Weekend admission and mortality from acute exacerbations of chronic obstructive pulmonary disease in winter.

Historically, acute medical staffing numbers have been lower on weekends and in winter numbers of medical admissions rise. An analysis of acute exacerbations of chronic obstructive pulmonary disease (AECOPD) admissions to Portsmouth Hospitals over a seven-year period was undertaken to examine the effects of admission on a weekend, of winter, and with the opening of a medical admissions unit (MAU). In total, 9,915 admissions with AECOPD were identified. Weekend admissions accounted for 2,071 (20.9%) of cases, winter accounted for 3,026 (30.5%) admissions, and 522 (34.4%) deaths. Adjusted odds ratio (OR) for death on day 1 after winter weekend admission was 2.89 (95% confidence interval (CI) 1.035 to 8.076). After opening the MAU, the OR for death day 1 after weekend winter admission fell from 3.63 (95% CI 1.15 to 11.5) to 1.65 (95% CI 0.14 to 19.01). AECOPD patients have an increased risk of death after admission over a weekend in winter and this effect was reduced by opening a MAU. These findings have implications for the planning of acute care provision in different seasons.

Breast cancer follow up: a randomised controlled trial comparing point of need access versus routine 6-monthly clinical review.

AIM: To examine a model of care for breast cancer patients based on the concept of point of need access and investigate the effectiveness of this model compared to routine 6-monthly clinical reviews. DESIGN: A parallel randomised controlled trial was used to examine point of need access to specialist care via the nurse specialist, compared to routine hospital based 6-monthly clinical review at year two post breast cancer diagnosis. A total of 237 patients were recruited to the study. METHODS: Outcome measures at baseline, 9 and 18 months included psychological morbidity using the GHQ12 questionnaire, quality of life using the FACT-B plus endocrine subscale, fear and isolation. An analysis of covariance was used to detect changes over time. Recurrences and methods of detection were recorded as secondary outcome measures. RESULTS: Two hundred and fourteen patients completed the study. Overall patients were not exposed to risks of increased psychological morbidity (p=0.767) or decline of quality of life (p=0.282) when routine review was discontinued and no significant differences were detected during an 18-month period. Patients not receiving regular review did not feel isolated, and at the end of 18 months did not wish to return to 6-monthly clinical reviews. The presentation of recurrences and short symptom history demonstrate that the recurrences observed were unlikely to have been detected at a routine visit. CONCLUSIONS: Point of need access is acceptable to the majority of patients. Although a third of patients may wish to maintain a regular review, patient choice is important. Findings suggest that after 2 years following the diagnosis of breast cancer there is no evidence to support the view that regular clinical review improves psychological morbidity or quality of life. Patients do not appear to be compromised in terms of early detection of recurrence. Point of need access can be provided by suitably trained specialist nurses and provides a fast, responsive management system at a time when patients really need it.

Does severity of low-dose, double-blind, placebo-controlled food challenges reflect severity of allergic reactions to peanut in the community?

BACKGROUND: The severity of allergic reactions to food appears to be affected by many interacting factors. It is uncertain whether challenge-based reactions reflect the severity of past reactions or can predict future risk. OBJECTIVE: To explore the relationship of a subject's clinical history of past reactions to the severity of reaction elicited by a low-dose, double-blind, placebo-controlled food challenge (DBPCFC) with peanut. METHOD: Cross-sectional questionnaire assessment of community-based allergic reactions and low-dose DBPCFC in self-selected peanut-allergic subjects. Reaction severity was assessed using a novel scoring system, taking account of the dose of allergen ingested. RESULTS: Forty subjects (15 males, 23 children, 23 asthmatics by history) were studied. Only the most recent community reaction predicted the severity of reaction in the DBPCFC, but even this association was weak (r=0.37, P=0.03). Peanut-specific IgE (PsIgE) and skin prick test (SPT) weal size were not associated with community score but PsIgE level correlated well with the challenge score (r=0.6, P=0.001). Asthma did not affect the eliciting dose or challenge score directly but the association of PsIgE and challenge score was stronger in those without asthma (r=0.72, P=0.001) than in those with asthma (r=0.48, P=0.02). CONCLUSIONS: The scoring system developed appears to improve the sensitivity of assessment of reactions induced by DBPCFC. This is the first prospective study showing an association between PsIgE levels and clinical reactivity in DBPCFC, an effect that is more pronounced in non-asthmatics. This finding has important implications for the clinical care of subjects with food allergy. There is a poor correlation between the severity of reported reactions in the community and the severity of reaction elicited during low-dose DBPCFC with peanut.

