 mM/L) and the creatinine concentration to 297 μM/L (SE 25, 95% CI 243–351 μM/L), respectively. The mean ultrafiltrate volume was 441 mL/hr (SE 33, 95%, range 50–1050 mL/hr). There were no complications related to the extracorporeal circuit, the filter, anticoagulant therapy, electrolyte status or changes in patients' haemodynamic state. Excellent biochemical control of azotaemia was uniformly achieved during CAVHD therapy. Five patients (41.6%) survived to be discharged from the Intensive Care Unit. CAVHD is a simple, safe and effective continuous renal replacement therapy. CAVHD offers technical advantages over alternative therapy while providing equivalent or better biochemical control of azotaemia and volume status in critically ill patients with acute renal failure.
Burning oral and mid‐facial pain in ventral pontine infarction
Authors: Reutens D. C.
Published: March 2008

The symptom of burning orofacial pain may help to identify the site of ischaemia in otherwise pure motor strokes resulting from infarction of the ventral pons. A patient with hemiplegia due to ventral pontine infarction, in whom burning oral and mid‐facial pain was a prominent initial symptom, is described. Similar pain preceded transient episodes of the ‘locked‐in’ state. Awareness of this herald symptom may permit early recognition and careful monitoring of patients at risk of progressing to the ‘locked‐in’ state.
Echocardiographic and electrocardiographic study of the normal kangaroo heart
Authors: Sugishita Y. , Iida K. , O'Rourke M. F. , Kelly R. , Avolio A. , Butcher D. , Reddacliff G.
Published: March 2008

Abstract Healthy kangaroos are prone to sudden death. To investigate possible causes of this phenomenon, echocardiographic and electrocardiographic studies were conducted in seven healthy sedated (intramuscular ketamine 20 mg/kg, xylazine 2 mg/kg) kangaroos aged 1.5–5 years weighing 5.5–48 kg. As in human hypertrophic cardiomyopathy, kangaroos showed relative left ventricular hypertrophy measured as a ratio of (internal left ventricular end‐diastolic diameter)/(septal + posterior wall thickness): 1.7 (SD 0.2) in kangaroos and 1.3 (SD 0.4) in hypertrophic cardiomyopathy cf 2.6 (SD 0.6) in normal man (p < 0.001 respectively). Peak left ventricular diastolic filling velocity was smaller in kangaroos (2.6 (SD 0.3)/sec) and hypertrophic cardiomyopathy (3.3 (SD 0.7)/sec) than in normal man (4.1 (SD 1.0)/sec) (p <0.01, p <0.05). The end of T wave occurred earlier than the closing of aortic valve. Corrected QT interval (0.20 (SD 0.02) sec) was shorter than the normal value for man (0.34–0.40 sec). In conclusion, kangaroos have cardiac hypertrophy of unknown aetiology, with impaired diastolic function, as in non‐obstructive hypertrophic cardiomyopathy patients. Corrected QT interval was short. These echocardiographic and electrocardiographic findings may explain the mechanism of sudden death in kangaroos, a species which may be used as an experimental model of non‐obstructive hypertrophic cardiomyopathy in man.
Disseminated prostatic carcinoma presenting with acute interstitial nephritis and microangiopathic haemolytic anaemia
Authors: McGregor A. R. , Moore M. L. , Bailey R. R. , Robson R. A. , Lynn K. L.
Published: March 2008

Abstract A 74‐year‐old man with metastatic prostatic carcinoma developed acute oliguric renal failure, a microangiopathic haemolytic anaemia and thrombocytopaenia. A renal biopsy showed an acute interstitial nephritis but no changes suggestive of the haemolytic uraemic syndrome. He recovered normal renal function after treatment with haemodialysis and prednisone 20 mg daily for five days. Previous assumptions about the renal lesion in patients with malignancy‐associated microangiopathic haemolytic anaemia may need review.
Effect of eicosapentaenoic acid on restenosis rate, clinical course and blood lipids in patients after percutaneous transluminal coronary angioplasty
Authors: Nye E. R. , Ablett M. B. , Robertson M. C. , Ilsley C. D. J. , Sutherland W. H. F.
Published: March 2008

Abstract In order to study the effects of eicosapentaenoic acid (Maxepa®), Maxepa® placebo and aspirin/dipyridamole combination on the clinical course and restenosis rate of atherosclerotic lesions after percutaneous transluminal coronary angioplasty 79 men and 29 women were randomly divided into three treatment groups and restudied angiographically within one year of the procedure.

Angina recurred less in the Maxepa® group than in the other groups, although not statistically so. Restenosis rate was significantly reduced in the Maxepa® group (11%) compared to the placebo group (30%) but, while less, was not significantly lower than in the aspirin/dipyridamole group (17%).

