Seafield Hospital

S ummary . Red‐cell glutathione peroxidase (GSH‐Px) activity has been assayed in 62 normal subjects and in 163 patients with various diseases. In nine cases of iron deficiency anaemia, the mean GSH‐Px activity per cell or per volume of cells was low; during the first 2–4 weeks of treatment with iron, red‐cell GSH‐Px increased in parallel with haemoglobin. High enzyme activities, above the normal range, were found in 11 cases of megaloblastic anaemia due to deficiency of vitamin B 12 ; rapid and marked fall in GSH‐Px activity followed the start of vitamin B 12 therapy. Abnormally high values for red‐cell GSH‐Px were found in acute myeloblastic leukaemia and in myelofibrosis whereas the enzyme activity tended to be low in chronic lymphocytic and in chronic myeloid leukaemia. In two cases of chronic myeloid leukaemia, red‐cell GSH‐Px increased to normal during the early stage of remission produced by cytotoxic therapy. Normal red‐cell GSH‐Px was found in six cases of polycythaemia vera. In patients with carcinoma, there was a wide variation in red‐cell GSH‐Px but the mean value was significantly less than normal.

Excessive coagulation is a typical response to the vascular injury occurring in gram negative sepsis. This study evaluated the pharmacological effects of the use of a recombinant Escherichia coli derived form of tissue factor pathway inhibitor (ala-TFPI) in a baboon model of septic shock. Several doses of ala-TFPI were administered either 30 or 120 min after the initiation of a lethal intravenous infusion of E. coli into baboons. Treatment at 30 min with either 2.7 or 7.4 mg/kg of ala-TFPI resulted in the same survival rates and attenuation of both the coagulation response and cellular injury, as measured by clinical chemistry. When administration of ala-TFPI was delayed for 120 min, a dose of ala-TFPI protein continued to provide a benefit to survival. Ala-TFPI reduced the drop in mean systemic arterial pressure compared to control baboons in addition to partially attenuating the coagulopathic response. Baboons given ala-TFPI also maintained lower levels of plasma interleukin-6 (IL-6) and thrombin-antithrombin. These results suggest that the site of action of the protein may involve the later stage components of the coagulation and inflammatory pathways.

Identifying children's views of their experience of hospitalization is essential to the development of appropriate services. Previous research has mainly concentrated on specific paediatric populations or negative aspects of their experience. This study had two aims. First, to investigate a broader range of experiences in a general paediatric population, and second, to determine the most effective way of obtaining the information. School-aged children (n = 213) from the paediatric wards of two district general hospitals completed one of four questionnaire types. The themes identified were generally positive and mainly related to the children's physical surroundings. A verbal structured questionnaire was found to be the most efficient at obtaining the children's views, whereas a visual structured questionnaire was the only method which recognized the children's sequence of feelings before, during and after hospitalization.

The incidence of cardiac arrhythmias occurring during laparoscopy was studied in 100 consecutive patients who received carbon dioxide to inflate the abdomen and compared with that in 45 patients in whom nitrous oxide was substituted for carbon dioxide. Seventeen patients receiving carbon dioxide and two receiving nitrous oxide developed multiple arrhythmias, the commonest variety being fusion beats due to ventricular ectopic beats. Blood gas determinations showed that carbon dioxide caused a significantly higher level of Paco(2) and a lower pH than did nitrous oxide.

The intracellular trafficking, proteolysis, and dissociation of invariant chain (li) associated with nascent class II molecules was examined in B-lymphoblastoid cells. Metabolic labeling and Percoll gradient centrifugation was used to assess the kinetics of delivery and processing of class II-li complexes within the endocytic pathway. Catabolism of class II-li complexes rapidly followed their delivery from post-Golgi compartments to dense lysosome-like compartments distinct from early and late endosomes. Direct peptide binding assays revealed that class II molecules associated with even small N-terminal fragments of li failed to bind peptide. Cysteine protease inhibitors alone blocked li proteolysis/dissociation and accumulation of class II-li biosynthetic intermediates within lysosome-containing compartments. Active-site labeling of cysteine proteases in B cells was used to identify cysteine proteases capable of mediating li proteolysis within endosomal compartments. Our results indicate rapid, possibly direct, transport of nascent class II-li complexes from the Golgi/trans-Golgi network to dense lysosomal compartments wherein cysteine protease(s), likely including cathepsin B, mediate complete removal of li. Inhibition of cysteine protease activity results in the accumulation of incompletely processed class II-li complexes, which lack peptide binding ability, within lysosomal compartments.

