bluuebunny/crossref_metadata_2025 huggingface dataset:
ORBITAL MYOSITIS: A STUDY OF SIX CASES
Authors: HANKEY G. J. , EDIS R. H. , SILBERT P. L. , NICOLL A. M.
Published: March 2008

Abstract Orbital myositis implies orbital inflammation confined to one or more of the extraocular muscles. Orbital computerised tomography (CT) demonstrates irregular extraocular muscle enlargement which extends anteriorly to involve the tendon (muscle insertion).

Six cases of presumed orbital myositis are reported, in each of whom the diagnosis was suspected clinically and confirmed by the orbital CT scan appearances. The mean age of the patients was 33 years (range 8–45 years). All presented with painful ophthalmoplegia and the majority manifested proptosis (five cases), conjunctival congestion (five cases) and periorbital and eyelid edema (two cases). Systemic corticosteroid therapy was used in two patients initially and also in another patient who relapsed, with rapid and dramatic responses. Extraocular muscle biopsy was performed in one case, disclosing features of non‐specific muscle inflammation and no evidence of vasculitis.

It is considered that orbital myositis is a discrete, identifiable subgroup within the spectrum of the nonspecific idiopathic orbital inflammatory syndromes; termed previously orbital ‘pseudotumours’. Although the clinical features are frequently suggestive, they are nonspecific, and non‐invasive investigations such as orbital ultra‐sonography and CT scanning are required for precise anatomical tissue localisation and diagnosis. The role of ocular muscle biopsy is probably limited to atypical cases, or those unresponsive to steroid therapy, particularly to exclude neoplasia.

Orbital myositis may be acute, subacute or recurrent. The acute form responds well to high doses of oral corticosteroids tapered gradually, but it may recur or become chronic. The subacute form of the disease responds less well.
FATAL HEPATIC NECROSIS ASSOCIATED WITH MULTIPLE ANTICONVULSANT THERAPY
Authors: SMITH D. W. , CULLITY G. J. , SILBERSTEIN E. P.
Published: March 2008

:We report six fatal cases of hepatic necrosis in children associated with multiple anticonvulsant therapy. There was insufficient evidence to incriminate any single drug or combination of drugs, but it is noteworthy that sodium valproate was involved in only one case. We consider that an idiosyncratic metabolic reaction to the anticonvulsants was most likely. In five of the six cases hepatic failure was immediately preceeded by a prolonged fit and we speculate that metabolic change from excessive neuronal activity may unmask the hepatofoxicity of anticonvulsants.
A PROSPECTIVE RANDOMISED TRIAL OF CYCLOSPORIN VERSUS METHOTREXATE AFTER HLA‐IDENTICAL SIBLING MARROW TRANSPLANTATION FOR PATIENTS WITH ACUTE LEUKEMIA IN FIRST REMISSION: ANALYSIS 2.5 YEARS AFTER LAST PATIENT ENTRY
Authors: ATKINSON K. , BIGGS J. C. , CONCANNON A. , DODDS A. , DOWNS K. , ASHBY M.
Published: March 2008

:The results of a prospective randomised trial comparing cyclosporin (CSP) with methotrexate (MTX) as immunosuppressive therapy after HLA‐identical sibling marrow transplantation for patients with acute leukemia in first remission were analysed 2.5 years after entry of the last patient into the trial. Patients given cyclosporin showed a faster rate of marrow engraftment, less oro‐pharyngeal mucositis, more azotemia and more diastolic hypertension than those receiving methotrexate. Actuarial four‐year survival was 69% for patients receiving MTX and 43% for those receiving cyclosporin (not significant). Actuarial four‐year survival in continuous complete remission from the time of transplant was 69% and 38% respectively (not significant, p = 0.09). While there was no difference in the incidence or severity of acute or chronic graft‐versus‐host disease, the actuarial rate of leukemic recurrence was 0% in the MTX and 36% in the CSP group (p = 0.02). This finding emphasises the importance of long‐term follow up for the full assessment of new therapeutic protocols of marrow transplantation in the treatment of hematological malignancy.
SURGERY FOR GASTRIC CANCER IN SINGAPORE, 1951–1980, WITH PARTICULAR REFERENCE TO RACIAL DIFFERENCES IN INCIDENCE
Authors: KANG J. Y.
Published: March 2008

The incidence of surgery for gastric cancer in Singapore increased during the period 1951 to 1980 (males from 3.5 to 8.7 per 100 000 per year: females from 0.5 to 4.2 per 100 000 per year). This increase occurred mainly during the first decade of the study and was confined to persons aged 55 and above. Chinese had the highest incidence, followed by Indians and then Malays. These racial differences remained unchanged over the period of study.
PANCYTOPENIA INDUCED BY LOW‐DOSE METHOTREXATE FOR RHEUMATOID ARTHRITIS
Authors: KEVAT S. G. , McCARTHY P. J. , HILL W. R. , AHERN M. J.
Published: March 2008

Four cases of pancytopenia related to low‐dose weekly pulse methotrexate therapy for rheumatoid arthritis are described. All patients were aged above 60 years and had renal impairment. In every case marrow recovery followed withdrawal of methotrexate. However, one patient developed pneumonitis and died. Cholangitis, respiratory infection and increase in methotrexate dose were precipitating factors. Pharmacokinetic data indicated prolonged tissue drug exposure in two cases studied; dose‐related toxicity was further supported by successful resumption of methotrexate in reduced dosage in two cases. It is possible that methotrexate dose should be modified during intercurrent illness in patients older than 60 years who have renal impairment.
LUNG INFECTION CAUSED BY RHODOCOCCUS
Authors: HART D. H. L. , ANDREW J. H. , PEEL M. M. , BURDON J. G. W.
Published: March 2008