Maxepa® treatment appears to reduce restenosis rate of coronary artery lesions after percutaneous transluminal coronary angioplasty and may be an acceptable and equally effective alternative therapy to aspirin/dipyridamole.
Length of hospital stay after acute myocardial infarction
Authors: Heller R. F. , Dobson A. J. , Steele P. L. , Alexander H. M. , Al‐Roomi K. , Malcolm J. A. , Gibberd R. W.
Published: March 2008

Abstract A number of trials show that long stay in hospital after an acute myocardial infarction (AMI) is not necessary for many patients and that stays of three‐ten days may be adequate. All patients aged under 70 years with a diagnosis of AMI admitted to the seven public hospitals in the Lower Hunter Region of New South Wales are monitored as part of the WHO MONICA Study. Between August 1984 and December 1985 of 438 hospitalised patients with a ‘definite’ AMI according to MONICA criteria and a clinical discharge diagnosis of AMI, 386 (88%) patients were discharged alive from hospital. Four patients had lengths of stay between 46 and 77 days and have been omitted from further analysis. The mean length of hospital stay was 13.6 days (95% confidence intervals 12.9 to 14.3 days); 74% of all patients stayed in hospital for more than ten days. The mean length of stay in the Coronary Care Unit (CCU) was 4.5 days (95% confidence intervals 4.2 to 4.8 days) with 60% staying longer than three days. Mean hospital stay varied from 10.5 to 17.4 days among the seven hospitals, although most of this variation was accounted for by three hospitals with few patients. Restricting analysis to the four hospitals with 90% of all the patients, multiple regression analysis showed that the CK enzyme levels, the evolution of Q waves on ECG, the presence of an anterior AMI and the use of nitrates and digoxin during hospitalisation were all associated with increased length of stay in hospital. Nevertheless the proportion of the variance in length of stay explained by all the statistically significant variables together was only 17%.

We conclude that, at the time of this study, length of stay in hospital following AMI was longer than necessary. Patient characteristics and severity of infarction explain little of the variability. This suggests that length of hospital stay could be reduced without adverse effects for the patients.
Permanent junctional reciprocating tachycardia misdiagnosed as ‘cardiomyopathy’
Authors: McGuire M. A. , Knight P. , Lau Kai‐chiu , Uther J. B. , Ross D. L. , Davis L. M.
Published: March 2008

In a nine‐year‐old female, cardiac failure was erroneously attributed to idiopathic cardiomyopathy and cardiac transplantation was planned. The actual cause of cardiac failure was permanent junctional reciprocating tachycardia (PJRT), a rare form of supraventricular tachycardia. The diagnostic error was discovered before transplantation was performed and the arrhythmia was treated surgically. This resulted in return of near normal cardiac function. (Aust NZ J Med 1991; 21: 239–241.)
Acute pancreatitis and rhabdomyolysis: a new association
Authors: Nankivell B. J. , Gillies A. H. B.
Published: March 2008

Abstract Fourteen cases of acute severe pancreatitis complicated by non‐traumatic rhabdomyolysis are described and compared to case controls. Pancreatitis of various aetiologies was confirmed by surgical diagnosis, laparotomy, abdominal paracentesis, CAT scan and post mortem. Pancreatitis was severe with a high Ranson prognostic score (7.4 ± 0.5 vs controls 1.9 ± 0.4, p< 0.001), longer ICU admission and a mortality of 79%. Rhabdomyolysis occurred two to 19 days after the onset of pancreatitis (with a median CPK peak at 6.5 days) and was accompanied by multiple organ failure in 93% of cases. Severe rhabdomyolysis and myoglobinuric renal failure occurred in three patients out of 12 with acute renal failure. Hypocalcaemia was common (93%), severe (with a mean minimum value of 1.79 ± 0.07 vs 2.34 ± 0.04mmol/L, p<0.01) and prolonged (remaining abnormal for 5.2 ± 0.8 vs 0.07 ± 0.07 days, p < 0.001). Intravenous calcium supplements were required in 50% of patients. Plasma phosphate, potassium, urate and anion gap were elevated (all p<0.05) and accompanying clinical features included fever, ascites, leuco‐cytosis, hypoalbuminaemia and abnormal liver function tests.

Rhabdomyolysis is associated with acute severe pancreatitis, appearing as a late phenomenon in the context of severe prolonged hypocalcaemia, multiple organ failure and a poor outcome. (Aust NZ J Med 1991; 21: 414–417.)
GM‐CSF after allogeneic bone marrow transplantation: accelerated recovery of neutrophils, monocytes and lymphocytes*
Authors: Atkinson K. , Bradstock K. , Biggs J. C. , Lowenthal R.M. , Downs K. , Dale B. , Juttner C. , Szer J.
Published: March 2008

Abstract Ten patients given HLA‐identical sibling marrow transplants for lymphoid malignancy received recombinant human granulocyte macrophage‐colony stimulating factor (GM‐CSF) from day 7 to day 13 inclusive post transplant. Patients were prepared for transplantation with busulphan 16 mg/kg and cyclophosphamide 120 mg/kg.

