Encephalopathy secondary to isoniazid in patients on hemodialysis.

We report isoniazid (INH)-induced encephalopathy in two male patients on hemodialysis. One of them had tuberculous adenitis, and the other had pulmonary tuberculosis. Both were given rifampicin, INH, pyrazinamide, and ethambutol with pyridoxine 40 mg/day. Two patients developed disturbances in consciousness. After excluding other causes, INH-induced encephalopathy was suspected so the drug was stopped and dose of pyridoxine increased. Both patients retained their consciousness within 1 week and were discharged.

Nosocomial postneurosurgical Acinetobacter baumannii meningitis: a retrospective study of six cases admitted to Hamad General Hospital, Qatar.

This article reports six cases of nosocomial Acinetobacter baumannii meningitis in patients who had undergone neurosurgical procedures with placing of external ventricular drains. The mean time between surgery and onset of infection was 27 days [standard deviation (SD) 14] Multi-drug resistance was observed in three cases (50%) and carbapenem resistance was noted in two cases (33%). All patients had received empirical antibiotics and these were appropriate in five cases (83%). The mean duration of antimicrobial treatment was 12.5 (SD 2.4) days. Two of the six patients (33%) died in hospital.

Etiology of pleural effusion among adults in the state of Qatar: a l-year hospital-based study.

There have been no systematic studies of diseases causing pleural effusion in Qatar. This prospective, hospital-based study involved all adult patients (> 15 years) with pleural effusions who were admitted to referral hospitals over a 1-year period. A total of 200 cases of pleural effusion were identified (152 males and 48 females); mean age 45.1 (SD 18.5) years. A majority of patients (73.5%) were non-Qataris, mostly from the Asian subcontinent. The most frequent cause of pleural effusions was tuberculosis (32.5%), followed by pneumonia (19%), cancer (15.5%) and cardiac failure (13%). The most frequent cause of malignant effusion was bronchogenic carcinoma (38.7%), whereas Gram-positive organisms were the most frequent isolates from empyema fluid (62.5%). Histological examination and culture of pleural biopsy were the most useful diagnostic workup for tuberculosis effusions, whereas repeated cytological examination of pleural fluid and pleural biopsy were most useful for malignant effusions.

Rhabdomyolysis: a review of the literature.

Rhabdomyolysis is a potentially life-threatening syndrome that can develop from a variety of causes; the classic findings of muscular aches, weakness and tea-coloured urine are non-specific and may not always be present. The diagnosis therefore rests upon the presence of a high level of suspicion of any abnormal laboratory values in the mind of the treating physician. An elevated plasma creatine kinase (CK) level is the most sensitive laboratory finding pertaining to muscle injury; whereas hyperkalaemia, acute renal failure and compartment syndrome represent the major life-threatening complications. The management of the condition includes prompt and aggressive fluid resuscitation, elimination of the causative agents and treatment and prevention of any complications that may ensue. The objective of this review is to describe the aetiological spectrum and pathophysiology of rhabdomyolysis, the clinical and biological consequences of this syndrome and to provide an appraisal of the current data available in order to facilitate the prevention, early diagnosis and prompt management of this condition.

Rhino-orbital zygomycosis secondary to Rhizopus oryzae in a renal transplant recipient successfully treated with liposomal amphotericin B.

Rhino-orbital zygomycosis is usually an aggressive, fulminant and, at times, fatal disease that requires urgent medical and surgical treatment. We report a case of rhino-orbital zygomycosis caused by Rhizopus oryzae that developed in a 41-year-old male renal transplant recipient. He was diagnosed in the early post transplant period after anti-rejection therapy. The infection was successfully managed with liposomal amphotericin B and functional endoscopic sinus surgery.

Thyrotoxic periodic paralysis admitted to the medical department in Qatar.

