Brucella endocarditis of pseudoaneurysm of an aortic composite graft

The occurrence of Brucella endocarditis following Bentall operation is a rare and life threatening condition, particularly when it is complicated by development of a pseudoaneurysm. Here we present a 40-year-old veterinarian with bicuspid aortic valve, who developed type A aortic root dissection and required Bentall operation. His past medical history was positive for an episode of treated brucellosis. Four months after the operation, he developed signs, symptoms and serological findings of brucellosis for the second time and was treated with antibiotics. Then after he was well untill about 14 days prior to his recent admission, when he again developed hip pain, fever, shortness of breath, profound fatigue and weakness. His transthoracic echocardiography was suggestive of endocarditis. A transesophageal echocardiogram revealed detachment of valve-conduit from the annulus and the mitral-aortic intervalvular fibrosa and the presence of a large aortic pseudoaneurysm with multiple vegetations attached to its Dacron walls. A huge pseudoaneurysm was detected at surgery and the whole valve-conduit was replaced with a 25 mm homograft. Blood and vegetation cultures turned to be positive for Brucella melitensis. Early echocardiographic diagnosis and prompt surgical intervention were helpful for survival of our patient who had aortic pseudoaneurysm complicated by Brucella endocarditis.

Effect of omega-3 on brain natriuretic peptide and echocardiographic findings in heart failure: Double-blind placebo-controlled randomized trial

BACKGROUND

Possible beneficial effects of dietary omega-3 supplementation on patients with congestive heart failure (CHF) were investigated.

METHODS AND RESULTS

100 patients with CHF who had a tri-chamber pacemaker and automated defibrillator were initially recruited, and 70 agreed to participate.38 patients received 2 g/day of omega-3 and 32 received placebo capsules. BNP level, 6-min walk test and echocardiographic parameters were recorded at baseline and after 6 months of treatment. BNP levels decreased significantly after 6 months in the omega-3 group, from 1766.2 ± 1978.1 pg/mL to 1159.4 ± 1430.9 pg/dL (P < 0.005). Tei index and late diastolic velocity index were significantly improved in treated group. Mortality and hospitalization rates did not differ.

CONCLUSION

The beneficial effects of omega-3 supplementation in patients with CHF were not as clear as hypothesized; however, omega-3 fatty acids can result in small changes in plasma BNP levels and modest improvements in echocardiographically assessed diastolic function (Clinical trial.gov registration: NCT01227837).

Earliest time of change in QT dispersion after stenting in patients with single vessel coronary artery disease

Dispersion of the QT interval (QTd) is a measure of inhomogeneity of ventricular repolarization, and its prolongation may provide a suitable substrate for life-threatening ventricular arrhythmias. The present study was performed to determine the onset time of change in the corrected QT (QTc) interval and QTd in patients with stable angina and single vessel coronary artery disease. Electrocardiograms of 60 patients with successful stenting, obtained 1 h before and 1 h, 6 h, 12 h and 24 h after the procedure were analyzed. The QTc interval, QTc maximum, QTc minimum and QTd were measured. All electrocardiograms were scanned, and then underwent computer-based analysis. There was a significant reduction in the mean QTc interval as early as 12 h after the procedure (from 474±41 ms to 460±31 ms; P<0.001), which persisted to the 24 h follow-up. This was associated with a significant reduction in mean QT maximum (from 496±31 ms to 418±66 ms; P<0.001) and a significant prolongation in mean QT minimum (from 403±21 ms to 444±12 ms; P<0.001) at the same time intervals. Therefore, successful stenting of coronary arteries in patients with single vessel coronary artery disease and stable angina decreases QTd as early as 12 h after the procedure. This phenomenon may be the result of improved regional myocardial circulation, and reduced ischemia. A persistently low QTd in the following months may therefore have prognostic significance, and can be used as a noninvasive marker of stent patency. Further studies are necessary to define the clinical applicability of QTd in the assessment of long-term stent patency in such patients.

Posttraumatic coronary artery-right ventricular fistula with multiple ventricular septal defects

The combination of posttraumatic coronary artery-right ventricular fistula and multiple ventricular septal defects is a rare and interesting phenomenon. We describe a case of a 19-year-old male with these findings following a blunt chest trauma after a motorcycle accident.

