Renal function predicts colchicine toxicity: guidelines for the prophylactic use of colchicine in gout

In order to establish the degree of renal malfunction necessary for colchicine toxicity in patients receiving it daily for the prevention of recurrent acute gout, we obtained serum creatinine levels and measured or estimated creatinine clearances in a consecutive series of 17 patients with demonstrated colchicine myotoxicity. An estimate of creatinine clearance, based on ideal body weight and age, was nearly always 50 ml/min or less, and was the most practical predictor of the risk of toxicity. By comparison, patients with gout from the same clinical data base, but without myotoxicity, had normal renal function. The data yield clear guidelines for safe use of colchicine chronically.

Therapy in gout

The effective management of patients with gout is outlined. The treatment of the acute attack, the prevention of recurrent episodes, and the dissolution of tophi, when present, are generally straightforward and associated with relatively few complications. Patients with a resistant acute attack, with extensive tophaceous deposition, or with allergy or toxicity to any of the standard drugs, present more complex treatment decisions. All agents must be used in an individualized manner for each patient with appropriate concern for risks as well as for benefit.

Review: systemic toxicity associated with the intravenous administration of colchicine--guidelines for use

Published experiences with severe toxicity with intravenous colchicine have been reviewed. All reported cases reflect inappropriate use of the drug. Therapeutic rules for colchicine have been derived from this information: (1) Single intravenous doses should not exceed 2-3 mg, and cumulative total doses for an attack should not be more than 4-5 mg. (2) Patients should receive no more colchicine by any route for 7 days. (3) Colchicine doses must be reduced in the presence of renal or hepatic disease, and in the older patient with apparently normal renal function. (4) Intravenous colchicine doses should be half the size of oral ones. (5) Absolute contraindications to intravenous colchicine therapy for acute gout include combined renal and hepatic disease, creatinine clearances below 10 cc/min, and extrahepatic biliary obstruction.

A new technique to improve cortical-evoked potentials in spinal cord monitoring. A ratio method of analysis

Systemic effects such as anesthesia, hypotension, hypothermia, and hypoxia affect the cortical evoked responses. We propose, that by sequential stimulation of the median and posterior tibial nerves, and the construction of a ratio from the value of their amplitudes, the systemic effects can be eliminated and thus improve the reliability of the cortical evoked responses. Two groups of scoliosis patients who underwent spinal surgery with instrumentation were analyzed retrospectively. Both groups had spinal cord monitoring using peripheral nerve stimulation and cortical recordings of the somatosensory-evoked response (SER). In Group I, 50 patients were analyzed for changes in posterior tibial nerve response before and after distraction. Wide variability in the response suggested this method to be less reliable in predicting spinal cord conduction deficits. Thirty-eight patients in Group 2 were analyzed using both the median and posterior tibial nerve amplitudes. A ratio of the posterior tibial to median nerve wave amplitude was constructed, thus eliminating any systemic variables. A critical value, alerting the surgeons to possible decreases in spinal cord conduction, was calculated by subtracting one standard deviation from the mean of the postdistraction ratios of the posterior tibial to median nerves (1.20-.633 = .567).

The allopurinol hypersensitivity syndrome. Unnecessary morbidity and mortality

Patients receiving allopurinol are at risk of developing the allopurinol hypersensitivity syndrome, an immunologic reaction to the drug, characterized by multiple abnormalities such as fever, rash, decreased renal function, hepatocellular injury, leukocytosis, and eosinophilia. The records of 8 patients with the allopurinol hypersensitivity syndrome evaluated at the Downstate Medical Center hospitals and an additional 72 patients described in the literature were reviewed. All were seriously ill. Three of the 8 patients at the Downstate Medical Center hospitals died as a result of allopurinol hypersensitivity; 19 of the 72 previously described patients also died from consequences of taking the drug. Only 1 of our 8 patients with allopurinol hypersensitivity was given allopurinol for an appropriate reason. Eight of the 59 previously described patients on whom there was adequate information had legitimate indications for allopurinol therapy. Severe, often fatal iatrogenic disease occurred unnecessarily in the others.

Safety and efficacy of ticarcillin plus clavulanic acid in the treatment of infections of soft tissue, bone, and joint

