Stepping-down inhaled corticosteroid therapy in stable asthma: a secondary care perspective.
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Administration, Inhalation↗
Biomedical subjects
D A Promnitz
Publications and source records attributed to D A Promnitz.
Renal and neuromuscular respiratory failure--is this a syndrome associated with cantharidin poisoning?
OBJECTIVE: To describe the clinical and laboratory features of patients with renal and neuromuscular respiratory failure due to suspected cantharidin poisoning. DESIGN: Retrospective record review of cases with neuromuscular respiratory failure. SETTING: Intensive Care Unit (ICU), Hillbrow Hospital, Johannesburg. PATIENTS: Out of a total of 47 patients with neuromuscular respiratory failure admitted to the ICU between January 1983 and December 1990, 10 with suspected cantharidin poisoning were selected and studied further. OUTCOME MEASURES: Description of clinical features, laboratory data, treatment and prognosis. RESULTS: In 10 of the 47 patients, the cause of renal and neuromuscular respiratory failure that which precipitated the need for ICU admission was suspected to be cantharidin poisoning. This was based on the history and clinical and laboratory features. In 4 cases trace amounts of cantharidin were detected in blood and/or urine, strengthening the diagnosis. There were 8 males and 2 females. All had evidence of renal injury and 9 had gastro-intestinal symptoms. All presented with fixed dilated pupils, varying cranial nerve palsies and muscle weakness, usually ascending and progressive, necessitating admission to the ICU. All but 1 of the patients were mechanically ventilated, 5 required significant inotropic support of the blood pressure, and 6 dialysed. Four patients died soon after admission and the remainder survived with relatively complete return of neurological function. CONCLUSION: This study highlights the possibility that cantharidin poisoning may be a cause of a 'Guillain-Barrè-like' syndrome.
Adult↗
A study of acute community-acquired pneumonia, including details of cardiac changes.
We prospectively studied 102 patients, aged 15-50 years, with acute community-acquired lobar pneumonia without underlying cardiorespiratory illness, admitted to Baragwanath Hospital May 1990-April 1991. Demographic, clinical, microbiological and laboratory data and negative prognostic features of these patients are described. In particular, we documented electrocardiographic changes and studied their possible relevance in patients with pneumonia. Electrocardiographic changes occurred in 32 patients (31%). The commonest changes were clockwise rotation (16%), followed by P. pulmonale (9.8%) and S1 Q3 T3 pattern (7.8%) Other changes included right axis deviation (n = 6), right bundle branch block (n = 3), ventricular extrasystoles (n = 2), atrial fibrillation (n = 1) and nodal rhythm (n = 1). These changes returned to normal in survivors after a mean of 2 days. The S1 Q3 T3 pattern was associated with cardiac enzyme leak (CK-MB fraction), hypoxia and a high Simplified Acute Physiology Score (SAPS). In addition, P. pulmonale, right axis deviation and clockwise rotation correlated with hypoxia and a high SAPS score. Clockwise rotation also correlated with serum (including cardiac fraction) enzymes leak (LDH and CK-MB fraction), and pulmonary artery pressure. The overall mortality rate was 10.8%, with no association between electrocardiographic changes and mortality. The negative prognostic factors documented were hypoxia (p < 0.0001), multilobar pulmonary consolidation (p < 0.0001), tachycardia (p = 0.0001), tachypnoea (p = 0.0002), renal dysfunction function (p = 0.0009), hypotension (systolic p < 0.02, diastolic p < 0.003), bacteraemia (p = 0.003), and serum (including cardiac fraction) enzymes leak: LDH (p < 0.02), CK (p < 0.002) and CK-MB fraction (p = 0.0002). These factors, with the exception of renal dysfunction, also correlated with the need for intensive care unit admission. Acute and reversible electrocardiographic changes are common in acute community-acquired lobar pneumonia. Electrocardiographic changes, especially those compatible with acute cor pulmonale and accompanied by cardiac enzyme (CK-MB fraction) leak, correlated with severity of illness but not with mortality.
Adolescent↗
The clinical significance of Haemophilus influenzae and H. parainfluenzae isolated from the sputum of adult patients at an urban general hospital.