Seroprevalence of brucellosis and risk factors related to high risk occupational groups in Kazeroon, South of Iran

BACKGROUND

Brucellosis is a major zoonosis worldwide. Many people for their professions are at higher risk of contracting the disease.

OBJECTIVE

To determine the seroprevalence of brucellosis and its risk factors in a group of high risk professions.

METHODS

In a cross-sectional study, all personnel or students of veterinary schools, slaughters and butchers working in the city were invited to participate (n = 141). A comparison group (n = 44) randomly selected from patients who were selected at random from people attended our healthcare center for reasons other than the infectious diseases.

RESULTS

4 veterinarians, 15 veterinary assistants, 42 veterinarian students, 52 butchers, 17 slaughters, 8 slaughterhouse workers and 3 chefs made the first group and 14 storekeepers, 5 students of engineering, 11 clerks, 13 freelance workers, and 1 high school student made the comparison group. While the rate of consumption of most of the studied dairy products was almost similar in both groups, comparison group patients consumed more often milk (p<0.001) and cream (p<0.001) than the high risk group. 11 (7.8%; 95% CI: 3.4%-12.2%) cases from high risk group and none of the comparison group were found seropositive for Brucella.

CONCLUSION

Profession is the main factor in seropositivity. Consumption of dairy products and raw milk is not associated with a higher risk of seropositivity.

Isolated tricuspid valve Libman-Sacks endocarditis and valvular stenosis: unusual manifestations of systemic lupus erythematosus

The most common valves involved in systemic lupus erythematosus are the mitral and aortic valves. Although isolated tricuspid valve involvement is quite rare, the authors report such a case. A 42-year-old woman presented with exertional dyspnea and was found to have a cardiac murmur. Echocardiography showed a stenotic tricuspid valve with vegetations on all 3 cusps. No other valvular vegetation could be detected. Concomitant tricuspid regurgitation was noted too. Blood culture results were negative. Clinical findings and serologic tests confirmed the diagnosis of systemic lupus erythematosus. The patient was successfully treated with prednisolone and hydroxychloroquine, and follow-up echocardiography showed the disappearance of the vegetations.

Patent foramen ovale in patients with tension headache: is it as common as in migraineurs? An age- and sex-matched comparative study

The association of patent foramen ovale (PFO) and atrial septal aneurysm (ASA) with migraine headache attack (MHA) has been clearly shown. The same findings have been recently demonstrated also in cluster headache. Although tension-type headaches (TTH) are the most common kind of headache, their association with these atrial septal abnormalities has never been studied before. The study was conducted to clarify whether there was a significant association between the presence of such atrial septal abnormalities and tension headache, when compared with migraineurs. One hundred consecutive patients with migraine and 100 age- and sex-matched subjects with TTH and 50 healthy volunteers with no headache were enrolled in the study and underwent a complete transesophageal echocardiographic study with contrast injections at rest and with the Valsalva maneuver. There was no significant difference between the age and the sex of the participants of the three groups. The overall prevalence of PFO was 23% in patients with TTH and that of large PFOs was only 11%. The 23% prevalence of PFO in patients with TTH was not statistically different from 16% found in our normal control group. Furthermore, we found a significantly higher prevalence of PFO in migraineurs (50%) when compared with patients with tension headache (p < 0.001). This was also true for the collective presence of large PFOs and ASAs (35%) (p < 0.001). Although atrial septal anomalies have an association with MHA, they do not have a significant association with TTH.

Exercise intolerance and chronotropic impairment-The long-term cardiovascular sequelae of mustard gas exposure: A paired-comparative study

BACKGROUND

Although there are some data regarding the pulmonary manifestations of mustard gas exposure, little is known about its cardiovascular sequelae.

METHODS

The spirometric and exercise tolerance test results of two groups of patients with chronic bronchitis one with (group A) and one without (group B) previous exposure to mustard gas and a group of veterans with no bronchitis (group C) were compared.

