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Introduction: Sexually transmitted infections (STIs) are a common reason for Emergency Department (ED) visits.  The objective of this study was to see if there were gender differences in CDC diagnosis and treatment guidelines as documented by emergency physicians.Methods: A retrospective chart review was performed to idenitfy patients treate for urethritis, cervicitis, and PID in the EDs of three hospitals in a PA network during a calendar year.  Cases were reviewed to assess for compliance in documentation with CDC guidelines. Descriptive statistics were used to assess the distributions of study variables by patient sex.  Student t-tess, chi-square tests, and logistic regression were used in the analysis.  Statistical significance was set at p less than or equal to 0.05.Results: 286 patient records were identified, of these 39 were excluded due to incorrect disease coding, the patient was admitted and treated as an inpatient for their disease, or the patient left the emergency department after refusing care.  Of the 247 participangs, 159  (64.4%) were female.  Females were significantly younger (26.6 years, SD=8.0) than males (31.2, SD=11.5%), (95%CI:2.0-7.0, p=0.0003). All of the males (n=88) in the cohort presented with urethritis;25.8% of females presented with cervicitis and 75.2% with PID. Compliance with documentation for the 5 CDC criteria ranged from 68.8% for patient history to 93.5% for patient diagnostic testing including urine pregnancy, and gonorrhea/chlamydia cultures. Significant differences were obesrved by patient sex.  54% of the charts had symptoms recorded for female patients that were consistent with CDC characteristics for diagnostic critera compared to over 95% for males , (OR=16.9, 95% CI 5.9-48.4, p less than 0.001). Similar results were observed for patient discharge instructions, with physicians completely documenting deliver of discharge instructions to 51.6% females compared to 97.7% of complet documentation in males OR=42.3;95%CI;10.0-178.6, p

1 The effect of small doses of carbimazole on the binding rate constant of intrathyroidal iodide, plasma methimazole concentrations and circulating thyroid hormone concentrations in five hyperthyroid patients is presented. 2 In all patients there was a marked reduction in iodide binding with carbimazole doses as low as 5 to 10 mg daily. 3 In three patients little further reduction in the observed binding rate occurred with daily doses in excess of 10 mg despite progressive increases in plasma methimazole concentrations. 4 At the end of 4 weeks' treatment with 10 mg carbimazole daily, the reduction in thyroid hormone concentrations and clinical improvement were such as to suggest that this dose may be an effective starting dose in many patients. [ABSTRACT FROM AUTHOR]

1 Methimazole plasma concentrations were measured in two groups of hyperthyroid subjects after the oral administration of either carbimazole or methimazole. 2 With the HPLC method it was also possible to measure the concentration of a methimazole metabolite, 3-methyl-2- thiohydantoin in one patient. 3 Large interindividual differences were observed, especially within the carbimazole group. 4 Incomplete absorption of carbimazole could explain particular high apparent volumes of distribution and apparent clearances. [ABSTRACT FROM AUTHOR]

One hundred and ninety four diabetic men completed a questionnaire designed to identify their perception of erectile dysfunction (ED). Nine percent (17/186) of patients defined ED incorrectly. Thirty per cent (54/183) of patients were unaware that ED was a complication of diabetes and 42% (70/165) thought the problem was an inevitable consequence of advancing age. Nearly one half of the patients (47%, 87/188) were unaware that treatment was available for ED. In those patients who were aware of ED as a complication of diabetes or potential treatment for this problem, this information was more likely to have been obtained from sources other than a healthcare professional. Fifty per cent (96/194) of patients suffered from ED, 56% (54/96) of these patients felt the relationship with their partner had suffered as a consequence. Despite the high prevalence of ED and the misconceptions that existed, the questionnaire indicated that there had been little discussion between the patient and the healthcare professional about this problem. As a result of our questionnaire which enhanced the patient's knowledge of ED, the majority (>90%) said they would seek medical advice for the problem if it arose. We have also identified several key areas concerning ED that should be addressed by healthcare professionals involved in both primary and secondary diabetes care. [ABSTRACT FROM AUTHOR]

1 A high performance liquid chromatographic (HPLC) method was used to study the pharmacokinetics of methimazole after oral administration of carbimazole to women in various stages of pregnancy. 2 In one patient it was possible to conduct the study in the first and third timesters: there was an appreciable increase in the apparent clearance of methimazole. 3 Based on the assumption of complete absorption and hydrolysis of carbimazole to methimazole the mean apparent clearance was found to be significantly higher in pregnant patients receiving 10 mg carbimazole than in non-pregnant patients receiving the same dose. [ABSTRACT FROM AUTHOR]

We present the case of an elderly non-diabetic female who was admitted to hospital as an emergency due to loss of consciousness. Her clinical presentation was consistent with hypoglycaemia due to a massive insulin overdose. However, the patient refuted the possibility of insulin administration, and the circumstances were reported to the police for investigation. This case demonstrates the clinical and biochemical characteristics of insulin overdose. Furthermore, it serves to illustrate the sequence of events that may be created when foul play is suspected, and the factors related to patient confidentiality that require consideration by the responsible physician.