We report a case of lung infection, clinically resembling tuberculosis, caused by Rhodococcus rubropertinctus. The patient had no apparent immunosuppression which is unusual for disease caused by the ‘rhodochrous’ complex. The infection responded successfully to oral antituberculous therapy, which included rifampicin, and to oral tetracycline.
MYOPATHIES ASSOCIATED WITH HYPOTHYROIDISM: A REVIEW BASED UPON 13 CASES
Authors: MASTAGLIA F. L. , OJEDA V. J. , SARNAT H. B. , KAKULAS B. A.
Published: March 2008

The clinical and myopathological features of 13 patients with a myopathy occurring in association with hypothyroidism are presented. Seven patients had hypothyroid myopathy, including two with the Hoffmann syndrome and one with the Kocher‐Debre‐Semelaigne syndrome. Five patients had an inflammatory myopathy and one had polymyalgia rheumatica. Serum CK activity was elevated up to 12‐fold in the patients with hypothyroid myopathy and returned to normal after treatment with thyroxine. Pathological changes in these cases included type 1 or type 2 fibre atrophy or hypertrophy, myofibre necrosis and regeneration in four cases and, in one case, prominent core‐like areas containing amorphous granulo‐filamentous material. The findings in this series of cases illustrate the clinical and histopathological heterogeneity of patients with hypothyroid myopathy and the need to consider other myopathies in hypothyroid patients who present with muscular symptoms.
TOPHACEOUS GOUT OF THE AXIAL SKELETON
Authors: ARNOLD M. H. , BROOKS P. M. , SAVVAS P. , RUFF S.
Published: March 2008

A 72‐year‐old female with a recent episode of podagra, without peripheral tophi, presented with nocturnal back pain and a destructive lesion of the right lamina of L4. A tophus was excised at laminectomy. Evidence of an axial skeletal tophus causing an irritative radiculopathy via mass effect is presented.
PROTEIN‐LOSING ENTEROPATHY IN SYSTEMIC LUPUS ERYTHEMATOSUS
Authors: EDMUNDS S. E. J. , GANJU V. , BEVERIDGE B. R. , FRENCH M. A. , QUINLAN M. F.
Published: March 2008

Two patients with systemic lupus erythematosus (SLE) presented with anasarca, pleural effusions and severe hypoalbuminema, Both were demonstrated to have protein‐losing enteropathy, a rare complication of SLE. Other causes of gastrointestinal protein loss were excluded. There were marked similarities in both cases including circulating ANF with speckled staining, anti‐(U1)RNP antibodies and low serum complement levels. Complete remission was achieved in both with prednisolone. Anti‐(U1)RNP may be a marker for a subset of SLE in which protein‐losing enteropathy is a major manifestation.
LONG‐TERM SURVIVAL IN SMALL CELL LUNG CARCINOMA
Authors: HITCHINS R. N. , PHILLIPS J. , WOODS R. L.
Published: March 2008

We assessed outcome in 208 patients with small cell lung carcinoma two to seven years after treatment with combination chemotherapy, with or without chest and cranial radiotherapy. Fourteen patients (6.7%) survived cancer free for 30 months or longer. Nine of these (64%) had limited disease at diagnosis and four others had extensive disease with only one metastatic site. Two patients remain alive and disease free more than five years after diagnosis but median survival is still only 3.2 years. One patient died from intercurrent causes at 5.4 years but was free from small cell lung carcinoma at autopsy. Six patients are alive and disease free at intervals greater than 30 months but less than five years from diagnosis. All surviving patients are fully active with lifestyles similar to that prior to diagnosis. Five patients died from small cell lung carcinoma which relapsed more than 30 months after diagnosis. A few patients with small cell lung carcinoma are cured but 30‐month survival is insufficient to show cure as late relapses do occur. Late toxicity from aggressive therapy does not appear to outweigh the benefits of long‐term survival and potential cure in small cell lung carcinoma.
THE SYDNEY AIDS PROJECT: DEVELOPMENT OF ACQUIRED IMMUNODEFICIENCY SYNDROME IN A GROUP OF HIV SEROPOSITIVE HOMOSEXUAL MEN
Authors: TINDALL B. , COOPER D. A. , DONOVAN B. , BARNES T. , PHILPOT C. R. , GOLD J. , PENNY R.
Published: March 2008

The Sydney AIDS Project is a prospective immunoepidemiological study of 996 homosexual/bisexual men enrolled between February 1984 and January 1985. By January 1987, 32 of 386 homosexual men who were seropositive at enrolment in the study had developed AIDS, yielding a crude progression rate of between 2.8% and 4.2% per annum. Of these subjects, 23 (72%) developed AIDS within 12 months of enrolment.

In univariate analysis, the only lifestyle differences between seropositive subjects who progressed to AIDS and those that did not progress were less frequent oral sex activity and more use of marijuana in the three months prior to enrolment. In multivariate analysis, seropositive subjects who progressed to AIDS were more likely to have a lower percentage of CD4+ cells, a higher percentage of CD8+ cells and to have used marijuana in the three months prior to enrolment than the seropositive subjects who did not progress. No HIV seropositive subject who was asymptomatic and had normal T‐cell subsets at enrolment had developed AIDS by January 1987. Persistent generalised lymphadenopathy was not associated with progression to AIDS.

