A one year-review of anti-epileptic drug monitoring in Trinidad

OBJECTIVE: To audit anti-epileptic drug monitoring in tertiary hospitals in Trinidad. METHODS: Epileptic patients, from hospital clinics, who were receiving maintenance therapy and were referred for plasma drug level monitoring, gave informed consent and were enrolled. Blood collection was at trough levels of drug and coded plasma samples were analysed by competitive immunoassay on the TDx Monitoring system. RESULTS: All 93 patients consented to participate. Phenytoin and carbamazepine were the two major drugs prescribed. The use of multiple drugs did not influence the occurrence of seizures in the patients; (31 percent) receiving polytherapy. Phenobarbital was the most frequent agent added to the drug regime in 24/9 patients (83 percent). Low plasma levels of drugs were detected in 58 percent and 36 percent of patients receiving polytherapy with phenytoin and carbamazepine respectively; but an association was not found between the range of drug levels and the frequency of seizures. Seventy-seven (83 percent) patients reported good compliance. Plasma drug levels were significantly below normal (p=0.004) in patients who reported poor compliance. CONCLUSIONS: Multiple drug therapy did not influence the prognosis of seizure control in this study. Suspected non-compliance, drug toxicity and failure to individualize dosing are considerations for plasma level drug monitoring in the protocol for management of epilepsy.(Au)

Suspected acute myocardial infarction: intravenous beta-blockade outside the coronary care unit: a pilot study

Shortage of Coronary Care Unit (CCU) beds prompted a study (I) to determine the number of patients with a suspected acute myocardial infarction (SAMI) who could not be placed in the CCU, but qualified for intravanous (IV) B-Blocker therapy, and (II) to assess the safety of such therapy in a general medical ward. During a six-month period, 34 patients with chest pain and E.C.G. changes of SAMI could not be placed in the CCU. Criteria for exclusion from B-Blocker therapy were the presence of >= 1 of the following: (1) age > 70 years, (2) Systolic B.P. < 100 mmHg, (3) Heart rate < 60 /min., (4) Cardiac failure, (5) Heart block, (6) Poor peripheral circulation, (7) Asthma or chronic bronchitis, and (8) Prior therapy with B-Blocker or calcium antagonists. 15 (44 percent) patients were excluded from therapy based on the above criteria. 19 (56 percent) received 5-10 mg atenolol IV within 3-10 hours of onset of chest pain and atenolol 100 mg daily was started immediately and continued indefinitely. 12 of these patients had an anterior wall, and 3 an inferior wall infarction. 3 developed congestive cardiac failure and none required anti-arrhythmic therapy. There were 2 deaths - 1 from ventricular asystole, and the other from cardiogenic shock 8 and 12 hours respectively after IV atenolol. While this small-scale study highlights the need for more CCU beds for optimum care, our results suggest that selected patients with SAMI managed in the general medical wards can still safely obtain the benefits of IV B-Blockade. (AU)

Sick sinus syndrome and primary systemic amyloidosis

A sixty-eight-year-old woman with documented sick sinus syndrome was found to have, five years later, florid clinical features of systemic amyloidosis which only then led to recognition of an underlying IgA, Kappa paraproteinaemia. The literature on this association is outlined. Underlying plasma cell dyscrasias should be excluded in cases of unexplained sick sinus syndrome.(AU)

Modified plasma exchange in life-threatening Guillain-Barre syndrome - abstract

Modified plasma exchange (MPE), a simpler procedure than a conventional plasmapheresis which uses automated equipment and expensive replacement fluids, has recently been recommended for use in hospitals with limited resources in the management of patients with Guillain-Barre Syndrome (GBS). We have performed MPE in 7 patients with life-threatening respiratory failure due to GBS, using fresh frozen plasma as replacement fluid. In 5 out of 6 patients, in whom MPE was started at the onset of mechanical ventilation, rapid improvement inconsistent with the natural history of the disease was noted. In 2 of these patients, due to severity of illness, more plasma per day than previously recommended was safely removed. In one patient, MPE was started with a peak expiration flow rate of 2.2 litres per minute and assisted ventilation was unnecessary due to rapid improvement. Death occurred in one patient from respiratory complications and was not directly due to MPE. Our study confirms the safety and efficacy of MPE and suggests that more plasma can be safely exhanged by this method than previously recommended (AU)

Acute porphyria in Trinidad - abstract

Prompted by reports of acute porphyria in continental Africa and India, and in African populations in the U.S.A., a prospective study was undertaken to determine prevalence and characteristics of acute porphyria amongst emergency admissions to the medical wards of a West Indian general hospital over a 30-month period. The population surveyed was about 500,000 persons mainly from African and Indian (Asian) descent. Criteria for diagnosis were suggestive clinical features, past medical history and the presence of excess of urinary porphobilinogen as determined by the Watson Schwartz test. Six unrelated cases of typical acute porphyria were identified from among 25,000 admissions. Sixty controls matched for age, sex and ethnic origin had a negative Watson Schwartz test. Patients ranged in age from 13 to 26 years and none had a family history of porphyria-type illness. Ethnic origin was not a distinctive feature and there was considerable morbidity due to non-recognition that acute porphyria is more common in West Indians than hitherto suspected and there should be greater efforts to diagnose the disease (AU)

Malignant carcinoid syndrome: failure of anti-oestrogenic therapy

A pre-menopausal patient with a six-year history of symptoms of the metastic carcinoid syndrome leading to progressively worsening carcinoid heart disease is described. The failure of anti-oestrogenic therapy (sequential bilateral oophorectomy and Tamoxifen therapy) to halt progression of disease was documented. Death resulted from right ventricular failure associated with pulmonary and tricuspid valvular disease (AU)

Monosodium acid methanearsonate (M.S.M.A.) poisoning in man

A case of self-poisoning by the weed-killer monosodium acid methanearsonate is reported. Complications observed included gastritis, deafness, myocarditis, hepatitis, nephritis, peripheral neuropathy and eosinophilia. Transverse white bands (Aldrich Mee's lines) appeared on the finger nails eight weeks later, and severe bilateral sensorineural deafness, an hitherto undescribed complication, was still present after one year. There is need for an increased awareness of the toxic effects of this arsenical used locally (AU)