A patient presented to our unit with seizures and profound hyponatraemia after ingestion of a single tablet of ecstasy. The seizures proved resistant to therapy and ventilation on the intensive care unit was required. Resolution of the seizures occurred on correction of the metabolic abnormalities. The pathogenesis of seizures and hyponatraemia after ecstasy use is discussed. Ecstasy use should be considered in any young patient presenting with unexplained seizures and attention should be directed towards electrolyte levels, particularly sodium.

Objective: The optimal antithyroid drug regimen for Graves' disease remains a matter of controversy. The European Multicentre Trial Group has investigated the effects of methimazole drug dose on the long-term outcome of Graves' disease., Design: Extended follow-up of patients from a prospective multicentre trial, designed to study methimazole dose effects on the outcome of Graves' disease. We have reported previously that the relapse rates did not differ after a medication-free observation period of 12 months; the relapse rates were 37% and 38%, respectively. In this paper, we describe the outcome in these patients after a mean observation period of 4.3 +/- 1.3 years and have looked for potential predictors of this outcome., Patients: Three hundred and thirteen patients with Graves' disease were randomized to treatment with a constant dose of 10 or 40 mg of methimazole for 1 year, with levothyroxine supplementation as required., Measurements: At the time of inclusion into the trial: thyroid size, T4, T3, TSH-binding inhibiting immunoglobulins, urinary iodide excretion, thyroid uptake, Crook's therapeutic index of hyperthyroidism (a measure of clinical disease severity). At the time of follow-up examination: TSH, T4, T3, thyroid size, thyroid ultrasound, THS-binding inhibiting immunoglobulins., Results: The overall relapse rate was 58%. There was no difference in relapse rates between patients treated with either 10 or 40 mg of methimazole (58.3 vs. 57.8%). Five patients had become spontaneously hypothyroid, without obvious relationship to antithyroid drug dose. Patients who relapsed and patients who remained in remission did not differ with respect to: age, goitre size, ophthalmopathy, median iodine excretion, serum T4 or serum T3, Crook's therapeutic index and thyroid uptake at the time of study entry. Thus, none of these variables was potentially suitable for predicting outcome. This finding was confirmed by Cox's proportional hazard regression. Thyroid volume, measured by ultrasound, did not differ between patients in remission and patients with relapse. There was no difference in the course of endocrine eye signs, in the requirement for steroid and radiotherapy for eye signs, or in thyroid echostructure between patients in the 10 and in the 40 mg group, nor was serum TSH different in patients who had remained in remission (0.8 +/- 0.6 mU/l in the 10 mg group, 1.0 +/- 0.8 mU/l in the 40 mg group)., Conclusions: The dose of methimazole in Graves' disease therapy can safely be kept to the minimal required dose. This will provide the same chance of remission as higher doses, and provide the best balance of risk and benefit.

We highlight the case of a 35-year-old male who suffered a respiratory arrest as a result of methaemoglobinaemia secondary to skin contamination and inhalation of petrol octane booster following a road traffic accident. It is important that petrol octane booster is stored safely in leak-proof containers and that suitable warnings are displayed to alert the user of potential toxicity.

