Showing papers by "Royal Melbourne Hospital published in 1980"

Diabetes mellitus in urban and rural communities in Papua New Guinea. Studies of prevalence and plasma insulin.

Abstract: Oral glucose tolerance tests (75 g) in 185 urban residents of Port Moresby and 105 ethnically similar rural villagers showed that 15.8% of urban residents had diabetes mellitus (two hour plasma glucose > 11.0 mmol/l and a total of 22% were glucose intolerant (plasma glucose > 9.0 mmol/l), compared with 1.0% and 5.5% in rural people. — Urban men and women were significantly fatter than rural people, but within each population glucose tolerance was not significantly related to weight or to age, although the numbers of old people studied were small. Compared to Australians the Papua New Guinea subjects had a higher fasting plasma insulin (16.5 vs 10.7 μU/ ml, p = < 0.05); independent of weight fasting plasma insulin was significantly higher in the rural than urban people studied. After the glucose load, plasma insulin and glucose levels were positively correlated in rural people. In contrast, for the urban group the relation best fitted a quadratic function, with decline in plasma insulin at high levels of glucose. — The prevalence of diabetes in urbanised Melanesians in Papua New Guinea appears similar to other South Pacific countries.

The small-tined pacemaker lead--absence of dislodgement.

Abstract: The Medtronic 6961 unipolar transvenous ventricular lead has four symmetrically placed, small tines that protrude backward just proximal to the tip, and are designed to become entrapped beneath or between right ventricular trabeculae. One hundred leads were implanted. Initially, the leads were more difficult to position at the right ventricular apex as the tines tended to anchor on intracardiac structures. This was overcome by rotating the lead. The time of negotiating the lead from right atrium to right ventricular apex averaged 3.1 minutes for all leads. The first 20 procedures averaged 4.2 minutes and the last 20 averaged 2.1 minutes. In this latter group, 11 of the 20 passages took 60 seconds or less. Once adequate positioning was obtained, the lead was retracted using slight tension to demonstrate tip entrapment. There were no lead dislodgements. Eight deaths occurred following institution of pacing and lead dislodgement was not detected in any of these cases. Four patients had complications associated with pacing, two transient diaphragmatic pacing not requiring reoperation, one right ventricular perforation and one raised threshold with intermittent failure of pacing without lead perforation or dislodgement. Because of the absence of dislodgement, this lead appears to have significant advantages over conventional leads.

The technique and early results of high gastric reduction for obesity.

Abstract: The high gastric reduction operation has been performed on one hundred and nine obese patients over a sixteen-month period. Patient selection, preoperative care, operative technique and postoperative care are described. Our early results show that a satisfactory initial and continuing weight loss can be sustained for a twelve-month period with a low morbidity and mortality. Further follow-up of these patients is required before the ultimate place of this procedure is established.

The Refurbished Puise Generator

Abstract: With the advent of long-life lithium puise generators, normally functioning puise generators with a potential life of more than five years have been removed from patients and become available for re-implantation. Although puise generator refurbishing is widely employed, the practice has not been accepted in the United States. At The Royal Melbourne Hospital, all lithium puise generators removed because of patient death or other causes were washed in a quaternary ammonium compound and soaked in formaldehyde. Puise generators were then electronically tested and, if within specification, were made available for re-implantation. Puise generators were then washed under sterile conditions in distilled water and gas-sterilized with ethylene oxide. Between 1975 and 1978 (48 months), 600 puise generators were implanted and 93 puise generators removed. There were 56 deaths, 22 cases of pre-erosion, erosion, or infec-tion and 15 elective removals either due to lead problems or impending power source depletion. Eighty-three (89%) puise generators were refurbished (14% of total implants). This included 12 puise generators refurbished on two occasions. Ten puise generators were returned to manufacturers, seven because of impending power source depletion, two with suspected electronic faults, and one with a damaged case. Two complications occurred in patients with refurbished puise generators. An infective process present with the previous puise generator spread to a new pocket. The other puise generator was removed 35 months post second implantation because of impending power source depletion. Primary infection or unusual tissue reactions did not occur. Puise generator refurbishing as described was found to be a safe and economic procedure.

Ontogenic development of B-lymphocyte function and tolerance susceptibility in vivo and in an in vitro organ culture system.