Although there are a number of lifestyle factors that may be associated with HIV infection, this study did not implicate most of these in the progression of HIV seropositive subjects to end‐stage AIDS. We conclude that antecedent changes in T‐cell subsets are associated with progression to AIDS and we emphasise the prognostic value of enumeration of T‐cell subsets in HIV seropositive persons. (Aust NZ J Med 1988; 18: 8–15).
AMIODARONE‐INDUCED HYPERTHYROIDISM: ASSESSMENT OF THE PREDICTIVE VALUE OF BIOCHEMICAL TESTING AND RESPONSE TO COMBINED THERAPY USING PROPYLTHIOURACIL AND POTASSIUM PERCHLORATE*
Authors: NEWNHAM H. H , TOPLISS D. J. , GRAND B. A. LE , CHOSICH N. , HARPER R. W. , STOCKIGT J. R.
Published: March 2008

In order to assess the value of thyroid function testing during amiodarone therapy, we reviewed all available tests in 128 patients treated with this drug. Nine patients (7.0%) developed biochemical hyperthyroidism with elevation of both free thyroxine index (FT4I) and free triiodothyronine index (FT3I) and marked suppression of serum thyroid stimulating hormone (TSH) after 1–46 months of therapy; six of these nine patients had clear clinical evidence of thyroid overactivity. Where serial tests were available before development of hyperthyroidism, this complication developed suddenly, despite previously stable normal indices of thyroid function, and could not be predicted by currently‐available biochemical tests such as T4, T3, sensitive TSH, thyroglobulin or sex hormone binding globulin (SHBG) assays. Clinical features such as unexplained weight loss, proximal myopathy, exacerbation of arrhythmia, or heat intolerance appear to be the key to prompt diagnosis of this complication.

Hyperthyroxinemia without T3 excess was found in 32.8% of patients without progression to true hyperthyroidism. Serum TSH remained detectable by sensitive assay in 17 out of 18 patients with amiodarone‐induced euthyroid hyperthyroxinemia and was significantly higher than in patients with equivalent hyperthyroxinemia due to thyroxine therapy. Serial levels of SHBG were higher in patients with true hyperthyroidism than in those with euthyroid hyperthyroxinemia.

The effect of combined treatment with propylthiouracil (800 mg/day) and potassium perchlorate (800 mg/day) was evaluated in five of the six clinically hyperthyroid patients. Biochemical euthyroidism was achieved after 7–19 weeks, a response slower than previously reported, indicating that this drug combination does not result uniformly in prompt resolution of amiodarone‐induced hyperthyroidism. (Aust N2 J Med 1987; 18: 37–44.)
Rhodococcus Equi: An Emerging Opportunistic Pathogen?
Authors: Jones M. R. , Neale T. J. , Say P. J. , Horne J. G.
Published: March 2008

Human infection with Rhodococcus equi is apparently rare with most published reports describing the development of lung abscesses in immunocompromised hosts. Of only 18 cases of infection previously recorded, four have recently occurred in patients with the acquired immune deficiency syndrome (AIDS). In Australasia, R. equi has frequently been isolated from soil and infected farm animals yet no human infections have been reported thus far. Three cases of R. equi infection have occurred in New Zealand and, collectively, they cover a wider spectrum of disease than that previously recognised. The natural history of R. equi infections, their clinical features and treatment are described in the light of our recent experience. (Aust NZ J Med 1989; 19: 103–107.)
DECISION‐MAKING IN 100 PATIENTS REFERRED TO THE AUSTRALIAN NATIONAL LIVER TRANSPLANTATION UNIT
Authors: McCAUGHAN G. W. , DORNEY S. F. A. , GALLAGHER N. D. , PAINTER D. M. , VICKERY R. , KYD G. , RICKARD K. , BOOKALLIL M. , WAUGH R. , THOMPSON J. F. , STEPHEN M. S. , SHEIL A. G. R.
Published: March 2008

One hundred patients were referred to the Australian National Liver Transplantation Unit between January 1986 and August 1987. The commonest disorders for referral were chronic active hepatitis in adults (22 cases), fulminant hepatic failure (14), primary biliary cirrhosis (PBC) (12) and primary sclerosing cholangitis (PSC) (10). Of the 100 patients 31 were activated for transplantation while 35 were deferred and 34 were found to be unsuitable. The decision‐making in these patients is discussed according to disease category. Timing of transplantation in PBC and PSC seemed clearcut, with 50% of referred patients being activated. However, major difficulties in timing of transplantation were found, particularly in patients with chronic active hepatitis (CAH) and fulminant hepatic failure (FHF). Of 36 patients with CAH (22) or FHF (14) only five were put on the active waiting list and only two were transplanted. Overall, 25 of the 31 patients underwent orthotopic liver transplantation, with 16 alive two‐30 months later.
AN INTRACRANIAL ARTERIOVENOUS MALFORMATION AND PALATAL MYOCLONUS RELATED TO PSEUDOXANTHOMA ELASTICUM
Authors: CHALK J. B. , PATTERSON M. C. , PENDER M. P.
Published: March 2008

Pseudoxanthoma elasticum is a rare hereditary disorder of elastic tissue with central nervous system manifestations due to occlusive vascular disease and aneurysm formation. Here we report the first recorded case of an intracranial arteriovenous malformation (AVM) in a patient with pseudoxanthoma elasticum. The AVM, which was located in the pons, also had an unusual manifestation, namely palatal myoclonus.
PROSPECTIVE EVALUATION OF A FLEXIBLE PROTOCOL FOR STARTING TREATMENT WITH WARFARIN AND PREDICTING ITS MAINTENANCE DOSE
Authors: COSH D. G. , MORITZ C. K. , ASHMAN K. J. , DALLY R. J. , GALLUS A. S.
Published: March 2008

We have evaluated a flexible warfarin dose induction protocol by monitoring its performance in 100 elderly inpatients.

The protocol (designed by Fennerty et al., has two aims: (a) to move the prothrombin time (PT) ratio smoothly and quickly into its therapeutic range, and (b) to predict the steady‐state warfarin requirement from the PT ratio measured on the fourth treatment day.

