CSF neurofilament levels: a potential prognostic marker in Guillain-Barré syndrome.

Long-term morbidity from Guillain-Barré syndrome (GBS) is caused by axonal damage. This prospective study demonstrated that neurofilaments (NfHs), a biomarker for axonal damage, were of prognostic value in GBS. CSF NfH levels correlated with the F score and Medical Research Council summed score and were higher in patients with neurophysiologic evidence of axonal degeneration compared to those without. Pathologically high CSF NfH levels (>0.73 ng/mL) predicted worse motor and functional outcome.

Clinical presentation and management of patients with uncontrolled, severe hypertension: results from a public teaching hospital [abstract]

During the period 1st January, 2000 to 30th June, 2000, 156 patients who presented to the Accident and Emergency Department and had a blood pressure defined by WHO-ISH as grade 3 (severe) hypertension and received nifedipine 10 mg, were reviewed. The most common presentation was epigastric pain. All patients responded rapidly and effectively to nifedipine without tachycardia, gastrointestinal or other notable side effects of nifedipine. Contrary to current medical opinion, the study found that nifedipine was safe and effective, creating a possible dilemma for its use by primary care physicians in a developing country. (AU)

Acute severe asthma in Trinidad and Tobago.

SETTING: Accident and emergency department, General Hospital, Port of Spain, Trinidad and Tobago. OBJECTIVE: To measure the occurrence and clinical management of acute severe asthma. DESIGN: Data collected prospectively for consecutive attendees with asthma over a period of 3 months. RESULTS: Asthma accounted for 8.8% of attendances. Treatment for the acute attack included nebulised salbutamol in 1031 (85%) and nebulised atrovent in 769 (63%). Systemic corticosteroids were given to 623 (51%) patients. Only 247 (20%) had planned follow-up arrangements recorded. Usual maintenance treatment included inhaled salbutamol in 767 (63%) and inhaled corticosteroid in 286 (24%). Inhaled corticosteroids were more often used by patients aged > or =15 years or who had had previous hospital admissions for asthma. CONCLUSION: The survey identified deficiencies in the clinical management of acute asthma attacks and in longterm asthma care. Caribbean guidelines for asthma care have subsequently been published, and follow-up surveys should be carried out to evaluate their implementation.

Acute severe asthma in Trinidad and Tobago

SETTING: Accident and emergency department, General Hospital, Port of Spain, Trinidad and Tobago. OBJECTIVE: To measure the occurrence and clinical management of acute severe asthma. DESIGN: Data collected prospectively for consecutive attendees with asthma over a period of 3 months. RESULTS: Asthma accounted for 8.8 percent of attendances. Treatment for the acute attack included nebulised salbutamol in 1031 (85 percent) and nebulised atrovent in 769 (63 percent). Systemic corticosteroids were given to 623 (51 percent) patients. Only 247 (20 percent) had planned follow-up arrangements recorded. Usual maintenence treatment inlcuded inhaled salbutamol in 767 (63 percent) and inhaled corticosteroid in 286 (24 percent). Inhaled corticosteroids were more often used by patients aged > or =15 years or who had had previous hospital admissions for asthma. CONCLUSION: The survey identified deficiencies in the clinical management of acute asthma attacks and in longterm asthma care. Caribbean guidelines for asthma care have subsequently been published, and follow-up surveys should be carried out to evaluate their implementation.(Au)

Hypokalaemia during insulin-induced hypoglycaemia in hypopituitary adults with and without growth hormone deficiency.

