Characteristics of patients presenting with erythema nodosum and sarcoidosis.

We explored the relationship between erythema nodosum (EN) and sex, age, serum angiotensin converting enzyme (ACE), bronchoalveolar lavage lymphocytosis (BAL-I), interstitial granulomas and radiological stage in patients presenting with pulmonary sarcoidosis in Ireland. Sixty-nine patients diagnosed with sarcoidosis between 2003 and 2006 were studied. Forty one patients (59%) were male. Sixteen patients (23%) presented with EN. Forty one patients of 65 (63%) had transbronchial biopsies demonstrating non-caseating granulomas. Patients with sarcoidosis presenting with EN were more likely to be female (p=0.042), younger (p=0.012) and have earlier stage pulmonary disease (p=0.02). There were no correlations between serum ACE, interstitial granulomas and disease stage. BAL-I did however predict increasing disease radiological stage (p=0.042). In this study, one quarter of patients with sarcoidosis presented with EN among their presenting features. These patients were more likely to be young females with early stage radiological disease.

Short term treatment with St. John's wort, hypericin or hyperforin fails to induce CYP450 isoforms in the Swiss Webster mouse.

This investigation was designed to determine whether St. John's wort (SJW)(435 mg/kg/d), a readily available antidepressant, or its purported active constituents hypericin (1 mg/kg/d) and hyperforin (10 mg/kg/d) were able to induce various hepatic cytochrome P450 (CYP450) isoforms. SJW, hypericin and hyperforin were administered to male Swiss Webster mice for four consecutive days and hepatic microsomes were prepared on day 5. None of the three treatments resulted in a statistical change in total hepatic CYP450 (SJW treated 0.95 +/- 0.09 nmol/mg vs control 1.09 +/- 0.14 nmol/mg). Furthermore, the catalytic activities of CYP1A2. CYP2E1 and CYP3A were unchanged from control following all three treatments as determined by ethoxyresorufin O-deethylation, p-nitrophenol hydroxylation and erythromycin N-demethylation respectively. Additionally, western immunoblotting demonstrated that there was no significant change in the polypeptide levels of any of the three isoforms. These results indicate that four days of treatment with moderate to high doses of SJW, hyperforin or hypericin fails to induce these CYP450 isoforms in the male Swiss Webster mouse.

Essential oils from dalmatian sage (Salvia officinalis l.): variations among individuals, plant parts, seasons, and sites.

The factors affecting oil yield and quality of essential oils from Dalmatian sage (Salvia officinalis L.) are analyzed. Distillations of oils from individual plants and GC analyses revealed the presence of three chemotypes with different proportions of alpha- and beta-thujone (alpha/beta 10:1, 1.5:1, and 1:10). Different accessions could also be classified as having high (39-44%), medium (22-28%), or low (9%) total thujone contents. Flowering parts of S. officinalis had higher oil contents (1.6 versus 1.1%) and beta-pinene levels (27 versus 10%) than leaves and lower thujone levels (16 versus 31%). Major seasonal changes were found in the composition of oil distilled from a flowering type of Dalmatian sage, but oil yields from healthy, established plants did not vary greatly. Total thujone levels were lowest (25%) around flowering in spring and summer, so autumn or winter was the best harvest time to obtain oils with high thujone levels.

Attitudes to osteoporosis and hormone replacement therapy among elderly women.

This study compares the attitudes toward osteoporosis and its treatment between a group of elderly women admitted to hospital for therapy of an osteoporotic fracture and a control group admitted for joint replacement surgery. We surveyed 97 women (64 with a fracture, and 33 controls) and found that the two groups of patients demonstrated a similar risk factor profile for osteoporosis and poor knowledge of osteoporosis and its available treatments, including hormone replacement therapy (HRT). By selecting a control group of women with no recent fracture, we hoped to highlight the effect of sustaining a recent fracture on attitudes to treatment. Initially only 10% (8 in the fracture group and 2 in the control group) were interested in treatment for osteoporosis, but those women who had been admitted with a fracture were significantly more receptive to education about osteoporosis and to the offer of further investigation and treatment of osteoporosis (38 versus 10, p = 0.007). We conclude that it is worthwhile offering education, screening and treatment to elderly patients who present with a fracture.

Delirium: making the diagnosis, improving the prognosis.

Delirium is a common development in at-risk older patients hospitalized for acute illness or postoperative care. Although delirium's risk factors are well documented, less is known about its pathophysiology and long-term prognosis or about the relationship between delirium, dementia, and depression. Evaluation and management of delirium is a medical emergency. Diagnostic tools include the Confusion Assessment Method rating scale, patient history from capable informants, and physical/mental examinations. Management consists of prevention, treatment of underlying causes or associated factors, supportive care, and pharmacologic intervention (as indicated). Studies that have looked at the reversibility of delirium suggest that patients often are slow to recover their previous level of function.