RESULTS

The exercise capacity was similar in groups "A" and "B" patients. Both groups, showed a remarkable impairment of exercise capacity (p<0.001) compared to the group "C" individuals. Although the mean resting heart rate was significantly higher in group "A" patients than group "B" individuals (p=0.01), their mean peak exercise heart rate was significantly lower (p=0.01). Both groups, however, achieved a significant lower peak exercise heart rates, compared to the group "C" subjects (p<0.001).

CONCLUSION

Mustard gas exposure can limit the exercise capacity and abolish the normally expected chronotropic response to exercise.

Endocardial hydatid cyst: a rare presentation of echinococcal infection

A previously well 45-year-old male presented with 20 days of being generally unwell with a fever and dyspnoea on exertion. Transthoracic echocardiography was done and revealed a round cystic structure (3 x 3 cm) attached to the tricuspid valve. Multiple small calcified particles (daughter cysts) were also seen in the cyst which was most consistent with the diagnosis of Hydatid cyst. The serology for Echinococcus granulosus antibody was positive and confirmed the diagnosis. The patient was sent for cardiac surgery and hydatid cyst which was endocardial in location, and adherent to the tricuspid valve leaflets was the intraoperative finding. The patient improved and was discharged on long-term chemotherapy. The most common cite of cardiac involvement is the myocardium followed by the pericardium, whereas endocardial involvement is extremely rare. In the present study, we demonstrated a very rare case of endocardial hydatid cyst with attachment to the tricuspid valve.

P-wave dispersion in patients with rheumatic mitral stenosis

It has previously been shown that maximum P-wave duration and P-wave dispersion in 12-lead surface electrocardiogram (ECG) are significantly increased in patients prone to developing atrial fibrillation. Because patients with mitral stenosis (MS) are also susceptible to developing atrial fibrillation, the present study was carried out to determine whether maximum P-wave duration and P-wave dispersion are prolonged in MS patients during normal sinus rhythm. In addition, the correlation between these P-wave variables and the left atrial size, transmitral valve gradient and mitral valve area were determined. Fifty consecutive patients (40 women and 10 men; mean age 35.76±6.59 years) with MS who were in normal sinus rhythm, and a control group of 50 age- and sex-matched healthy persons were studied.A 12-lead ECG was obtained for each subject. All ECGs were scanned through a Cannon scanner at 300 dpi and saved as images in a personal computer. The minimum and maximum P-wave durations, as well as P-wave dispersion, were subsequently calculated. In addition, all patients were evaluated by echocardiography to measure the left atrial size, transmitral valve gradient and mitral valve area by planimetry. The P-wave parameters were compared between the two groups and the correlation between these parameters and the echocardiographic variables were determined in patients with MS. The most important findings included a significant prolongation of maximum P-wave duration in patients with MS compared with controls (P<0.001), and a strong correlation between the maximum P-wave duration and left atrial size (r=0.505, P<0.001), transmitral valve gradient (r=0.371, P=0.01) and a significant negative correlation with mitral valve area (r=-0.379, P=0.007). There was no correlation between the P-wave dispersion and echocardiographic parameters.

Constrictive pericarditis: Detection of mycobacterium tuberculosis in paraffin-embedded pericardial tissues by polymerase chain reaction

BACKGROUND

Although the utility of polymerase chain reaction (PCR) for diagnosis of acute pleuro-pericardial tuberculosis has been well established, its use for chronic constrictive pericarditis is yet to be reported.

AIMS

To define the sensitivity and specificity of PCR for diagnosis of tuberculosis (TB) in patients with constrictive pericarditis.

METHODS

The medical records of 30 consecutive patients with constrictive pericarditis were reviewed. In addition their historical paraffin-embedded pericardial tissues were used for new histopathologic examination and PCR amplification for Mycobacterium tuberculosis genome.

RESULTS

There were 23 males and 7 females with a mean age of 35+/-19.5 years. The anticipated causes of constriction included idiopathic (n=21), tuberculosis (n=5), cardiac surgery (n=2) and post traumatic (n=2). PCR became positive in nine patients. Four out of 5 patients with tuberculous granuloma had a positive test result. In addition all 4 patients with non-tuberculous constrictive pericarditis had a negative test result. Therefore considering the presence or absence of granuloma as a diagnostic criteria, the sensitivity and specificity of PCR were 4/5 (80%) and 20/25 (80%), respectively.

