Density estimates reveal that fragmented landscapes provide important habitat for conserving an endangered mesopredator, the spotted-tailed quoll.

Native predators are increasingly exposed to habitat loss and fragmentation globally. When developing conservation and management strategies, it is important to determine whether fragmented landscapes can still support similar predator densities to intact areas, and thereby constitute important habitat for these species. The spotted-tailed quoll (Dasyurus maculatus) is an endangered Australian mesopredator that is often considered to be forest-dependent. While quolls are known to occur in some fragmented forest landscapes, it is unclear whether these areas represent sub-optimal habitat where quolls merely persist, or whether quolls can still occur at densities similar to those observed in intact forest landscapes. We used camera traps to detect quolls in both a fragmented and intact forested site, over three years. We used each quoll's unique pelage pattern to identify individual quolls and estimate population density at each site. We were able to assign more than 94% of quoll image sequences across both sites to identify 173 individuals during the study. Density estimates of 0.13-0.66 quolls per km2 at the fragmented site were comparable to estimates of 0.28-0.48 quolls per km2 at the intact site. Our results highlight the importance of retaining and protecting forest fragments for the conservation of endangered quoll populations.

Toxic epidermal necrolysis: retrospective analysis of 21 consecutive cases managed at a tertiary centre.

BACKGROUND: Toxic epidermal necrolysis (TEN) is a rare, severe blistering disease. Outcome data in British patients is limited to case reports or small series. AIMS: To characterize the aetiology, clinical features, complications and outcome in TEN, and to evaluate the effect of treatments including intravenous immunoglobulin (IVIg). METHODS: This was a retrospective study of 21 consecutive patients with histologically confirmed TEN presenting between 1995 and 2007 to a tertiary referral unit for TEN in a university hospital in the UK. RESULTS: The mean age of the patients was 53.5 years. The mean surface area of denuded skin was 44% (range 30-90%). An adverse drug reaction was implicated in all patients, with mean time of TEN onset being 17 days (range 2-41 days) after initial drug exposure. The SCORTEN index was calculated in 19 patients (median SCORTEN 3, range 2-5). The SCORTEN predicted 7.3 deaths in this cohort, and 7 deaths were seen in the group of patients for whom SCORTEN was calculated. The overall mortality was 8/21 (38%). Ten patients received corticosteroids before transfer to our centre. In the steroid-treated group 4/10 patients (40%) died, and 4/11 patients (36%) who were not treated with steroids also died. Between 1995 and 2000, patients were treated with cyclophosphamide 1.5 mg/kg/day (n=2; both died) and subsequently with ciclosporin 2.5-4 mg/kg/day (n=3; 2 deaths). From 2000, patients were treated with IVIg 0.4-1 g/kg/day (n=14; 3 deaths); the SCORTEN-predicted mortality in this group was 5 deaths. Complications included sepsis (n=18), and organisms included Enterococcus, Acinetobacter, Staphylococcus aureus and methicillin-resistant S. aureus strains). Other complications included anaemia (n=17), lymphopenia (n=11) and neutrophilia (n=9). The presence of neutropenia (n=6; 4 deaths), renal impairment (n=5; 4 deaths) and disseminated intravascular coagulation (n=4; all died) were strong risk factors for mortality. Of 12 patients with ocular involvement, 6 (50%) developed symblepharon and/or visual impairment. CONCLUSIONS: This study confirmed the validity of SCORTEN in our series. In the subgroup treated with IVIg, there were three deaths, compared with the SCORTEN predicted mortality of five deaths. Corticosteroids did not seem to be beneficial.

A retrospective analysis of 34 patients with cutaneous sarcoidosis assessed in a dermatology department.

BACKGROUND: Sarcoidosis is a multisystem granulomatous disease of unknown aetiology, which most often involves the lungs and lymphatic system. Cutaneous involvement is found in approximately 25% of cases of sarcoid. Most previous studies of cutaneous sarcoidosis have been drawn from populations with defined pulmonary disease, so may represent a population with more systemic involvement. OBJECTIVE: We describe a cohort of patients with cutaneous sarcoid seen in a dermatology department. METHODS: Case records were reviewed for patients with a histopathological diagnosis of noncaseating sarcoidal granuloma on skin biopsy, taken between 1996 and 2005. RESULTS: In total, 34 patient records were analysed; 21 patients were found to have extracutaneous systemic sarcoid and 10 patients had sarcoid localized to the skin. Patients with lupus pernio and with ulcerated sarcoid lesions all had extracutaneous disease. No other cutaneous features, including the extent of cutaneous disease, were found to be predictive of systemic involvement. CONCLUSIONS: All patients presenting to a dermatology department with cutaneous sarcoidal granulomas require investigation for systemic sarcoid. Our data suggest that approximately 30% of patients seen in a dermatology clinic with cutaneous sarcoidal granulomas will have disease apparently limited to the skin.