It proved simple to use and reasonably successful, since after four days, 67/100 patients had achieved a therapeutic level of PT ratio, nine exceeded the therapeutic range, and 24 remained sub‐therapeutic, while none had bled due to excessive anticoagulation. Maintenance dose prediction was tested by comparing the predicted and observed maintenance doses in patients within the ‘therapeutic range’ of PT ratio after various median times of treatment. After ten days, the observed dose was within 1 mg of that predicted in 65/86 patients (76%). This proportion became 57/77 (74%) after 18 days, and 49/79 (62%) after 34 days.
TWO‐DIMENSIONAL DOPPLER ECHOCARDIOGRAPHIC FLOW IMAGING – EXPLORATION OF CLINICAL IMPACT AND PROBLEMS
Authors: McDONALD I. G. , GUTMAN J. M. , HAMILTON G.
Published: March 2008

Recent advances in electronic engineering have allowed Doppler echocardiography to be presented in the form of a real‐time two‐dimensional image. The resulting image of blood flow has been described as a ‘non‐invasive angiogram’, but the analogy with angiography should not be pushed too far since the technical determinants of these images are entirely different. Nevertheless, the colour flow map does allow rapid and direct exclusion, detection and quantitation of regurgitant and stenotic lesions, and semi‐quantitative assessment of valvular regurgitation and shunts. To achieve optimum results, it is necessary to standardise recording procedure, to take account of patient variables which influence the image appearance and quality and to be aware of the possibility of artefact. As for all investigations, results which are not coherent with other echocardiographic data, with other investigations and with the clinical assessment should be subjected to particular scrutiny with the possibility of false diagnosis in mind.
CORONARY RISK FACTOR OUTCOMES FOLLOWING CORONARY ARTERY BYPASS SURGERY
Authors: OLDENBURG B. , PIERCE J. , SICREE R. , ROSS D.
Published: March 2008

The coronary risk factor status of patients prior to and following coronary artery bypass surgery (CABG) has been poorly investigated. Two consecutive series of CABG patients were surveyed following CABG. One hundred and thirty patients were assessed immediately following CABG and 530 patients were assessed 12–30 months following CABG. For the long‐term post‐CABG group, over 80% of those who had ever smoked had ceased. Sixty‐four per cent of these males and 50% of females were classified as being overweight. Twenty‐five per cent of males and 34% of females reportedly had high serum cholesterol (i.e. 6.5 mmol/L). Comparing these CABG data with age‐adjusted National Heart Foundation Risk Factor Prevalence Survey data, there was a higher prevalence of ex‐smokers, overweight, hypertension, and elevated cholesterol. It was concluded that on most coronary risk factors, except for smoking, these CABG patients had a worse profile than the general Australian community. This problem warrants further research and the development of appropriate treatment programs.
MASSIVE BENIGN THYMOMA PRESENTING AS OCULAR MYASTHENIA
Authors: GOADSBY P. J. , ADAMS R. W. , LANCE J. W.
Published: March 2008

A case of ocular myasthenia was found to be associated with a massive benign thymoma and responded to its removal. This is an exception to the generalisation that larger tumours of the thymus gland are more likely to be malignant and that thymectomy is not the treatment of choice for ocular mysthenia.
THE ROLE OF BRONCHOALVEOLAR LAVAGE IN THE ASSESSMENT OF DIFFUSE LUNG DISEASES
Authors: GIBSON P. G. , ROBINSON B. W. S. , McLENNAN G. , BRYANT D. H. , BREIT S. N.
Published: March 2008

Bronchoalveolar lavage is a safe and simple technique for sampling the inflammatory cells of the lung. However, while its use in the evaluation of pulmonary pathogenic mechanisms is both well accepted and described, its clinical utility is more controversial. Marked variation in results may occur through variation in the lavage procedure. Standardisation of the lavage technique and laboratory processing of the specimen are essential for reliable results. This review examines the current clinical role of bronchoalveolar lavage in the assessment of patients with diffuse lung diseases, and immunocompromised patients with pulmonary infiltrates. In this latter category, for patients with Acquired Immunodeficiency Syndrome, lavage is of equal efficacy to lung biopsy and can establish the cause of pulmonary infiltrates in over 90% of cases. Bronchoalveolar lavage can detect abnormalities in patients with diffuse lung diseases prior to the development of irreversible fibrosis. Lavage features have been described for sarcoidosis, cryptogenic fibrosing alveolitis, extrinsic allergic alveolitis, connective tissue diseases, and asbestosis. In cryptogenic fibrosing alveolitis lavage data may be used to indicate a subsequent deterioration in the patient's condition, or predict a favourable response to therapy.
BLEEDING DUE TO AN ACQUIRED INHIBITOR OF PLATELET ASSOCIATED FACTOR V
Authors: GRIGG A. P. , DAUER R. , THURLOW P. J.
Published: March 2008

Factor V inhibitors are uncommon, bleeding manifestations variable and recommendations for management are unclear. We present a patient with non‐Hodgkins lymphoma who developed gastrointestinal bleeding and was found to have a Factor V inhibitor. The inhibitor was active against both plasma Factor V and platelet associated Factor V, and was associated with a five‐fold increase in platelet associated IgG. Fresh frozen plasma was ineffective in preventing bleeding. Resolution of bleeding was associated with a fall in the levels of the inhibitor and of platelet associated IgG. The patient had no further bleeding episodes nor evidence of progression of his lymphoma, but six months later died as a result of metastatic adenocarcinoma.
SIMVASTATIN (MK 733): AN EFFECTIVE TREATMENT FOR HYPERCHOLESTEROLEMIA
Authors: LINTOTT C. J. , SCOTT R. S. , NYE E. R. , ROBERTSON M. C. , SUTHERLAND W. H. F.
Published: March 2008

This study describes the efficacy of the drug simvastatin. It is likely to be the first HMG CoA reductase inhibitor in Australia and New Zealand available for the treatment of hyperlipidemia.

Twenty‐four patients, 12 men and 12 women with primary hypercholesterolemia were randomly allocated to treatment by cholestyramine (eight patients) or to simvastatin (16 patients) for a 12‐week period.