Abstract: The maturation of B-lymphocyte function during fetal development was studied in vivo and in an in vitro organ culture system. The results indicated that the progenitors for 2,4-dinitrophenol (DNP)-specific B cells are present as early as 14 d of gestation in liver and possibly as early as 15 d in spleen. In addition, it was found that the organ culture system supports the development of B lymphocytes as measured by an increase in both the percentage of surface immunoglobulin-positive cells and the frequency of clonable DNP-specific B cells after culturing. The majority of anti-DNP-secreting clones resulting from the antigenic stimulation of fetal B cells produced only the IgM isotype, and the ability to secrete the IgG isotypes increased as a function of gestational age. Because fetal DNP precursors from spleens and livers that had been incubated in organ culture resulted in a greater proportion of clones secreting IgG compared with age-matched uncultured controls, it was concluded that the maturation with regard to the ability to secrete IgG can occur in vitro. In studies relating to the ontogenetic development of tolerance susceptibility, it was found that up to one-half of the DNP-specific B-cell precursors from livers and spleens less than 18 or 19 d of gestation were resistant to tolerogen treatment for 24 h as if in a pretolerant phase. However, if tolerogen were present for 3--5 d during organ culture there was near total elimination of potential DNP clones. This finding suggested that the 24-h induction period was insufficient for affecting the DNP-specific precursors in livers and spleens from the earlier gestational ages, and that a proportion of precursors could subsequently form DNP clones in the splenic focus assay after the removal of tolerogen.

A clinical evaluation of serum angiotensin converting enzyme in sarcoidosis.

Abstract: Summary: Angiotensin converting enzyme was measured in the serum of 52 patients with sarcoidosis, 67 healthy control subjects and 64 patients with pulmonary and non-pulmonary diseases. The patients with sarcoidosis were classified on clinical grounds as having active or inactive disease. In 26 patients with active sarcoidosis not taking corticosteroids the mean serum ACE was significantly higher than in normal controls (P < 0.001). 73% of these patients had elevated serum ACE. Only two out of 12 (17%) patients with inactive sarcoidosis not taking corticosteroids had elevated serum ACE. Serum ACE was normal in patients taking oral corticosteroids for longer than two weeks. Eighty per cent of patients with active sarcoidosis with radiological evidence of pulmonary parenchymal involvement had an elevated serum ACE compared to 25% in patients with normal chest X-rays and 60% of those with bilateral hilar lymphadenopathy. All sarcoid patients with hypercalcaemia had elevated serum ACE whereas only half of those with normal serum calcium had elevated ACE. In the patients with other thoracic and granulomatous conditions serum ACE was normal or rarely marginally elevated. Serum ACE appears to be of value in the diagnosis of active sarcoidosis.

The effect of long-term diphenylhydantoin therapy on glucose tolerance and insulin secretion: a controlled trial.

Abstract: SUMMARY The influence of long-term administration of diphenylhydantoin (DPH) on glucose tolerance and insulin secretion was studied in a random controlled trial in non-epileptic patients receiving the drug for 2 years following recovery from myocardial infarction. While receiving DPH, insulin response to glucose was less than that in the control group, both in absolute terms and when related to the blood glucose level. Despite this, glucose tolerance did not differ from the control group. One month after cessation of DPH, the plasma insulin response had returned to the levels found in the control group, and glucose tolerance had improved to be significantly better than that found in the control group. Thus, the tendency of DPH to impair the insulin response to glucose has been confirmed in this controlled study. However, this does not result in significantly impaired glucose tolerance; it is suggested that the decreased insulin secretion is accompanied by improved insulin sensitivity.

Prospective Angiographic Assessment of Factors Affecting Early Patency of Saphenous Vein‐Coronary Artery Bypass Grafts

Abstract: Summary: Between November 1977 and September 1978, early post-operative angiography was performed in 50 of 53 consecutive patients undergoing coronary artery bypass surgery. An average of 2–4 grafts per patient were applied. The overall patency rate was 82% and was not affected by the degree of proximal native vessel stenosis. Grafts to circumflex marginal vessels had a significantly lower (P < 0·05) patency rate (72%) than grafts to the left anterior descending (84%) and its diagonal branches (85%), or to the right coronary artery (90%). Ten single grafts were applied and all were patent. Forty-nine of the 50 patients had at least one patent graft. Fifty-three per cent of the grafts were considered of excellent quality and 25% patent but of fair quality only. There was a 100% patency rate for vessels of 2 mm diameter or more, which is significantly better (P < 0·01) than for vessels of 1–2 mm diameter (78%) or for vessels of less than 1 mm diameter (50%). There was a suggestion of a lower patency rate (74%) for vessels with evidence of distal disease, compared with vessels without such disease (85%). An assessment of the overall quality of the recipient vessel was made, taking both diameter and disease into account. This showed improved results for better quality vessels in terms of graft patency (P < 0·1) and graft quality (P < 0·05).

