Reversible khat-induced hepatitis: two case reports and review of the literature.

Recreational chewing of Catha edulis (khat) leaves is part of the ethnic culture of Somali, Yemeni and other East African societies for its stimulant properties. With increasing emigration, khat use has become common in these ethnic groups once they move to other areas such as Europe and the USA; one-third of the UK Somali population report khat use within the last month. Cathinone, the active component of the khat leaves, is controlled under the UK Misuse of Drugs Act, but the use of the khat plant and its leaves remains not subject to control in the UK. There have been several previous reports of acute hepatitis related to chronic use of khat leading to acute liver failure, and resulting in transplantation or death. We report two cases with severe acute khat-related hepatitis that resolved on cessation of khat use initially, but relapsed with further use, reinforcing the importance of permanent khat cessation to prevent progression to liver failure. With reference to the current literature, we also consider the difficult diagnosis of this disorder, then go on to consider the pathophysiology, mechanisms of liver injury and potential future areas of research.

An overview of techniques used to measure wound area and volume.

If wound area is to be used as an indicator of healing, then it is vital that all measurements are accurate and consistent. This depends largely on the measurement tool used. This paper offers an insight into the available evidence.

The Child Protection Register: a tool in the accident and emergency department?

AIMS: To determine the number of children on the Child Protection Register (CPR) attending the accident and emergency (A&E) department and the referral source, diagnostic category, and frequency distribution for such attendances. To determine whether lack of knowledge that a child is on the CPR results in failure to suspect non-accidental injury (NAI) if the standard indicators of NAI have been sought. METHODS: Access to the CPR was obtained. Records of each child attending the A&E departments of the United Hospitals Trust between June 1994 and May 2000 were reviewed. RESULTS: Over the six years 191 children were on the CPR. Seventy nine (41%) attended A&E departments on 206 occasions. Frequency of attendance ranged to 18 with a mean of 2.6. Self referral was the commonest source of referral (81%) followed by general practitioners (13%), 999 calls (5%), and a small number from schools (1%). Most presentations involved trauma-upper limb (21%), lower limb (14%), and head injury (8%). Almost all cases of trauma were adjudged to be consistent with the history and NAI not suspected. Common childhood illnesses accounted for the remainder of presentations. Only six children were identified as being on the CPR at the time of presentation. Concerns were raised in two other cases and concerns should have been raised in three other children. Social Services were alerted on five occasions directly by the parents themselves. CONCLUSIONS: It is concluded that in the absence of knowledge of the status of a child on the CPR attending the A&E department, that screening for the standard indicators of NAI is adequate to detect most cases of NAI.

Where do we go after the three standard cervical spine views in the conscious trauma patient? A survey.

The objective of this study was to assess, by questionnaire survey, national practice in respect of radiological assessment of the cervical spine in the conscious adult patient with suspected neck injury. The physicians in charge of accident and emergency departments with more than 25000 new patients per year were sent a questionnaire. One hundred and ninety-one replies were received from 243 physicians (79%). Sixty-five per cent of departments have written protocols for imaging the cervical spine. Seven per cent of departments use fewer than the three standard views for clearing the cervical spine. If adequate views do not visualize the cervicothoracic junction, 89% use swimmer's views and 12% use supine oblique views, prior to computerized tomography scanning. It is concluded that the majority of departments use three standard views in the first instance. Swimmer's views are the most common additional X-rays taken if the C7-T1 junction is not visualized, even though supine oblique views give better information about spinal alignment. Imaging of the cervical spine following trauma is difficult and guidelines should be drawn up to address these problems.

Violence and verbal abuse against staff in accident and emergency departments: a survey of consultants in the UK and the Republic of Ireland.