A rare case of recessive dystrophic epidermolysis bullosa and verruciform xanthoma.

A 33-year-old man with recessive dystrophic epidermolysis bullosa presented with a 3-month history of an enlarging mass within scarring on the posterior aspect of the right shoulder. The clinical appearance of the mass with an almost cobbled, verrucous surface, and its rapid evolution suggested the development of a squamous cell carcinoma (SCC) in a chronically scarred site. Histopathological examination of a biopsy taken from the lesion subsequently revealed it to be a verruciform xanthoma. This case shows that benign phenomena can mimic SCC and underlines the need for a biopsy to be taken promptly.

Lung cancer mimicking left atrial mass.

Cardiac involvement in lung cancer is found in up to 25% of autopsy cases. However, despite the considerable mortality and morbidity associated with cardiac metastasis, antemortem diagnosis is unusual. A rare case of lung cancer presenting as a left atrial mass is reported.

Pulmonary carcinoid associated with melanoma: two cases and a review of the literature.

To our knowledge, this is the first report in the British literature documenting the co-occurrence of melanoma and pulmonary carcinoid. The only other report is from America and documents pulmonary carcinoid in association with a parathyroid hormone-producing melanoma. We report two patients with melanoma who presented with nodules on chest X-ray. Both underwent resection of assumed lung metastasis which unexpectedly revealed primary pulmonary carcinoid. Evidence of an association between these two tumours which show striking biological and pathological similarities is discussed. The incidence of pulmonary carcinoid is increasing and with the improved power of radiological assessment we may see additional accounts of such an association in the near future.

Protective medical legislation deficient knowledge of maternity (health and safety) rights for work-adjustment exists amongst flexible trainee doctors: is there a risk to maternal and foetal health?

OBJECTIVE: To assess awareness, identify knowledge source and evaluate uptake amongst doctors of "health and safety rights" (HSR) contained within the current European protective medical legislation for pregnant workers. STUDY DESIGN: A descriptive cross-sectional pilot study, by a postal questionnaire during the period 1998-1999, targeted 97 UK doctors (West Midlands region) after their first pregnancy. RESULTS: Of 67 respondents (response rate 73%), 41 (61%) were Registrars (SpR) and 25 (37%) SHOs: 80% work-schedules did not change during pregnancy. Only 11% (95% CI, 4-21%) of the doctors surveyed actually knew their maternity rights. 66.2% had no knowledge of maternity legislation; 80% of respondents had not taken up health and safety rights. Fifty-two percent (95% CI, 40-65%) reported maternal and neonatal complications. CONCLUSIONS: In a self-selected group of flexible trainees following their first pregnancy, only one in five female doctors have adequate knowledge about the legislative "health and safety rights" of work-schedule adjustment. A combination of reasons may contribute to the low uptake of these rights. The question of whether or not poor knowledge and uptake of legislative rights may be detrimental towards pregnancy and neonatal complications requires a large prospective study. An improvement in the knowledge of current maternity legislation could occur by targeting all medical students, all doctors, postgraduate trainers and National Health Service (NHS) employers.

Admissions with atrial fibrillation in a multiracial population in Kuala Lumpur, Malaysia.

BACKGROUND: There are established differences in cardiovascular disease in different racial groups. Worldwide, the literature regarding the clinical epidemiology of atrial fibrillation in non-white populations is scarce. OBJECTIVES: To document the prevalence of atrial fibrillation (AF) in the multiracial population of Malaysia, and to describe the clinical features and management of these patients. SETTING: Busy city centre general hospital in Kuala Lumpur, Malaysia, over a 1-month period. SUBJECTS: One-thousand four hundred and thirty-five acute medical admissions, of whom 40 patients (2.8%) had AF. RESULTS: Of 1435 acute medical admissions to Kuala Lumpur General Hospital over the 4-week study period, 40 had AF (21 male, 19 female; mean age 65 years). Of these, 18 were Malay, 16 Chinese and six Indian. Nineteen patients had previously known AF (seven with paroxysmal AF) and 21 were newly diagnosed cases. The principal associated medical conditions were ischaemic heart disease (42.5%), hypertension (40%) and heart failure (40%). Dyspnoea was the commonest presentation, whilst stroke was the cause of presentation in only two patients. Investigations were under-utilised, with chest X-ray and echocardiography in only 62.5% of patients and thyroid function checked in 15%. Only 16% of those with previously diagnosed AF were on warfarin, with a further three on aspirin. Anticoagulant therapy was started in 13.5% of patients previously not on warfarin, and aspirin in 8%. Records of contraindications to warfarin were unreliable, being identified in only 25%. For those with known AF, 58% were on digoxin. For new onset AF, digoxin was again the most common rate-limiting treatment, initiated in 38%, whilst five patients with new onset AF were commenced on amiodarone. DC cardioversion was not used in any of the patients with new onset AF. CONCLUSION: Amongst acute medical admissions to a single centre in Malaysia the prevalence of AF was 2.8%. Consistent with previous similar surveys in mainly western (caucasian) populations, standard investigations in this Malaysian cohort were also inadequate and there was underuse of anticoagulation, medication for ventricular rate control and cardioversion to sinus rhythm.