Fatal dwelling-house fires account for 10% of all accidental deaths in the United Kingdom with one-quarter of the deaths being of elderly people. No study had described the characteristics of elderly individuals who die in fires. We report results from a retrospective review of all fatal dwelling-house fires in Scotland from 1980 to 1990. Of 1096 people dying in fires, 243 (23%) were aged over 75. When compared with patients under the age of 75, older patients were significantly less likely to be smokers. Significantly more fires killing elderly people were caused by faulty or misused electrical items in the house, particularly electric blankets. These differences between elderly and younger individuals dying in dwelling-house fires may suggest that preventive strategies for the elderly population require a different emphasis from those for younger people.

A case is described in which a Jehovah's Witness patient who refused blood transfusion suffered massive antepartum haemorrhage, her haemoglobin falling as low as 2.0 g.dl(-1). She was treated on an intensive care unit with intermittent positive pressure ventilation and general supportive measures, pulsed hyperbaric oxygen therapy and recombinant human erythropoietin.

An automated follow-up register for the detection of iatrogenic thyroid disease has been established as a joint venture between the general practitioners in the north-east of Scotland and the thyroid clinic of Aberdeen General Hospitals.The data-processing operations in the system are handled by an International Computers Limited 4/50 computer. Patients are followed up at predetermined intervals and the system has been designed to process, screen, and store clinical and biochemical follow-up data and report results to the patients, general practitioners, and the hospital records department.

Exercise maintained for approximately eight minutes results in a fall in F.E.V.1 a rise in airway resistance, and impaired gas distribution in asthmatic subjects. These effects are usually maximal within 15 minutes after cessation of exercise and recovery takes place over the next 30 minutes. Measurement of airway resistance before and after exercise in normal subjects suggests that the same mechanism is operating in them. Hyperventilation stimulated by the inhalation of carbon dioxide has failed to produce a similar effect. Chlorpromazine, atropine, mepyramine maleate, and hydrocortisone administered before exercise have failed to block the effect but adrenaline has succeeded. It has been possible in a few subjects to lessen the effect of exercise by repeated exercise on the same day and we interpret this as pointing towards the depletion of a bronchoconstrictor substance released in the earlier periods. The possible substances are discussed.

ABSTRACT Using a method dependent upon paper chromatography, the urinary excretion of the individual corticosteroids and the individual 17-oxosteroids has been studied before and after electro-convulsive therapy in five female patients suffering from a depressive illness. The corticosteroids, which are normally associated with stress, were found to show a fall in excretion from abnormally high levels before treatment to normal levels thereafter. The 11-deoxy-17-oxosteroids, on the other hand, showed a low level of excretion prior to treatment which was followed by a rise to normal values in clinical remission. These findings are discussed.

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A study of patients with recurrent thyrotoxicosis after subtotal thyroidectomy has shown that the operation has a profound effect on the natural history of Graves's disease. It is followed by pronounced changes in the immunological features of the disease, with a fall in the prevalence of serum thyroid autoantibodies, including the long-acting thyroid stimulator. Thyroid suppression returns to normal in 70% of patients. The treatment produces two populations of patients. In the larger group there is a permanent remission of the disease process. In the smaller group the disease process persists and, consequently, recurrent hyperthyroidism may develop. The mechanism of the change in the larger group of patients probably has an immunological basis.