OBJECTIVES: In this study we describe the clinical presentation and electrolyte disturbances of thyrotoxic periodic paralysis (TPP) in patients admitted to the Department of Medicine at Hamad General Hospital. METHODS: Retrospective descriptive study involving patients admitted to the medical department of Hamad General Hospital with paralysis and hyperthyroidism. RESULTS: Eighteen patients with TPP were identified over a three-year period (2004-2007). Their mean age was 32.4 +/- 8.52 years (range 21 to 48 years); all were males. Eleven patients were from the Philippines, five were from Nepal, one was Indian and one was from Sri Lanka. Fourteen patients (77.8%) had the attack in the summer while the remaining four in winter. Nine had a history of severe exertion, five had ingested a heavy carbohydrate meal, two had a sore throat, one had ingested alcoholic and one was without a precipitating cause. Fifteen patients had no previous history of hyperthyroidism. Later on, all patients proved to have hyperthyroidism. All patients were hypokalaemic, while seven patients had hypophosphataemia and three had hypomagnesaemia. Urinary potassium was <20 mmol/l in all patients. Fifteen patients had ECG changes. All patients had proximal myopathy. Twelve patients had signs of hyperthyroidism in the form of goitre, warm sweaty palms, tachycardia, and tremor. Nine patients had attacks of paralysis before diagnosis. After discharge, ten patients had recurrences within one to seven months. CONCLUSION: The causes of hypokalaemia and lower-extremity paralysis are numerous; TPP should be taken into consideration in the differential diagnosis of all acute episodes of motor paralysis, especially in young Asian male patients.

Ascites in the state of Qatar: aetiology and diagnostic value of ascitic fluid analysis.

INTRODUCTION: Ascites is common and represents an important feature of liver disease and other diseases. The aim of this study is to determine the causes of ascites in Qatar, and to evaluate the value of ascitic fluid analysis in different types of ascites. METHODS: This is a descriptive, prospective study of all patients admitted to the medical department at Hamad General Hospital with ascites between January 2004 and January 2005. RESULTS: Of the 104 patients enrolled in the study, 70 (67.3 percent) were males and 34 (32.7 percent) were females, with a mean age of 52.9 (+/-14.8) years. Liver cirrhosis was the most frequent cause of ascites in 62 patients (59.6 percent), while chronic alcoholism was the main cause of liver cirrhosis. Other frequent causes of ascites were malignant ascites in 12 patients (11.5 percent), malignancy-related ascites in ten patients (9.6 percent), and tuberculous peritonitis in eight patients (7.7 percent). Based on the serum-ascites albumin gradient (SAAG), different causes of ascites were divided into two main groups. The first group was characterised by a mean SAAG of 1.1 or higher, and the second group was characterised by a mean SAAG of less than 1.1. The most common cause of high gradient ascites was liver cirrhosis, while the most common causes of low gradient ascites were carcinomatous peritonitis and tuberculous peritonitis. The mean ascitic lactate dehydrogenase (LDH) level was higher in cancer patients than in tuberculous patients (p-value is less than 0.05), while the mean ascitic glucose concentration was significantly lower in peritoneal tuberculosis than in carcinomatous peritonitis (p-value is less than 0.05). CONCLUSION: Liver cirrhosis is the main cause of ascites in Qatar. SAAG is a better distinguishing marker for separating ascites related to portal hypertension from other causes of ascites without portal hypertension. In patients with low gradient ascites, ascitic fluid glucose and LDH level are useful indicators for separating tuberculous from malignant ascites.

Typhoid osteomyelitis of the lumbar spine.

A 25-year-old Nepali man presented with a 20-day history of fever associated with a lower backache. Physical examination found tenderness over the lower lumbar vertebrae. Magnetic resonance imaging following intravenous contrast injection showed enhancement of the L4 and L5 vertebrae, particularly pronounced around the intervening disc, and areas of endplate erosion. Extra-vertebral enhancement and a small subligamentous anterior collection were also noted. Computed tomography-guided needle aspiration was performed at the level of L4/5 disc material and culture of the specimen grew Salmonella typhi sensitive to ampicillin, ciprofloxacin, and ceftriaxone. The patient received intravenous ampicillin 2 g per 4 hours for 6 weeks. The back pain resolved completely and the patient was discharged. Typhoid osteomyelitis of the spine should be considered in the differential diagnosis in patients from endemic areas who present with fever and backache.