Cholesterol absorption, synthesis, and fecal output in postmenopausal women with and without coronary artery disease.

Hypercholesterolemia is a prominent risk factor for coronary artery disease (CAD), yet cholesterol metabolism has not been evaluated in women with CAD. The objective of this study was to determine the interrelations of CAD, serum squalene and sterols, and cholesterol metabolism with each other in postmenopausal women. For this purpose, we measured serum squalene and sterols and fecal steroids (cholesterol and bile acids) and squalene by gas-liquid chromatography and evaluated cholesterol absorption and synthesis in postmenopausal women with CAD (n=29) and age-matched controls (n=20). On similar dietary lipid intake, the cholesterol absorption efficiency and mean serum cholesterol level were comparable, but the squalene-to-cholesterol ratio was higher in cases than in controls. The presence of CAD was inversely associated with fecal total steroids (logistic regression coefficient beta/SE=-2.11, P=0.04) and cholesterol synthesis (beta/SE=-2.14, P=0.04) and turnover (beta/SE=-2.19, P=0.03) after adjustment for dietary cholesterol, family history of CAD, smoking, low and high density lipoprotein cholesterol, and serum triglyceride levels. A high serum squalene ratio was not related to cholesterol synthesis but was inversely related to fecal squalene excretion, which was lower in cases than in controls. In conclusion, the presence of CAD in postmenopausal women is independently associated with altered cholesterol metabolism, as reflected by low synthesis and inefficient elimination of cholesterol.

Postprandial retinyl palmitate and squalene metabolism is age dependent.

Most of our awake time is spent in a postprandial state. It has not been investigated in detail whether the post-prandial clearance of triglyceride-rich lipoproteins is age dependent. In addition, postabsorptive squalene metabolism has not been studied in relation to age. Accordingly, we investigated postprandial lipid metabolism in six young (22-25 years of age) and eight old (78-79 years of age) healthy men by use of an oral fat load containing 345,000 IU of vitamin A and 0.5 g of squalene as postprandial markers. Postprandial samples were drawn after 3, 4, 6, 9, 12 and 24 hours after the fat load. The retinyl palmitate area under the incremental curve of the old subjects was higher in plasma than that of the young subjects (p < .01). The pattern of postprandial very low density lipoprotein squalene responses differed significantly in the old compared with the young subjects (p < .01), but the areas under the incremental curve did not differ. Postprandial retinyl palmitate and squalene concentrations correlated significantly at 3-12 hours (p < .01). These data suggest that postprandial lipoprotein metabolism measured by retinyl palmitate and squalene is retarded with increasing age.

Sialic acid content of low-density lipoprotein in women with coronary artery disease.

A low sialic acid content in low-density lipoprotein (LDL) has been associated with coronary artery disease (CAD) in studies that have included mostly male subjects. We compared the sialic acid-to-apolipoprotein B ratios of total LDL and its subfractions in middle-aged women with CAD (CAD+, n = 22) with those ratios in healthy female control subjects (CAD-, n = 11). CAD+ subjects had a lower sialic acid ratio in total LDL and in its subfractions as compared with results in CAD- subjects. In total, light, and dense LDL, the sialic acid ratio was negatively correlated with the respective cholesterol and phospholipid concentrations, and in very dense LDL, it was negatively correlated with triglyceride concentration. In multivariate analysis, CAD and LDL cholesterol contributed to the explanation of the variability of LDL sialic acid ratios. In summary, a low sialic acid-to-apolipoprotein B ratio in LDL was associated with the presence of CAD in middle-aged women with mild to moderate hypercholesterolemia.

Independent association of serum squalene and noncholesterol sterols with coronary artery disease in postmenopausal women.