Evaluation of the hemodynamic performance of St. Jude mitral prostheses: a pilot study by dobutamine-stress Doppler echocardiography

In contrast to the widespread use of dobutamine stress Doppler echocardiography in the hemodynamic evaluation of the prosthetic valves in aortic position, it has been rarely, if ever, used for assessment of these valves in mitral position. Therefore, this pilot study was done to assess the hemodynamic performance of St. Jude prosthetic mitral valves (functional orifice area 25-31) with dobutamine-stress Doppler echocardiography. Twenty consecutive patients (13 women and 7 men, aged 23 to 42 years) who had undergone mitral valve replacement 6 to 4745 days previously and 16 healthy volunteers (5 women and 11 men, aged 18 to 42 years) underwent dobutamine-stress Doppler echocardiography. Dobutamine infusion was started at a rate of 5 microg/kg per minute and was increased by 5 microg increments at 3-minute intervals. Maximum and mean gradients as well as pressure halftime were measured at rest and at the end of each stage. The correlation between Doppler-derived variables versus the heart rate was assessed and a regression equation was obtained for each of them. A significant increase in blood pressure, heart rate, maximum and mean gradients was noted during dobutamine infusion in both groups. There was a significant positive linear correlation between the increasing transprosthetic mitral valvular maximum and mean gradients and the increments in the heart rate (G(max) = 4.47 + 0.093 [HR], r= 0.474, p<0.05) and (G(mean) = 3.0+0.003 [HR], r=0.2697, p<0.05), respectively, indicating the heart rate dependency of these parameters. Pressure halftime, on the other hand, had an inverse but linear relationship with the heart rate (PHT = 142 - 0.55 [HR], r= -0.577, p<0.05). Similar findings were found for the control group as well. Standard dobutamine-stress echocardiography can safely be performed in patients with St. Jude mitral valve prostheses. Single Doppler measurements of the pressure gradients and pressure halftime may yield erroneous conclusions regarding the function and size of these valves unless corrected for the patients simultaneous, online heart rate. The use of the regression equations obtained in this pilot study may help to partly overcome some of these difficult issues.

Erysipeloid cutaneous leishmaniasis: treatment with a new, topical, pure herbal extract

Fourteen consecutive cases of erysipeloid cutaneous leishmaniasis were seen and evaluated. There were 13 females and one male patient with a mean age of 59 years. Diagnosis was based on clinical grounds and the presence of amastigotes in the lesions. Patients were divided into acute and chronic groups, with chronicity being defined as a disease duration of more than a year. All cases were treated with a fresh preparation of a herbal mixture, namely "Z-HE". The paste was applied once daily for 5 consecutive days and thereafter every 2 weeks, as needed, for a maximum period of 3 months. Two patients didn't appear for their regular follow up, the remaining 12 cases were followed up for more than a year after termination of therapy. Eleven (92%) of patients had complete healing in a matter of 1 to 7 months with no relapse after 12 months of follow up. In spite of a successful initial clinical response, the remaining one patient with the acute type of ECL had a subsequent relapse. Otherwise the acute and chronic cases had similar responses to therapy and outcome. No drug related side effect was noted. The high success rate, low cost, ease of preparation, and lack of toxicity makes "Z-HE" a promising new drug. Further investigations are needed to illuminate its mechanism(s) of action and also controlled trials are recommended to confirm its efficacy.

Cutaneous leishmaniasis: what about a new, inexpensive, effective, topical herbal remedy?

Cutaneous leishmaniasis (CL) remains an important disease and public health problem in many parts around the world especially in the Middle East. In the absence of adequate treatment, the lesion could become chronic and disfiguring. We report on three cases with chronic CL lesions that were successfully treated with topical application of a new herbal mixture named "Z-HE". It is clearly demonstrated that this inexpensive, simple, effective and non toxic topical drug has a promising curative role in the treatment of CL.

