Blood lactate conzcetrationis-Thc mean fasting blood lactatc concentrations were higher in patients taking hypoglycaemic tablets (table II). None of the drugs produced any significant fall in fasting blood lactate concentrations. During hypoglycaemia the control mean blood lactate concentration rose by 76 "O at 90 minutes in diet-treated subjects and by 67",, in tablct-treated subjects. Acebutolol impaired this blood lactate response in tablet-treated subjects (P < 0 05) with a rise of only 33 ", at 90 minutes. Propranolol slightly reduced the inc-emental area of blood lactate response in diet-treated subjects (P < 005). Atenolol had no significant effects on blood lactatc concentrations in either group.Blood NEFA conicenitrations-All drugs significantly lowered fasting blood NEFA concentrations in diet-treated subjects, and acebutolol also lovered them in drug-treated subjects (table III). After intravenous insulin administration the blood NEFA concentrations fell in all groups. The placebo blood NEFA concentration fell by 56",, at 30 minutes in drug-treated subjects, and by 52",, at 30 minutes in diettreated subjects. The secondary rise of blood NEFA concentrations from adrenaline-mediated lipolysis was reduced in acebutolol-and propranolol-treated diet-controlled subjects. No significant effects on blood NEFA concentrations were observed in the tablet-treated subjects. DiscussionThe results show that these beta-adrenoreceptor blocking drugs differ in their effects on the metabolic responses during insulin-induced hypoglycaemia, and this probably reflects differences in pharmacological selectivity and ancillary properties. Propranolol delayed glucose recovery, as it does in normal subjects. Acebutolol potentiated the hypoglycaemic action of insulin in drug-treated diabetics in a manner similar to that found in normal subjects. Throughout the recovery phase the mean blood glucose concentration remained on average 0 7 mmol/l (12 6 mg/100 ml) lower when patients were taking acebutolol than when they were taking placebo, the incremental area being identical with that for control and atenolol curves. This implies that the magnitude of the adrenaline-induced glycogenolytic response was unaffected but that acebutolol impaired hepatic glucose output in some other way.The beta-adrenoreceptors of the liver and skeletal muscle are thought to be predominantly of the beta2 type. Hence the beta2 adrenoreceptor blockade of the non-selective drugs might be expected to antagonise adrenaline-mediated glycogenolysis whereas the beta,-blocking drugs should have no such effect.Hepatic glycogenolysis may, however, also be stimulated directly by a low blood glucose concentration. Studies on liver preparations and exercising normal subjects have shown that drugs with a membrane-stabilising action inhibit glucose release from the liver in response to a low blood glucose concentration. 9 Thus propranolol, possessing this action, impaired postexercise recovery of the blood glucose, whereas metoprolol, without membrane-stabilising activi...

Reduction of hospital-acquired infections is a patient safety goal and regularly monitored by Performance Improvement committees. There is discordance between the ventilator-associated pneumonia (VAP) rate reported by the Infection Control Committee (ICC) and that observed by our Trauma Service. To investigate this difference, a retrospective evaluation of cases of VAP diagnosed on a single service was undertaken. A prospectively collected database was queried for VAP in intensive care unit patients between January 2010 and June 2011. This was compared with the list of mechanically ventilated patients provided by the ICC. Comparison for criteria used to diagnose pneumonia, ventilator day of the diagnosis, was recorded. The ICC identified two VAPs from 136 potential patients compared with the Trauma Service identifying 36 VAPs. A difference in diagnostic criteria between the ICC and the Trauma Service focused on use of the National Nosocomial Infection Survey (NNIS) algorithm versus quantitative microbiology from bronchoalveolar lavage specimens. Thirty-five of 36 Trauma Service VAPs were not identified as VAPs by the NNIS algorithm as a result of the chest radiographs. Application of differing definitions of VAP results in markedly different VAP rates. The difference has significant implications as infection rates are increasingly reported as a quality metric.

Acute kidney injury (AKI) is a complication associated with vancomycin. Previous studies demonstrated that the combination of vancomycin and piperacillin-tazobactam increases the risk of AKI compared to vancomycin with meropenem or cefepime.

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Psoriasis is a chronic, relapsing dermatosis characterised by scaling, erythema, and less commonly pustulation. Although the clinical spectrum is broad and the nature of the underlying defect responsible for the production of psoriasis uncertain, all currently available effective remedies are capable of inhibiting epidermal mitosis and this remains the most widely accepted concept in the management of psoriasis.