Images in clinical medicine. Paget's disease of bone.
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Aged↗
Biomedical subjects
D Howarth
Publications and source records attributed to D Howarth.
Impact on blood lead in children and adults following relocation from their source of exposure and contribution of skeletal tissue to blood lead.
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Adult↗
"Window on the heart" technique for diagnosis of recent myocardial infarction using Tc-99m pyrophosphate SPECT subtraction imaging.
Detection of acute myocardial infarction by SPECT with Tc-99m pyrophosphate is complicated by overlying bony structures, such as the ribs and sternum. The authors report a technique using volume rendered rotating SPECT images with digital subtraction of overlying ribs. The technique is described and illustrated by case reports in which the diagnostic accuracy was improved with its use. This technique has diagnostic use in difficult clinical cases, and where avid radiotracer uptake in the ribs or sternum obscures the underlying myocardium.
Female↗
SPECT in avulsion injury of the multifidus and rotator muscles of the lumbar region.
A 37-year-old man was investigated for a work-related back injury with plain radiography, CT scan, bone scintigraphy, and SPECT. SPECT was able to demonstrate multiple sites of increased isotope uptake not seen on plain radiographs, CT scan, or planar images. Consequently, the diagnosis of avulsion injury of the multifidus and rotator muscles of the lumbar region was made. SPECT appears to have a role in the specific diagnosis of work-related back injuries.
Adult↗
Influence of azathioprine on the ferrokinetics of patients with renal failure before and after treatment with erythropoietin.
In 16 patients (9 on azathioprine, 7 not) the ineffective iron turnover (IIT) was much higher in the azathioprine group (62.7 +/- 6.7 vs. 23.5 +/- 3.5 mumol/l blood/day, p < 0.0001, 2-tailed t test), though the red cell iron turnover (RCIT) was similar (42.8 +/- 2.9 vs. 41 +/- 4.8). Erythropoietin improved the anaemia in all patients and raised the RCIT (4 still on azathioprine to 72.2 +/- 9.8, p < 0.003; 7 non-azathioprine patients to 62.7 +/- 5.3, p < 0.01); the IIT remained higher in the azathioprine-treated (85.5 +/- 19.3 vs. 37.1 +/- 5.4; p < 0.013). In 2 patients who discontinued azathioprine, the IIT declined markedly to normal. In summary, azathioprine exacerbates the anaemia of renal failure by augmenting ineffective erythropoiesis, while erythropoietin benefits those on azathioprine as much as other renal patients by stimulating both effective and ineffective erythropoiesis.
Anemia↗
Slow-release verapamil poisoning. Use of polyethylene glycol whole-bowel lavage and high-dose calcium.
OBJECTIVE: To present three cases of slow-release verapamil poisoning that demonstrate the prolonged absorption of the drug and the role of polyethylene glycol and high-dose calcium in management. CLINICAL FEATURES: Three patients with slow-release verapamil poisoning are presented. An 18-year-old woman took 2.3 g and developed hypotension and bradyarrhythmias 18 hours after ingestion, despite gastric lavage and administration of charcoal at three hours. A 23-year-old woman took 4.8 g and presented two hours later clinically unaffected. A 44-year-old woman presented 24 hours after taking 15-20 g. She had a systolic blood pressure of 50 mmHg, no measurable diastolic blood pressure and bradyarrhythmias. INTERVENTION AND OUTCOME: Case 1 responded to administration of 30 g of calcium and fluids intravenously. Case 2 was given polyethylene glycol on admission which resulted in passage of a tablet bezoar and no toxicity. Polyethylene glycol was ineffective in Case 3. She responded initially to high doses of calcium and other treatments, but subsequently died of hypotension and cardiac conduction block 39 hours after the overdose. CONCLUSION: The severity of poisoning with slow-release verapamil warrants aggressive pre-emptive treatment. Polyethylene glycol should be used routinely irrespective of the clinical state. High doses of calcium may be required to treat conduction block and hypotension.
Adolescent↗
Effects of azathioprine on response of renal anaemia to subcutaneous recombinant human erythropoietin.