Mitral valve prolapse in patients with pure rheumatic mitral stenosis: an angiographic study

Of 122 adult patients suspected of having rheumatic mitral stenosis, 112 fulfilled the hemodynamic and angiographic criteria for pure, isolated mitral stenosis. There were 88 females and 24 males with an age range of 16 to 60 years. The left ventriculograms (30 degrees right anterior oblique) were subjectively assessed for gross bulging of the mitral valve leaflets beyond the mitral fulcrum into the left atrium during a beat with maximal opacification. Seventeen percent of cases had typical evidence of mitral valve prolapse, which is much higher than the 3% to 5% rate reported for the general population. This phenomenon was independent of the patients' age, sex, hemodynamic findings, and/or their underlying cardiac rhythm, thus implying the direct role of rheumatic mitral stenosis in the genesis of secondary mitral valve prolapse.

Tetanus in the elderly: is it different from that in younger age groups?

Our aims were to itemize the clinical features and the outcome of tetanus in the elderly, as well as any age and sex differences in its acquisition. Therefore, we compared the demographic and clinical data of 12 elderly (group 1) cases of tetanus with 69 middle-aged patients (group 2) and 12 children (group 3) suffering from the same disease. There was no significant difference between the site of entry and incubation period or in the clinical and paraclinical findings among the three groups of patients. Acute respiratory failure was found more commonly in group 1 than in groups 2 and 3 (p = 0.0167 and p = 0.0006, respectively). It was also more common in group 2 than in group 3 (p = 0.0140). A mild form of tetanus was more often detected in children than in middle-aged and elderly cases (p = 0.0213 and p = 0.0013, respectively). Severe tetanus was seen more often in group 1 than in groups 2 and 3 (p = 0.0167 and p = 0.0006, respectively). Despite this, the mortality rate was not statistically different among the three groups of patients. Females were affected much less frequently than males with a female:male ratio of 1:3 in all three age groups. Our results suggest that elderly patients are at higher risk of acquiring a more severe form of tetanus and the subsequent development of acute respiratory failure. In addition, the disease is more common in males of all age groups, and age and sex have no apparent effect on the outcome of patients with tetanus.

Lactate dehydrogenase in bronchoalveolar lavage fluid of patients with active pulmonary tuberculosis

BACKGROUND

Serum lactate dehydrogenase (LDH) concentration is an indicator of tissue injury. It may be increased in a variety of interstitial diseases and in pulmonary tuberculosis (PTB).

OBJECTIVE

To investigate the value of LDH levels in bronchoalveolar lavage fluid (BALF) for the diagnosis of active PTB and to assess its relationship with serum LDH levels.

METHODS

The study was a prospective clinical study. It included 25 consecutive patients with documented active PTB and 20 healthy adults who underwent bronchoscopy with bronchoalveolar lavage (BAL). Both total serum and LDH levels were measured.

RESULTS

BALF LDH level was increased in all patients with active PTB. The mean BALF LDH level was significantly higher in patients with PTB (198.84+/-88.31 mIU/ml) as compared to controls (14.01+/-8.69 mIU/ml) (p = 0.0001). There was a significant correlation between BALF LDH and serum LDH levels in patients with PTB (r = 0.55, p = 0.006).

CONCLUSION

BALF LDH levels are not specific and may be increased in many diseases. A very low value (possibly less than 60 mIU/ml) may, on the other hand, be useful to exclude the diagnosis of active PTB.

Characteristics of bronchoalveolar lavage fluid in patients with sulfur mustard gas-induced asthma or chronic bronchitis

PURPOSE

To examine the pattern of immunoglobulins and cellular constituents in bronchoalveolar lavage fluid obtained from patients with sulfur mustard gas-induced asthma or chronic bronchitis as compared with healthy control subjects.

SUBJECTS AND METHODS

We studied two groups of nonsmoking veterans with either bronchial asthma (n = 21) or chronic bronchitis (n = 28) believed to have been caused by sulfur mustard gas exposure and a third group of healthy, nonsmoking, non-sulfur mustard gas exposed controls (n = 17). Bronchoalveolar lavage was performed in all three groups. The cellular constituents, albumin content, and immunoglobulin concentrations were determined.