With simvastatin, total cholesterol levels decreased by 37.5% from a baseline mean of 10.33 mmol/L to 6.4 mmol/L after 12 weeks. Low density lipoprotein (LDL) cholesterol concentration decreased by 48.2% from 8.40 mmol/L to 4.39 mmol/L. These effects were better than observed for cholestyramine alone where cholesterol and LDL‐cholesterol reductions were 24.9% and 33.1% respectively.

Thirteen patients, however, did not achieve target LDL levels of 3.62 mmol/L, or below, and therefore were treated with a combination of cholestyramine and simvastatin, resulting in a decrease of total cholesterol and LDL‐cholesterol by 45.5% and 53.5% of baseline values studied over an eight‐week period.

No major clinical side‐effects were encountered. One patient appeared to have had a change in colour vision at the end of the study at 20 weeks, without loss of visual acuity.
LIVER TRANSPLANTATION: AN UPDATE FOR PHYSICIANS
Authors: POWELL L. W.
Published: March 2008

End‐stage irreversible liver disease, previously treated only by partially‐effective, symptomatic measures, can now be reversed by successful liver transplantation at reasonable cost and with comparatively little increase in resources. Three Australian liver transplant programs are now established with results comparable to those of more experienced overseas centres. New organ‐preservation techniques and reduced‐size orthotopic transplantation in children should significantly increase donor organ availability.

Orthotopic liver transplantation should be considered as a therapeutic option once a patient has been diagnosed as suffering from intractable, non‐malignant chronic liver disease.
RESEARCH IN CHOICE OF MEDICAL SPECIALITY: A REVIEW OF THE LITERATURE 1977–87
Authors: MOWBRAY R. M.
Published: March 2008

Studies of the factors which influence the selection of a specialty in medicine represent a major theme in research in medical education. The journal literature in this area is reviewed for the last ten years under the headings of:

Reasons for choice of specialty

Timing and consistency of choice

Expectations of financial success

Attitudes and choice of specialty

Predictive methods

Effect of the curriculum

Academic performance

Psychiatry as a career choice

General differences

Personality factors

It is concluded that there are a number of inadequacies in the investigations reported in this field. The research is not based on any theoretical model, focuses on only one or a few of the many possible factors and uses different study populations. Greater consistency and applicability of the findings could be achieved by a central organisation conducting appropriately designed multivariate studies using defined populations at a large number of centres.
A RANDOMISED TRIAL OF EMPIRICAL ANTIBIOTIC THERAPY IN FEBRILE NEUTROPENIC PATIENTS WITH HEMATOLOGICAL DISORDERS: CEFTAZIDIME VERSUS AZLOCILLIN PLUS AMIKACIN
Authors: GIBSON J. , DATE L. , JOSHUA D. E. , YOUNG G. A. R. , WILSON A. , BENN R. , BENSON W. , ILAND H. , VINCENT P. C. , KRONENBERG H.
Published: March 2008

One hundred and two patients with neutropenia (<1 × 109/L) secondary to primary hematological disorders or chemotherapy for hematological malignancies were prospectively randomised, upon the development of fever or other signs of infection, to receive empirical antibiotic treatment with either ceftazidime (± flucloxacillin) (n = 52) or azlocillin plus amikacin (± flucloxacillin) (A&A, n = 50). The two groups were equivalent with respect to clinical and laboratory parameters prior to antibiotic therapy and flucloxacillin was added to approximately 25% of the patients in each group on the clinical suspicion of Gram positive infection. When assessed at 96 hours, the complete response rates were 59.6% for the ceftazidime treated patients and 44% for A&A treated patients. Partial response rates were 17% and 20% respectively. This difference was not statistically significant. Eight patients died whilst on the trial, three of those initially randomised to ceftazidime and five initially randomised to A&A. Moderate to severe hypokalemia was encountered significantly less often in the ceftazidime treated group (p< 0.01), whilst other parameters of toxicity were equivalent. No primary or acquired resistance to ceftazidime was encountered. Separate analysis of those patients who did not receive flucloxacillin yielded identical results.

We conclude that ceftazidime (±flucloxacillin) is as efficacious as azlocillin plus amikacin (±flucloxacillin) in the empirical antibiotic management of such patients and is associated with a lower incidence of moderate to severe hypokalemia.
LONG TERM EFFICACY OF TRANSVENOUS CATHETER ABLATION OF THE ATRIOVENTRICULAR JUNCTION FOR REFRACTORY SUPRAVENTRICULAR TACHYCARDIA
Authors: MURDOCK C. J. , DAVIS M. J. E. , COPE G. D. , MEWS G. C.
Published: March 2008

Twenty‐four patients who underwent transvenous catheter ablation of the atrioventricular (A‐V) junction between November 1982 and February 1987 were followed from 18–72 months (mean 47.9) to assess the long term efficacy and safety of the procedure. All had severely symptomatic supraventricular tachyarrhythmias refractory to standard treatment. Atrioventricular conduction was abolished in 23 patients, 22 having permanent pacemakers implanted. Conduction has recovered, though it is modified, in one patient who is asymptomatic on digoxin. Four patients have died; one suddenly 20 months following the procedure, one of progressive heart and liver failure due to hemochromatosis, and two of a stroke. Four patients have had complications related to permanent pacing; one patient has required generator replacement and one patient ventricular lead replacement, one patient had asystole and one patient had a pacemaker‐related tachycardia. Two patients remain symptomatic but improved by the procedure. Seventeen patients are free of their original symptoms, 11 having no intervening morbid events.