AIMS: To determine the effect of concomitant azathioprine treatment on the response of patients with renal failure to treatment with subcutaneous recombinant human erythropoietin (r-HuEPO). METHODS: Two groups of patients with renal failure not receiving haemodialysis were studied. One comprised seven patients receiving erythropoietin alone, the second consisted of nine patients who were also treated with azathioprine. The haematological changes were monitored, and the functional erythropoietic response was studied by two different ferrokinetic models. One analysed the initial, the other the extended plasma iron clearance. Studies were performed before r-HuEPO treatment on all 16 patients, and repeated on 11 of these when the target haemoglobin (10-11 g/dl) was achieved and stabilised. Total erythropoiesis was determined using both techniques. Analysis of the extended plasma iron clearance also permitted calculation of both effective and ineffective erythroid activity. RESULTS: The haematological response to r-HuEPO was the same for both patient groups. Measurement of total erythropoiesis by both ferrokinetic methods showed good correlation. For those receiving long term azathioprine, the percentage ineffective erythropoiesis was high compared with that of the other patients, and remained so for as long as they continued with azathioprine. For those uncomplicated by azathioprine treatment, r-HuEPO increased levels of both effective and ineffective erythropoiesis by the same degree. A substantial reduction in ineffective erythropoiesis was shown only by those patients who either discontinued or reduced their azathioprine once they started r-HuEPO treatment. CONCLUSIONS: Azathioprine increases ineffective erythropoiesis. In this study, the r-HuEPO dose was sufficient to overcome this effect and promoted effective erythropoiesis so that the anaemia lessened. Measurement of total erythropoiesis provided limited information on the functional changes involved, differentiation of effective from ineffective erythropoiesis being necessary to define the changes after azathioprine reduction or withdrawal.
Anemia↗
Monitoring of iron requirements in renal patients on erythropoietin.
We studied 38 patients (9 haemodialysis, 18 peritoneal dialysis, 11 advanced renal failure) over the first 12 weeks of erythropoietin therapy. In 14 iron-overloaded patients (ferritin > 500 micrograms/l the haemoglobin (+/- SEM) increased from 6.74 +/- 0.27 to 9.85 +/- 0.36 g/dl (P < 0.0001) entirely by mobilizing iron reserves (reduced from 1,220 +/- 73 to 739 +/- 111 mg, P < 0.0001). In the 24 non-overloaded patients (ferritin < 500 micrograms/l) the haemoglobin rose similarly from 7.04 +/- 0.18 to 10.70 +/- 0.36 g/dl (P < 0.0001), partly from iron reserves (depleted from 200 +/- 74 to -44 +/- 77 mg, P = 0.016) and partly from oral iron supplements (305 +/- 110 mg). In the overloaded patients the ferritin declined from 1057 micrograms/l (geometric mean, range 504-3699) to 317 micrograms/l (42-1505, P < 0.0001). In the non-overloaded patients it declined from 82 micrograms/l (8-461) to 45 micrograms/l (5-379, P = 0.016). The transferrin saturation (TS) in the overloaded patients appeared to decline from 38.3 +/- 7.2% to 24.0 +/- 3.7% but this was not statistically significant. In the non-overloaded the TS was unchanged (23.3 +/- 2.4 before and 28.1 +/- 3.6% after treatment). Considering all 38 patients together, the haemoglobin correlated negatively with the ferritin (r = 0.3731, P < 0.001) but not with the TS. The TS correlated with the serum ferritin initially (r = 0.75, P < 0.001) but not after the first 4 weeks.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Calcium ionophore A23187 stimulates production of a 144 kDa gelatinase.
To determine whether intracellular calcium could be involved in regulating gelatinase production, bovine synovial fibroblasts were incubated with the calcium ionophores A23187 or ionomycin. Addition of calcium ionophore stimulated production of a gelatinase with an apparent molecular weight of 144 kDa. To ensure that the calcium ionophore was elevating cytosolic free calcium levels, calcium levels were determined using Indo-1. Addition of 0.1 microM ionomycin raised [Ca2+]i up to 1053 +/- 163 nM (mean +/- SD). Our data shows that calcium ionophore A23187 stimulates production of a high molecular weight gelatinase. The appearance of p144 gelatinase correlates with an increase in intracellular calcium.