Immunosuppression to minimise the risk of graft‐versus‐host disease (GVHD) was cyclosporin/short methotrexate. Results were compared with a historical control group of patients (n = 16) given matched sibling transplants for acute leukaemia and receiving the same immune suppressive regime but not given GM‐CSF. Recovery of total white cells, neutrophils, monocytes and lymphocytes was more rapid in the GM‐CSF recipients (p< 0.02). There was a suggestion of a decrease in non‐viral infections in the first 30 days in the GM‐CSF recipients (p = 0.09). There was, however, no significant difference in the severity of oropharyngeal mucositis nor in the duration of the transplant hospitalisation. Surprisingly, the severity of acute GVHD was higher in the GM‐CSF recipients with six of eight evaluable patients having grade II‐IV acute GVHD (p = 0.003). Two GM‐CSF recipients developed a fluid retention/capillary leak syndrome. These findings indicate a need for caution in the use of GM‐CSF after allogeneic marrow transplantation.
Dubbo study of the elderly: sociological and cardiovascular risk factors at entry
Authors: Simons L. A. , Simons J. , McCallum J. , Powell I. , Friedlander Y. , Heller R.
Published: March 2008

Abstract A prospective study of elderly Australians commenced in 1988 in Dubbo, NSW. Its goals are to identify predictors of mortality, hospitalisation and placement in long‐term care, with special focus on risk factors for cardiovascular disease. The study population were non‐institutionalised subjects, comprising 1237 males and 1568 females 60 years and over. This report describes the baseline findings: demographic, educational and economic data; tobacco and alcohol usage, self‐medication and other habits; medical contacts and past diagnoses; prescribed medication and in study diagnoses; psychosocial variables, functional health and social support; blood lipid and lipoprotein data; blood pressure, spirometry and glucose data; heights and weights. Where comparison has been feasible, the findings in Dubbo closely resemble those obtained from the rest of Australia. The findings presented provide the basis for aetiological studies of future outcomes.
A single genetic locus for adult polycystic kidney disease in five Australian families of southern European origin
Authors: Savige J. A. , Gill M. C. , Kincaid‐Smith P.
Published: March 2008

Abstract The gene causing adult polycystic kidney disease (APKD) in most northern European families has been localised to the short arm of chromosome 16, close to the alpha globin gene (PKD1). A DNA probe 3' to the alpha globin locus (3'HVR) has been used to test such families but a second genetic locus (PKD2) was recently proposed when two families from Italy failed to show linkage to that locus. The presence of two or more loci could significantly reduce the value of linked probe analysis as a tool for the diagnosis of APKD and we have therefore examined five Mediterranean families using the 3'HVR probe. In these families we have not demonstrated any mutations at the second locus. The 3'HVR gene remains the most useful probe in making the diagnosis of APKD disease in an Australian Caucasian population, and the certainty with which the diagnosis is made may be enhanced by the additional use of other nearby probes when the defect involves the PKD1 locus.
Giant cell arteritis in two Chinese patients
Authors: Wing Y. K. , Kay R. L. C. , Lai F. M.
Published: March 2008

Abstract Giant cell arteritis is virtually unknown in Orientals. We report two cases of histologically proven giant cell arteritis in two elderly Chinese men, one of whom presented with typical symptoms and the other with occult features of the disease.
Spontaneous dissection of the left main coronary artery: case report and review of the literature
Authors: Alvarez J. , Deal C.W.
Published: March 2008

Abstract Primary coronary artery dissection is a rare cause of myocardial infarction. It should be suspected in young, healthy females. It is a condition which is treated by myocardial revascularisation. (Aust NZ J Med 1991; 21: 891–892.)
A comparison of standard Madopar and controlled release Madopar in Parkinson's disease
Authors: Graham J. S. , Henderson J. M. , Morris J. G. L. , Yiannikas C.
Published: March 2008

In a randomised, double‐blind cross‐over study, objective measures were used to compare the effect of a single oral dose of a standard preparation of levodopa‐benserazide (Madopar M) with a sustained‐release preparation (Madopar HBS) in 9 Parkinsonian patients with ‘end of dose deterioration’. The response of patients to an optimised regimen of each preparation was also assessed using a patient diary.

In all patients the onset of effect of Madopar HBS following a single dose was delayed compared with Madopar M. The duration of effect of a single dose of Madopar HBS was substantially (38‐120%) longer than Madopar M in five patients and the same or shorter in four patients. According to the patients diaries, six patients noted an increase in ‘on’ hours while on Madopar HBS. The duration and severity of dyskinesia was similar for the two preparations.

Madopar HBS is likely to be useful in some Parkinsonian patients with ‘end of dose deterioration’. As the effect of each dose is delayed it is probably best given in combination with standard Madopar.
Ventricular dysfunction following direct‐current shock atrioventricular junction ablation
Authors: Warren R. J. , Vohra J. K. , Chan W. , Lichtenstein M. , Mond H. G. , Hunt D.
Published: March 2008

Catheter‐induced His bundle ablation for refractory supraventricular arrhythmias is most commonly performed with direct‐current shock energy of 200‐300 joules. The high energy pulse delivered by direct‐current shock produces a lesion in the atrioventricular node by fulguration, with the residual energy being dissipated as a pressure wave.

The effect of direct‐current shock His bundle ablation on global and regional ventricular function was assessed in 14 consecutive patients by radionuclide ventriculography performed before and after ablation and again three months later. All studies were performed with ventricular pacing at 110 bpm.