Some studies have suggested that increasing the daily dose of anti-thyroid drugs might improve long-term remission rates of Graves' disease. Therefore, this question was addressed in a prospective multicenter trial involving 18 thyroid clinics in Europe, mostly in iodine-deficient or moderately iodine-sufficient regions. Five hundred and nine patients with Graves' hyperthyroidism were enrolled in a prospective randomized trial comparing the remission rates after treatment with methimazole (MMI) at two fixed dosages (10 vs. 40 mg) with levothyroxine supplementation. The treatment and follow-up periods lasted 12 months each. Sixty and seven-tenths percent of the recruited patients (total, 309; 153 in the 10 mg, 156 in the 40 mg group) were finally evaluated, and comparison of the two groups showed that they were well matched with respect to a wide range of variables, including parameters of thyroid function. With 10 mg MMI daily, 68.4% of the patients were euthyroid after 3 weeks, and 84.9% after 6 weeks, compared to 83.1% and 91.6%, respectively, with the use of 40 mg MMI daily. TSH receptor antibodies decreased similarly in the two groups, 25% of patients in the 10 mg group, and 30% in the 40 mg group still being TSH receptor antibodies positive after 12 months. One hundred and ninety six (63.4%) of the 309 patients achieved remission of Graves' disease. The two MMI doses were equally effective; 35.9% compared to 37.2% of patients treated with 10 and 40 mg MMI, respectively, had relapses. There was no difference in the length of the time interval between stopping treatment and recurrence between the two groups. However, the rate of adverse drug reactions increased from 39/251 (15.5%) in the 10 mg group to 67/258 (26.0%) in the 40 mg group (P < 0.01). Under conditions of iodine deficiency or borderline sufficient iodine supply, 40 mg MMI daily will render more patients with Graves' disease euthyroid within the first 6 weeks of treatment than 10 mg daily, but at the expense of an increased rate of adverse reactions. However, patients treated with 40 mg MMI daily for 1 yr have no higher chance of remission than patients treated with 10 mg. It does not appear justified at present to recommend MMI doses higher than required for the control of hyperthyroidism (with the goal of immunosuppression).

Patients leaving hospital after 131I treatment for thyrotoxicosis face restrictions on their contact with other members of the public. These restrictions depend on the level of residual body radioactivity which for practical purposes can be taken to be almost entirely in the thyroid gland. This study provides an appropriate data base from which to draw advice to patients consistent with current radiological protection requirements in terms of the duration of these restrictions. Thyroidal retention of 131I was measured in 77 thyrotoxic patients over a period of 1-50 days after a first therapeutic administration of the radionuclide. Mean 131I activity in the gland (+/- S.D.) at 1 day was 56.1 +/- 11.1% of the administered dose activity and thereafter retention followed a single exponential decay pattern with a mean effective half-life (+/- S.E.M.) of 6.35 +/- 0.14 days. In patients who required further 131I therapy, there was evidence that retention could be markedly reduced if there was virtual ablation of thyroid tissue. It is proposed that these retention data can be used to determine body radioactivity at any interval after the administration of 131I for treatment of thyrotoxicosis, thus obviating the need for serial measurements in every individual patient.

The clinical and biochemical characteristics of 15 elderly patients with low levels of thyrotrophin (TSH) (< 0.1 mU/L) but normal free tri-iodothyronine (T3) and free thyroxine (T4) (group S) were compared with 10 euthyroid subjects (group E) and 10 hyperthyroid patients (group T). Free T3 and free T4 were significantly higher (p < 0.05) in group S (6.3 +/- 0.5 and 18.6 +/- 1.0 pmol/l, respectively) than in group E (4.6 +/- 0.3, 12.6 +/- 0.6). In common with elderly hyperthyroid patients (group T), patients in group S had few signs or symptoms of thyrotoxicosis, but the Wayne score (clinical index of hyperthyroidism) was higher in group S than in euthyroid subjects (p < 0.05). Thyroid microsomal, thyroglobulin or thyrotrophin receptor antibodies were common in group T (n = 9) but not in groups S (n = 2) or E (n = 1). This suggests a low prevalence of Graves' disease in group S compared to group T. Combined thyrotrophin releasing hormone (TRH; 200 micrograms i.v.) and gonadotrophin releasing hormone (GnRH; 100 micrograms i.v.) tests were performed; no cases of low TSH due to hypopituitarism were identified in group S. During a mean of 7.9 (4-12) months of observation TSH reverted to the normal range (> 0.2 mU/L) in 7 of 15 patients in group S; thyroid hormone concentrations rose above the normal range in four, however, only two patients required treatment for hyperthyroidism.(ABSTRACT TRUNCATED AT 250 WORDS)

The feasibility has been investigated of a physician in a district general hospital implementing an assessment and treatment service for male erectile impotence. Over an 8-month period a questionnaire was given to 200 men attending a diabetes review clinic. There were 50 replies declaring a problem of impotence, 34 of whom expressed interest in discussing treatment. These men and 17 others who spontaneously mentioned an impotence problem were further assessed with a view to treatment. After a full assessment and discussion the following treatments were agreed and successfully implemented: no treatment 30 (59%), self-injection of papaverine 12 (24%), urology referral 4 (8%), psychosexual clinic referral 2 (4%), vacuum devices 2 (4%), adjustment of drug therapy 1 (2%). Only 18% of questionnaire respondents ultimately opted for active treatment compared with 88% of the spontaneous complaints. A successful impotence assessment and treatment service, including self-injection of vasoactive drugs, can be provided by a physician as part of the diabetes care service. Active treatment is gratefully accepted. The numbers involved are manageable if resources are concentrated on those spontaneously mentioning the problem. Our experience suggested self-injection of vasoactive drugs to be the most successful treatment option.