RESULTS

The three groups did not differ in age or in the serum albumin and immunoglobulin concentrations. The volume of bronchoalveolar lavage fluid recovered was approximately 10% less in the patients with asthma and chronic bronchitis (P = 0.008). The proportions of lymphocytes among the bronchoalveolar lavage cells were similar in all three groups, whereas the proportion of eosinophils was greater in lavage fluid from the asthmatic subjects than in either the healthy control subjects or the patients with chronic bronchitis (P = 0.0001). Both the total number of the recovered cells per milliliter of lavage fluid and the proportion of neutrophils were significantly greater in bronchoalveolar lavage from patients with chronic bronchitis than in healthy subjects or in the patients with asthma (all P <0.001).

CONCLUSION

The bronchoalveolar lavage cellular constituents of patients with sulfur mustard gas-induced asthma and chronic bronchitis are similar to those that have been observed previously in patients with asthma and chronic bronchitis from other common causes.

Immunoglobulins and cellular constituents of the BAL fluid of patients with sulfur mustard gas-induced pulmonary fibrosis

STUDY OBJECTIVE

The acute heavy exposure to sulfur mustard gas can lead to pulmonary fibrosis (PF). This study was performed to determine the cellular and protein content of BAL fluid in 24 patients with sulfur mustard gas-induced PF.

PATIENTS

Twenty-four veterans with sulfur mustard gas-induced PF and 18 nonexposed veterans serving as control subjects were enrolled into the study.

MEASUREMENTS

Chest roentgenograms, pulmonary function tests (PFTs), tests for carbon monoxide diffusing capacity of the lung (DLCO), high-resolution CT scans of the chest, BAL via fiberoptic bronchoscopy, analyses of BAL fluids for cellular and protein constituents, and determinations of serum albumin and Ig levels were performed in all cases. A transbronchial lung biopsy was done in all patients following BAL.

RESULTS

Neutrophilic alveolitis was the predominant feature. Neutrophils (p = 0.0001) and eosinophils (p = 0.0001) were the predominant cell types in the BAL fluid of patients with PF. There was a strong correlation between the BAL fluid neutrophil count (p = 0.76; p = 0.0003) or its percentage (p = 0.77; p = 0.0003) and the degree of fibrosis. Of the BAL fluid Ig levels, only the IgG level in the study group was significantly higher than the IgG level of the control group (p = 0.0001). Of the PFT physiologic parameters, only the percentage of DLCO showed a significant correlation with the degree of fibrosis (p = -0.76; p < 0.001).

CONCLUSION

The cellular constituents of BAL fluid in patients with sulfur mustard gas-induced PF are very similar to the cellular constituents seen in patients with idiopathic PF, and this finding indicates the presence of an ongoing active alveolitis in PF.

A comparative analysis of three methods of contraception: Effects on blood glucose and serum lipid profiles

BACKGROUND

Hormonal contraceptives are one of the major means of family planning, yet their use is not without side effects. In this study, we have tried to assess some of the metabolic effects of three hormonal contraceptives commonly used by young females.

PATIENTS AND METHODS

Three hundred young, healthy, nonsmoking and normotensive women of childbearing age who were seeking contraceptive advice were randomly allocated to one of the three groups receiving ethinyl estradiol and norgestrel (group 1), medroxyprogesterone acetate (group 2), and levonorgestrel capsules (group 3). Levels of fasting blood glucose (FBG), total cholesterol (TC), triglyceride (TG), low-density lipoprotein cholesterol (LDL-C), and high-density lipoprotein cholesterol (HDL-C), were measured prior to the initiation of therapy and after termination of the study (6 months).

RESULTS

There was no significant difference between the three groups as far as the mean age, height and weight were concerned. FBG increased in all three groups, but the difference in the rate of increase was not statistically significant (P=0.29). Total cholesterol, TG and LDL-C increased, while HDL-C level decreased in groups 1 and 2. These changes were, however, more profound in the group 2 cases. In those receiving levonorgestrel, all lipid parameters decreased. The amount of change for the total cholesterol and triglyceride was quite significant (P<0.001), while the reduction in HDL-C was not significantly different from the other two groups by pairwise comparisons (Tukey-HSD procedure). The LDL-C/HDL-C ratio was found to be significantly increased in groups 1 and 2, but it remained almost unchanged in the group 3 cases (P<0.001).