Fifty-seven patients, from whose sputum Haemophilus influenzae (49 cases) or Haemophilus parainfluenzae (8 cases) was isolated during a 7-month period, were studied. In the majority of cases there were well-defined predisposing factors to respiratory tract colonisation or infection with the isolates, in particular bronchiectasis and chronic obstructive airways disease. Colonisation of the airways, bronchopneumonia in patients with underlying lung disease, acute lobar pneumonia, and postoperative chest infections were the commonest clinical diagnoses. Primary acute lobar pneumonia with these organisms alone was uncommon. All of the H. influenzae isolates were nontypeable, and there was a wide range of biotypes of both organisms. Three H. influenzae isolates produced beta-lactamase, and there was, in general, a low incidence of resistance to a wide range of antimicrobial agents on disc susceptibility testing.
Adult↗
Does primary Streptococcus viridans pneumonia exist?
In 4 adult black patients admitted to an urban general hospital with community-acquired pneumonia, Streptococcus viridans alone was isolated from blood culture (first subculture), in the absence of any other positive microbiological finding. Sputum examination by Gram staining and culture in 3 cases was reported as negative. Echocardiography was performed in 3 cases and was normal, without evidence of endocarditis. The clinical course of illness in the 4 patients is described. The chest radiograph showed a segmental or subsegmental consolidation in all cases; this appeared 'mass-like' in 2 patients. Viridans streptococci may be a more important, if still uncommon, cause of community-acquired pneumonia than previously suspected. The organism should be considered as a possible cause of chest infection, particularly in patients with appropriately positive blood cultures and no other positive microbiological finding.
Adult↗
Sarcoidosis in Johannesburg--a comparative study of black and white patients.
Fifty-one black and 31 white patients with histologically proven sarcoidosis were managed in the respiratory units of the Johannesburg and Hillbrow Hospitals between January 1965 and October 1987. A number of differences in the demographic, clinical and laboratory features of the disease were documented in the two groups. While none of the black patients presented with erythema nodosum, direct skin involvement was significantly more common (P less than 0.05), occurring in 59% of these patients. The mean serum angiotensin-converting enzyme level was raised in both groups, but hypercalcaemia occurred infrequently in black patients. Almost 60% of the patients received corticosteroids, and the clinical and objective response to therapy was not significantly different in the two groups. Before referral the diagnosis was often labelled tuberculosis in the black patients who had frequently received antituberculosis chemotherapy. The tuberculin skin test is helpful, since it was negative in all but 2 black patients with sarcoidosis.
Adult↗
Septic shock in the Intensive Care Unit, Hillbrow Hospital, Johannesburg.
The records of all patients with septic shock admitted to an intensive care unit during a 15-month period were analysed retrospectively. The main purpose of the study was to describe the aetiology and clinical features of illness, and to determine the outcome of the patients, including those factors influencing prognosis. Thirty-five patients (46% medical, 54% surgical) fulfilling the criteria for the diagnosis of septic shock were admitted to the study. There were 21 male and 14 female patients. Most infections were community-acquired (69%). The two most common sources of infection were the respiratory tract and abdomen. All patients required inotropic blood pressure support. Most patients (94%) were mechanically ventilated and 7 required dialysis. Organisms, sometimes multiple, were isolated in 18 patients. Fifty percent of the isolates (12 of 24) were Gram-negative, 10 were Gram-positive and there were 2 associated Candida albicans bacteraemias. The overall mortality rate was 40%. There was no difference in outcome between community or hospital-acquired infections, infections with Gram-positive or Gram-negative organisms, or in patients with differing sources of sepsis. Features associated with a poorer prognosis were older age and higher bilirubin value.
Bacterial Infections↗
Methaemoglobinaemia due to accidental sodium nitrite poisoning. Report of 10 cases.
Nitrates and nitrites are widely used in the food and chemical industry. Poisoning with these agents may be potentially life-threatening as a result of the production of methaemoglobin. A group of 10 patients suffering from moderate to severe methaemoglobinaemia after accidental intoxication with a sodium nitrite salt is described. One patient died but the other 9 recovered rapidly. The low mortality rate was attributed to prompt diagnosis and institution of appropriate therapy with methylene blue and ascorbic acid.
Adult↗