Global left ventricular ejection fraction was found to be significantly reduced at the three month study (0.43 ± 0.03 vs 0.50 ± 0.03, pre ablation, p= 0.02). A significant reduction in wall‐motion score was also seen in six of the seven patients who had normal wall motion in pacing rhythm prior to ablation. Deterioration was mainly seen at the left and right ventricular apices.

The observed reduction in ventricular function that follows direct‐current shock His bundle ablation may result from myocardial damage from electro‐coagulation or from barotrauma and supports continued investigation into alternative, less traumatic energy sources for the procedure.
Diarrhoea—an unrecognised hazard of coeliac plexus block
Authors: Dean A. P. , Reed W. D.
Published: March 2008

Coeliac plexus block is a safe procedure with relatively few side‐effects. We report two cases of persistent severe diarrhoea following coeliac plexus block and explore the possible reasons for this previously unrecognised side‐effect. We postulate that somatostatin analogue may be useful as treatment for diarrhoea following neurolytic coeliac plexus block that is unresponsive to conventional anti‐diarrhoeal agents.
The musculo‐skeletal examination
Authors: Ahern M. J. , Soden M. , Schultz D. , Clark M.
Published: March 2008

One hundred and sixty‐six patients admitted to general medical wards of a teaching hospital were examined on the day of discharge to determine whether they had been assessed for musculoskeletal disorders during their admission.

Of these patients, 54.8% had musculo‐skeletal symptoms with 17.5% having a significant rheumatological disorder which had been ignored. A history of musculo‐skeletal symptoms was recorded in 40.4% of all patients and the examination in only 14.5%. This contrasted with the documentation of the cardiovascular (99.4%), respiratory (100%), gastrointestinal (97.6%) and central nervous (53%) systems' examination. Eighty per cent of symptomatic patients received either no treatment for their rheumatic disorder, or treatment that we regarded as suboptimal or inappropriate.

Musculo‐skeletal symptoms are common in patients admitted to medical wards, but are being inadequately assessed or at worst ignored. The omission of the musculo‐skeletal system examination, in contrast to the almost universal inclusion of other systems' examination, demands correction. Undergraduate and postgraduate training programmes require re‐evaluation. The implications of these findings are discussed.
T cell receptor and immunoglobulin gene rearrangement analysis as a laboratory aid in the diagnosis of human malignant lymphoproliferative diseases
Authors: Dietzsch E. , Hong J. , Leslie D. E. , Martin L. , Rolland J. , Benson E. , Toh B. Hock , McCluskey J.
Published: March 2008

The identification of clonal rearrangements of the immunoglobulin heavy chain and T cell receptor beta chain gene loci by Southern blot analysis has led to advances in the diagnosis and classification of lymphoproliferative disorders. This paper reviews our experience with this technique over a three and a half year period. Specimens from 99 patients with suspected haemato‐logical malignancy were tested for leucocyte immunophenotype and immunoglobulin or T cell receptor gene rearrangement. Genotyping provided evidence of clonality in malignancies from 28 patients and demonstrated malignant cell lineage in eight patients not formally deduced from immunophenotyping alone. Our findings suggest that this technique can be employed in conjunction with immunophenotyping to aid in the determination of malignant cell lineage derivation and identification of malignant cell clonality, as well as potentially estimating the extent of disease, detecting relapse, and monitoring disease progression.
Spontaneous haemarthrosis in amyloid arthropathy of the shoulder
Authors: Vecchio P. , Hazelton R. A.
Published: March 2008

A patient is reported who has had episodes of spontaneous haemarthroses of the shoulder. On aspiration of the acute haemarthrosis, amyloid was found after appropriate staining of the centrifuged sediment. This may be a predisposing factor for haemarthrosis in haemodialysed patients.
Chorioretinitis as a possible very early manifestation of subacute sclerosing panencephalitis
Authors: Zagami A. S. , Lethlean A. K.
Published: March 2008

Ocular changes occur in up to 50% of cases of subacute sclerosing panencephalitis (SSPE) usually at the same time as other neurological signs. Occasionally, visual symptoms precede other manifestations by a few weeks or months. Fundal changes (most commonly a macular chorioretinitis) are the most frequent ocular manifestation of SSPE. Inclusion bodies occur in the retina of patients with chorioretinitis and SSPE and it is believed that the lesions are due to actual viral invasion. We report a case of SSPE in which an atypical chorioretinitis preceded the onset of the typical clinical features of the disease by almost two years. Our case is unusual because of the long interval between the visual symptoms and the onset of other features of SSPE. We wish to emphasise the importance of thinking of SSPE in cases of chorioretinitis which are atypical or occur in young patients. Although treatment of SSPE thus far has been mostly disappointing, earlier diagnosis may offer the hope of better results.
Transoesophageal echocardiography in heart disease—old technologies, new tricks
Authors: Lee Lincoln C. L. , Black Ian W. , Hopkins Andrew , Walsh Warren F.
Published: March 2008

Cardiac ultrasound and upper gastrointestinal endoscopy are relatively old technologies. With the introduction of new ultrasound probes and by incorporating ultrasound technology into conventional endoscopes, ‘new tricks’ in cardiac imaging were discovered. Posterior structures of the heart are now able to be imaged clearly by the ultrasound probe from the oesophagus. Consequently, better resolution of cardiac anatomy allows more accurate diagnosis of cardiac pathologies which is not possible using conventional transthoracic (TT) approach.

