Stress-induced hyperglycaemia is an important clinical entity. It is an adaptive immune-neurohormonal response to physiological stress in an attempt to increase metabolic substrates to struggling organs during a time of crisis. However, this acute hyperglycaemia is also responsible for a number of detrimental effects implying that treatment is necessary. Hence, admission hyperglycaemia is not necessarily equivalent to a diagnosis of diabetes mellitus but the blood glucose level needs to be interpreted in context of the patient's presenting complaint and previous glycaemic status. Stress-induced hyperglycaemia is associated with increased morbidity and short-term mortality. Thus prompt recognition of stress-induced hyperglycaemia and high risk hyperglycaemic patients with the stress hyperglycaemia ratio can help improve inpatient management. Patients with stress-induced hyperglycaemia who have recovered from their acute illness should be followed up as they remain at risk for incident diabetes. This review focuses on the definition, pathophysiology, targets, management and significance of stress-induced hyperglycaemia.

Summary:Inhalation of small amounts of carbon monoxide diminishes the pain threshold in patients with stable angina pectoris. The aim of this study was to identify and describe patients who had been exposed unknowingly to toxic inhalations of this gas and subsequently presented to hospital with a clinical picture of unstable angina. Blood carboxyhaemoglobin levels of 104 patients referred with unstable angina to a coronary care unit were determined on admission. The Ukely source ofcarbon monoxide was identified in all patients. Three patients had definite carbon monoxide intoxication. Another five patients had evidence of minor exposure. When the three cases with carbon monoxide poisoning were excluded, the mean carboxyhaemoglobin level was 2.5% (± 1.3) for smokers (n = 30) and 0.6% (± 0.5) for non-smokers (n = 71). Use of fossil fuel combustion in an enclosed environment was responsible for the three most serious intoxications and one of the minor cases. We suggest that a number of patients admitted for coronary care with unstable angina may have significant carbon monoxide poisoning. This intoxication is often overlooked by attending physicians with the result that high concentration oxygen therapy is not administered, when it is in fact a necessary part of treatment.

Lithium is a mood stabiliser widely used in the treatment and prophylaxis of mania, bipolar disorders and recurrent depression. Treatment with lithium can give rise to various endocrine and metabolic abnormalities, including thyroid dysfunction, nephrogenic diabetes insipidus and hypercalcaemia. Lithium may induce hypercalcaemia through both acute and chronic effects. The initial acute effects are potentially reversible and occur as a result of lithium's action on the calcium-sensing receptor pathway and glycogen synthase kinase 3, giving rise to a biochemical picture similar to that seen in familial hypocalciuric hypercalcaemia. In the long term, chronic lithium therapy leads to permanent changes within the parathyroid glands by either unmasking hyperparathyroidism in patients with a subclinical parathyroid adenoma or possibly by initiating multiglandular hyperparathyroidism. The latter biochemical picture is identical to that of primary hyperparathyroidism. Lithium-associated hyperparathyroidism, especially in patients on chronic lithium therapy, is associated with increased morbidity. Hence, regular monitoring of calcium levels in patients on lithium therapy is of paramount importance as early recognition of lithium-associated hyperparathyroidism can improve outcomes. This review focuses on the definition, pathophysiology, presentation, investigations and management of lithium-associated hyperparathyroidism.

The use of inhalers or other devices is dependent on proper technique. Aim: To evaluate Asthma and COPD patients and determine factors that predict proper inhaler use. Methods: 167 patients (Male 45%, Mean age 57.6, std 15.3 years) were recruited both from hospital outpatients and from the community. Patients had to be on regular inhalers. 41.3% were under the care of a respiratory physician, 25.7% GP, 19.8% both, and 13.2% none. A questionnaire was filled by the patient followed by direct observation of inhaler technique.

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