OBJECTIVES: To determine the incidence of verbal abuse and physical violence in accident and emergency (A&E) departments and to discover the extent of provision of security measures and instructions for staff on how to deal with these problems. DESIGN: A postal questionnaire. SETTING: A&E departments in the UK and the Republic of Ireland. SUBJECTS: Two hundred and seventy three consultants named in charge of 310 departments. MAIN OUTCOME MEASURES: Frequency of physical violence and verbal abuse, injuries sustained, perceived precipitating factors, security measures instituted, and legal action taken. RESULTS: Two hundred and thirty three replies were received. Alcohol, waiting times, recreational drug usage, and patients' expectations were perceived as the chief causes. Patients were the chief perpetrators with nurses being the commonest victims. Staff sustained 10 fractures, 42 lacerations, and 505 soft tissue injuries. There were 298 arrests and 101 court appearances that resulted in 76 convictions. Panic buttons and video cameras were the most common security measures. CONCLUSIONS: Staff within A&E departments are regularly abused, both verbally and physically. Inner city departments appear to be most affected. Documentation is poor. Perpetrators are seldom convicted. There do appear to be actions which hospitals could undertake that might help to ameliorate these problems.

Notification of infectious diseases by junior doctors in accident and emergency departments.

OBJECTIVE: To assess the knowledge about notifiable infectious diseases by accident and emergency (A&E) senior house officers. METHODS: A telephone questionnaire of senior house officers was carried out over a one week period at the end of their six month attachment in A&E departments in Northern Ireland. RESULTS: 81 (91%) of the senior house officers participated in the study; 23 (29%) realised that the doctor diagnosing the notifiable disease had a statutory duty to notify that disease; nine (11%) were aware there were three statutory lists in the United Kingdom. Knowledge about which infectious diseases require notification varied from 79/81 (98%) for meningococcal disease to 15/91 (19%) for methicillin resistant S aureus. Seventy nine (98%) of the doctors thought that a poster displayed in the A&E department would be helpful. There was no significant difference between duration of qualification and performance on the questionnaire (p = 0.2). CONCLUSIONS: Despite varying experience, junior doctors in A&E do not know which infectious diseases are notifiable by statute. They felt that it would be helpful to have a poster in the A&E department listing the notifiable diseases of that region. To encourage accurate reporting, interregional variation between the statutory lists should be abolished and replaced by one nationally agreed list.

Lack of specificity of new negative U waves for anterior myocardial ischemia as evidenced by intracoronary electrogram during balloon angioplasty.

Negative U waves on the surface electrocardiogram are reported to be a specific marker of myocardial disease. In the setting of ischemia, they correlate with stenosis of the left main and left anterior descending coronary arteries. To determine whether U wave changes are unique for anterior ischemia, the development of new U waves on the intracoronary electrogram was correlated with the location and magnitude of ischemia during coronary balloon angioplasty. Recordings were obtained during dilation of 43 vessels in 37 patients. New negative U waves developed during dilation of 12 vessels (7 of the left anterior descending, 4 of the left circumflex and 1 of the right coronary artery). New positive U waves developed during dilation of 18 vessels (12 of the left anterior descending, 3 of the left circumflex and 3 of the right coronary artery). The magnitude of ST segment change was 10.9 +/- 6.7 mm in the presence of a new U wave but only 3.4 +/- 2.8 mm in the absence of a new U wave (p less than 0.001). It is concluded that 1) negative U waves on the intracoronary electrogram are not specific for anterior ischemia; 2) new positive U waves on the intracoronary electrogram are as sensitive as new negative U waves for acute ischemia; 3) the development of a new positive or negative U wave is associated with the magnitude of myocardial ischemia; and 4) the recording of U waves may be related to the proximity of the recording leads to the location of ischemia.

Intracoronary electrocardiogram during torsade des pointes secondary to intracoronary papaverine.

Papaverine, a potent coronary vasodilator, is now commonly used to measure coronary reserve. We recorded intracoronary electrogram in a patient who developed Torsade des pointes after 10 mg of papaverine. This was associated with marked prolongation of the QT interval. The ventricular tachycardia self-terminated with shortening of the QT interval. We believe that although papaverine is a good agent because of its short duration of action, it must be used cautiously because of its effects on repolarization, which can result in arrhythmias.

Metabolic protection by verapamil during graded coronary flow reduction independent of effect on baseline systolic function. Separation of mechanical and ionic markers of ischemia.