Over a period of two years, 1200 cases of transoesophageal echocardiography (TOE) were undertaken in our institution. The major indications were diseases of the aorta (10%), source of cardioembolism (28%), assessment of native and prosthetic valve function (20%), suspected endocarditis and its complication (17%), pre and post percutaneous transluminal mitral valvotomy (PTMV [13%], congenital heart disease (2%) and others (10%).

The greatest impact with TOE is in the diagnosis of aortic dissection and transection, TOE is superior to conventional TT approach in detecting potential source of embolism, valvular vegetations and its complication, native and prosthetic valve dysfunction and LA thrombus prior to PTMV.

Observations by TOE such as spontaneous echo contrast (SEC) in the left atrium open new challenges for further research in its role in the pathogenesis of LA thrombus and its association with cardioembolic event. Other areas of interest include; reclassification of distal aortic dissection and the use of TOE in intra‐operative work.
Mitral valve billowing and prolapse—an overview
Authors: Barlow John B.
Published: March 2008

Three decades after it was demonstrated that nonejection systolic clicks and late systolic murmurs have a mitral valve origin and that a specific syndrome is associated with the primary degenerative mitral lesion, numerous questions remain unanswered. A principal cause of confusion is the use of the term ‘prolapse’, which essentially implies a pathological state, in many patients with minimal evidence of a mitral valve anomaly. It should be recognised that no specific feature, whether evaluated by high standard echocardiography or indeed by careful morphological and histological examination, can be defined which distinguishes a normal variant from a pathological valve. There is a grandation from the normal billowing doring ventricular systole of mitral leaflet bodies to marked billowing. With advanced billowing or floppy leaflets, failure of leaflet edge apposition supervenes (true prolapse). This is functionary abnormal and allows mitral regurgitation. Prolapse in turn may progress to a flail twfltT and hence gross regurgitation.

Relatively rare complications of this degenerative mitral valve anomaly include systemic emboli, infective endocarditis, arrhythmias and, arguably, autonomic nervous system abnormalities. An attempt is made to ctarify the management of some symptoms and other aspects of mitral prolapse ‐ including rheumatic anterior leaflet prolapse (without billowing) which remains prevalent in South Africa and Third World countries.
Prevention of sudden cardiac death: the ICD, or an electrical end‐point with preceding opportunities for intervention?
Authors: Tonkin Andrew M.
Published: March 2008

Sudden cardiac death (SCD) is usually due to monomorphic ventricular tachycardia and/or ventricular fibrillation. However, in the vast majority of patients these arrhythmias are associated with advanced structural disease. In our society, this is usually due to coronary artery disease (CAD).

The implantable cardioverter – defibrillator is the logical approach to management in survivors of SCD. Its rational use must be guided by electrophysiology study. However, a realistic and cost‐effective approach to the prevention of a first cardiac arrest must be multifaceted and take cognisance of other aspects including primary prevention. Limitation of the size of myocardial infarction (MI) is vital. Trials already suggests that effective thrombolysis may impinge long‐term on arrhythmic end‐points. Following infarction, ventricular arrhythmias and sudden death may also be decreased by aspirin, beta‐blockers, and possibly angiotensin converting enzyme inhibitors and amiodarone.

Many post‐infarction studies employ a combined end‐point of death and clinical arrhythmias. However, death is usually confined to those with an ejection fraction <35%. In them, treatment of associated heart failure is often a consideration and if the ejection fraction < 15–20%, depending on donor availability, transplantation may even be the preferred therapeutic option to the cardioverter‐defibrillator.
Reduced synthesis of tissue plasminogen activator by vascular endothelium during acute myocardial infarction
Authors: Norris R. M. , Ockelford P. A. , Cross D. B. , Rivers J. T. , Smith J. M. , Takayama M. , White H. D.
Published: March 2008

We management levels of tissue plasminogen activator (t‐PA) antigen in 100 patients within six hours of the onset of acute myocardial infarction, in 34 patients with chronic angina but no recent infarction, and in 36 normal subjects. We also assayed von Willebrand factor in the acute patients and in the normal subjects. Measurements were repeated in 40 acute patients at three weeks after myocardial infarction. Although resting levels of t‐PA antigen were not significantly different from normal during myocardial infarction, the capacity of the vascular endothelium to release t‐PA after five minutes of venous occlusion was impaired (P<0.01). The acute phase vessel wall release of von Willebrand factor was increased during acute iafarction (p<0.01). We conclude that impairment of t‐PA production is associated with acute coronary thrombosis although it is not possible to differentiate between a causative role or a secondary response due to exhaustion of the t‐PA producing mechanism.
Reoperation for recurrent coronary artery disease – a ten year experience
Authors: Horton D. A. , Hicks R. G.
Published: March 2008

