Biomedical subjects
Publications and source records attributed to J A Hicks.
Renal cell carcinoma presenting as a mass in the left testis or spermatic cord has previously been described with retrograde venous spread along the gonadal artery as the suggested mechanism. However a right-sided presenting lesion has not been described and suggests an alternative method of spread.
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BACKGROUND: Sleep effects of antidepressants are important clinically and for elucidating mechanism of action: selective serotonin reuptake inhibitors disturb sleep and 5-HT(2) receptor-blocking compounds may enhance sleep quality. AIMS: To compare the objective and subjective effects on sleep of paroxetine and nefazodone in patients with moderate to severe depression. METHOD: Forty patients with depression were randomised to take paroxetine 20-40 mg/day or nefazodone 400-600 mg/day for 8 weeks. Objective and subjective quality of sleep and depression measures were assessed throughout. RESULTS: Nefazodone significantly increased objective sleep efficiency and total sleep time, and improved subjective sleep on days 3 and 10. Paroxetine decreased sleep efficiency early in treatment and some sleep disruption remained at week 8. Paroxetine but not nefazodone produced marked suppression of rapid eye movement (REM) sleep. CONCLUSIONS: Nefazodone improves sleep in early treatment compared with paroxetine in patients with moderate to severe depression. These effects are seen within the first 2 weeks of treatment and diminish thereafter.
In the United States, blacks are more frequently diagnosed than whites with end-stage renal failure (ESRF) from primary hypertension or diabetic nephropathy. We performed a validation retrospective case-note study of all blacks with ESRF who started renal replacement therapy (RRT) at three teaching hospitals in London, England, during 1991 to 1995 to investigate and validate the causes of primary renal disease using standard criteria. We identified 144 black patients with a mean age of 52.0 +/- 16.0 (SD) years; 59% were men and 32% had renal histological data. One hundred forty-four whites who were matched for age, sex, and onset of RRT (42% with renal histological data) underwent a similar validation exercise. Before the validation, the principal working diagnosis in the black patients had been diabetic nephropathy in 35% (89%, type 2; 11%, type 1); primary hypertension, 19%; glomerulonephritis (GN), 18%; and uncertain cause, 15%. After validation analysis, this changed to diabetes, 38% (16% biopsy proven); uncertain, 24%; GN, 20%; and primary hypertension, only 10% (28% biopsy proven). Among the uncertain cases (n = 34), 19 patients had hypertension, but this could not be established as the primary disease; 94% of all blacks had hypertension, accelerated in 21%. Among whites, only 3.5% had primary hypertension, and this proportion was not changed by the validation study. Type 2 diabetes is the most common single cause of ESRF in black patients in London, and although hypertension is more common and more severe in blacks, the proportion of renal failure attributed to primary hypertension is overestimated, and the diagnosis is often made using inadequate criteria.
Although the short- and medium-term (5-10 years) outcome of patients with lupus nephritis has been studied extensively, there are very few data on the second and subsequent decades. We studied outcome in 110 local patients investigated at a single centre before 1986, who all had potential follow-up of more than 10 years (actual 2-31 years, median 15.5 years). At last follow-up, 40 patients were dead and 70 alive, nine of whom were on maintenance dialysis or transplanted, actuarial survivals being 84%, 72%, 62%, 61% and 54% at 5, 10, 15, 20 and 25 years for the group as a whole. Survival was better in the cohort 1976-86 (n = 60) than in that from 1963-75 (n = 50) (90, 81 and 76% vs. 78, 56 and 43% at 5, 10 and 15 years, p < 0.001). Sepsis (12) and myocardial infarction (8) were the principal causes of death. Of living patients with renal function, 38% had normal urine and renal function, 11 were off all treatment (19%), 62% had persistent proteinuria and 18% had reduced but generally stable renal function. Renal failure, in those patients who developed it, occurred during the first decade and none of 67 patients actually followed more than 10 years subsequently went into renal failure. Induction treatment was with prednisolone, combined with azathioprine in more severe forms of nephritis, and from the middle 1970s to 1986, 30 with methylprednisolone and in 12 cases plasma exchange. Seventeen other patients were treated using oral cyclophosphamide during the 1960s. No patient received i.v. cyclophosphamide as induction therapy, although nine patients had this form of treatment later, largely because of non-compliance. Serious complications of lupus and/or its treatment occurred in 49%: sepsis in 32, ischaemic heart disease in 20, thrombosis in one and avascular necrosis of bone in eight. In contrast, fracturing osteoporosis occurred in only three, and cataracts requiring surgery and diabetes mellitus in none. The very long-term outlook of lupus nephritis, especially its more severe forms, has improved, but that with current management strategies only a minority of patients are able to stop treatment altogether, and the incidence of serious complications is high.