The efficacy and safety of ticarcillin plus clavulanic acid in the treatment of patients with infections of soft tissue, bone, and joint were evaluated in this open study. Clinical diagnoses included osteomyelitis, soft tissue abscess or ulcer, cellulitis, bite wound, traumatic or postoperative cellulitis, necrotizing fasciitis, septic arthritis, septic bursitis, and septic thrombophlebitis. Trauma or underlying disease such as diabetes mellitus or vascular insufficiency was common (more than 50 percent) in the patient population. Clinical efficacy was evaluable in 66 patients who received 3 g of ticarcillin and 0.1 g of clavulanic acid every four or six hours for a mean of 23.4 days. A satisfactory clinical response was observed in 92 percent of the patients. Major pathogens isolated were Enterobacteriaceae, anaerobic cocci, Staphylococcus aureus, and beta-hemolytic Streptococcus. Of the 143 isolates recovered from 55 bacteriologically evaluable cases, 87 percent were eradicated by therapy. Overall, a satisfactory bacteriologic outcome occurred in 93 percent of the patients, and the pathogen(s) persisted in 7 percent. More than 98 percent of the isolates were susceptible to ticarcillin plus clavulanic acid in vitro. Emergence of resistance during therapy occurred with three strains of Pseudomonas aeruginosa. Adverse drug-related reactions required discontinuation of treatment in two patients, although other minor abnormal laboratory findings were common. These results indicate that ticarcillin plus clavulanic acid offers safe and effective therapy for infections of soft tissue, bone, and joint.

Deliveries after cesarean birth in two Asian university hospitals

The task force of the consensus conference on cesarean birth of the National Institutes of Health, USA, has recommended substituting a trial of labor and vaginal delivery for elective repeat cesarean section in selected women. This paper assesses the benefits and risks associated with that recommendation using data from two Asian teaching hospitals, one in Jakarta, Indonesia and the other in Colombo, Sri Lanka. Data recorded on the Maternity Record Form designed by the International Fertility Research Program and the International Federation of Gynecology and Obstetrics were used for analysis. Consistent findings were derived from the two hospitals, in spite of the different medical care delivery systems in their countries. No significant increase in maternal and infant mortality and morbidity were associated with women having vaginal delivery subsequent to cesarean birth as compared to those with repeat cesarean section. Savings in medical cost were considerable in the former group.

Scoliosis in the institutionalized cerebral palsy population

A prospective review of 272 institutionalized cerebral palsy residents was undertaken in order to determine the incidence and characteristics of neuromuscular scoliosis in this population. The types of cerebral palsy in the group consisted of 75% spastic, 8% dyskinetic, 4% ataxic, 8% mixed, and 5% undefined. There was a 64% incidence of roentgenographic scoliosis greater than 10 degrees. Two distinct curve patterns were determined with equal frequency, single and multiple. The significance of the curve patterns could not be determined. Scoliosis was most common in the spastic group with the highest incidence in the spastic quadriplegics. The incidence directly paralleled the severity of the neurologic deficit but also appeared to be aggravated by the effects of gravity when the individuals were artificially placed in the sitting position. There was a definite inverse relationship between the level of ambulation and scoliosis: the higher the level of ambulation the lower the incidence of scoliosis. Hip stability per se could not be correlated with the incidence of scoliosis. The most important factors in predicting scoliosis in this population are the presence of spasticity and the severity of the neurologic deficit.

Familial deficiency of two subunits of the first component of complement. C1r and C1s associated with a lupus erythematosus-like disease

Complete absence of C1r and almost complete absence of C1s were found in 4 of 8 living siblings. Two of the 4 suffer from a syndrome that combines discoid lupus erythematosus and nondeforming rheumatoid-like arthritis; one of the siblings has mild nephritis. The other 2 C1 deficient family members are clinically well. Evidence from this and other families suggests that deficiency of C1 components or C4 is associated with higher risk of developing a lupus-like disease than is deficiency of C2.

Medical treatment of Serratia arthritis with trimethoprim-sulfamethoxazole

A patient with moderately severe rheumatoid arthritis and diabetes mellitus receiving steroids developed septic arthritis due to Serratia marcescens. Treatment with a new cephalosporin analogue, intra-articular and intramuscular gentamicin, and chloramphenicol alone and in combination proved ineffective. Finally, trimethoprim-sulfamethoxazole therapy, given for a protracted period, eradicated the infection without the need for surgical drainage.

Preliminary criteria for the classification of the acute arthritis of primary gout

The American Rheumatism Association sub-committe on classification criteria for gout analyzed data from more than 700 patients with gout, pseudogout, rheumatoid arthritis, or septic arthritis. Criteria for classifying a patient as having gout were a) the presence of characteristic urate crystals in the joint fluid, and/or b) a topus proved to contain urate crystals by chemical or polarized light microscopic means, and/or c) the presence of six of the twelve clinical, laboratory, and X-ray phenomena listed in Table 5.

Radioimmunoassay for colchicine in plasma and urine

A radioimmunoassay for the measurement of colchicine (in quantities as small as 0.05 nanogram) in plasma and urine was developed with the use of an antibody from immunized rabbits. After the intravenous injection of 2 milligrams of colchicine in seven subjects, the calculated zero-time concentration in the plasma was 2.9 +/- 1.5 micrograms per deciliter, and the mean half-time in the plasma was 58 +/- 20 minutes. Declining, but measurable, amounts of colchicine could be detected in urine up to day 9 after the drug was administered.