Reduced responses to noradrenaline of isolated digital arteries from hypertensives.

Abstract: SUMMARY 1. Strips of digital arteries obtained post-mortem from thirteen hypertensives have been compared with those from thirteen normotensives. 2. The strips from hypertensives and from males had a significantly greater response to 80 mmol/1 KCl, but this was due to the increased cross-sectional areas of the strips from hypertensives and from males. 3. The maximum responses to noradrenaline and serotonin, but not the pED50 values, were significantly smaller in the strips from the hypertensives than in those from the normotensives, but there were no differences between the strips from hypertensives and normotensives in either the maximum response or pED50 values to angiotensin or barium chloride. 4. It is concluded that these results suggest a decreased number of α-receptors are present in human hypertensive vascular smooth muscle and this is a sequel either of the increased pressure itself, or of increased exposure in vivo of the blood vessels from hypertensives to noradrenaline.

Mesangial IgA Nephropathy in Pregnancy

Abstract: The clinical and renal biopsy findings in a group of 12 patients with mesangial IgA nephropathy who had 22 pregnancies are recorded. Seventeen pregnancies were successful. Hypertension was noted in 9 pregnancies and in 12, features of pre-eclamptic toxaemia developed. One patient had post-partum eclampsia. Proteinuria tended to increase during pregnancy and one patient developed nephrotic syndrome which resolved after delivery. Glomerular lesions in these women differed from those in non-pregnant patients with mesangial IgA nephropathy. Focal and segmental proliferative and hyalinosis-sclerosis changes were seen far more frequently than is usual in biopsies from patients with mesangial IgA nephropathy, suggesting that focal and segmental lesions develop during pregnancy.

Sensitivity to coconut diethanolamide.

Abstract: A 55-year-old woman attended with hand dermatitis which had been present for 3 months. During that time the dermatitis had become severe and had spread to the forearms, as well as involving the face and eyelids on occasions. She worked with her husband in a small printing works handling ink, paper, solvents and some hand creams and cleansers: rubber gloves had been worn only after the onset of the dermatitis. Patch testing was carried out to the European standard series, rubber chemicals, likely sensitizers, and agents used in her work. The only positive test was to a hand gel (diluted 1:10 in soft paraffin). This gel was applied before work and washed off after work: her husband could use it withoat irritation. The ingredients of the hand gel were obtained and diluted in soft paraffin to the concentration of each in the gel, and patch testing results were as follows:

Cushing's syndrome due to an ACTH-secreting adrenal medullary tumour.

Abstract: Summary A 35-year-old man with Cushing's syndrome due to ectopic ACTH production is described. The six-week history and severe proximal myopathy were highly suggestive of a malignant tumour, but a solitary phaeochromocytoma of the left adrenal gland was the source of ACTH production. The surgical outcome was successful and three months post-operatively the hypothalamic-pituitary-adrenal axis was normal. At 12 months follow-up he remains well with complete regression of the features of Cushing's syndrome.

Sensitivity to thiourea in plan printing paper

Abstract: A 29-year-old chemist was working on the synthesis of new H 2 antagonists in pharmacology. During 18 months he had frequent attacks of erythema, edema, pruritus and minimum eczematization of the eyelids, forehead, cheeks and dorsa of the hands. No symptoms appeared during rest periods or holidays. Patch tests with ICDRG and Spanish standard series were negative. The substances used in his pharmacological work were tested (Table 1). All were prepared in two aqueous solutions and in two ethanol solutions, all at 1 % and 0.1% The product 2[4(5) methyl-5(4)-imidazolylmethyl-thio]-C13 at 0.1 % and 1 % in aqueous and ethanol solutions gave a positive ( + +) reaction at 96 h. Twenty normal controls gave negative results to all substances tested. The patient improved when avoiding contact with this compound. It is related to the H 2 antagonists and has the common structure of imidazol-thio-ether-aminothiol (alcohol).

The demonstration of sialic acid in kidney stone matrix.

