Provision of home mechanical ventilation and sleep services for England survey.

The Department of Health is promoting the generation of specialist networks to manage long term ventilatory weaning and domiciliary non-invasive ventilation patients. Currently the availability of these services in England is not known. We performed a short survey to establish the prevalence of sleep and ventilation diagnostic and treatment services. The survey focussed on diagnostic services and Home Mechanical Ventilation (HMV) provision, and was divided into (a) availability of diagnostics, (b) funding, and (c) patient groups. This survey has confirmed that the majority of Home Mechanical Ventilation set-ups are currently for Obesity Related Respiratory Failure and Chronic Obstructive Pulmonary Disease. We have found that there is variable provision of diagnostic services, with the majority of units offering overnight oximetry (95%) but only 55% of responders providing a home mechanical ventilation service. Even more interestingly, less than two thirds of units charged their primary care trust for this service. These data may assist in the development of regional networks and specialist home mechanical ventilation centres.

Analysis of an adult Duchenne muscular dystrophy population.

BACKGROUND: Advances in management have led to increasing numbers of patients with Duchenne muscular dystrophy (DMD) reaching adulthood. Older patients with DMD are necessarily severely disabled, and their management presents particular practical issues. AIM: To review the management of a late adolescent and adult DMD population, and to identify areas in which the present service provisions may be inadequate to their needs. DESIGN: Retrospective review. METHODS: We studied 25 patients with DMD referred to an adult neuromuscular clinic over a 7-year period. Clinical details were obtained retrospectively, from case notes or direct observations. RESULTS: There were 24 males and one symptomatic female carrier. Nine patients died during the observation period. There was no significant correlation between age of wheelchair confinement and age of death. Sixteen patients received non-invasive positive pressure support. Twelve attended mainstream schools and 12, residential special schools. All the patients lived at home for some or all of the time, when their main carers were either one or both of the parents. The most striking difficulties were with the provision of practical aids, including appropriate hoists and belts, feeding and toileting aids, and the conversion of accommodation. Patients rarely wished to discuss the later stages of their disease, and death was often more precipitate than expected. Death usually occurred outside hospital and the final cause was often difficult to establish. DISCUSSION: Adult patients with DMD develop progressive impairment, due to respiratory, orthopaedic and general medical factors. However, the particular areas of difficulty in this study often reflected inadequate and poorly directed social and medical support, illustrating the need for improvements in the structure, co-ordination and breadth of rehabilitation services for adult patients with DMD.

Hypothyroidism--an unexpected diagnosis following emergency treatment for heatstroke.

Heat illness is a common presentation to emergency departments during periods of high ambient temperatures. The thyroid axis is involved in thermoregulation, and its dysfunction dysfunction leads to loss of thermal homeostasis. Hyperthyroidism predisposes an individual to heat illness and hypothyroidism to hypothermia. For heat illness to be the presenting feature of hypothyroidism is very rare. In this report, a case is presented and a discussion of the thyroid axis, thermoregulation, its failure and possible mechanisms follows on.

Acute adult asthma--assessment of severity and management and comparison with British Thoracic Society Guidelines.

To investigate the accuracy of clinical severity assessment of asthmatics and to compare emergency and subsequent ward management with British Thoracic Society (BTS) Guidelines, the records of all patients admitted for severe asthma (46) over a 5-month period to a District General Hospital were inspected. Variations from recommended management were revealed. Appropriate oxygen administration was often not provided in casually and patients frequently left hospital before their discharge criteria were attained: recommended diurnal variations in peak flow were exceeded in 26%. Eleven per cent of discharges were against medical advice, making provision of adequate management logistically difficult. Adherence to BTS guidelines on the need for arterial blood gas (ABG) analysis would have led to a failure to detect significant hypoxaemia in 25% of cases. This study identified substantial variations from BTS management guidelines. It is suggested that oximetry is necessary on arrival to guide selection for arterial blood gas analysis.

A major outbreak of asthma associated with a thunderstorm: experience of accident and emergency departments and patients' characteristics. Thames Regions Accident and Emergency Trainees Association.

OBJECTIVE: To investigate the time course of an epidemic of asthma after a thunderstorm, characteristics of patients affected, and the demand on emergency medical resources. DESIGN: Study of registers and records in accident and emergency departments and questionnaire to staff. SETTING: London area. SUBJECTS: All patients presenting at 12 accident and emergency departments with asthma or other airway disease. MAIN OUTCOME MEASURES: Numbers of patients, clinical features, information on shortage of resources--equipment, drugs and staff. RESULTS: The epidemic had a sudden onset on 24 June 1994; 640 patients with asthma or other airways disease attended during 30 hours from 1800 on 24 June, nearly 10 times the expected number. Over half (365) the patients were aged 21 to 40 years. A history of hay fever was recorded in 403 patients; for 283 patients this was the first known attack of asthma; a history of chronic obstructive airways disease was recorded in 12 patients. In all, 104 patients were admitted (including five to an intensive care unit). Several departments ran out of equipment or drugs, called in additional doctors, or both. CONCLUSIONS: This study supports the view that this epidemic was larger than previously reported epidemics and the hypothesis that "thunderstorm associated asthma' is related to aeroallergens. Demands on resources were considerable; a larger proportion of patients needing intensive care would have caused greater problems.