The need for reoperation caused by recurrence of coronary artery disease is becoming increasingly common. Although reoperation is more difficult and time‐consuming, with careful surgical technique it can be carried out with the same mortality as that described by many units for primary coronary artery bypass grafting (1.2 – 2.0%). In the 172 patients described here, who had coronary artery reoperations between 1981 and 1990, there were two in‐hospital deaths (1.2%). There were three postoperative bleeds which required return to theatre. No patient suffered a postoperative neurological deficit or postoperative myocardial infarction. These reoperations comprised 6.9% of the 2497 coronary artery operations carried out in the same period. Follow‐up disclosed eight late deaths, from five‐62 months after operation; all survivors claim to be symptomatically improved. Consideration should be given to the potential problems of reoperation when carrying out primary myocardial revascularisation.
Clinical experience with surgery for paroxysmal supraventricular tachycardia: a report of 103 cases
Authors: Vohra J. , Sathe S. , Tatoulis J. , Fenelon T. , Chan W. , Hamer A. , Kertes P. , Graham D. , Riter A. , Hunt D.
Published: March 2008

One‐hundred‐and‐three patients underwent surgery for paroxysmal supraventricular tachycardia (PSVT). In eighty‐three patients (81%), PSVT was due to an accessory atrioventricular pathway (Group I) and in 20 (19%) to Atrioventricular Junctional (AV nodal) Reentrant Tachycardia (AVJRT:Group II). Initial surgery successfully divided 77 of 83 accessory pathways, including 58 of 60 left free wall pathways, 12 of 15 posteroseptal pathways, six of seven right free wall pathways and one anteroseptal pathway. Twenty patients had successful surgery for AVJRT. Surgery was performed with low morbidity and no early or late mortality in either group. One patient in each group required permanent pacemaker implantation. Immediate (within one week) postoperative electrophysiological study using epicardial wires was performed in 96% of patients and repeat electrophysiological study six months later was possible in 65/103 (63%) patients. Patients with surgery for accessory pathways were followed‐up for a mean 34 ± 23 months, while those with surgery for AVJRT for a mean of 13 ± seven months. No patient with successful surgery has had a clinical recurrence of PSVT. Thus the results indicate that surery is a safe and curative therapy for patients with PSVT. (Aust NZ J Med 1992; 22: 134–138.)
Taming demons: the reduction of harm resulting from use of illicit drugs
Authors: Wodak ALEX
Published: March 2008

Restricting availability is the major response to illicit drugs in most Western countries including Australia. Prohibition may reduce harm when the drug in question is in low demand, controls are difficult to subvert, and when similar drugs are less toxi; or unavailable. However, the health, social and economic costs of supply reduction are substantial and increasing for both injecting drug users and the general community. Population adjusted mortality of heroin users has doubled in Australia in the last decade. The possible impact of supply reduction policy on the spread of HIV infection among IDUs is an important but largely neglected consideration. The effectiveness of supply restriction policy in decreasing the availability of drugs or in reducing drug‐related harm is unlikely to be increased significantly by more vigorous implementation of supply reduction or adoption of new technology. Conversely, on the basis of existing data, greater availability of HIV prevention measures attractive to the target population (including especially drug treatment such as methadone maintenance) is likely to be effective and cost‐effective. The costs and benefits of innovative methods of providing currently illicit drugs to those who are determined to use them requires careful evaluation and comparison with existing policies. Policy on illicit drugs in most countries including Australia is still dominated by concern about drug use rather rhan focused on the need to reduce drug‐related problems which is the agreed aim of national drug policy. (Aust NZ 3 Med 1992; 22: 204–208.)
Brief and early intervention: experience from studies of harmful drinking
Authors: Saunders JOHN B. , Foulds KIM
Published: March 2008

Brief and early interventions represent an innovative strategy for the prevention of harm from alcohol and other drugs. The pioneering study of early intervention, undertaken by Kristenson et al. (1983) as part of a preventive medicine programme, demonstrated the efficacy of this approach for problem drinking. Subsequent studies have confirmed these findings. Brief and early interventions have been shown to be effective in a wide range of health care settings, including hospital wards and outpatient clinics, general practice, private health screening facilities and community‐based health screening programmes.

What is required now is the ascertainment of the most effective settings for brief and early interventions and the incentives needed for incorporation into routine practice. (Aust NZ J Med 1992; 22: 224–230.)
Autosomal dominant polycystic kidney disease (ADPKD)—mechanisms of cyst formation and renal failure*
Authors: Geberth E. Ritz S. , Zeier M. , Gebert S. , Waldherr R.
Published: March 2008

None of the hypotheses proposed so far to explain cyst formation in autosomal dominant polycystic kidney disease (ADPKD) is entirely satisfactory, e.g. the theory of tubular obstruction by intraluminal polyps or dilatation of nephron segments as a consequence of abnormal compliance of the basement membrane. Recent in vitro studies show that (i) synthesis of basement membrane material is abnormal and that (ii) the direction of transepithelial resorptive flux into a secretory mode is reversed as a consequence of faulty insertion of Na, K‐ATP'ase into the luminal membrane.