This report describes the case of a 44-year-old woman presenting to a Sleep and Alertness clinic with symptoms of narcolepsy. The patient had clinical and polysomnographic features of narcolepsy, which disappeared after disclosure of severe psychological stress. Following a discussion of the differential diagnosis of narcolepsy, alternative diagnoses are considered. The authors suggest that the patient had a hysterical conversion disorder, or "pseudo-narcolepsy." Careful inquiry into psychological factors in unusual cases of narcolepsy may be warranted.
BACKGROUND: Although immunodeficiency predisposes to CAPD peritonitis with fungal or unusual organisms, the role of immunosuppression as a predisposing factor for CAPD peritonitis, as well as the outcome of such episodes, remains uncertain. METHODS: The incidence, spectrum of infectious organisms, and outcome of CAPD peritonitis was retrospectively reviewed in 39 immunosuppressed and 146 non-immunosuppressed patients treated with CAPD over the calendar year 1993. RESULTS: Immunosuppressed patients were younger (mean 44 vs 57 years, P<0.001) and had an increased incidence of previous transplantation, glomerulonephritis, systemic lupus erythematosus, and vasculitis. Immunosuppressed patients had more episodes of peritonitis (69/29 patients vs 99/147, P<0.001), required more frequent hospital admission (25/39 vs 33/146, P<0.001), had more days off CAPD (331 vs 242, P<0.001), and required more laparotomies to remove infected CAPD catheters (11/39 vs 14/146, P<0. 01). Immunosuppression was associated with increased infection due to S.aureus and fungi, which may have contributed towards increased morbidity in this group. Current immunosuppression or a recent history of immunosuppression appeared to be equally potent risk factors for infection. There was a trend for the incidence of infection to parallel the aggressiveness of immunosuppression. CONCLUSIONS: Immunosuppression is an important risk factor for CAPD peritonitis. A high index of suspicion for infection and aggressive chemotherapy are mandatory. CAPD may not be the initial therapy of choice in this high-risk group.
Anti-glomerular basement membrane antibody mediated disease (anti-GBM disease) is an uncommon cause of renal failure. Presentation is usually dramatic, with renal failure and alveolar hemorrhage leading to an early diagnosis. In contrast, we here describe 3 cases which presented with atypical features, and where diagnosis was delayed due to the presence of other factors which were initially felt sufficient to explain the clinical status. No patient recovered renal function, and one died from sepsis. We also present data on 15 patients presenting to Guy's Hospital over the past 10 years with anti-GBM disease and creatinine > 500 mumol/l. The median delay from presentation to diagnosis was 7 days, range 1-81 days. Two patients died, and only one recovered renal function. We speculate that earlier referral and renal biopsy might have improved outcome in these patients, and recommend a policy of early biopsy in all cases of acute renal failure with atypical feature, delay in recovery, or where a clearcut cause is not established.