OBJECTIVES: The purpose of the study was to investigate whether cholesterol metabolism is associated with coronary artery disease (CAD) in postmenopausal women. BACKGROUND: Although hypercholesterolemia, a predominant risk factor of CAD, is related to cholesterol metabolism, the association between cholesterol metabolism and CAD is not well known. METHODS: In addition to conventional coronary risk factors, fasting serum squalene, delta8-cholestenol, desmosterol, lathosterol (indicators of cholesterol synthesis), cholestanol, campesterol and sitosterol (indicators of cholesterol absorption) were measured in 48 50- to 55-year-old consecutive women with angiographically verified CAD and in 61 age-matched healthy controls. RESULTS: The coronary patients had elevated ratios of squalene (p < 0.001), desmosterol (p = 0.005), campesterol (p = 0.028) and sitosterol (p = 0.022) to cholesterol, but had lower respective lathosterol value (p = 0.041) compared with the controls, despite similar serum cholesterol levels. Adjusted for age, body mass index, family history of CAD, smoking, hypertension, serum triglycerides, low-density lipoprotein (LDL) and high-density lipoprotein (HDL) cholesterol level and glycosylated hemoglobin A1c% (GHbA1c), the ratios of squalene (odds ratio, 1.36; 95% confidence interval, 1.17 to 1.57), lathosterol (0.98; 0.97 to 0.99), campesterol (1.01; 1.00 to 1.01) and sitosterol (1.01; 1.00 to 1.03) were significantly associated with the risk of CAD. In addition, family history of CAD and GHbA1c% were also independently related to the presence of CAD. CONCLUSIONS: The results suggest that women with elevated ratios of serum squalene, campesterol and sitosterol to cholesterol and low respective lathosterol values have enhanced risk for CAD. Thus, enhanced absorption and reduced synthesis of cholesterol may be related to coronary atherosclerosis.

Serum squalene in postmenopausal women without and with coronary artery disease.

Squalene, found in earlier studies in human atherosclerotic plaques, was measured in the serum of postmenopausal women with coronary artery disease (CAD) (n = 25) and randomly chosen age-matched healthy controls (n = 30). The squalene concentrations of the whole population ranged from 37.5 to 115.5 microg/dl, and were higher in serum of the CAD than healthy women (91.4+/-2.6 versus 65.2+/-2.6 microg/dl, P = 0.000), a finding observed also in relation to cholesterol (43.8+/-1.8 versus 32.9+/-1.1 10(2)x mmol/mol of cholesterol, P = 0.000). The squalene concentration was also increased in chylomicrons, VLDL and d>1.006 g/ml lipoproteins, and the proportions to cholesterol in VLDL and d>1.006 g/ml lipoproteins. The respective squalene and cholesterol concentrations were related to each other in serum, VLDL and d>1.006 g/ml lipoproteins (r = 0.52, 0.85 and 0.55, respectively), whereas the correlation with triglycerides was seen only in VLDL (r = 0.84) over the whole population. Besides enhanced intestinal secretion, it remains to be shown whether higher serum squalene in postmenopausal coronary women is due to increased cholesterol synthesis or a defect in squalene conversion to lanosterol.

Impaired postprandial clearance of squalene and apolipoprotein B-48 in post-menopausal women with coronary artery disease.

It is not known in detail whether postprandial lipaemia is associated with coronary artery disease (CAD) in women. To investigate this, we administered an oral vitamin A/squalene/fat meal to 24 post-menopausal women with angiographically proven CAD who were not taking hormone replacement therapy, and to 30 healthy controls (18 without and 12 with hormone replacement therapy) to evaluate the effects of CAD on postprandial lipoprotein metabolism. This was done by assessing squalene, triacylglycerols, retinyl palmitate and apolipoprotein B-48 (apoB-48) during the subsequent 24 h. The subjects with CAD had significantly higher fasting concentrations of squalene and apoB-48 in triacylglycerol-rich lipoproteins (TGRL) compared with the controls. The postprandial areas under the incremental curve of TGRL apoB-48, chylomicrons, very-low-density lipoprotein (VLDL) and TGRL squalene, and of retinyl palmitate in VLDL only, were significantly higher in women with CAD than in controls. Adjustment for fasting values did not eliminate the differences in postprandial squalene and apoB-48 between CAD and controls. The postprandial responses of control subjects were not influenced by hormone replacement therapy. The peaks of squalene and retinyl palmitate of the controls, but not of the women with CAD, occurred significantly earlier (P<0.01 for both) in chylomicrons than in VLDL. The findings suggest that lipoproteins that accumulate postprandially are labelled by dietary squalene, and that these lipoproteins may be atherogenic in post-menopausal women.

Attenuation of anti-ischemic efficacy during chronic therapy with nicorandil in patients with stable angina pectoris.

After 2 weeks of nicorandil therapy, time to ischemia on stress testing was significantly less than on day 1 and not different from placebo. These data are consistent with attenuation of the anti-ischemic effects of this drug and suggest that the potassium channel-opening properties do not compensate for development of attenuation to the nitrate component of nicorandil.

Neurogenic bladder in neuroleptic malignant syndrome.

Urinary retention or incontinence is not an infrequent clinical finding in patients with neuroleptic malignant syndrome. We studied the pathophysiology of this voiding disorder by urodynamic testing. It revealed involuntary bladder contraction and rigidity of external sphincter (dyskinesia). These findings are analogous to those in Parkinson disease patients and support the dopamine deficiency theory as the cause of neuroleptic malignant syndrome.