We have used a method based on a perchlorate discharge test to estimate the duration of antithyroid effect of two doses of methimazole (MMI). Six patients with diffuse toxic goitre took 5 mg MMI twice daily and six took 20 mg twice daily over the study period of 12 weeks. Biochemical control of hyperthyroidism was achieved in all patients and thyroid hormone supplementation was required by all of the patients in the higher dose group to avoid hypothyroidism. Discharge of radioiodine from the thyroid by perchlorate diminished in both groups with time after MMI. After 5 mg MMI, perchlorate discharge as a percentage of the 30-min uptake (mean +/- SD), was 81.7 +/- 3.3% at 2.2 h, 69.3 +/- 18.9% at 5.9 h, 22.6-23.4% at 13.4 h and 2.7-6.7% at 25.1 h. After 20 mg MMI, the discharge was 92.5 +/- 1.9% at 2.2 h, 84.3 +/- 8.8% at 6.3 h, 64.8 +/- 24.1% at 13.3 h and 26.9-29.4% at 25.1 h. Only four patients (one in the lower dose group) showed a detectable discharge at 25 h and one of the patients treated with the lower dose showed no discharge at 13 h. These estimates of the effect of MMI on thyroidal iodide organification are not in keeping with published thyroidal MMI concentrations which do not show a fall between 3-6 h and 17-20 h after carbimazole. The explanation for this disparity is not clear but may be based on a redistribution of thioureylenes within the thyroid with time after dosage.(ABSTRACT TRUNCATED AT 250 WORDS)

A prospective study of thyroid function including serial tracer radioisotope uptake measurements in 55 patients treated with 131I therapy is described. Five patients had an episode of transient hypothyroidism within eight months of treatment: in three of these patients this was due to impaired organification of iodide, with normal iodide trapping by the thyroid (as measured by a twenty minute 123I uptake) being preserved. In contrast, in all patients who developed permanent hypothyroidism, iodide trapping was markedly diminished and did not recover. It is suggested that hypothyroidism due to organification failure following 131I therapy is potentially short-lived; where hypothyroidism is associated with gross impairment of iodide trapping, recovery is unlikely. Early iodine uptake measurements may be of value in selecting those patients whose hypothyroidism is transient and who do not require permanent thyroid hormone replacement.

Six clinically-healthy young men provided plasma samples every 30 min for 24 h (from 09:00-09:00 on 2 occasions. TSH, free T3 and free T4 were determined in the 30-min samples, while prolactin was determined in samples 1-3h apart. During the first test span, each man received an infusion of physiologic saline between 21(00)-01(00). Upon re-sampling several weeks later, 3 men received a low dose of dopamine (0.1 microgram/kg/min) and 3 men received a high dose (1.0 microgram) over the same hours (21:00-01:00). The least-squares fit of a 24-h cosine to each data series described a statistically-significant circadian rhythm (p less than 0.01) for each subject on each day of study. While overall group comparisons revealed no significant difference in mesor for any hormone studied, some intra-individual differences in rhythm parameters between saline and dopamine infusion were found. Dopamine Rx produced a statistically-significant increase in amplitude for PRL and T4 and an advance in acrophase for TSH, T3 and T4, but a delay for PRL. Studies measuring hormones of interest for the 24th immediately preceding and the 24th immediately following dopamine infusion at varying circadian stages (rather than only between 21:00-01:00) are warranted and have to be individualized--one of the points of this paper. The other main point is that data reduction to a mean and a standard deviation entails loss of information that can be recovered by chronobiologic methods, here used only as a model, in view of the limitations of the sampling design on hand.

A survey of district facilities and staffing for diabetes care in the South East Thames Region of England (population 3.58 million) is reported, and compared with the recommendations of the Royal College of Physicians and British Diabetic Association. Hospital Activity Analysis for diabetic patients in the Region for the year 1985 is also reported and costs assessed. Compared with recommended staffing levels there was a deficit of 12.8 Consultant Physicians with a weekly deficit of 109 sessions, and of 49.6 whole time equivalent Specialist Nurses. There were 11,857 admissions of diabetic patients, 4185 with diabetes as a primary cause. Seventy-six per cent of these were for diabetes without mention of complications and were therefore theoretically and potentially preventable. Total cost of diabetes care was estimated to be pounds 21.6 million p.a. for the Region of pounds 1.44 million per District Health Authority. We suggest it is time every Regional and District Health Authority gave some priority to diabetes care and established formal care strategies. To provide adequate staffing and facilities would improve standards of care, reduce morbidity and hospital admission rates, and be cost effective.