Forty-three patients with secondary or autonomous hyperparathyroidism complicating chronic renal failure (CRF) underwent total parathyroidectomy (PTX) (follow-up 2-18 years, mean 8.7 years). Five were on conservative treatment for CRF, 35 on regular dialysis, and only three had a functioning allograft. At PTX, the most frequent findings were uncontrollable hypercalcaemia, musculo-skeletal pain, radiographic changes in the phalanges, and raised plasma parathyroid hormone (PTH) concentration. Pre-operatively, all patients were loaded with dihydrotachysterol or 1-alpha-OH cholecalciferol. Postoperatively, they were maintained on tapering doses of the same drugs and, briefly, oral calcium supplements. Five glands were identified and removed in two patients, four in 35 patients, three in three patients and only two in one patient. All had changes of hyperplasia and adenoma formation, except for one with a parathyroid carcinoma. Prompt symptomatic and radiographic improvement occurred, with normalization of plasma calcium and alkaline phosphatase. Postoperative PTH levels were available in 33 patients (23 by intact PTH assay): they were persistently high in 10/33 (2/23 intact); normal in seven (6 intact); low in 11 (3 intact), and undetectable in four (3 intact). Thus, PTX was incomplete in the majority of patients. Following transplantation, 3/20 (3/18 intact) patients still had detectable PTH. Only one patient developed symptomatic recurrent parathyroid disease requiring re-operation, and complications were few. Small dosages of vitamin D continue to be required, but not calcium supplementation, and no clinical effects of possible adynamic bone have been noted. At later renal transplantation in 27 patients, an easily treatable, uncomplicated hypocalcaemia was noted in 33%.(ABSTRACT TRUNCATED AT 250 WORDS)
Seventy-three women who requested epidural analgesia during labour were randomly allocated in a prospective study to receive either a continuous epidural infusion of 0.075% bupivacaine at a rate of 12-18 ml/hour (38 mothers) or intermittent top-ups of 0.5% bupivacaine (35 mothers). Both groups received an initial dose of 6-8 ml bupivacaine 0.5%. Patients were asked to score their pain using a 10-cm linear scale prior to insertion of the epidural, 30 minutes after its insertion and hourly thereafter. The quality of analgesia in the continuous infusion group was significantly better than in the intermittent top-up group (p less than 0.025). There was no significant difference in the total dose of bupivacaine given to the two groups.
Preoperative anxiety was assessed using the hospital anxiety and depression (HAD) scale, multiple affect adjective check list (MAACL) and linear analogue anxiety scale (LAAS) in 100 consecutive day case patients undergoing termination of pregnancy. The HAD scale, a recently introduced self assessment scale comprising 7 multiple choice questions, was readily accepted and easily understood by patients. There was a high degree of correlation between the HAD scale and both the MAACL (correlation coefficient 0.74) and the LAAS (correlation coefficient 0.67). There was only a moderate degree of correlation between the HAD scale and the anaesthetist's assessment of anxiety (correlation coefficient 0.46). The HAD scale is a useful method of subjective measurement of preoperative anxiety.
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The survival of patients in end-stage renal failure from lupus nephritis offered renal substitution therapy has been the subject of conflicting reports. Trying to clarify the reasons for this discrepancy, we analysed our experience with dialysis and transplantation in systemic lupus erythematosus (SLE). Of our 138 patients with lupus nephritis, 26 reached end-stage renal failure, of whom 24 received replacement therapy. Fourteen patients had a marked acute deterioration in renal function immediately before reaching terminal uremia, associated with active SLE in 12 and acute tubular necrosis after hypotension in one. Nine patients in this group died, 8 within 1 month of beginning dialysis. Nine patients progressed slowly to endstage renal failure over 2 to 7 years, without evidence of active SLE: only 1 required aggressive treatment and only 3 patients died, 1 five years after transplantation. Eight patients received altogether 10 allografted kidneys; 4 still functioning 10-24 months later; 2 patients are back on dialysis and 2 died, 1 of a myocardial infarct. There was no evidence of active SLE after transplantation. Ten patients were dialysed for more than 3 months; most were maintained on prednisolone and azathioprine whilst on dialysis and lupus activity tended to abate. The exclusion of the group of patients with rapid pre-terminal decrease in renal function from some series may explain some of the differences in reported survival. Stable patients with SLE present few problems in end-stage renal failure or after transplantation.