The independent effects of exercise and estrogen on lipids and lipoproteins in postmenopausal women.

OBJECTIVE: To assess the effects of a moderate exercise program with and without oral estrogen replacement on levels of lipids and lipoproteins in postmenopausal women. METHODS: One hundred one postmenopausal women were randomized into four groups: control or sedentary (N = 20), exercise alone (N = 25), estrogen replacement using 0.625 mg conjugated equine estrogen (N = 28), and exercise supplemented with conjugated equine estrogen (N = 28). The exercise groups were placed on a moderate exercise program. Following baseline testing, each group returned at 3 and 6 months for cardiorespiratory fitness testing and serum lipid and lipoprotein profiles. RESULTS: We found a significant decrease in systolic blood pressure (P < .05) in all treatment groups. The maximum oxygen uptake increased by 9.0 and 7.8% in the exercise and conjugated equine estrogen/exercise groups, respectively, compared to the other groups (P < .05). These responses were seen at both 3 and 6 months. Total exercise time (time spent on the treadmill until exhaustion during testing) significantly increased in the exercise group by 21% (P < .01). Exercise alone was associated with significant decreases in total cholesterol (5.2%, P < .05), triglycerides (2%, P < .05), and low-density lipoprotein (LDL) cholesterol (10%, P < .01), and a significant increase in the high-density lipoprotein (HDL) cholesterol-LDL ratio (17.2%, P < .01). Significant changes were noted in these values, as well as increases in HDL cholesterol (16 and 14.8%; P < .01) and apolipoprotein A1 (25.6 and 26.5%; P < .001) in the conjugated equine estrogen and conjugated equine estrogen/exercise groups, respectively. However, there were no differences in the changes observed in the conjugated equine estrogen groups with versus without exercise. No direct correlation was seen between measures of exercise performance and the changes seen in lipids and lipoproteins. CONCLUSIONS: Estrogen therapy alone had the greatest beneficial effect on lipids and lipoproteins. Exercise alone resulted in a significant reduction in cholesterol, triglycerides, and LDL cholesterol, and an increase in the HDL-LDL ratio. However, combined conjugated equine estrogen and exercise did not demonstrate an added improvement in lipid metabolism. Physical fitness levels increased in the exercise groups, but not in the control group or the estrogen-alone treated women.

Changes in coagulation and anticoagulation in women taking low-dose triphasic oral contraceptives: a controlled comparative 12-month clinical trial.

OBJECTIVE: The effects of two triphasic oral contraceptives on coagulation and anticoagulation factors were compared in a 12-month open-label study. STUDY DESIGN: Fifty-two women (mean age 26 years) were enrolled in and completed the study; 20 had been randomly assigned to receive levonorgestrel plus ethinyl estradiol, 24 had been randomly assigned to receive norethindrone plus ethinyl estradiol, and eight surgically sterile women acted as untreated controls. Coagulation and anticoagulation factors were measured at baseline and during the sixth and twelfth months. RESULTS: Both oral contraceptives produced significant decreases from baseline in prothrombin time and partial thromboplastin time; there were also significant changes in laboratory control times. Factor XII was significantly increased in both oral contraceptive groups after 6 and 12 months. Fibrinogen antigen was significantly increased for norethindrone plus ethinyl estradiol after 6 and 12 months and for levonorgestrel plus ethinyl estradiol after 12 months. Platelet counts were unchanged. There was a significant increase in antithrombin III activity with norethindrone plus ethinyl estradiol at 12 months. Antithrombin III antigen was unchanged with the oral contraceptives; however, significant increases existed for alpha 1-antitrypsin antigen and plasminogen antigen and activity after 6 and 12 months and for alpha 2-macroglobulin antigen after 12 months for both oral contraceptives. alpha 2-Antiplasmin antigen was significantly increased for norethindrone plus ethinyl estradiol at the 12-month evaluation. There were no significant differences between the oral contraceptives for any coagulation or anticoagulation factor, and mean values generally remained within reference ranges. CONCLUSIONS: Levonorgestrel plus ethinyl estradiol and norethindrone plus ethinyl estradiol had equivalent, minimal effects on hemostasis, and changes in coagulation factors appeared to be balanced by changes in anticoagulation factors.