A comparison has been made of the patterns of secretion of bicarbonate, trypsin, and bile pigment into the human duodenum in response to various dose rates of secretin alone and in combination with pancreozymin. Pancreozymin increased the output of bicarbonate to levels greater than achieved with secretin alone. High dose rates of secretin delayed and lowered the pancreozymin-induced pancreatic secretion of enzymes and discharge of bile pigment into the duodenum. The different patterns of response to changing absolute and proportional amounts of stimulant hormones must be taken into account when pancreatic exocrine secretory capacity is to be measured.

Serial nerve conduction velocities in the peroneal and ulnar nerves have been measured in 10 patients on regular dialysis treatment over a three year period. Each patient alternated between phases on dialysis with magnesium-containing dialysate (1·5-1·7 m-equiv/l.) and phases on `magnesium-free' dialysate (0·2 m-equiv/l.). Plasma magnesium concentrations were high both pre- and post-dialysis during magnesium-containing dialysis, and normal to low on magnesium-free dialysis. All patients had defects in nerve conduction, mainly asymptomatic. Increases in nerve conduction velocity coincided with magnesium-free dialysis, and decreases occurred when the patients reverted to magnesium-containing dialysate. The significance of the correlation by the sign test was P<0·0005. It is concluded that extracellular magnesium levels can influence the rate of nerve conduction in vivo.

By tradition treatment by breathing exercises is well established in chronic lung disease, particu-larly where emphysema and bronchospasm are present. Weiser (1950) noted that it had its supporters amongst the Chinese in 2500 B.C. and later in classical and mediaeval times. It is not lacking supporters to-day, although in recent years some scepticism has been expressed about its effects. Donald (1953) in his review of respiratory function says that, although he has no evidence, he believes breathing exercises have no effect on emphysema and bronchospasm. Herxheimer (1952) agrees that in asthma much of the benefit claimed can be attributed to the psychological effects and he urges the necessity for objective

MWICAL JOURNAL of cases the staphylococci were of the resistant type generally associated with hospitals.

Heinz bodies were produced in vitroin normal human red cells by incubation with ascorbic acid, menadione, sodium azide, primaquine diphosphate, acetyl phenylhydrazine, potassium chlorate, sodium nitrite and p-phenetidine. All compounds causing Heinz body formation also produced methaemoglobin, and most led to reduction in catalase activity; sodium nitrite and p-phenetidine caused no inhibition of catalase. Catalase inhibition was not found with any of the drugs studied which did not produce Heinz bodies. Catalase inhibition appeared to be partly responsible for Heinz body formation by ascorbic acid and menadione, but not for the effects of the other drugs studied. The results of this study support the view that glutathione peroxidase is the most important factor in protecting haemoglobin from the action of oxidant drugs

The patterns of gastric emptying of an acid load, or of saline during acid perfusion through the duodenum, have been investigated in healthy subjects and in patients with disease of the upper alimentary tract. The gastric emptying of patients with gastric ulcer was normal. Patients with duodenal ulcer showed either a reversal of the normal pattern with increase in the rate of gastric emptying during duodenal acidification or accentuation of the normal slowing of gastric emptying by acid in the duodenum, like patients with achlorhydria. The latter type of response may prove useful in predicting which patients with duodenal ulcer are likely to develop the clinical syndrome of ‘pyloric stenosis’.

Metaplastic foci do not appear to have been previously described in the mucosa of the appendix. Eight examples are reported, two of which were found in a series of 100 consecutive appendicectomies.

Patients with chronic renal failure who were on maintenance haemodialysis, were given monthly 600 mg iron intravenously as iron-dextran complex to a body replacement total of 5-6 g iron. Those patients who had been on maintenance haemodialysis for a long period and had received numerous blood transfusions failed to show a rise in haemoglobin levels. Those patients who received iron from the commencement of maintenance dialysis, and who had not received blood transfusions, showed a significant increase in haemoglobin concentrations which has been maintained for more than 18 months after iron therapy ceased, despite a concurrent decrease in serum iron concentrations. Pre-treatment and post-treatment levels of serum iron are not of predictive value for the success of iron treatment, neither for the haemoglobin nor the serum iron response. A body replacement dose of iron given intravenously over a year benefits the majority of patients on maintenance haemodialysis and is recommended for the treatment of their anaemia.