Fifty-three patients who by clinical and/or histological criteria were judged to have vasculitis affecting the kidney were reviewed. Patients with systemic lupus or Schönlein-Henoch purpura were excluded. Segmental necrotising glomerulitis was taken as a manifestation of vasculitis ('microscopic polyarteritis'). Those patients in whom vasculitis was confined to glomerular capillaries were compared with those who in addition had vascular lesions outside the glomeruli. The two groups were found to have identical clinical features. Clinical presentation was predominantly extrarenal, and exclusively renal in only two. Three patients were classified histologically as Wegener's granulomatosis, four had malignant tumours and two relapsing polychondritis. Hepatitis B surface antigen was absent in all of 37 patients tested. Renal disease presented with microscopic haematuria and minor proteinuria in the majority (32) but 16 patients presented with rapid deterioration of renal function, including seven with anuria. Histologically 42 patients showed segmental necrotising glomerulitis ('microscopic polyarteritis'), six diffuse proliferative glomerulonephritis,and in five only minor or ischaemic glomerular changes were present. Crescents were found in 41/42 of those with segmental necrotising glomerulitis, nd involved more than 50 per cent of glomeruli in 15 patients. Immunohistochemical studies were generally negative except the fibrin. Electron microscopy showed no evidence of immune deposits in necrotising glomerulitis, but these were present in 2/6 patients with diffuse proliferative glomerulonephritis. Overall prognosis was poor, 35 patients having died, 20 early in the course of the disease and 15 later. Oligoanuria and extensive crescent formation were adverse signs. Survivals were 54, 38 and 34 per cent at one, five and 10 years respectively. Of those who survived the initial illness, 12 were stable with apparently inactive disease, whilst 16 continued to show clinical signs of activity and required treatment. A variety of treatments was employed including oral and intravenous corticosteroids, immunosuppressive agents, anticoagulants; only one patient was treated by plasmapheresis. It is difficult to draw any firm conclusions as to the efficacy of treatment and survival rates remain unsatisfactory.
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Continuous exposure of HeLa cells in culture to elevated temperatures (41-45 degrees) results in cell killing which increases exponentially as the time at the elevated temperature increases linearly. When cells are returned to 37 degrees after an initial thermal dose, cellular sensitivity to subsequent hyperthermic doses is reduced. Cell inactivation rates for cultures previously treated with 44 degrees for either 0.5 or 1 hr followed by incubation at 37 degrees for 2 hr, showed D0's of 1.1 and 1.5 hr, respectively, for subsequent thermal treatments at 44 degrees. Cultures receiving no prior hyperthermic dose had a D0 of 0.5 hr for treatments at 44 degrees for up to 3.5 hr. The viable progeny of cells treated with 44 degrees for 1 hr, however, had the same sensitivity to thermal doses at 44 degrees as did previously unheated cells. These results and others demonstrate that (a) single thermal dose produce a state of thermotolerance in HeLa cells to subsequent hyperthermic doses; (b) the degree of thermotolerance produced is dependent on the magnitude (i.e., temperature and time at the elevated temperature) of the first thermal dose; (cy thermotolerance does not develop at the elevated temperature but requires a return of culture temperatures to 37 degrees; (d) cellular acquisition of thermal tolerance is dependent on cell metabolism, as demonstrated by an inhibition of the effect at 0 degrees; and (e) this effect is a transient phenomenon which is lost as cells divide following the first thermal dose.
The radiation dose to the base of the bladder and anterior rectal wall during radium applications for gynecologic cancer is a function of the distances between the source and the bladder and rectum. Precise measurement of these distances depends on a number of factors and cannot be obtained with current radiographic localization techniques. B-mode ultrasound is useful as a means of supplementing available information. While it is not necessarily more accurate than standard radiographs, it offers a three-dimensional appreciation of pelvic anatomy and does appear to be more accurate than transverse axial tomography.