It remains unclear why cystic transformation of a few percent of nephrons should cause endstage renal failure. Our clinical and experimental studies do not provide evidence to support some hypotheses proposed in the past, i.e. that renal parenchyma is compressed by expanding cysts and that glomeruli are overperfused. Our histological studies show that progression to endstage renal failure is associated with (i) progressive arteriolar lesions (out of proportion to the vascular lesions seen in extrarenal vascular beds; and (ii) progressive interstitial fibrosis. It appears that fibroblasts in ADPKD are particularly sensitive to platelet derived growth factor (PDGF) which is secreted by epithelial cells of the cyst wall in a paracrine fashion.

In contrast to previous opinion, which was presumably skewed by ascertainment bias, it appears that not all, and perhaps not even a majority, of ADPKD patients progress to endstage renal failure. Factors related to progression are gender, family history and hypertension. Both abnormal sodium excretion and inappropriate renin secretion play a role in the genesis of hypertension. Elevated blood pressure, albeit within the normotensive range, is demonstrable even in prepubertal children. The involvement of renin in renal vasoconstriction of normotensive ADPKD patients suggests a particular role of ACE inhibitors in the management of these patients.
Visualisation of arterial structure in vivo with intravascular ultrasound
Authors: Jeremy R. , Huang Hui , Hasche E. , Waugh R. , Sinclair E. , Bailey B. , Brieger D.
Published: March 2008

Abstract Background: Contrast angiography provides a silhouette of the arterial lumen, but does not give information about arterial wall structure. Catheter‐tip ultrasound transducers can now provide a cross‐sectional image of the arterial wall. This study examined the pathological correlation of intravascular ultrasound images and the accuracy of ultrasound measurements of vascular geometry.

Methods: Intravascular ultrasound images were obtained with a mechanically rotated catheter‐tip transducer and recorded on videotape. Initial validation studies were performed in fresh, postmortem arterial specimens, which were filled with saline at physiological pressures. Ultrasound images at specific sites were compared with the pathological findings at that site and measurements of luminal diameter were compared with corresponding angiographic measurements. Subsequently, intravascular ultrasound was employed to examine the aorta, ilio‐femoral and coronary arteries in patients undergoing balloon angioplasty.

Results: The pathological correlations showed that intravascular ultrasound can detect early initial thickening and mild atherosclerotic lesions that do not result in luminal deformation. Ultrasound images provided definition of calcified, fibrotic and lipid‐filled lesions. Ultrasound measurements of luminal diameter correlated well with pathology measurements (r = 0.93), as did ultrasound measurements of plaque area (r = 0.89). The in vivo studies demonstrated that intravascular ultrasound can define atheroma lesions not evident on contrast angiography and permits detailed evaluation of the results of interventions such as balloon angioplasty.

Conclusions: Intravascular ultrasound provides a unique window upon arterial structure and pathology in humans. Ultrasound images allow accurate measurements of vascular geometry and define early atheromatous lesions that are not evident with angiography.
The effect of pregnancy on the epilepsies: a study of 37 pregnancies
Authors: Kilpatrick C. J. , Hopper J. L.
Published: March 2008

Abstract Background: Although studies have assessed the effect of pregnancy on epilepsy, usually the types of epilepsy are not differentiated and most have not included a control group, despite the natural history of epilepsy including fluctuations in seizure frequency.

Aims: To assess the effect of pregnancy on seizure frequency and compare this with changes in seizure frequency in non‐pregnant patients. In addition, the relationship between seizure frequency during pregnancy and epilepsy type, seizure frequency prior to pregnancy and duration of epilepsy will be assessed.

Methods: Seizure frequency was assessed retrospectively in 37 pregnancies from 24 women by comparing the seizure number for the nine‐month period prior to pregnancy with the number during the pregnancy. An increase in frequency was defined as a 50% or greater increase in the number of seizures. Twenty‐four non‐pregnant women, matched for age and epilepsy type, were included to assess fluctuations in control.

Results: In 41% of pregnant women, there was an increase in seizure frequency, in 51% no change and in 8% improvement. In the control group, 24% had an increase, 65% no change and 11% improvement. There was no correlation between seizure frequency during pregnancy and epilepsy type and seizure frequency prior to pregnancy, but those with longer duration of epilepsy were more likely to deteriorate (p < 0.05). Alterations in anticonvulsants to reduce the risk of teratogenicity was a common identifiable cause of deterioration in control.

Conclusions: Significant random fluctuations in epileptic control occur, but pregnancy may have a deleterious effect on epilepsy, particularly when appropriate therapy is withdrawn to reduce teratogenicity.
Percutaneous transhepatic measurement of the pressure gradient between the portal and hepatic veins
Authors: Gibson P. R. , Firkin A. G. , Hebbard G. S. , Bhathal P. S. , Gibson R. N.
Published: March 2008

Abstract Background: Knowledge of the portal pressure may be of value in the assessment of patients with chronic liver disease but its measurement is problematic.

