Mourad Labib

The low‐dose ACTH test does not provide a useful assessment of the hypothalamic–pituitary–adrenal axis in secondary adrenal insufficiency

OBJECTIVE The 1 µg ACTH stimulation test has been introduced to improve the sensitivity of ACTH as a test of the integrity of hypothalamic–pituitary–adrenal axis (HPAA). This study aims to compare the sensitivity, specificity and diagnostic accuracy of the ‘low‐dose’ 1 µg ACTH (LDACTH) test and the ‘standard dose’ 250 µg ACTH (SDACTH) test, with the overnight metyrapone test (OMT) which assesses the entire HPAA.

Hypogonadism and low bone mineral density in patients on long-term intrathecal opioid delivery therapy

Objectives This study aimed to investigate the hypothalamic-pituitary-gonadal axis in a sample of male patients undertaking intrathecal opioid delivery for the management of chronic non-malignant pain and the presence of osteopaenia and/or osteoporosis in those diagnosed with hypogonadism. Design Observational study using health data routinely collected for non-research purposes. Setting Department of Pain Management, Russells Hall Hospital, Dudley, UK. Patients Twenty consecutive male patients attending follow-up clinics for intrathecal opioid therapy had the gonadal axis evaluated by measuring their serum luteinising hormone, follicle stimulating hormone, total testosterone, sex hormone binding globulin and calculating the free testosterone level. Bone mineral density was measured by DEXA scanning in those patients diagnosed with hypogonadism. Results Based on the calculated free testosterone concentrations, 17 (85%) patients had biochemical hypogonadism with 15 patients (75%) having free testosterone <180 pmol/L and 2 patients (10%) between 180 and 250 pmol/L. Bone mineral density was assessed in 14 of the 17 patients after the exclusion of 3 patients. Osteoporosis (defined as a T score ≤−2.5 SD) was detected in three patients (21.4%) and osteopaenia (defined as a T score between −1.0 and −2.5 SD) was observed in seven patients (50%). Five of the 14 patients (35.7%) were at or above the intervention threshold for hip fracture. Conclusions This study suggests an association between hypogonadism and low bone mass density in patients undertaking intrathecal opioid delivery for the management of chronic non-malignant pain. Surveillance of hypogonadism and the bone mineral density levels followed by appropriate treatment may be of paramount importance to reduce the risk of osteoporosis development and prevention of fractures in this group of patients.

Hyperlipidaemia and primary prevention of coronary heart disease: are the right patients being treated?

Background In 1997, the Standing Medical Advisory Committee report suggested that patients with a coronary heart disease risk of 3% per year or greater should be considered appropriate for lipid-lowering medication. The report stated that cholesterol concentration alone is a poor predictor of absolute risk of coronary heart disease and recommended the Sheffield table as a method of estimating the coronary heart disease risk. Objective To assess the impact of the Standing Medical Advisory Committee report on the management of patients with hyperlipidaemia in the primary prevention of coronary heart disease in primary care. Method A survey questionnaire giving the clinical details of 20 patients with various coronary heart disease risk factors was sent to 200 general practitioners in the West Midlands, UK. Results Forty-eight percent of the respondents used clinical assessment/perception as the sole means of risk assessment and 26% used the Sheffield table. In patients who did not require treatment, 40.1% of the decisions were inappropriate and, in patients who required treatment, 35.1 % of the decisions were inappropriate. Overall, inappropriate decisions were made in 37.9% of the responses. Despite the clear advice in the Standing Medical Advisory Committee report on the importance of incorporating multiple risk factors in estimating absolute coronary heart disease risk, only total cholesterol and triglycerides were significant in influencing treatment decisions. Conclusions The Standing Medical Advisory Committee recommendations on the management of hyperlipidaemia in primary prevention of coronary heart disease are not widely used. Large savings could be made by correctly identifying and treating individuals at high risk. We recommend use of the full Framingham risk score in assessment of coronary heart disease risk in primary care.