Hospital in the home: a randomised controlled trial.

OBJECTIVES: To compare treatment of acute illness at home and in hospital, assessing safety, effect on geriatric complications, and patient/carer satisfaction. DESIGN: Randomised controlled trial. SETTING: A tertiary referral hospital affiliated with the University of New South Wales. PARTICIPANTS: 100 patients (69% older than 65 years) with a variety of acute conditions, who were assessed in the emergency department as requiring admission to hospital. INTERVENTIONS: Patients were allocated at random to be treated by a hospital-in-the-home (HIH) service in their usual residence or to be admitted to hospital. MAIN OUTCOME MEASURES: Geriatric complications (confusion, falls, urinary incontinence or retention, faecal incontinence or constipation, phlebitis and pressure areas), patient/carer satisfaction, adverse events, and death. RESULTS: There was a lower incidence of confusion (0 v. 20.4% [95% CI, 9.1%-31.7%]; P = 0.0005), urinary complications (incontinence or retention) (2.0% [95% CI, -1.8%, 5.8%] v. 16.3% [95% CI, 6.0%, 26.6%]; P = 0.01), and bowel complications (incontinence or constipation) (0 v. 22.5% [95% CI, 10.7%, 34.1%]; P = 0.0003) among HIH-treated patients. No significant difference in number of adverse events and deaths (to 28 days after discharge) in the two groups was found (although numbers were small). Patient and carer satisfaction was significantly higher in the HIH group. CONCLUSIONS: Home treatment appears to provide a safe alternative to hospitalisation for selected patients, and may be preferable for some older patients. We found high levels of both patient and carer satisfaction with home treatment.

Antimicrobial and cytotoxic phenolic glycoside esters from the New Zealand tree Toronia toru.

Two new compounds, 4-hydroxyphenyl 6-O-(4-hydroxy-2-methylenebutanoyl)-beta-D-glycopyranoside (1) and 4-hydroxyphenyl 6-O-[(3R)-3,4-dihydroxy-2-methylenebutanoyl]-beta-D-glucopyranosid e (2), have been isolated from foliage of Toronia toru. Compound 2 was the main antimicrobial component (7 mg/g of dry foliage) of the crude extract and also showed significant cytotoxic activity against P-388 leukemia cells.

High prevalence of familial sarcoidosis in an Irish population.

Previous studies in the Republic of Ireland have demonstrated a high national prevalence of sarcoidosis. Observations in our sarcoid clinic suggested a high prevalence of the disease among siblings and prompted a survey to quantify this phenomenon. The study group comprised 114 index patients with biopsy proved sarcoidosis and a total sibling pool of 534 individuals. Eleven of the index patients (9.6%) were found to have at least one sibling with sarcoidosis. Of the 13 siblings thus identified, eight had biopsy proof of the disease, while the remaining five showed highly suggestive clinical and radiological evidence of sarcoidosis. There was no significant difference in the mode of presentation between the sibling pairs or between familial and non-familial cases and there was an equal distribution of like sex and unlike sex pairs. In only two instances was the temporal profile of onset of the disease suggestive of intrafamilial spread of a transmissible agent. The high prevalence of sarcoidosis among siblings reported here (2.4%) suggests that genetic factors significantly predispose to the development of sarcoidosis and that family members of affected patients should be screened for this disease.

Sarcoidosis and lymphoma in the same patient.

A case of lymphocytic lymphoma in a patient with coincidental sarcoidosis is described, and the possible relationship of the two conditions is discussed. A revised set of diagnostic criteria is proposed to overcome previous difficulties encountered in validating such dual pathology.

Bromocriptine in severe adult asthma--a negative report.

A pilot study had suggested that bromocriptine (a dopamine agonist) might be of benefit in severe asthma, particularly in patients with marked diurnal variation in peak flow. Two studies are reported: (1) a longterm double-blind, controlled trial comparing bromocriptine (B) with placebo (P) in patients with severe asthma and, (2) a withdrawal study in patients who had received known bromocriptine, with apparent benefit, for at least one year. Of 27 patients (16B, 11P) admitted to the double-blind trial only eight (4B, 4P) completed 52 weeks on the trial drug as nine (6B, 3P) had been withdrawn for side-effects, eight (4B, 4P) for failure and two (2B) for both reasons. The results, based on changes in steroid dosage and other medication, daily symptom scores and PEF values, suggest that bromocriptine has little effect in asthma. In addition side-effects were frequent and troublesome. In the withdrawal study, ten patients who had been taking bromocriptine for a year or more were switched to an indistinguishable placebo if their asthma was considered to be stable. The results, of this second study, support the conclusion of the double-blind study, that bromocriptine has little beneficial effect in asthma.