Aims: To evaluate the ease and safety of percutaneous transhepatic measurement of the pressure gradient between the portal and hepatic veins and to determine directly the need for an internal zero.

Methods: Sixty‐one patients undergoing liver biopsy for suspected liver disease had pressures in branches of portal and hepatic veins measured using a flexible 22G (Chiba) needle.

Results: The procedure was successful in all patients, took less than ten minutes in most, and was associated with minimal discomfort. Post‐procedure morbidity was similar to that of liver biopsy. Portal pressure using an external zero (either puncture site or sternal angle) was inaccurate compared with pressures obtained using the generally accepted gold standard internal zero, hepatic venous pressure, and led to incorrect classification of the presence or absence of portal hypertension in at least 10% of patients. Variations in hepatic venous pressure were not predictable on clinical grounds. The only histopathological feature predictive of portal hypertension was cirrhosis, 20 of 25 patients with and four of 36 patients without cirrhosis having portal hypertension. Of routine biochemical and haematological tests, only plasma albumin and platelet count jointly (and negatively) predicted hepatic venous pressure gradient on multiple regression analysis (R2= 0.40).

Conclusions: The use of an internal zero is essential for accurate measurement of portal pressure and this can be achieved safely using the percutaneous, transhepatic route in patients with well compensated liver disease.
Aconitine poisoning following the ingestion of Chinese herbal medicines: a report of eight cases
Authors: Chan T. Y. K. , Tomlinson B. , Critchley J. A. J. H.
Published: March 2008

Background:
Traditional Chinese medicines often contain ‘chuanwu’ and ‘caowu’, the roots of certain Aconitum species which are thought to have an anti‐inflammatory effect in many conditions. Excessive amounts of these materials, which contain diterpene alkaloids particularly aconitine, can produce toxic effects and occasional fatalities.

Aims:
This study was conducted to document the adverse effects related to these herbal medicines which resulted in hospital admission and to determine the outcome in these patients.

Methods:
A retrospective survey was conducted of patients admitted to the Prince of Wales Hospital, Hong Kong with suspected adverse effects from Chinese herbal medicines containing chuanwu or caowu over a two year period from 1989 to 1991.

Results:
Eight patients were identified with features of mild to moderate intoxication including nausea and vomiting, paraesthesiae or numbness in the mouth and extremities, hypotension and ventricular extrasystoles. The management of aconitine poisoning is essentially supportive and in‐hospital observation with ECG monitoring should be continued for at least 24 hours because of the risk of cardiovascular collapse and ventricular arrhythmias. The medical profession and general public should be alerted to the potential toxicity of these herbs and their usage should be controlled by legislation in Hong Kong as it is in some other countries. (Aust NZ J Med 1993; 23: 268–271.)
Unrelated volunteer bone marrow transplantation: initial experience at St Vincent's Hospital, Sydney
Authors: Atkinson K. , Downs K. , Dodds A. J. , Marshall G. , Concannon A. J. , Wilson F. , Milliken S. , Staniforth D.
Published: March 2008

Background: Only 30% of patients with leukaemia have an HLA‐compatible family member able to act as a marrow donor. The recent development of volunteer bone marrow donor registries has supplied HLA‐matched donors for a number of such individuals.

Aims: To define the problem and outcome of the first cohort of patients given HLA‐matched unrelated volunteer bone marrow transplants at St Vincent's Hospital, Sydney.

Methods: Post transplant outcome of patients with advanced leukaemia given HLA‐identical unrelated donor marrow transplants was compared to that of patients transplanted concurrently from HLA‐identical sibling donors, in terms of survival, leukaemia‐free survival, incidence and severity of acute graft‐versus‐host disease (GVHD), duration of neutropenia, incidence of infection and duration of transplant hospitalisation.

Results: Sixteen patients with advanced leukaemia and without a histocompatible family member donor received unrelated donor bone marrow transplants. Actuarial survival at two years post transplant was 30%. Actuarial survival of 23 recipients of HLA‐identical sibling bone marrow transplants with advanced leukaemia transplanted during the same time period was 17% (not significant). Actuarial disease free survival at two years was 30% and 13% respectively. Three of five long term survivors of the unrelated transplants had chronic myeloid leukaemia in blastic transformation at the time of transplant; thus blastic transformation should not preclude consideration of unrelated marrow transplantation. Recipients of unrelated allografts had a higher incidence of acute GVHD which occurred earlier and with greater severity than in recipients of sibling allografts, a longer duration of post transplant neutropenia (24 days to reach 0.5 × 109/L versus 19.5, p= 0.07), a higher frequency of infection in the first 100 days post transplant (p= 0.0004) and a longer duration of transplant hospitalisation (p= 0.04). Transplant‐related complications were the commonest cause of death in the unrelated donor recipients, while leukaemic recurrence was the commonest single cause of death in the HLA‐identical sibling recipients. Improvements are needed in prophylaxis of infection and in prevention and treatment of acute GVHD in recipients of unrelated donor transplants. Nevertheless, this modality provides curative treatment for patients with otherwise incurable haematological malignancies and should no longer be considered experimental. (Aust NZ J Med 1993; 23: 450–457.)