The haemodynamic effects of crystalloid and colloid volume resuscitation on primary, derived and efficiency variables in post-CABG patients.

BACKGROUND: Recent studies in haemodynamic management have focused on fluid management and assessed its effects in terms of increase in cardiac output based on fluid challenges or variations in pulse pressure caused by cyclical positive pressure ventilation. The theoretical scope may be characterised as Starling-oriented. This approach ignores the actual events of right-sided excitation and left-sided response which is consistently described in a Guyton-oriented model of the cardiovascular system. AIM: Based on data from a previous study, we aim to elucidate the primary response to crystalloid and colloid fluids in terms of cardiac output, mean blood pressure and right atrial pressure as well as derived and efficiency variables defined in terms of Guyton venous return physiology. METHOD: Re-analyses of previously published data. RESULTS: Cardiac output invariably increased on infusion of crystalloid and colloid solutions, whereas static and dynamic efficiency measures declined in spite of increasing pressure gradient for venous return. DISCUSSION: We argue that primary as well as derived and efficiency measures should be reported and discussed when haemodynamic studies are reported involving fluid administrations.

Adult-onset inflammatory myopathy: North Canterbury experience 1989-2001.

AIM: To perform a clinical audit of all patients diagnosed with inflammatory myopathy in the North Canterbury region. METHODS: A retrospective case note audit of patients with a discharge diagnosis of inflammatory myopathy from June 1989 to June 2001 was performed. The audit was based at Christchurch Hospital, New Zealand, which services a population of 430,000. RESULTS: Of 77 case notes reviewed, 44 patients were identified who were considered to fulfil clinical criteria for inflammatory myopathy. There was a female preponderance (80% female, 20% male). Diagnostic categories in descending order of frequency included: dermatomyositis (41%), polymyositis (39%), inclusion body myositis (IBM) (14%) and overlap syndromes (6%). Malignancy-associated myositis occurred in 20% overall (dermatomyositis 11%, polymyositis 9%). Delays in diagnosis and late age at presentation (average 72 years) were seen in the IBM group. Proximal limb weakness was common, but not universal at presentation (80%). A muscle biopsy was performed in all patients and electromyography in 82%. All were treated with high dose prednisone (0.5-1 mg/kg) of whom 29% were maintained on prednisone alone. Immunosuppressives/immunomodulators used included: azathioprine (58%), methotrexate (31%), intravenous immunoglobulin (13%), chlorambucil (13%), and cyclophosphamide (9%). Thirteen patients (42%) required more than one agent, with three trialling five agents. There were 59 relapses in 20 patients (45%), with mean time to first relapse of 7.8 months. At audit completion, 33% had deceased with malignancy and respiratory failure the main causes. CONCLUSION: Inflammatory myopathy is a challenging condition in both diagnosis and management. Our audit has shown delays in the diagnosis of IBM, a relatively high incidence of malignancy and a notable risk of relapse and mortality.

Variation in the risk of peptic ulcer complications with nonsteroidal antiinflammatory drug therapy.

OBJECTIVE: To assess the risk of perforation or hemorrhage of peptic ulcer on treatment with nonsteroidal antiinflammatory drugs (NSAIDs), both as a class and as individual agents. METHODS: A case-control study of medication histories in 494 patients and 972 matched control subjects. RESULTS: The increase in risk (odds ratio) with NSAID therapy was 5.1 times the risk in controls. The odds ratio for piroxicam was 6.3 (95% confidence interval [CI] 3.3-12.0), as compared with 2.9 for diclofenac, ketoprofen, and sulindac combined (95% CI 2.0-4.2). The effect of other risk factors was also considered, and the adjusted odds ratios were 4.1 for all NSAIDs, 6.4 (95% CI 2.8-15.0) for piroxicam, and 3.3 (95% CI 2.0-5.5) for diclofenac, ketoprofen, and sulindac combined. CONCLUSION: The estimate of overall risk of peptic ulcer complications with NSAIDs is similar to that found in other studies. There appear to be differences in risk between agents.

Rheumatoid pleural effusion: response to intrapleural corticosteroid.

The management of a patient with a large symptomatic rheumatoid pleural effusion is described. Thoracentesis and bed rest gave only short term modest benefit. A more lasting and beneficial response was obtained with an intrapleural injection of (120 mg) depomethylprednisolone acetate. This treatment is a useful interim measure until disease suppressive therapy gives systemic control.

Possible mechanism for mianserin induced neutropenia associated with saturable elimination kinetics.

Two cases of mianserin induced neutropenia associated with prolonged elimination of the drug were studied. In each case the pharmacokinetic profile suggested saturable elimination kinetics, and the temporal relation of mianserin concentrations and the neutrophil count suggested a direct toxic effect of mianserin on the bone marrow. Until further studies are carried out the plasma mianserin concentration and neutrophil count should be measured in any patient who develops an infection while taking this drug.

Still's disease associated with Coxsackie infection and haemophagocytic syndrome.

At the onset of Still's disease (systemic-onset juvenile arthritis) in a 12-year-old girl, serological evidence of Coxsackie B virus infection was found. Two weeks later she developed a haemophagocytic syndrome which was then treated with cytotoxic therapy. Her arthritis is still active six years later.

Legionnaires' disease in a patient with polymyositis.

A 29 year old woman with polymyositis treated with azathioprine presented with pneumonia. Rising serum antibody titres have confirmed a diagnosis of legionnaires' disease. Infection with Legionella pneumophila must now be considered in New Zealand when patients present with pneumonia and severe pyrexia, especially if they show known risk factors.