OBJECTIVE: We have investigated plasma potassium changes during insulin-induced hypoglycaemia (IIH) in adult patients with growth hormone deficiency (GHD) who have low total body potassium and may also have a vulnerable myocardium due to an increased prevalence of atherosclerosis. DESIGN: Hypoglycaemia was induced through the administration of intravenous soluble insulin (0.1 U/Kg, i.v.). SUBJECTS: 23 consecutive adult patients undergoing routine biochemical evaluation for hypopituitarism. MEASUREMENTS: GH, cortisol glucose, sodium and potassium levels were measured at 0, 30, 60, 90 and 120 min after insulin administration. Pituitary function was also assessed through measurement of TSH, thyroid hormones, LH/FSH, testosterone and 17-oestradiol. IGF-I concentrations were also analysed. RESULTS: All patients achieved adequate hypoglycaemia (nadir glucose < 2 mmol/l). 15 patients had GHD (peak GH < 10 mU/l) either in isolation or as part of a spectrum of pituitary hormone deficiencies. The remaining 8 patients had normal pituitary function. Plasma potassium concentrations (mean +/- SEM) fell from 3.8 +/- 0.3 mmol/l (normals) and 3.8 +/- 0.2 mmol/l (GHDs) to nadir concentrations of 3.0 +/- 0.2 mmol/l and 3.1 +/- 0.3 mmol/l, respectively (P < 0.005). Overt hypokalaemia (< 3.5 mmol/l) occurred in 13/15 GHDs and all normals. There were no significant differences between the groups. CONCLUSIONS: Insulin-induced hypoglycaemia causes similar degrees of significant hypokalaemia in patients with normal pituitary function and in those with GH deficiency, either alone or in combination with other pituitary hormone deficiencies. Therefore, insulin-induced hypoglycaemia does not appear to be associated with any greater risk of hypokalaemia in hypopituitary adults with GHD compared to those with normal anterior pituitary function.

Acute severe asthma at the Port-of-Spain General Hospital, Trinidad

We studied attendance for acute asthma at an Accident and Emergency department over a three-month period. Clinical details were recorded for 1248 subjects with an estimated ascertainment rate of 54 percent. Of 1213 subjects with known age, there were 453 (37 percent) aged 0-11 years, 141 (12 percent) aged 12-17 years, and 619 (51 percent) aged 18 years or older. There were 846 (70 percent) Afro-Trinidadian; 751 (62 percent) had previous attacks; and 667 (55 percent) had previous hospital admissions. Indicators of the severity of the attack were recorded as follows; heart rate, 968 (80 percent). respiratory rate, 985 (81 percent), peak flow rate, 495 (41 percent). The patient's usual maintenance treatment included inhaled salbutamol in 767 (63 percent) and inhaled corticosteroid in 286 (24 percent). Inhaled corticosteroids were more often used by patients aged > 18 years or who had previous hospital admissions for asthma. The acute attack was treated with nebulized salbutamol in 1031 (85 percent), nebulized atrovent in 769 (63 percent), intravenous corticosteroids in 268 (22 percent) or oral corticosteroids in 370 (31 percent). Overall corticosteroids were given in the acute attack to 623 (51 percent), corticosteroids were more often given to those > 18 years and those with higher respiratory rates (OR 1.41, 95 percent CI 1.02 yo 1.96). Only 247 (20 percent) had planned follow up arrangements recorded. We conclude that asthma attacks are common and often recurrent. Prophylactic treatment with inhaled corticosteroids may be under-utilized. Acute attacks are mostly treated with bronchodilators. Planned follow-up is not usual. It is possible that morbidity might be reduced through greater use of prophylactic treatment in those with recurrent symptoms.(AU)

Assessment of swallowing and referral to speech and language therapists in acute stroke.

The best clinical assessment of swallowing following acute stroke, in order to decide whether to refer a patient to a speech and language therapist (SLT), is uncertain. Independently of the managing clinical team, we prospectively investigated 115 patients (51 male) with acute stroke, mean age 75 years (range 24-94) within 72 h of admission, using a questionnaire, structured examination and timed water swallowing test. Outcome variables included referral to and intervention by a speech and language therapist (SLT), dietary modification, respiratory complications and death. Of those patients in whom an SLT recommended intervention, 97% were detected by an abnormal quantitative water swallowing test; specificity was 69%. An SLT was very unlikely to recommend any intervention if the test was normal. Inability to perform a water test and/or abnormality of the test was associated with significantly increased relative risks of death, chest infection and dietary modification. A timed water swallowing test can be a useful test of swallowing and may be used to screen patients for referral to a speech and language therapist after acute stroke.

Growth hormone deficiency and hypogonadism in a patient with multiple sclerosis.

We describe the case of a 30-year-old female patient with a 7-year history of multiple sclerosis, who presented with an 18-month history of secondary amenorrhoea and vague symptoms which included poor sleep and impaired concentration. Endocrine investigations revealed hypogonadotrophic hypogonadism and GH deficiency, a probable consequence of a hypothalamic plaque. This is the first report of hypogonadotrophic hypogonadism and GH deficiency occurring in conjunction with multiple sclerosis. As such, it should raise suspicion of endocrine dysfunction occurring in a condition with such a vast spectrum of disability as multiple sclerosis.