FAT ARMS,OBESITY AND CHOICE OF BLOOD PRESSURE CUFF SIZE IN DIABETIC PATIENTS

SUMMARY Four hundred consecutive diabetic patients had their mid-arm circumference (AC) measured and body mass index (BMI) calculated to determine the proportion of an unselected clinic group who would require a larger than standard adult blood pressure (BP) cuff and whether or not BMI could be used to predict AC and hence choice of appropriate BP cuff size. More than 75% of both men and women had an AC ≥29cm, justifying a larger than standard adult cuff for their BP measurement. When patients were classified according to their BMI, at least 80% with a BMI ≥30 and more than 70% with a BMI of 25-29 had a measured AC ≥29cm, while less than a third of patients with a BMI ≥25 had an AC ≥29cm. These results indicate that, in a diabetic clinic, most patients with a BMI ≥25 are likely to require an alternative adult BP cuff if their blood pressure is to be measured precisely.     

Assessment of fetal pulmonic stenosis by ultrasonography

This study was designed to determine (1) the value of Doppler echocardiography in depicting the presence of a fetal pulmonary stenosis, (2) its reliability in the assessment of the severity of the lesion, and (3) the usefulness of additional markers from the left side of the heart as criteria of severity. Fourteen pregnant ewes were included in this study (gestational age, 90 to 120 days). Banding of the fetal main pulmonary artery created mild (n = 3), moderate (n = 3), and severe (n = 5) stenosis. Three lambs were sham operated. Intrauterine fetal Doppler echocardiographic data obtained 15 days after surgery were compared with preoperative values. Peak velocities recorded through the band increased linearly from baseline in the groups with mild and moderate stenosis but did not show any further increase in the group with severe stenosis. Compared with the sham-operated group, right ventricular output in the group with stenosis was either similar or reduced significantly. The increase in right ventricular free wall thickness was significantly greater in the groups with stenosis compared with that of the sham-operated group; the correlation with the degree of severity was r = 0.65 and p < 0.05. A stronger positive correlation was found between the severity of stenosis and aortic valve diameters; r = 0.82 and p < 0.01. The strongest correlation was found for right ventricular/left ventricular outputs (r = 0.92; p < 0.001). Thus Doppler peak velocities through the obstruction can help detect pulmonic stenosis but are not reliable for the assessment of its severity during fetal life. Other ultrasound measurements such as the size of the aortic anulus and especially the ratio of right ventricular/left ventricular output could be used as sensitive markers of the severity of stenosis.     

LOGISTICS OF PERFORMING AN OPHTHALMIC ASSESSMENT IN ELDERLY INPATIENTS

SUMMARY To assess the feasibility of performing an ophthalmic assessment on elderly inpatients, we examined 48 patients over 75 years of age who were consecutively admitted to an acute elderly-care ward. Difficulties were encountered in 35 patients (73%). By employing simple methods to overcome these problems, useful information was obtained in all cases and the time taken to complete the examination ranged from six to 20 minutes (mean 7.5 minutes). Doctors looking after elderly patients should be encouraged to assess visual function and must not be deterred by anticipated logistical difficulties.     

AN ATYPICAL CASE OF ATYPICAL PNEUMONIA

SUMMARY A 23-year-old man, previously fit and well, presented with an atypical pneumonia, associated with microangiopathic anaemia, thrombocytopenia, rhabdomyolysis and renal impairment. Despite administration of intravenous fluids and antibiotics, his condition rapidly deteriorated, and the possibility of an aggressive connective tissue disorder was raised. Thus he was treated with high-dose oral steroids and plasma exchange until autoantibodies were shown to be negative. At this stage it transpired that the patient had swallowed water from a stream three weeks earlier, and leptospira antibody titres were subsequently found to be elevated. Antibiotics were continued, and after a protracted course he made a full recovery. Leptospirosis should be remembered as a rare cause of atypical pneumonia, particularly if there is associated hepatic or renal impairment.     

DIAPHRAGMATIC PARALYSIS IN MOTOR NEURONE DISEASE: USE OF NON-INVASIVE INVESTIGATIVE AND THERAPEUTIC TECHNIQUES

SUMMARY Two cases of bilateral diaphragmatic weakness are described in which the condition was the presenting feature of motor neurone disease. Inspiratory muscle strength was assessed by a non-invasive technique involving measurements of pressures generated within the mouth. One patient with severe inspiratory muscle weakness is being treated with domiciliary nasal ventilation and has returned to a good-quality life. The other patient with less severe weakness has thus far required no ventilatory support.     

Incidence of achalasia in New Zealand, 1980-84: An epidemiological study based on hospital discharges

One hundred and fifty-two patients with achalasia were first admitted to hospital in New Zealand between 1980 and 1984. The discharge of these patients was recorded by the National Health Statistics Centre which records details of all public health hospitals in New Zealand. The overall incidence was 0.95/100 000 population per year and was similar in North and South Islands and in men and women. The incidence increased with age and was 5.4/100 000 population per year in people aged over 80 years old. The disease was more common in Polynesian migrants (1.3/100 000 population per year) than other ethnic groups. Variations in incidence were seen across the Health Boards with the highest incidence of 2.9/100 000 population per year in Hawkes Bay and Tauranga.     

Unique features ofHelicobacter pylori disease in children

In a six-year period, 41 children had endoscopically documented duodenal ulcer disease or primaryH. pylori antral gastritis without duodenal ulcer. Of 37 children withH. pylori gastritis, group 1 comprised 23 patients with duodenal ulcer disease and group 2 had 14 patients without ulcers (primaryH. pylori gastritis). Group 3 comprised four children with duodenal ulcer disease andH. pylori-negative antral biopsies. During the study period, all primary chronic ulcer disease was duodenal; no primary chronic gastric ulcer was present. Two distinct types of duodenal ulcer disease were identified; the majority (85%) was always associated with significant activeH. pylori antral gastritis (group 1). The minority (15%) had virtually absent gastritis and noH. pylori (group 3). Native Indian children were represented in group 1 quite out of proportion to the referral population and had the most severe disease. While it is established that a higher prevalence of asymptomaticH. pylori infection exists in non-Caucasians, this appears to be the first demonstration of a higher prevalence of symptomatic ulcer disease in non-Caucasian children or adults. Caucasian children tended to have primaryH. pylori gastritis (group 2) or duodenal ulcer withoutH. pylori (group 3). Antral nodularity was found to be an important specific endoscopic sign, unique to those children withH. pylori disease. It has not been described in adultH. pylori disease. Non-Caucasian children, especially Native Indians, in British Columbia have more prevalent and more severeH. pylori disease than Caucasians. Endoscopy with gastric antral biopsies is necessary to distinguish different types of duodenal ulcer disease and to diagnose primaryH. pylori gastritis.