Pretreatment with the calcium channel-blocking agent verapamil lowers the coronary flow associated with the first rise in myocardial extracellular potassium [( K+]e). The mechanisms underlying this effect are unclear. It is not known whether this effect is a manifestation of verapamil-induced reduction in baseline cardiac work before the reduction in coronary flow, is dependent on a selective depression of contractility within the low-flow region, or is independent of an effect on myocardial work. This study was performed to determine the relations between changes in regional contractility and [K+]e before and after verapamil (0.2 mg/kg followed by 6.5 micrograms/kg/min) when left anterior descending (LAD) coronary flow is progressively reduced and when verapamil-induced alterations in baseline myocardial work are prevented by atrial pacing and by dobutamine (4.3 +/- 2.2 micrograms/kg/min) to maintain systemic arterial blood pressure and contractility. Before verapamil-dobutamine, myocardial [K+]e rose and regional contractility fell when LAD coronary flow was reduced to 87.7 +/- 9.6% and 83.4 +/- 7.4%, respectively, of the unrestricted control value (p = NS). After verapamil-dobutamine, the threshold flow for rise in [K+]e decreased to 56.4 +/- 13.5% of the unrestricted control flow (p = 0.003), but the threshold flow for regional contractility fall was unchanged (84.8 +/- 11.3%). Our results indicate that the protective effect of verapamil on preventing ischemia-induced [K+]e release is not dependent on a reduction in baseline myocardial work. In this setting, calcium channel blockade by verapamil results in a dissociation between the ionic and mechanical events that occur when coronary flow is reduced.

Effects of verapamil and propranolol on changes in extracellular K+, pH, and local activation during graded coronary flow in the pig.

The beta-adrenergic and calcium channel blocking agents are known to reduce heart rate and alter myocardial contractility. More recent evidence suggests that both agents affect the metabolic consequences of ischemia, independent of their effects on heart rate and contractility. We used a low-flow model of ischemia in swine with heart rate held constant by atrial pacing. Blood was shunted from the carotid artery to the left anterior descending coronary artery through a controlled-flow roller pump to assess the threshold flow for the rise in extracellular potassium ([K+]e) and fall in extracellular pH (pHe) associated with ischemia during control situations and after the administration of either propranolol or verapamil. We also measured the changes in activation delay and contractility associated with graded flow reductions in the presence and absence of these drugs. We found that when heart rate is held constant, 1) verapamil shifts the threshold flow for [K+]e and pHe to lower levels, but propranolol does not; 2) verapamil lessens activation delay, while propranolol aggravates the delay; and 3) verapamil reduces afterload and selectively depresses contractility in the reperfused ischemic zone. We conclude that the calcium channel blockers and the beta-adrenergic-blocking agents have different effects and possibly different modes of action and should not be considered interchangeable when evaluating therapeutic options for patients with ischemic heart disease.

Purification of a calcium-activated neutral proteinase from bovine brain.

A calcium-activated neutral proteinase (CANP) resolved into three components has been partially purified from bovine brain. The method of isolation has resulted in 22,000, 7,100, and 8,000-fold purification for CANP I, II and III respectively. All three fractions require Ca2+ for activation. The characterization of the purified CANP I has shown that it is activated by 250 microM Ca2+ and the enzyme loses its activity when incubated in the presence of Ca2+ without substrate. Mg2+ is ineffective. The enzyme degrades neurofilament triplet proteins, tubulin and casein efficiently. The myelin basic protein is hydrolyzed after longer incubation. Bovine serum albumin and histones are unaffected. The enzyme is active at pH 5.5 to 9.0 with optimum between pH 7.5 and 8.5. It has a Km of 1.8 X 10(-7) M for the 69,000 dalton neurofilament protein. The enzyme is inhibited by sulphydryl blocking reagents and also by EGTA, leupeptin and E-64c. The SDS-PAGE analysis of the enzyme fractions has shown a major band at 66-68,000 daltons and two minor bands at 60,000 and 48-50,000 daltons for CANP I; a major band at 48-50,000 daltons and a minor band at 30-32,000 daltons for CANP II and a predominant doublet at 30-32,000 daltons with a minor band at 48-50,000 daltons for CANP III. The degradation of neurofilament proteins suggests that the CANP(s) may be involved in the turnover of these proteins.