A Simple HPLC Method for the Separation of Amphetamine Isomers in Urine and its Application in Differentiating between ‘Street’ Amphetamine and Prescribed D-Amphetamine

D-amphetamine has been increasingly prescribed to treat amphetamine abusers. Prescribing D-amphetamine requires laboratory evidence or confirmation of current use of ‘street’ amphetamine, using a method which should be capable of differentiating between ‘street’ amphetamine and prescribed D-amphetamine. We have developed a simple high-performance liquid chromagraphy (HPLC) method for the separation of the two isomers of amphetamine in urine and have assessed its use in differentiating between ‘street’ amphetamine and prescribed D-amphetamine. The method is reproducible, free from interference and has a detection limit of 0·1 μg/mL for each isomer. Urine from patients prescribed D-amphetamine contained only a trace amount of L-amphetamine (less than 4%) whereas urine from those taking ‘street’ amphetamine contained more than 50% L-amphetamine. The method is applicable to confirmation of ‘street’ amphetamine misuse and for monitoring patient compliance with treatment. The presence of 4% or less L-amphetamine in urine would suggest that the patient is only taking prescribed D-amphetamine whereas the presence of L-amphetamine in higher concentrations suggests that the patient is taking ‘street’ amphetamine, with or without prescribed D-amphetamine.

The effects of opioids on the endocrine system: an overview

Opioids commonly used for pain relief may lead to hypogonadism, which is characterised by suppression of production of the gonadotropin-releasing hormone (GnRH) resulting in inadequate production of sex hormones. The aim of this narrative review was to highlight the effects of opioids on the endocrine system and the development of hypogonadism. MEDLINE, EMBASE and Cochrane Library were searched for relevant articles investigating hypogonadism in patients undertaking opioid therapy by using a combination of both indexing and free-text terms. The suppression of GnRH leading to a decrease in sex hormones has been described as the principal mechanism of opioid-induced hypogonadism. However, there is no consensus on the threshold for the clinical diagnosis of hypogonadism. Evidence indicates that chronic opioid use can lead to hypogonadism. Clinicians should be aware of symptomatology associated with hypogonadism and should regularly monitor patients with appropriate laboratory investigations.

Neopterin Levels in Alcohol-Dependent Patients

Chronic alcohol exposure appears to suppress cell-mediated immunity which may contribute to the high incidence of infections among alcohol-dependent patients. We measured serum neopterin, as a marker of macrophage function and T-lymphocyte activation, in 26 alcohol-dependent patients. The mean serum neopterin in these patients was significantly lower than the mean serum neopterin in matched controls. In those who abstained, the mean serum neopterin at 3 weeks rose and was no longer significantly different from controls. Our findings suggest that alcohol-dependent patients have suppressed macrophage function which may be reversible within 3 weeks of abstention.

The DUBASCO SCORE: A scoring system for selecting patients for consideration of bariatric surgery

The National Institute for Health and Clinical Excellence guidance states that bariatric surgery should be available as a treatment option for people with a body mass index (BMI) of > 40.0 kg/m 2 and those with a BMI 35.0–40.0 kg/m 2 and other significant disease that may be improved with weight loss. Despite this, funding criteria are different between primary care trusts (PCTs) in England and some use a cut-off BMI of > 50.0 kg/m 2 . However, BMI may not be the best parameter to decide on who would benefit most from bariatric surgery. We have developed a scoring system, which takes into account the number and severity of four comorbidities in addition to BMI and age. Using this scoring system, 24% of patients with BMI > 50.0 kg/m 2 did not score high enough, whereas 63% of patients with BMI 35.0–50.0 kg/m 2 had significant comorbidities and would have potentially benefited more from undergoing bariatric surgery. The advantage of using a scoring system, is that the cut-off level for referral for surgery can be adjusted up or down depending on the level of resources available, but will always identify those patients who would benefit most from surgery. Br J Diabetes Vasc Dis 2011;11:17-20.