Abstract: 1. The organic matrices of 12 kidney stones containing calcium and two composed of uric acid were solubilized, with ethylenediaminetetra-acetate for the former and sodium hydroxide for the latter. 2. The solubilized matrices and residual fine particulate material were examined for sialic acid by the thiobarbituric acid method. 3. Sialic acid was found in every stone in either the soluble and/or insoluble material. 4. The identity of sialic acid was confirmed by the absorption spectrum of the colour produced and by its release from the protein by neuraminidase. 5. The presence of sialic acid in all stones despite widely varying composition suggests that it may be passively deposited.

A trial of imidazole carboxamide and corynebacterium parvum in disseminated melanoma: clinical and immunologic results.

Abstract: Nonspecific immunotherapy with monthly intramuscular (IM) injections of Corynebacterium parvum has been investigated in patients with disseminated melanoma. Forty‐nine patients were randomized to receive either imidazole carboxamide (DTIC) alone or DTIC plus C parvum. A 24% overall objective response rate was observed, with no significant difference between the response rate or survival of the two treatment groups. Immunologic studies revealed no significant difference between the two groups. One patient undergoing chemoimmunotherapy demonstrated profound pancytopenia which responded to cessation of therapy, but toxic reactions were otherwise minimal. No advantage was obtained by adding IM injected C parvum to standard chemotherapy in the treatment of disseminated melanoma. Cancer 46:475–479, 1980.

The use of isolated digital arteries to study factors influencing adrenergic-transmitter release in man.

Abstract: 1. In order to compare pre- and post-synaptic mechanisms influencing human vascular smooth muscle contraction, post-mortem digital arteries have been studied in vitro. After preloading transmitter stores with [ 3 H]noradrenaline, stimulation-induced total tritium outflow and the associated pressure response were measured. 2. Tetrodotoxin either partially or completely abolished both stimulation-induced tritium outflow and constrictor response. 3. Neither the total tritium outflow nor the degree of its reduction by tetrodotoxin was related to the time after death the arteries were removed. Similarly no correlation was observed between stimulation-induced tritium outflow and age, sex, previous medications or underlying disease of the patient from whom the arteries were removed. 4. Total tritium outflow per impulse was markedly enhanced by increasing the frequency of stimulation from 1 Hz to 6 Hz. 5. Cocaine produced only a modest increase in stimulation-induced tritium outflow. Phentolamine more markedly enhanced stimulation-induced tritium outflow, whereas clonidine significantly reduced the outflow, thus demonstrating the presence of presynaptic α-adrenoreceptors. 6. It is concluded that post-mortem human digital arteries are suitable for the study of adrenergic transmitter release in man and that the two most important factors influencing transmitter release are frequency of stimulation and presynaptic receptors.

The results of surgery for carcinoma of the pancreas.

Abstract: A retrospective analysis was performed on 104 consecutive patients with carcinoma of the pancreas treated between 1970 and 1974 inclusive. Fifty-three per cent underwent palliative bypass, 13% laparotomy only, 6% had a Whipple operation, 7% various miscellaneous operations, and 21% did not undergo operation. The operative mortality of palliative bypass and diagnostic laparotomy was 13% and 71% respectively. The mean survival of patients after biliary bypass was 6.7 months. Seven patients undergoing bypass had tumours of the pancreatic head, five centimetres or less in diameter, and apparently localized disease, and their means survival was 15.9 months. The mean survival of the four patients surviving radical surgery was 15.5 months. There were no cures. It was concluded that cholecystojejunostomy without enteroenterostomy was an appropriate biliary bypass operation and that diagnostic laparotomy should be avoided in patients without obstructive jaundice and with disseminated disease.

Effects of quinidine and disopyramide on serum digoxin concentrations.

Abstract: Although quinidine and digoxin are frequently given together, it has only recently become apparent that serum digoxin concentration may rise during quinidine treatment. A prospective study was performed to compare the effects of quinidine and disopyramide in patients receiving maintenance digoxin therapy. During quinidine administration serum digoxin concentration rose by more than 50% in seven of nine patients (the mean concentration rising from 1.43 +/- 0.20 to 2.61 +/- 0.43 nmol/l, P < 0.005). During the disopyramide treatment a small rise in serum digoxin was noted (mean 1.3 +/- 0.16 to 1.5 +/- 0.19 nmol/l, P < 0.05). We suggest that digoxin doses should be reduced immediately prior to commencing quinidine therapy in patients already receiving adequate maintenance digoxin, and patients should be followed carefully for evidence of digoxin toxicity. Disopyramide appears a suitable alternative anti-arrhythmic drug to quinidine in patients on maintenance digoxin.