PIP: Researchers from Gainesville, Florida compared data on 20 women who were randomly assigned the triphasic oral contraceptive (OC) Triphasil (ethinyl estradiol and levonorgestrel) with data on 24 women who were randomly assigned the triphasic OC Ortho-Novum (ethinyl estradiol and norethindrone) and data on 8 women who were controls to evaluate these 2 triphasic OCs' effects on coagulation and anticoagulation factors. They measured these factors at baseline and 6 and 12 months after beginning OC use. Both OCs significantly reduced prothrombin time (Triphasil at 6 and 12 months, p.001; Ortho-Novum at 6 months, p01, and at 12 months, p.001). They also decreased partial thromboplastin time (Triphasil at 6 months, p.01), and at 12 months, p.001; Ortho-Novum at 6 months, p.01). Both OCs significantly increased Factor XII after 6 and 12 months (Triphasil p.001 and p.01 for controls and p.05 from baseline, respectively; Ortho Novum p.01). Ortho-Novum considerably increased fibrinogen antigen at 6 and 12 months (p.05 and p.001 from baseline and p.05 for controls, respectively) while Triphasil increased it only at 12 months (p.05). Platelet counts remained the same. Ortho-Novum markedly increased antithrombin III activity after 6 months (p.05). Even though neither OC changed antithrombin III antigen, they did significantly increase alpha-1-antitrypsin antigen and plasminogen antigen and activity at 6 and 12 months as well as alpha-2-antiplasmin antigen at 12 months. Ortho-Novum increased alpha-s-antiplasmin antigen at 12 months. No great differences in coagulation or anticoagulation factors existed between the OCs. The mean values were within reference ranges. These results showed that the OCs had the same, limited effects on hemostasis and changes in coagulation factors offset changes in anticoagulation factors.

Lp(a) lipoprotein: relationship to cardiovascular disease risk factors, exercise, and estrogen.

OBJECTIVE: Lp(a) lipoprotein is a distinct lipoprotein particle that recently has been found to be associated with cardiovascular disease. A study was conducted to assess the influence of cardiovascular disease risk factors on levels of Lp(a) and to evaluate the effects of age, exercise, and estrogen on these levels. STUDY DESIGN: Two studies, a cross-sectional study of older men (n = 105) and women (n = 75) (mean age 76 years) and a prospective study of younger postmenopausal women (mean age 48 years), were carried out. Lp(a) and other lipoproteins were measured in the two studies and differences were sought by statistical analysis. RESULTS: In the cross-sectional study, serum Lp(a) was similar in men and women and was not influenced by age. Lp(a) levels in men and women were higher when there was more than one cardiovascular disease risk factor present (p less than 0.028). We could not demonstrate such a relationship with other lipid and lipoprotein measurements. In the prospective study exercise alone had no influence on Lp(a) levels. Oral estrogen decreased Lp(a) levels marginally (p = 0.08). The decrease in Lp(a) with oral estrogen was associated with increases in triglycerides (p less than 0.01) and very-low-density lipoprotein (p less than 0.06). CONCLUSIONS: These data confirm that elevated Lp(a) levels are an independent risk factor for cardiovascular disease. Lp(a) levels are primarily influenced by genetic factors and it appears estrogen may have a minor influence on its hepatic synthesis.

The effect of moderate aerobic exercise on physical fitness among women 70 years and older.