Animals↗
Influence of blood volume on the blood pressure of predialysis and peritoneal dialysis patients treated with erythropoietin.
Twenty-seven patients with renal failure (16 on CAPD and 11 predialysis) were treated with erythropoietin. At 12 weeks, the mean haemoglobin concentration (+/- SEM) in the CAPD patients had increased from 7.07 +/- 0.20 to 10.88 +/- 0.45 g/dl (two-tailed paired t test, P < 0.0001) and in the predialysis patients from 6.90 +/- 0.35 to 10.05 +/- 0.47 g/dl (P < 0.0001). Predialysis patients were taking more antihypertensive medication at baseline. No increase was required in either group after erythropoietin; there was no change in blood pressure in the CAPD patients, though in the predialysis patients the systolic blood pressure rose slightly from 132 to 146 mmHg (P = 0.029) and the mean blood pressure from 95 to 103 mmHg (P = 0.028). In 12 patients (6 on CAPD and 6 predialysis) the red cell volume, plasma volume, and total blood volume were measured before and after treatment. In the CAPD patients there was a marked expansion of the red cell volume from 912 +/- 127 to 1471 +/- 222 ml (P = 0.004) and a concomitant contraction of the plasma volume from 3932 +/- 250 to 3178 +/- 326 ml (P = 0.005), leaving the blood volume unchanged from 4843 +/- 352 to 4649 +/- 503 ml. Predialysis patients had a similar expansion of the red cell volume from 733 +/- 59 to 1304 +/- 161 ml (P = 0.017) but no contraction of the plasma volume (from 3417 +/- 354 to 3314 +/- 260 ml), so that the blood volume tended to expand from 4149 +/- 347 to 4618 +/- 414 ml (P = 0.053).(ABSTRACT TRUNCATED AT 250 WORDS)
Blood Pressure↗
High-frequency radio wave electrosection of full-thickness eyelid tissues.
The Ellman Surgitron, commonly used in dermatology practice, is an electrosurgical instrument with a high-frequency waveform that is modified by filtering and undamping the current so that an almost pure cut is possible, yet with a small amount of coagulation. This device was used in six patients undergoing full-thickness eyelid resection (unilateral in three and bilateral in three) for involutional entropion or ectropion. Nine lid margins were cut with scissors, and nine with the electrosurgical instrument. The latter was found to cause minimal tissue damage and to modify the superficial epithelial cell layer very slightly, without causing it to slough. The tissue was cut cleanly, with less bleeding than occurred with scissors incision.
Cautery↗
Experimental treatment of eyelashes with high-frequency radio wave electrosurgery.
Apart from mechanical epilation, which is a nuisance to both the patient and the ophthalmologist, standard techniques for removing unwanted eyelashes, such as electrosurgery (Hyfrecator) and cryosurgery, may cause eyelid tissue damage and other complications. Refinements in electrosurgical techniques have enabled production of a machine that can provide high-frequency radio waves with a modification of the waveform to produce a blended cut-coagulation effect (Ellman Surgitron). Treatment of hairs in fresh calf skin with the Ellman Surgitron resulted in destruction of the germinal cells of the hair follicle, with only a small amount of tissue change lateral to the track of the electrode; the Hyfrecator caused total sloughing of the epithelial cells, with marked superficial tissue changes due to heat spread. In six eyelids of six patients undergoing eyelid excision the Ellman Surgitron was effective in causing destruction of the germinal cells of the hair follicle, with very little lateral heat spread in the tissues or destruction of the skin epithelial cells. As well, there was no tissue damage anywhere near the conjunctival surface.
Animals↗
TEAMWORK in the South Seas.
The Pacific island nation of Kiribati has adopted the BDJ TEAMWORK initiative as a training programme for government dental assistants. TEAMWORK has proved to be adaptable to a hot climate.
Dental Assistants↗
Quality of life improvements in CAPD patients treated with subcutaneously administered erythropoietin for anemia.