Female sterilisation.

PIP: Over 800 laparoscopic sterilizations were performed (1966-72) using a variety of techniques including coagulation of the tube at several points without division or excision. Surgery was performed using a modified Steptoe approach. There were 9 subsequent pregnancies of which 4 occurred before sterilization and most early in the series. Complications requiring laparotomy included adhesions, coagulation of the bowel, insufflation of the omentum, bleeding, ovarian cyst and obesity.^ieng

Outcomes, cost and long term survival of patients referred to a regional weaning centre.

BACKGROUND: Regional weaning centres provide cost effective care for patients who have undergone prolonged mechanical ventilation. There are few published European data on outcomes in these patients. METHODS: Patients admitted for weaning to the Lane Fox Respiratory Unit (LFU) between January 1997 and December 2000 were identified. The proportion weaned from mechanical ventilation, in-hospital mortality, and subsequent survival after discharge were examined. RESULTS: A total of 153 patients had been ventilated for a median of 26 days before transfer. The daily cost per patient stay was 1350. Fifty eight patients (38%) were fully weaned, 42 (27%) died, and 53 (35%) required ventilatory support at discharge from hospital of whom 36 (24%) required only nocturnal ventilation. Univariate analysis showed increasing age (OR 1.06, p<0.001), length of ICU stay (OR 1.02, p = 0.001), APACHE II predicted risk of death score (OR 1.02, p = 0.05), and a surgical cause for admission (OR 4.04) were associated with mortality. Neuromuscular/chest wall conditions were associated with low mortality (OR 0.36) but low likelihood of weaning from ventilation (OR 0.28). Female sex (OR 2.13, p = 0.03) and COPD (OR 2.81) were associated with successful weaning. Overall survival at 3 years from admission was 47%. Long term survival was lowest in patients with COPD. CONCLUSIONS: Most patients survived to leave hospital, the majority having been liberated from ventilatory support. Survivors were younger and spent less time ventilated in the referring ICU. The underlying diagnosis determined success of weaning, hospital survival, and long term outcome.

The pulmonary physician in critical care. 11: critical care management of respiratory failure resulting from COPD.

Survival to hospital discharge of patients suffering exacerbations of COPD is better than other medical causes for ICU admission. Although non-invasive ventilation (NIV) may prevent progression to tracheal intubation, its failure in most cases should lead to a period of controlled mechanical ventilation aiming for early extubation, possibly supported by NIV and tracheostomy if this fails. A greater understanding of the physiological principles behind ventilatory support of patients with COPD should reduce patient-ventilator disharmony and avoid the excessive use of sedation. The risk of nosocomial infection increases with the length of time the patient remains in the ICU and commonly further prolongs the period of ventilator dependency. Weaning centres with an emphasis on general rehabilitation may offer the best support for such individuals.

Ventilatory control in normal man following five minutes' exposure to hypoxia.

Ventilatory control was studied in normal subjects following brief (5 min) exposure to hypoxia (inhalation 7-8% O2). The ventilatory response to rebreathing CO2 (hyperoxic) was assessed 20 min before and after 5 min exposure to (a) 7-8% O2, (b) 7-8% O2 rebreathing CO2, (c) rebreathing CO2 during hyperoxia, and (d) 10% O2, normocapnic. The slope of the V-PCO2 response (S) was increased for up to 40 min following (a) and (b) by 25-34%, but was unchanged following (c) and (d). Resting ventilation was unchanged throughout. The ventilatory response to normocapnic progressive hypoxia was measured as the slope of the V-Hb% SaO2 relationship (H); this was increased by 26%. The mechanism underlying this change in ventilatory control in man is unknown; it may relate to the process of acclimatization to hypoxia whereby chronic hypoxia is a greater stimulus to ventilation than acute hypoxia.

The adjustment of children of Australian Vietnam veterans: is there evidence for the transgenerational transmission of the effects of war-related trauma?

OBJECTIVE: The presence of posttraumatic stress disorder (PTSD) in trauma survivors has been linked with family dysfunction and symptoms in their children, including lower self-esteem, higher disorder rates and symptoms resembling those of the traumatized parent. This study aims to examine the phenomenon of intergenerational transfer of PTSD in an Australian context. METHOD: 50 children (aged 16-30) of 50 male Vietnam veterans, subgrouped according to their fathers' PTSD status, were compared with an age-matched group of 33 civilian peers. Participants completed questionnaires with measures of self-esteem, PTSD symptomatology and family functioning. RESULTS: Contrary to expectations, no significant differences were found between the self-esteem and PTSD symptomatology scores for any offspring groups. Unhealthy family functioning is the area in which the effect of the veteran's PTSD appears to manifest itself, particularly the inability of the family both to experience appropriate emotional responses and to solve problems effectively within and outside the family unit. CONCLUSION: Methodological refinements and further focus on the role of wives/mothers in buffering the impact of veterans' PTSD symptomatology on their children are indicated. Further effort to support families of Veterans with PTSD is also indicated.