The effect of phenobarbital (PB) and/or thyroxine on the thyroidal accumulation and oxidation of [35S]methimazole (MMI) and serum TSH levels was studied in rats. PB treatment increased the accumulation of MMI and the serum TSH levels, but concurrent administration of T4 reversed these effects. It was concluded that increased TSH secretion in PB-treated animals was likely to be the major mechanism involved in the increased MMI accumulation. PB also increased the intrathyroidal oxidation of MMI to sulphate. However, in contrast to the PB effect on accumulation, concurrent T4 administration only partially reversed the effect on oxidation. The results suggested that the increased oxidation of MMI in PB-treated animals was due to a direct effect of PB or possibly a combination of this direct effect and the indirect TSH effect. Possible mechanisms postulated for a direct effect were thyroidal microsomal enzyme induction and/or changes in thyroidal protein binding of MMI.

An early diastolic murmur thought to indicate functional aortic regurgitation was heard in 7 of 74 consecutive patients with end-stage renal failure assessed for chronic intermittent haemodialysis and transplantation. In all 7 cases the murmur was transient and related to episodes of hypertension and fluid overload and disappeared on correction of these factors. In a further 2 patients aortic regurgitation resulted from a structural abnormality of the aortic valve. Thus, an early diastolic murmur is not uncommon in this situation and does not necessarily indicate organic aortic valve disease which might preclude selection for haemodialysis and transplantation.

Two patients remained clinically euthyroid following treatment for thyrotoxicosis with antithyroid drugs in spite of persistently elevated thyroid radioiodine uptakes not suppressable by exogenous triiodothyronine. Perchlorate discharge tests showed a defect in the intrathyroidal organification of iodine. Circulating levels of thyroxine were normal. From our study of 105 patients treated for thyrotoxicosis with antithyroid drugs, apparent remission of thyrotoxicosis by this mechanism might occur in up to 2 percent of patients.

The thyroid accumulation and oxidation of a single intraperitoneal dose of [35-S] methimazole has been studied in iodine-deficient, normal and iodine-treated rats. A highly significant positive linear correlation was found between the thyroid oxidation of methimazole to sulfate and intrathyroidal iodine content. A single dose of potassium iodide given intraperitoneally (ip) to rats 1 h before administration of [35-S] methimazole (1 mg/kg ip) increased the thyroid accumulation and oxidation of methimazole. Conversely, the thyroids of rats maintained on a low iodine diet for 21 days showed a markedly reduced capacity to accumulate and oxidize methimazole. The level of oxidation found in the iodine-deficient, normal and iodide-treated groups was 0.21, 4.15 and 12.6 nmol sulfate/g thyroid respectively. The animals maintained on the low iodine diet for 21 days showed significant increases in thyroid weight and thus the decrease in methimazole oxidation occurred in spite of increased stimulation by endogenous TSH. These results show that the intrathyroidal iodine content is a critical factor in the metabolism of methimazole in the thyroid.

Nineteen patients with severe oedema due to either cirrhosis of the liver or to congestive cardiac failure, who had failed to respond to previous diuretic therapy, were treated with either increasing doses of frusemide (Group A), or with frusemide in a fixed dose of 80 mg daily and increasing doses of spironolactone (Group B). In Group A there was an inverse correlation between the baseline 24-hr urinary sodium: potassium (Na : K) ratio and the 24-hr urinary potassium excretion during diuresis, and a direct correlation between the urinary Na : K ratio before and after diuresis. Thus, in patients of this group during diuresis, there was a significantly higher urinary potassium excretion in those with a baseline urinary Na : K ratio of less than 1, as compared with those with a ratio of greater than 1. In Group B a satisfactory diuresis was achieved without marked urinary potassium loss in those patients with a baseline urinary Na : K ratio of less than 1, whereas no diuresis was obtained in the two patients with a baseline urinary Na : K ratio of greater than 1. These results suggest that the measurement of the baseline urinary Na : K ratio is of help in determining the potential value of spironolactone in patients with resistant oedema.

Thyrotoxicosis may be associated with deterioration in asthma. To determine whether bronchial reactivity to histamine is increased in hyperthyroidism 10 thyrotoxic non-asthmatic patients were assessed before and after treatment of their thyrotoxicosis. No significant change in bronchial reactivity was found after treatment.