CONCLUSION

Because of these favorable biochemical findings, we believe that levonorgestrel should be the contraceptive drug of choice for women of childbearing age who are seeking a safe method of contraception.

Transient renal glucosuria in patients with tetanus

BACKGROUND/AIMS

During our early years of experience with patients suffering from tetanus, some of them were found to have unexplained renal glucosuria.

METHODS

Thus, all the normoglycemic patients with tetanus who were consecutively encountered over the subsequent 8 years were studied for the presence of renal glucosuria.

RESULTS

From 92 cases of tetanus admitted to the intensive-care unit, 63 patients had normal blood sugar in the course of their illness. The quantitative measurement of 24-hour urine confirmed the presence of significant renal glucosuria in 52% (n = 33) of these cases. The renal glucosuria was of transient nature and decreased to normal levels in the recovery stage (4 weeks after discharge from the hospital). There was no significant difference in age, sex, severity of disease and site of entry between the two groups of the patients with and without renal glucosuria.

CONCLUSION

Significant but transient glucosuria of renal origin possibly induced by tetanospasmin is common in patients with tetanus.

Closed percutaneous pleural brushing: a new method for diagnosis of malignant pleural effusions

Pleural fluid cytology and pleural biopsy are the two most commonly employed diagnostic tests for malignant pleural effusions. Here, we have introduced a new diagnostic method, namely closed percutaneous pleural brushing, and have compared its diagnostic yield with those of pleural fluid cytology and pleural biopsy in patients with suspected malignant pleural effusion. Forty-three consecutive patients with suspected malignant pleural effusion underwent thoracentesis, closed pleural brushing and closed pleural biopsy using Cope's pleural biopsy needle and a cytological brush (BC-10C) which was introduced into the pleural cavity through the cannula of the same needle. All the samples were sent for bacteriological and cytological studies. Patients had a mean follow-up period of 9.28 +/- 1.87 months during which seven cases whose entire studies were non-diagnostic underwent thoracotomy and open pleural biopsy. Thirty-four cases were finally documented to have malignancy. Closed pleural brushing was positive in 31 (91%) of cases. This was superior to that achieved by either pleural fluid cytology (67%) (P = 0.01) or pleural biopsy (58%) (P = 0.002). No pneumothorax or other major complications were encountered with this method. Closed pleural brushing via Cope's needle is a relatively safe, simple and well-tolerated technique with a high diagnostic yield for patients with malignant pleural effusion. It may substitute for other more invasive and more expensive procedures such as thoracoscopy and thoracotomy in this group of patients.

Diagnostic value of closed percutaneous pleural biopsy vs pleuroscopy in suspected malignant pleural effusion or tuberculous pleurisy in a region with a high incidence of tuberculosis: a comparative, age-dependent study

OBJECTIVE

To compare the value of closed percutaneous pleural biopsy versus pleuroscopy for diagnosis of undiagnosed exudative pleural effusion in an age-dependent manner.

DESIGN

Prospective clinical study.

SETTING

University hospitals.

PATIENTS

Forty-nine consecutive patients with undiagnosed exudative pleural effusion following the initial clinical and paraclinical investigations, including bronchoscopy. Cases were divided into younger and older groups according to their ages.

INTERVENTION

Closed pleural biopsy immediately followed by pleuroscopy with a flexible fiberoptic bronchoscope from the same incision site.

RESULTS

In the older age group, pleuroscopy was superior to closed pleural biopsy for the diagnosis of the underlying pleural disease (P = 0.0007), while they were almost equally diagnostic in the younger cases (P = 0.58).

CONCLUSION

For those patients with undiagnosed exudative pleural effusion who are older than 50 years of age, pleuroscopy could be chosen as the first procedure of choice as compared to closed pleural biopsy if malignant pleural effusion is suspected.

The diversity of the effects of sulfur mustard gas inhalation on respiratory system 10 years after a single, heavy exposure: analysis of 197 cases

OBJECTIVE

To find out the late pulmonary sequelae of sulfur mustard gas inhalation in 197 veterans, 10 years after their exposure.

DESIGN

Cross-sectional clinical study.