These results demonstrate that patients with severely symptomatic supraventricular tachyarrhythmias may gain long term symptomatic relief from the procedure, but permanent pacing is a cause of significant morbidity and there is a small incidence of late sudden cardiac death.
ANGIOGRAPHICALLY DEMONSTRATED ARTERIAL SPASM IN A CASE OF BENIGN SEXUAL HEADACHE AND BENIGN EXERTIONAL HEADACHE
Authors: SILBERT P. L. , HANKEY G. J. , PRENTICE D. A. , APSIMON H. T.
Published: March 2008

Benign headaches related to sexual activity and exertion are being recognised with increasing frequency. We wish to report a case of benign sexual headache (Type 2) and benign exertional headache, occurring sequentially in the same patient. Multiple areas of cerebral arterial spasm were demonstrable on angiography. This observation would support the concept that benign sexual headache (Type 2) and benign exertional headache may have a similar pathophysiology.
TECHNOLOGICAL TRIUMPH—TRIVIAL PURSUIT
Authors: DUGGAN J. M.
Published: March 2008

It seems a necessary move, In an unnecessary action, Not for the good that it will do, But that nothing may be left undone, On the margin of the impossible. –T. S. Eliot The Family Reunion
PRIMARY CEREBRAL LYMPHOMA: PRESENTATION OF EIGHT CASES AND REVIEW OF THE LITERATURE
Authors: BOADLE D. J. , TATTERSALL M. H. N.
Published: March 2008

Eight cases of primary cerebral lymphoma (PCL) are presented, being the largest Australian series of this rare condition reported to date. The clinical, radiological, anatomical and histological features were found to be comparable with those of patients reported in other series between 1954 to 1986. The precise treatment of PCL remains undetermined due to its rarity and apparent heterogeneity. Whole brain irradiation forms the basis of therapy although the role of prophylactic spinal irradiation, surgery and chemotherapy have not been defined. Response to corticosteroids and chemotherapy has been documented. Reported cases associated with the acquired immune deficiency syndrome (AIDS) are discussed. With an anticipated increase in the numbers of cases of AIDS, the incidence of related PCL will also increase. Large, multicentric trials are required to further delineate optimal treatment.
HISTOPLASMOSIS IN THE ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS)
Authors: RAWLINSON W. D. , PACKHAM D. R. , GARDNER F. J. , MacLEOD C.
Published: March 2008

This case report describes a 50‐year‐old man from South America with AIDS who developed disseminated histoplasmosis with focal lymph node involvement. Treatment with ketoconazole was initially successful. Six weeks after cessation of ketoconazole he died of what was thought to be relapse of histoplasmosis.
HYPERCALCEMIA AND LIPOID PNEUMONIA
Authors: GREENAWAY T. M. , CATERSON I. D.
Published: March 2008

A 49‐year‐old man with an 11 year history of NIDDM presented hypercalcemic and with acute on chronic renal failure. His only symptoms were mild anorexia and nausea. Four years previously he had been diagnosed as haying lipoid pneumonia, with classical histological findings. On this admission, serum parathyroid hormone was suppressed and 1,25 dihydroxyvitamin D levels elevated. The cause of his hypercalcemia presumably was ectopic 1 hydroxylation of 25 hydroxyvitamin D in the chronic granulomata in his lungs. It should be emphasised that any chronic granulomatous disease, and not just sarcoidosis, may be a cause of hypercalcemia.
THE INFLUENCE OF AGE AND DIETARY FAT IN AN ANIMAL MODEL OF SUDDEN CARDIAC DEATH
Authors: McLENNAN P. L. , ABEYWARDENA M. Y. , CHARNOCK J. S.
Published: March 2008

The influence of dietary fat on myocardial vulnerability to arrhythmia was examined using coronary artery occlusion and reperfusion in the anesthetised rat as a whole animal model of ventricular fibrillation and sudden cardiac death. Animals were fed a reference (REF) diet alone or supplemented 12% by weight with tuna fish oil (TFO) (rich in n‐3 fatty acids), sunflower seed oil (SSO) (rich in n‐6 fatty acids) or sheep perirenal fat (SF) (rich in saturated fatty acids). Feeding periods of 6, 12, and 18 months and a total of 108 rats were used. The incidence of ventricular fibrillation in occlusion was reduced from 46% of REF animals to 6% and 21% in TFO and SSO groups respectively and increased to 68% in the SF‐fed rats. The incidence of ventricular tachycardia was also reduced by TFO and SSO. The incidence of fibrillation on reperfusion of acutely ischemic myocardium (15 minutes occlusion) was significantly reduced by TFO only (12%, REF = 50%, SSO = 30%, SF = 70%). Severity of arrhythmias increased with age as did the extent of dietary influence. Mortality from fibrillation which only occurred in rats aged 12 months or older (REF = 13%) was increased by SF (43%) mainly in reperfusion (38%) but did not occur in TFO or SSO. These results indicate the potential benefit of dietary modification to include a higher proportion of polyunsaturated fat especially fish oil in reducing risk of sudden cardiac death. It is suggested that, in addition to their effects on atherosclerosis or thrombosis, dietary fats can directly influence myocardial vulnerability to arrhythmic stimuli through incorporation into myocardial membranes. (Aust NZ J Med 1989; 19: 1–5.)
TO FOLLOW KNO WLEDGE. Edited by Josephine C. Wiseman.
Authors: Gandevia B.
Published: March 2008

TO FOLLOW KNO WLEDGE. Edited by Josephine C. Wiseman. Royal Australasian College of Physicians,
INFECTIOUS DIARRHEA IN CHILDREN UNDERGOING BONE‐MARROW TRANSPLANTATION
Authors: BLAKEY J. L. , BARNES G. L. , BISHOP R. F. , EKERT H.
Published: March 2008