This study investigated benefits of 26 weeks of moderate aerobic exercise for women 70 years or older. Sixteen healthy women with a mean age of 72.0 years were randomized into exercise (n = 10) and control groups (n = 6). The exercise group walked on a treadmill 3 times per week for 20 min, at 70% of maximum heart rate. Oxygen uptake VO2max expressed in l/min and ml.kg-1.min-1, total exercise time on the treadmill (TET), maximum heart rate (HRmax) and body mass index (BMI) were measured at baseline and 6 months. Two-way repeated measures analysis of variance (ANOVA) determined the effect of exercise intervention. Both measures of VO2max in addition to TET were significantly improved by the moderate training program, compared to the control group. VO2max in the exercise group increased by +/- 6.6% (S.E. 2.9) measured in l/min and 8.4% (S.E. 3.2) measured in ml.kg-1.min-1. TET increased by 25.4% (S.E. 4.9) in the exercise group. The ANOVA was unable to detect significance between the exercise and control groups for HRmax or BMI. All exercising subjects finished the program, apparently tolerating the intervention. The results indicate that healthy women over the age of 70 years can increase fitness measures with a moderate training program.

The effect of low-dose oral contraceptives on lipids and lipoproteins in two at-risk populations: young female smokers and older premenopausal women.

Young women who smoke and women over age 35 are considered to be at high risk for cardiovascular complications associated with oral contraceptive use. This study evaluated the effects of low-dose oral contraceptives on lipid and lipoprotein concentrations in 45 high-risk patients before, during, and after 6 months of treatment. Neither group showed a significant change from baseline in cholesterol, HDL cholesterol, LDL cholesterol or cholesterol ratios. Triglycerides increased and HDL2a levels decreased significantly in both groups but returned to baseline after treatment was discontinued, with the largest changes in both triglycerides and HDL2a levels occurring at 1 month. The change in triglyceride and HDL2a blood levels were within the laboratories' reference range. The lipid profile of these patients, therefore, was not worsened significantly through 6 months of oral contraceptive use. The young women who smoked did have consistently lowered levels of HDL cholesterol and its HDL2a subfraction when compared to their elder non-smoking cohort.

Effect of long-term triphasic oral contraceptive use on glucose tolerance and insulin secretion.

This study was designed to compare the effects of two low-dose triphasic oral contraceptives (OCs) on glucose tolerance and insulin secretion. Fifty-seven women were randomized to receive OCs containing ethinyl estradiol and either levonorgestrel or norethindrone. Ten subjects using nonhormonal contraception served as controls. Glucose tolerance and insulin secretion were measured at baseline and at 6 and 12 months after an oral glucose stimulus. Both preparations produced a relative hyperglycemia at 6 and 12 months compared with baseline, but within the norms for glucose tolerance. The insulin response, measured in 48 treated and eight control subjects, also increased over 12 months in both treated groups, but the total insulin area was within the range of the reference laboratory. Such minor changes have not been associated with cardiovascular diseases and support the safety of low-dose triphasic preparations.

Estrogen therapy and variable-resistance weight training increase bone mineral in surgically menopausal women.

This study was undertaken to examine the effect of estrogen replacement therapy alone and estrogen replacement therapy plus variable-resistance weight training on the bone mineral content of surgically menopausal women. A total of 20 surgically menopausal women were randomized and treated with either 0.625 mg conjugated estrogen daily or the same dose of estrogen plus a closely monitored exercise program involving the use of Nautilus muscle strengthening/endurance equipment. After 1 year's observation, the bone mineral density (BMD) of the spine determined by dual-photon absorptiometry increased in the exercising subjects by 8.3 +/- 5.3% (p = 0.004), 95% confidence limits (CL) 3.9-12.8%; the group with estrogen replacement therapy alone maintained their BMD: 1.5 +/- 12.4% (p = 0.36; 95% CL = -6.9-9.8%). The total body BMD of the exercising group increased by 2.1 +/- 1.5% (p = 0.003; 95% CL = 0.8-3.3%); the nonexercising women had a nonsignificant 0.6 +/- 2.9% change (p = 0.30; 95% CL = -1.4-2.5%). A significant increase of 4.1 +/- 4.3% (p = 0.01; 95% CL = 0.8-7.4%) in the radial midshaft BMD of the exercising group was found; the estrogen alone group recorded a nonsignificant change of -0.3 +/- 3.1% (p = 0.33; 95% CL = -1.7-2.4%). The results of this study suggest that variable-resistance training in estrogen-replete women adds bone to both the axial and appendicular skeleton.