Twenty-two continuous ambulatory peritoneal dialysis (CAPD) patients, mean age 48 years, at 3 U.K. renal units were assessed with the Nottingham Health Profile (NHP) before and after treatment with recombinant human erythropoietin (r-HuEPO). Mean (SD) hemoglobin (Hb) at baseline was 7.5 (1.0) gm/dL and 10.8 (1.5) gm/dL at retest. There were significant improvements in energy (p less than 0.0001), social life (p less than 0.005), relationships at home (p less than 0.05) and leisure pursuits (p less than 0.05). Twelve patients, mean age 51 years, who had already completed more than 9 months on r-HuEPO treatment were reassessed to determine the changes sustained. Mean (SD) Hb at second retest was 12.8 (1.3) gm/dL. Improvement in energy continued to be significant, and emotional wellbeing showed further improvement. Problems with household tasks, which had not shown significant improvement at Test B, were now considerably reduced (p = 0.016). The study showed far-reaching benefits similar to those reported in hemodialysis patients, in a population with a higher mean age and higher potential coexisting illness or disability than most reported hemodialysis studies.
Activities of Daily Living↗
The effect of hemoglobin concentration on peritoneal mass transfer and drain volumes in continuous ambulatory peritoneal dialysis.
OBJECTIVE: To determine whether a correlation exists between hemoglobin levels and peritoneal mass transfer or drain volumes in continuous ambulatory peritoneal dialysis (CAPD) patients. DESIGN: Prospective study of two groups of CAPD patients, identified on the basis of their stable hemoglobin levels. Group A--hemoglobin less than 8.5 g/dL; Group B--hemoglobin greater than 10.5 g/dL. Peritoneal mass transfer and drain volumes were measured for each patient, after which a subgroup of Group A was treated with rHuEPO (forming Group C) and measurements repeated once hemoglobin had risen by at least 2.0 g/dL. SETTING: Single renal unit of a university teaching hospital. PATIENTS: Twenty-seven patients established on CAPD, selected according to their stable hemoglobin level. Group A--14 patients; Group B--13 patients; Group C (subgroup of A)--8 patients. MAIN OUTCOME MEASURES: Difference between peritoneal mass transfer or drain volume in Group A versus Group B, and in Group C before and after rHuEPO therapy. Serum biochemical parameters in Group C before and after rHuEPO therapy. RESULTS: No statistically significant differences in any of the parameters measured were found between groups A and B, or before and after rHuEPO therapy in Group C. CONCLUSIONS: Peritoneal transfer of small solutes and water is not influenced by hemoglobin level, and does not change following otherwise effective treatment with rHuEPO.
Adult↗
'Why free sugars consumption should be below 15 kg per person per year in industrialised countries: the dental evidence'.
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Adult↗
Antithrombin III Northwick Park: demonstration of an inactive high MW complex with increased affinity for heparin.
It has been shown previously that antithrombin III Northwick Park has reduced ability to inactivate thrombin and is characterized by an additional anodal component on crossed immunoelectrophoresis (Howarth et al, 1985). We have applied plasma from an affected family member to heparin-Sepharose and eluted the antithrombin III with a salt gradient. Evidence is presented that a variant component has slightly higher affinity for heparin than normal antithrombin III. Furthermore, this variant component is present in plasma as an approximately 120,000 MW inactive antithrombin III complex that can be reduced with dithiothreitol to MW approximately 60,000, indicating disulphide bridging. Using ion-exchange chromatography, the inactive complex has been isolated and shown to migrate in the same position as the anodal peak on crossed immunoelectrophoresis.
Antithrombin III↗
Management of planned pregnancy in a patient with congenital antithrombin III deficiency.
Long-term warfarin therapy was changed to subcutaneous heparin to cover a planned pregnancy in a patient with congenital antithrombin III (AT III) deficiency. Satisfactory anticoagulation was easily maintained in spite of low levels of biologically active AT III. Delivery and the puerperium were covered by a reduced dose of heparin and alternate day infusions of AT III concentrate. A mean dose of 0.77 U/kg of AT III concentrate produced a rise of 1% in AT III and the half-life was of the order of 24 h, with no evidence of increased consumption during labour and delivery. Pregnancy and labour were uncomplicated and resulted in delivery of a healthy female infant. The importance of early and adequate anticoagulation during pregnancy is emphasized.
Adult↗