Fecal flora of 12 children undergoing bone‐marrow transplantation was monitored prospectively using comprehensive microbiological techniques. Diarrhea developed at least once in ten of the 12 children (83%), and a total of 24 episodes were recorded. Recognised gut pathogens were isolated from 11/21 (52%) diarrheal episodes where fecal specimens were obtained. Enteric pathogens identified included viral pathogens in 19% (rotaviruses, ‘enteric’ adenoviruses), parasites in 19% (cryptosporidium, Giardia lamblia) and cytotoxic C. difficile (14%). Excretion of clostridial species (including cytotoxin negative C. difficile, C. innocuum) occurred in 90% of diarrheal episodes when no enteric pathogen was identified. These results suggest that infection is often responsible for diarrhea associated with bone‐marrow transplantation. Prophylaxis against enteric infection might reduce the morbidity and mortality associated with severe diarrhea in bone‐marrow transplanted children. (Aust NZ J Med 1989; 19: 31–36.)
HYPOKALEMIA WITH NEPHROCALCINOSIS: A VARIANT OF BARTTER'S SYNDROME
Authors: WANG C. W. , SIMPSON I. J.
Published: March 2008

A 28‐year‐old male presented with profound hypokalemia and was found to have a variant of Bartter's syndrome with nephrocalcinosis, hypercalciuria, normal distal fractional reabsorption of chloride and normal sodium delivery to the distal tubule. (Aust NZ J Med 1989; 19: 58–60).
Autologous bone marrow transplantation for acute myeloid leukaemia in remission: a preliminary report
Authors: Bradstock K. F. , Posen J. , Kabral A. , Hughes W. G. , Koutts J. , Robertson T. I. , Lee C. H. , Castaldi P. A.
Published: March 2008

Autologous bone marrow transplantation, using unpurged cryopreserved autologous marrow, was performed on ten adult patients with acute myeloid leukaemia in remission. Seven patients were in first chemotherapy‐induced remission of their disease, while three were in later remission. Patients ages ranged from 24 to 52 years, with a median of 38.5 years. Conditioning therapy consisted of oral busulphan 16 mg/kg over four days and intravenous cyclophosphamide 60 mg/kg on two days. Bone marrow cells were thawed and infused two days later. All patients showed signs of marrow engraftment, however this was delayed in comparison with patients receiving allogeneic transplants. All patients developed fever requiring antibiotic therapy and one patient died of overwhelming sepsis. Another patient died of hepatic veno‐occlusive disease two months after transplant. Serious, but non‐fatal, hepatic complications occurred in two other patients. One patient, transplanted in third remission, relapsed 16 months post‐autograft. No other relapses have been seen, with one second remission patient remaining leukaemia‐free at 24 months, and six first remission patients in continuing remission 11 to 23 (median 20) months post transplant. These encouraging results require confirmation in a randomised clinical trial comparing autologous marrow transplantation versus standard chemotherapy.
Bacterial colonisation of the respiratory tract in chronic bronchitis
Authors: Butt H. L. , Clancy R. L. , Cripps A. W. , Murree‐Allen K. , Saunders N. A. , Sutherland D. C. , Hensley M. J.
Published: March 2008

One hundred and nine subjects with chronic bronchitis were studied prior to winter and without clinical infection, to determine baseline patterns of bacterial colonisation. Qualitative analysis of cultures of oropharyngeal swabs showed little difference from age matched normal controls (17) except for growth of small numbers of Gram negative coliforms in the chronic bronchitic group. Quantitation of bacteria colonising the oropharynx showed small numbers (mean of 105 cfu/ml), with no particular bacteria dominating. Haemophilus influenzae was present in 7.3% of throat swabs from chronic bronchitic patients, but the organism was always less than 10% of the total count. Quantitation of bacteria in sputum showed significantly higher numbers (mean 107 cfu/ml). H. influenzae was detected in 25.7% of available specimens, and when present constituted > 90% of the total count.

Biotyping of H. influenzae isolates demonstrated a separate colonisation of the upper and lower respiratory tracts.
Complications and causes of death in B cell chronic lymphocytic leukaemia: a long term study of 105 patients
Authors: Robertson T. I.
Published: March 2008

The complications and causes of death of 105 patients with B cell chronic lymphocytic leukaemia followed for a median period of 5.5 years are described. Infection and secondary primary malignant tumours were the most common complications and also caused most deaths. S. pneumoniae, S. aureus, S. haemolyticus, E. coli and the zoster‐varicella virus accounted for most infections and the lungs, skin and urinary tract were the sites affected. Even trivial infections were potentially serious. Haemolytic anaemia and vascular complications were also common. Older patients tended to have a shorter survival than the mean for the group whereas younger patients fared better. The mean survival was 6.2 years. Analysis confirmed the prognostic value of Rai staging. Advancing disease increased the liability to major infection. Light bone marrow infiltration five years post diagnosis indicated a good prognosis and preservation of normal immunoglobulin levels seemed beneficial. Immunoglobulin deficiency is the factor that correlates best with the frequency, severity and pattern of infection. Early stage disease provides a distinct benefit and there may be advantages in prompt diagnosis, regular assessment by immunoglobulin levels and bone marrow pattern and treatment on the first evidence of advancing disease. Fresh symptoms should be investigated in their own right because of the likelihood of second tumours.
Cryptococcosis in a renal unit
Authors: Kong N. C. T. , Suleiman A. B. , Shaariah W. , Wong Y. H. , Morad Z.
Published: March 2008

Cryptococcosis is a known opportunistic infection in immunosuppressed hosts. We report our experience of all cases presenting to our Department between December 1975 and September 1988. Eight post‐renal transplant patients and three systemic lupus erythematosus (SLE) patients were affected. All were receiving treatment with steroids, in association with either azathioprine or cyclosporin. The diagnosis of cryptococcal meningitis was initially based on a positive cerebrospinal fluid (CSF) cryptococcal antigen, by latex agglutination test, and subsequently confirmed by cultures. Common clinical presentations, in descending order of frequency, included headaches, fever, mental confusion, epilepsy and papilloedema. Meningism was not a prominent feature. CT brain scans were obtained in eight patients and one showed a focal lesion and one showed cerebral atrophy. Four patients also had an abnormal chest X‐ray (CXR) and one had disseminated cryptococcosis. Amphotericin and 5‐fluorocytosine were the mainstay of therapy, although ketoconazole alone was subsequently used in three selected patients with cure. Four early deaths occurred in patients with delayed diagnosis and treatment, usually in association with other severe concurrent infections. We conclude that awareness of cryptococcosis is essential in immunocompromised hosts presenting with headaches with, or without, mental confusion or fever.
Cervical cord compression due to ossified posterior longitudinal ligament associated with diffuse idiopathic skeletal hyperostosis
Authors: Yusof Zurkumai B. , Pratap R. C.
Published: March 2008