Recurrent aspiration and upper lobe cavitation

In May, 2010, a 49-year-old woman presented to the outpatient clinic with a 4-month history of feeling generally unwell with night sweats and a persistent productive cough of green and yellow sputum. She described coughing when lying fl at, particularly in the early morning hours. Medical history included laparo scopic adjustable gastric banding fi tted in September, 2008, for class III obesity, when her body-mass index (BMI) was 45·4 kg/m². She had been referred to a weight management clinic in July, 2008, at age 49 (BMI 46·2 kg/m²), and subsequently qualifi ed for gastric banding. Her initial response to surgery was modest and she underwent further band fi lls in 2008 and 2009. She was a known asthmatic and had been treated by her general practitioner for exacerbation of her asthma but with no improvement. On examination, her BMI was 32·6 kg/m² and her observations were within normal limits. Blood tests showed a high concentration of C-reactive protein (81 mg/L) and a high ESR (96 mm/h). Chest radiograph showed left upper zone cavitation. Given the radiographic appearance and the presence of persistent night sweats, tuberculosis was suspected. She was referred to the tuberculosis clinic and a subsequent thoracic CT scan confi rmed the presence of a 3·2 cm × 2·8 cm irregular cavitating lesion within the apical segment of the left upper lobe (fi gure). A moderate dilatation of the oesophagus, but no signifi cant thoracic lymphadenopathy, was also seen. Subsequent early morning sputum samples for acid fast bacilli were persistently negative and sputum culture showed only normal respiratory fl ora. Aspergillus precipitins were negative and an autoimmune screen showed no abnormalities. A bronchoscopy and subsequent washings did not yield acid fast bacilli. At this point, the diagnosis of recurrent aspiration and cavitation secondary to a severe restriction from her gastric banding was suspected. She was allergic to penicillin, and therefore treated with metronidazole and doxycycline.Her symptoms persisted, and after 6 weeks of anti-biotics she had only had short-term symptom relief. Therefore, her gastric band was completely emptied, after which her symptoms quickly resolved. A subsequent barium meal showed resolution of her oesophageal dilatation. Based on chest radiographs, the lung cavitation had fully resolved, along with her symptoms. At last follow-up in May, 2011, her BMI was 34·8 kg/m² and her gastric band had been cautiously refi lled with no symptom recurrence.Laparoscopic adjustable gastric banding is regarded as the least invasive surgical option for morbid obesity. However, the procedure is associated with high frequency of late complications, with pouch expansion and band slippage or erosion being the most common.

The millennium bug and the potential impact on NHS hospitals

An NHS hospital is a complex organisation with many departments which are all inter‐dependent. The “millennium bug” can potentially affect any or all of its systems. Disruption in one department, over the millennium period, is likely to affect the overall delivery of health care with potential threat to life. The NHS Executive has identified the year 2000 issue as the first non‐clinical priority and every hospital has established a business continuity plan. However, many of the critical risks are outside the hospitals’ direct control and service delivery will essentially depend on the ability of key suppliers to maintain their business continuity. Unlike in industry or profit‐making organisations, the cost of assessing the risk, testing and replacing non‐compliant equipment in hospitals cannot be passed to the consumer. Additional costs will have to be met from within existing resources which will have a major effect on the already stretched health care provisions.

Is using WHO criteria for impaired fasting glycaemia appropriate as an indication for OGTT in patients at high risk of developing diabetes

Aim:  Impaired fasting glycaemia (IFG) is an indication for oral glucose tolerance test (OGTT). World health organisation and International Diabetes Federation define IFG as fasting plasma glucose (FPG) levels of 6.1–6.9 mmol/l. However, American Diabetes Association still recommends a range of 5.6–6.9 mmol/l as IFG. We performed an audit to assess the outcome of OGTT at various cut offs of FPG levels in patients at high risk of developing diabetes.