SETTING

University hospital.

PATIENTS

One hundred ninety-seven veterans with a single, heavy exposure to sulfur mustard gas in 1986 and 86 nonexposed veterans as their control group.

INTERVENTIONS

Pulmonary function tests, carbon monoxide diffusion capacity, bronchoscopy, and high-resolution CT of the chest were performed in all patients. Transbronchial lung biopsy was done in 24 suspected cases of pulmonary fibrosis.

RESULTS

Asthma was diagnosed in 21 (10.65%), chronic bronchitis in 116 (58.88%), bronchiectasis in 17 (8.62%), airway narrowing due to searing or granulation tissue in 19 (9.64%), and pulmonary fibrosis in 24 (12.18%) cases. None of these were found among the control group except for a single case of chronic bronchitis.

CONCLUSION

Although the respiratory symptoms of an acute sulfur mustard gas inhalation are usually transient and nonspecific, it can lead to the development of a series of chronic destructive pulmonary sequelae in such cases.

Puerperal tetanus and hysterectomy

OBJECTIVES

To compare the clinical course and outcome of patients with post-partum tetanus (n = 21) to those of non-post-partum ones (n = 24) and to determine the effect of early hysterectomy on the survival of cases with severe post-partum tetanus (n = 20).

METHODS

In this prospective study we compared the clinical course and outcome of post-partum and non-post-partum cases of tetanus admitted to the intensive care unit. Moreover, early hysterectomy was done on every other patient with severe post-partum tetanus (n = 10). Chi-square and Student's t-tests were used for statistical purposes.

RESULTS

Post-partum cases were younger (P = 0.002), had a higher incidence of acute respiratory failure and a mortality rate compared to the non-post-partum group. In addition, early hysterectomy did not change the course of severe post-partum cases.

CONCLUSION

The mortality associated with post-partum tetanus is comparable to non-post-partum cases and early hysterectomy has no effect on its outcome.

Treatment of malignant pleural effusions with a combination of bleomycin and tetracycline. A comparison of bleomycin or tetracycline alone versus a combination of bleomycin and tetracycline

BACKGROUND

Treatment of patients with malignant pleural effusions is mostly palliative. Tetracycline and bleomycin are the two most commonly used agents for the treatment of pleurodesis. In this study, the authors used a combination of the two drugs for this particular purpose.

METHODS

Sixty patients with massive malignant pleural effusions were divided in 3 equal groups in a simple randomized manner. Tetracycline (20 mg/kg [maximum of 2 g] in 50 mL of normal saline) was administered through a chest tube in Group 1. Group 2 received bleomycin (1 U/kg [maximum of 60 U] in 50 mL of normal saline). Group 3 received the above 2 preparations (tetracycline, 20 mg/kg [maximum of 2 g] in 40 mL of normal saline and bleomycin, 1 U/kg [maximum of 60 U] in 30 mL of normal saline) instilled one after the other, while the chest tube was clamped for 5 minutes in the interim. Follow-up examinations were performed at 7 days, 30 days, 60 days, 90 days, and 6 months.

RESULTS

There was no significant difference in the complete response rate of the 3 groups during the first 4 months. At the end of the study, Group 3 had a significantly higher complete response rate (70%) compared with Groups 1 and 2 (35% and 25%, respectively) (P = 0.02).

CONCLUSIONS

The response to use of a combination of bleomycin and tetracycline for the treatment of patients with pleurodesis is superior to that achieved by either of these agents used alone.

Determination of creatine kinase in the sera of patients with myocardial infarction by a rho-nitrophenylglyoxal method

We have developed a new colorimetric method for the determination of creatine kinase (CK). This method is based on the reaction of creatine, formed enzymatically from creatine phosphate and ADP, with rho-nitrophenylglyoxal (PNPG) under mild alkaline conditions to produce a coloured complex which absorbs maximally at 480 nm. This method was applied to the sera of patients with myocardial infarction. The results obtained by the PNPG method agreed well with the results obtained by other available methods for CK. However, the PNPG method was more convenient and less expensive than other methods and required a single chromogenic reagent. The PNPG method might be easily adapted to routine clinical application.