We describe a case of cervical cord compression due to ossified posterior longitudinal ligament in association with diffuse idiopathic skeletal hyperostosis, in a young female. Characteristic CT findings are described.
Necrobacillosis‐primary anaerobic septicaemia due to Fusobacterium necrophorum
Authors: Golledge C. L. , Beaman M. H. , Weeramanthri T. , Riley T. V.
Published: March 2008

Necrobacillosis is a severe septicaemic illness caused by an anaerobic Gram‐negative bacillus, Fusobacterium necrophorum. It occurs predominantly in young people and is characterised by oropharyngeal infection and subsequent metastatic complications, frequently involving the lungs and/or large joints. We report four recent cases in previously healthy young men, describing the clinical features of the disease (including autopsy findings), and the problems associated with diagnosis and treatment.
Familial hypocalciuric hypercalcaemia and pancreatitis: no causal link proven
Authors: Stuckey B. G. A. , Gutteridge D. H. , Kent G. N. , Reed W. D.
Published: March 2008

A case of a patient with pancreatitis and familial hypocalciuric hypercalcaemia is presented and the literature linking FHH and pancreatitis is reviewed. The case for a causal link between the two conditions is not proven and seems unlikely. In view of this we strongly challenge the recommendation of total parathyroidectomy in such cases.
Physicians’ approaches to continuing education
Authors: Newble D. I. , Whelan G. , Hejka E. J.
Published: March 2008

A questionnaire survey was conducted of a random sample of 308 physicians to determine their actual and preferred approach to continuing education. Demographic data raised questions about the possible influence of the undergraduate institution attended, the future impact of the growing proportion of women physicians and the effect of increasing subspecialisation.

The average physician spends eight‐nine hours a week on educational activities and 2.5–4.0 hours a week teaching. Unstructured ad hoc reading and postgraduate activities predominate over methods based on specific, individual needs or on current patient problems. The educational desirability of this is questioned. Physicians are avid attenders at conferences with 10–15% being at a national or international meeting in any one survey week.

It appears physicians would prefer to use a wider range of educational activities including more refresher courses and innovative methods. By comparison, Canadian physicians showed similar, but more strongly evident, preferences.

These findings have important implications for the College. It appears physicians need to be better informed about potentially more effective learning methods and account ought to be taken of their preference for methods which are not currently widely available.
Splenomegaly—an insensitive sign of portal hypertension
Authors: Gibson P. R. , Gibson R. N. , Ditchfield M. R. , Donlan J. D.
Published: March 2008

The prevalence of splenomegaly associated with portal hypertension was examined in a consecutive population of III patients who had portal hypertension diagnosed using specific endoscopie, sonographic, and Doppler signs. Splenic size was measured objectively via its cranio‐caudal length on coronal section using ultrasound and by clinical examination. Sonographically, 52% of patients had a definitely large spleen and 35% a spleen less than one standard deviation from the normal mean, while a further 13% had equivocal splenomegaly. Only 52% of patients had splenomegaly on clinical assessment. Splenomegaly was less common in patients with alcoholic (41% definite, 15% equivocal) than in those with non‐alcoholic liver disease (66% definite, 17% equivocal, p= 0.02) and splenic length was significantly smaller in alcoholic patients (12.7±0.5cm) compared to patients with either non‐alcoholic liver disease (15.0±0.6cm, p= 0.003) or portal hypertension due to vascular occlusive diseases (16.5 ± 2.0 cm, p= 0.006). Splenomegaly, whether assessed sonographically or clinically, is an insensitive sign of portal hypertension and its absence cannot be used as a negative predictor of the presence of portal hypertension in patients with chronic liver disease.
Methylprednisolone in multiple sclerosis exacerbation: changes in CSF parameters
Authors: Anderson T. J. , Donaldson I. MacG , Shear J. M. , George P. M.
Published: March 2008

Twenty‐six patients with multiple sclerosis (MS) received a total of 45 courses of intravenous methylprednisolone daily for seven days, for acute neurological deterioration. Changes in CSF parameters and clinical status following methylprednisolone were determined and first and repeat courses were compared. There were significant reductions in CSF IgG, CSF albumin, serum IgG and serum albumin levels and CSF IgG synthesis rate in the first and repeat treatment groups. CSF IgG index fell significantly with initial methylprednisolone treatment but not with subsequent courses. Oligoclonal bands disappeared in three patients. Definite clinical improvement followed 30 methylprednisolone courses, possible improvement followed six and no change followed seven. Clinical response was not predicted by pre‐treatment CSF IgG synthesis status and did not correlate with its degree of reduction.
Management of fibrosing alveolitis with polymyositis dermatomyositis
Authors: Maccioni F. J. , Colebatch H. J. H.
Published: March 2008

A 38‐year‐old man with polymyositis‐dermatomyositis developed acute life‐threatening fibrosing alveolitis. We report a two year follow‐up of this patient, during which control of alveolitis was obtained using prednisolone, and was maintained with the addition of cyclophosphamide. Relapse of myositis responded to increased prednisolone. Serial measurements of vital capacity and transfer factor assisted management of alveolitis, but changes in vital capacity preceded changes in transfer factor, and were more convenient to perform during frequent outpatient review.