Thoracoabdominal mechanics during tidal breathing in normal subjects and in emphysema and fibrosing alveolitis.

Thoracoabdominal motion and intrathoracic (oesophageal), intra-abdominal (gastric), and transdiaphragmatic pressures were measured during tidal breathing in 20 erect subjects--six normal, seven, with emphysema, and seven with fibrosing alveolitis. In normal subjects all diameters increased synchronously during inspiration and were accompanied by rises in abdominal and transdiaphragmatic pressures. Five patients with fibrosing alveolitis showed a reduction in upper ribcage motion, but normal lower ribcage and abdominal motion; stiff fibrotic lungs may sometimes impair the ability of the diaphragm to expand the upper ribcage and result in proportionally more expansion of the bases. Four emphysematous patients showed increased anteroposterior motion of the ribcage and four showed paradoxical inward motion of the lower ribcage during inspiration. These changes apparently result from increased activity of intercostal and accessory muscles and altered configuration of the diaphragm. The muscles of patients with large, overinflated lungs are at a greater disadvantage than those with small fibrosed lungs.

Effect of hypoxia and CO on a cytochrome P-450-mediated reaction in rabbit lungs.

Evidence indicates that the diffusion of O2 and CO in tissue may be facilitated by a carrier molecule having a P50 that approximates tissue O2 partial pressure (PO2; 1-15 Torr) and a much higher affinity for CO than for O2. To determine whether cytochrome P-450 in lung satisfies these criteria, we measured the effect of hypoxia and of CO on the rate of metabolism of the cytochrome P-450 mediated O-demethylation of p-nitroanisole in isolated perfused rabbit lungs. Metabolism was inhibited by 50% of a control at an estimated tissue PO2 fo 4 Torr (5.5 microM). When inspired CO2 was kept at 200 Torr and inspired CO partial pressure (PCO) varied an estimated tissue PCO/PO2 ratio of 0.025 reduced the reaction rate by 50% of control, but some metabolism persisted at PCO/PO2 ratios larger than one. The relationship between reaction rate and PCO/PO2 ratio could not be fit by a single value for Haldane constant for M (CO affinity/O2 affinity) but could be described with a two-component model in which metabolism was equally divided between a high-affinity cytochrome (M = 200) and a low-affinity cytochrome (M = 2). These findings suggest that cytochrome P-450 could act as a carrier for O2 and CO in tissue with low PO2's.

Steady-state vascular responses to graded hypoxia in isolated lungs of five species.

In the isolated pig lung exposed to graded levels of hypoxia, steady-state pulmonary vasomotor tone is maximum at an O2 tension (PO2) of 50 Torr. Below 50-Torr decreases in PO2 cause steady-state tone to fall below this maximum. To determine whether this stimulus-response relation was peculiar to pigs, we measured the steady-state relation between PO2 and vasomotor tone in the isolated lungs of dogs, rabbits, cats, and ferrets, by using identical techniques in each species. Marked species differences were apparent in both the level of PO2 required to elicit responses and the amplitude of the responses. The ferret and the pig had the largest vasoconstrictor responses to hypoxia. No significant responses were obtained in the dog. The cat and rabbit were intermediate responders. In the ferret, cat, and rabbit, the stimulus-response relationship was biphasic, as in the pig. On the average, maximal constriction occurred at an PO2 of 25 Torr. When PO2 was lowered below 25 Torr, steady-state tone fell. Thus pulmonary vasodilation at low PO2 occurs in the isolated lungs of several species.

Anatomically localised re-expansion pulmonary oedema following pneumothorax drainage. Case report and literature review.

We describe the 15th recorded case of ipsilateral pulmonary oedema following re-expansion of a pneumothorax. In contrast to previously described cases, the oedema was exclusively confined to the right middle and lower lobes, with complete sparing of the right upper lobe. This strict anatomical localisation can best be explained by the presence of a discrete temporary obstruction of the bronchus intermedius during the critical period of rapid pneumothorax re-expansion. We believe that this case lends strong support to previous contentions that bronchial occlusion plays a crucial role in the genesis of re-expansion oedema.

Causes of elevated blood urea in 100 hospital cases.

In this prospective study we examined 100 consecutive in-patients found to have a blood urea concentration greater than 13.3 mmol/l (80 mg/dl) or a serum creatinine concentration greater than 176 µmol/l (2 mg/dl).Pre-renal causes were responsible in 32 of these patients and there was a 40% mortality rate in this subgroup of patients after one month follow up.In 14 cases inappropriate administration of diuretics was a major cause of blood urea elevation.