Outcome after treatment of neurological decompression illness is predicted by a published clinical scoring system.

BACKGROUND: After recompression therapy, some cases of neurological decompression illness (DCI) have a significant residual deficit. Boussuges et al. report a scoring system to predict sequelae using weighted historical and clinical indices at presentation which we applied to the British Hyperbaric Association (BHA) database of UK diving accidents, held at the Institute of Naval Medicine (INM). METHODS: A database search identified 234 cases of neurological DCI from the 2 yr, 1995-6. Of these, 217 case records contained sufficient data to apply the scoring system. Outcome was classified as severe sequelae (i.e., causing a functionally important deficit) or as mild/no sequelae. RESULTS: The median score in UK cases with severe sequelae was 13 (95% C.I. 11.5 to 14.5) and in cases with mild/no sequelae, 6 (95% C.I. 5.5 to 6.5). Significantly more cases with scores > 7 had severe sequelae than cases with scores < or = 7 (chi2, p < 0.0001). The sensitivity of a score > 7 (for severe sequelae) was 94% and the specificity was 65%. The positive predictive value of a score > 7 (for severe sequelae) was 18% and the negative predictive value of a score < or = 7 was 99%. CONCLUSIONS: When applied to the INM/BHA database a score of > 7 by this scoring system has a higher sensitivity and lower specificity for severe sequelae than reported by Boussuges et al. It has a higher predictive accuracy for successful outcome of treatment (99% vs. 89%) but a much lower predictive value for severe sequelae (18% vs. 86%). Convergence between this and other published scoring systems may allow derivation of a generic scoring system that could then be evaluated prospectively in multiple centers.

Arterialised earlobe blood gas analysis: an underused technique.

BACKGROUND: Techniques for sampling arterialised capillary blood from the finger pulp and the earlobe were first described over two decades ago but, although close agreement between arterial values and earlobe samples has been demonstrated in normal subjects, this technique is not in common usage. METHODS: Forty patients with chronic lung disease and a wide range of arterial blood gas values were studied. Simultaneous earlobe and arterial samples were drawn with the patient at rest and analysed in the same blood gas analyser. The respiratory function laboratory staff in 50 UK hospitals with a respiratory department were telephoned and asked whether the technique was used in their hospital and the reasons, if known, for not adopting it. RESULTS: Earlobe and arterial blood gas tensions agreed closely over a wide range of values of arterial pH, PCO2 (mean difference 0.21, 95% confidence intervals -0.24 to +0.67 kPa) and PO2 (mean difference -0.17, 95% confidence intervals -1.09 to +0.75 kPa), especially at arterial PO2 values lower than 8 kPa. Of 50 UK centres surveyed 18% used the arterialised earlobe technique and 4% had plans to introduce it. Reasons for not using it were lack of knowledge in 64%, no blood gas analyser in 6%, the technique was considered inaccurate in 4%, and insufficient staff in 4%. CONCLUSIONS: Although earlobe blood gas analysis is sufficiently accurate to be reliably substituted for arterial sampling in routine clinical practice, most centres in the UK do not use the technique. The main reasons for this appear to be lack of knowledge of its existence and uncertainty over its accuracy.

Covert multi-focal infective arthritis.

Six patients with pre-existing rheumatic joint disease presented with overwhelming septicaemia but without overt signs of joint inflammation. Joint aspirates demonstrated multifocal staphylococcal infective arthritis. Despite intensive care all six died from the infection or its immediate sequelae. The contrast between this clinical entity and classical infective arthritis, presenting with one or more swollen, tender joints, is discussed.

Changing patterns of respiratory disease in HIV positive patients in a referral centre in the United Kingdom between 1986-7 and 1990-1.

BACKGROUND: Respiratory illness is a significant contributor to morbidity and mortality in patients with human immunodeficiency virus (HIV) infection and the acquired immunodeficiency syndrome (AIDS). It has been suggested that Pneumocystis carinii pneumonia is no longer the most frequent cause of respiratory disease in this group because of widespread use of prophylaxis and anti-retroviral drugs. METHODS: A retrospective comparison of the diagnoses in HIV 1 antibody positive patients with respiratory illness admitted to a major UK centre in 1986-7 and 1990-1 was carried out to identify changes in patterns of respiratory disease. RESULTS: In the 1986-7 period there were 73 patients, of whom none received zidovudine or prophylaxis for pneumocystis pneumonia while in the 1990-1 period there were 122 patients. One hundred and ninety patients (98%) were male homosexuals. Pneumocystis pneumonia remained the commonest respiratory disease, comprising 68% of all diagnoses in the 1986-7 period and 48% in the 1990-1 period. Bacterial infections (bronchitis and pneumonia) were seen more commonly in the 1990-1 period (23%) than in the 1986-7 period (14%), as was pulmonary Kaposi's sarcoma (12% in 1990-1 and 4% in 1986-7). Mycobacterial infection remained uncommon (4% in 1986-7 and 6.5% in 1990-1). CONCLUSION: Despite widespread use of zidovudine and prophylaxis, pneumocystis pneumonia remains the commonest respiratory disease in homosexual men.

Clinical cases in AIDS. 2.

As the human immunodeficiency virus (HIV) epidemic continues, there are increasing numbers of patients with HIV-related disease. Those doctors studying for the MRCP exam will need to be familiar with the common manifestations of HIV infection and acquired immunodeficiency syndrome.

Clinical cases in AIDS. 1.

As the human immunodeficiency virus (HIV) epidemic continues there are increasing numbers of patients with HIV-related disease. Doctors studying for the MRCP exam will need to be familiar with the common manifestations of HIV infection and acquired immunodeficiency syndrome.