A randomized study of intermittent chemotherapy with or without BCG inoculation in maintenance therapy of childhood ALL

Abstract: One hundred ninety-six children with acute lymphocytic leukemia were entered into a randomized study of maintenance chemotherapy with either intermittent chemotherapy and immunotherapy with bacillus Calmette-Guerin (BCG) or only intermittent chemotherapy. On admission to the study, patients were stratified into three prognostic categories on the basis of clinical and laboratory features at presentation. Patients considered to have a favorable prognosis (PF) were induced with vincristine and prednisone; those with an unfavorable prognosis (PU) received combination chemotherapy consisting of either Ara-C, cyclophosphamide and asparaginase, or vincristine, prednisolone, and daunomycin followed by Ara-C and asparaginase; those with an average prognosis (PA) received vincristine and prednisolone followed by a single course of Ara-C and asparaginase. All patients received central nervous system prophylaxis with 2,400 rad cranial irradiation and four injections of intrathecal methotrexate. One hundred seventy-seven patients (90%) achieved complete remission, and 165 were randomized. Those randomized to Group A (83) received maintenance chemotherapy with six-week courses of 6-mercaptopurine, weekly oral methotrexate, and monthly vincristine. Each six-week course was followed by a two-week interval of no chemotherapy, and treatment was con tinued for 36 months. Patients randomized to Group B (82) received the same maintenance chemotherapy, but during the two-week interval without chemotherapy, they were given BCG inoculation. With a median follow-up of 110 weeks, no significant difference in duration of remission, survival, or CNS relapse was found between Groups A and B in the total patient population or within each prognostic category. In patients classified as PU, a significantly lower proportion (P 100 × 109/L had a significantly shorter duration of remission (P < 0.05). Patients classified as PF showed a This research was done by the Australasian Cancer Society Childhood Leukemia Group.

Renal infection with Mycobacterium chelonei.

Abstract: A case of renal infection with Mycobacterium chelonei is described. The infection probably occurred via haematogenous spread from an infected arteriovenous shunt in a uraemic woman. Prolonged treatment with intravenous cefoxitin combined with oral erythromycin and rifampicin eradicated the organism from the urine. Although renal function stabilised for one year, gradual deterioration to end-stage renal failure occurred.

Genetic determinants of autoimmune chronic active hepatitis.

Abstract: There has been a remarkable vindication over the past 15 years of Burnet’s forecast, with two particular themes of dominant interest to research on immunogenetics. The first is the association in inbred animals between genetic control of immune responses to antigens of limited heterogeneity and genes (Ir genes) of the major histocompatibility complex (MHC) [2, 39]. The second is the increasing refinement of typing methods for human histocompatibility antigens, of relevance to tissue transplantation, and associations between certain immunopathic diseases and HLA specificities [26, 31]. However, despite much experimental work and theoretical speculation, no unifying concept relating MHC-linked Ir genes effects and MHC- linked disease susceptibility has yet emerged.

Nickel sensitivity induced by skin clips.

Abstract: A 44-year-old woman was referred for dermatological advice after thyroidectomy. This operation was performed for an adenoma of the thyroid without any operative difficulty, and the wound was closed with chromic catgut and Michel clips. The clips were removed after 4 days, and at this time the wound and surrounding skin were normal. However, 21 days after operation, she was re-admitted to hospital with irritation, redness and swelling of the wound: probing allowed a ~mall amount of clear fluid to escape. The problem was regarded as wound infection and antibiotic therapy was given, but the wound became more inflamed and all cultures were negative. As the inflammation spread, it developed the characteristics of severe dermatitis, extending from the jawline to the clavicles, and across the whole anterior aspect of the neck. The rash was most severe 40 days after surgery, and then gradually and completely subsided. Biopsy of the skin 60 days after surgery showed features of allergic contact dermatitis. The p:1tient did not give any history of previous dermatitis or sensitivity to metal, and no obvious contact sensitizing agent had been used. Patch testing was performed using the European Standard Series, all antibacterial skin preparations used in the hospital, and samples of all dressings and catgut. Results of the tests were:

Diffuse fasciitis with eosinophilia.

Abstract: In 1974 Shulman described two patients who had a scleroderma-like thickening of the skin in association with eosinophilia. Biopsies revealed striking thickening of the fascia between the subcutaneous tissue and muscle, with intense infiltration of plasma cells and lymphocytes. There was no evidence of myositis or of the visceral manifestations of systemic sclerosis. Reports of similar patients have since appeared; we report a further patient thought to have this condition.