Thyroid storm presenting as multiple organ dysfunction syndrome.

Thyroid storm is a rare disorder characterized by hypertension, hyperthermia, and multiple systems involvement. Early recognition and treatment of thyroid storm are essential in reducing morbidity and mortality from this disorder. We present the case of a patient with an atypical (normothermic, normotensive) presentation of thyroid storm, accompanied by multiple organ dysfunction syndrome, including lactic acidosis and liver dysfunction, both of which are very rare complications. This case highlights both the multiple organ systems that can be involved in thyroid storm and the importance of recognizing atypical presentations of thyroid storm.

QE-Mail--improving communication between the hospital and general practitioners.

OBJECTIVE: To describe the process of developing a therapeutic bulletin with a view to improving communications between providers of primary and secondary care and to survey general practitioners to assess their responses to the bulletin and to ascertain their further information needs. METHODS: A clinical panel was convened to select relevant topics for inclusion in the bulletins. The topic for each bulletin was researched and written using standard information sources and relevant experts. A survey was mailed with the first edition of the bulletin, to GPs in the Western Division of General Practice and in country areas, and to Directors of Nursing from country hospitals. RESULTS: The overall response rate to the survey was 41%. The majority of respondents had read the bulletin and found it useful. Most thought that the presentation, in terms of length, detail and layout, was suitable. Topics suggested for future editions included antibiotics, antihypertensives and antidepressants. CONCLUSION: The bulletin, QE-Mail, was well received and helped to inform GPs about current practices at the hospital. Future directions include the use of e-mail to distribute the bulletins and a follow up survey to determine if the bulletin is still meeting practitioners' needs.

Epidemiological study of angioedema and ACE inhibitors.

BACKGROUND: Angioedema is an uncommon and poorly recognised adverse reaction to angiotensin converting enzyme inhibitors (ACE-Is). The epidemiology of this association has not been described. AIMS: To examine the epidemiology of angioedema and its relation to ACE inhibitor prescribing. To examine the characteristics of angioedema occurring in patients taking ACE inhibitors. METHODS: A retrospective case control study and a case note audit were conducted of 40 patients who presented to a teaching hospital Accident and Emergency Department with angioedema on 48 occasions. One hundred and sixty control subjects presenting to the same Accident and Emergency Department but without angioedema were matched to cases by age, sex and presentation date. An ecological study comparing the numbers of angioedema admissions by age cohorts to South Australian (SA) public hospitals with the prescription volumes of ACE-Is in Australia was also undertaken. RESULTS: Case control study: In patients presenting with angioedema compared with controls, the exposure odds ratio for ACE-Is was 5.1 (95% CI 2.03-12.89) and for non-steroidal anti-inflammatory drugs (NSAIDs) was 4.13 (95% CI 1.28-13.39). CASE NOTE AUDIT: 15/40 (38%) patients presenting with angioedema on 19/48 (40%) occasions were taking an ACE-I. These patients were older and less likely to have an atopic history than those not taking an ACE-I. The onset of angioedema after starting an ACE-I was delayed for greater than six months in nine patients. ACE-I therapy was continued after 53% of presentations. ECOLOGICAL STUDY: The number of admissions with angioedema to SA public hospitals increased between 1985-86 and 1994-95, predominantly in older patients, and paralleled the increasing prescription volumes of ACE-Is. CONCLUSIONS: A considerable proportion of patients presenting with angioedema will be taking an ACE-I or a NSAID. The association of ACE-Is and angioedema is not well recognised, partly because the onset of angioedema may be delayed for months or years after commencement of an ACE-I. A persisting risk of angioedema is present in patients who have initially commenced an ACE-I uneventfully. The epidemiology of angioedema is now changing in parallel with the increasing use of ACE-Is.

Androgens and sexuality.

A review of the literature reveals that the endocrine determinants of female sexuality are complex and difficult to characterize. In adolescent males, free testosterone directly affects sexual motivation, with social factors exerting little or no effect. In adolescent girls, by contrast, societal and peer pressure play a pivotal role in the appearance of certain sexual behaviors. Throughout a woman's life, hormonal and psychosocial factors are critical influences. It is possible that cyclic patterns of testosterone are less important for female sexual behavior than the "tonic" effect of overall testosterone levels. Although the estrogen dependence of the vaginal epithelium--important for postmenopausal women--has been clearly established, the role of other hormonal factors and treatments, particularly those involving androgens, in human female sexual behavior remains enigmatic. The search for an understanding of these relationships is not merely an interesting academic exercise but is necessary to determine what role, if any, androgens may play in the treatment of sexual dysfunction during the female reproductive years.

PIP: The strong association between testosterone, pubertal development, and libido observed in adolescent males does not appear in females. Rather, the sexuality of adolescent females seems to be affected to a larger extent by peer group interactions and psychosocial issues. Controlled studies of the effects of androgen administration as well as correlation studies focusing on circulating levels of androgens and female sexual behavior have produced divergent findings and are limited by a failure to measure biologically active testosterone. Generally, pooled data indicate that female sexual interest is highest shortly after, shortly before, or during menstruation. Other studies suggest that cyclic patterns of testosterone are less relevant to female sexuality than the "tonic" effect of overall testosterone levels. Oral contraceptive users have substantially lower levels of free testosterone than nonusers, yet there is no evidence that this change is linked with reduced sexual interest or activity. It is important that future research in this area take into account the confounding effects of psychosocial factors.

Adenotin and adenotin-like proteins coexist with adenosine receptors in mammalian tissues.

The relationship of adenotin, a low-affinity adenosine-binding protein, to adenosine receptors was examined in two human tissues and two mammalian cultured cell lines. An adenosine A2 receptor exists in the membranes from platelets, PC-12 cells, and JAR cells as shown by a stimulation of adenylate cyclase related to 5'-N-ethylcarboxamidoadenosine (NECA) or a NECA-related increase in intracellular cAMP levels. In contrast, binding studies with tritiated NECA revealed typical adenotin-like low-affinity binding sites on the membranes from the sources studied with agonist potencies as follows: NECA greater than 2-chloroadenosine greater than R-PIA. No evidence was found of coupling to a guanine nucleotide regulatory protein. Solubilization of platelet and placental membranes and precipitation with polyethylene glycol separated adenotin or the adenotin-like protein from a second adenosine binding site in each tissue. The pharmacologic properties of the precipitated binding sites were compatible with an adenosine A2 receptor in platelets and an adenosine A1 receptor in placenta. Our observations indicate that adenotin-like proteins exist outside the placenta. In addition, adenotin and adenotin-like proteins coexist with the adenosine A1 or A2 receptor in a number of cells and tissues and do not couple to a guanine nucleotide regulatory protein and stimulate adenylate cyclase. Therefore, adenotin is pharmacologically distinct from adenosine receptors, and its function remains to be discovered.