Pet allergen control measures for allergic asthma in children and adults.

BACKGROUND: Although pet removal has been recommended in guidelines on the management of allergic asthma, pet ownership remains high in families where one or more members have an allergy to pet dander. Allergen control measures such as air filtration units placed in the homes of pet-allergic asthmatics have been used as a means of reducing allergen exposure. OBJECTIVES: To determine the clinical efficacy of pet allergen control measures in the homes of people with pet-allergic asthma. SEARCH STRATEGY: An electronic search of the Cochrane Controlled Trials Register was carried out. No restriction was placed on language of publication. SELECTION CRITERIA: Randomised controlled trials comparing an active allergen reduction measure with control were considered for analysis. Participants had stable pet-allergic asthma. DATA COLLECTION AND ANALYSIS: 34 references were identified by electronic searching, but only three appeared suitable for potential inclusion in the review. Two met the inclusion criteria for the analysis. Both examined the effectiveness of air filtration units. Two reviewers extracted data independently. A limited amount of data were usable for a meta-analysis. MAIN RESULTS: Both trials were small (n=22 and n=35). No significant differences were detected between active intervention and control on the primary and secondary outcome measures reported in the studies. Data on absence from school or work were not reported in either study. No meta-analysis could be performed due to lack of common outcomes. REVIEWER'S CONCLUSIONS: The available trials are too small to provide evidence for or against the use of airfiltration units to reduce allergen levels in the management of pet-allergic asthma. Adequately powered trials are needed. There are no trials of other allergen reduction measures, such as pet washing or possibly pet removal.

Pre-natal sensitization in humans.

Allergy has a very strong hereditary component but even in identical twins, concordance for the development of allergic disease can be as low as 50%. This suggests that there is a very strong environmental influence on manifestations of sensitization. To what extent environment might have an influence on the ontogeny of sensitization antenatally has hitherto not been a focus of much research. However, circumstantial evidence suggests that this may be important.

Carcinogenicity of chloral hydrate administered in drinking water to the male F344/N rat and male B6C3F1 mouse.

Male B6C3F1 mice and male F344/N rats were exposed to chloral hydrate (chloral) in the drinking water for 2 years. Rats: Measured chloral hydrate drinking water concentrations for the study were 0.12 g/L, 0.58 g/L, and 2.51 g/L chloral hydrate that yielded time-weighted mean daily doses (MDDs) of 7.4, 37.4, and 162.6 mg/kg per day. Water consumptions, survival, body weights, and organ weights were not altered in any of the chloral hydrate treatments. Life-time exposures to chloral hydrate failed to increase the prevalence (percentage of animals with a tumor) or the multiplicity (tumors/animal) of hepatocellular neoplasia. Chloral hydrate did not increase the prevalence of neoplasia at any other organ site. Mice: Measured chloral hydrate drinking water concentrations for the study were 0.12 g/L, 0.58 g/L, and 1.28 g/L that gave MDDs of 13.5, 65.0, and 146.6 mg/kg per day. Water consumptions, survival, body and organ weights, were not altered from the control values by any of the chloral hydrate treatments. Enhanced neoplasia was observed only in the liver. Prevalence and multiplicity of hepatocellular carcinoma (HC) were increased only for the high-dose group (84.4%; 0.72 HC/animal; p < or = 0.05). Values of 54.3%; 0.72 HC/animal and 59%; 1.03 HC/animal were observed for the 13.5- and 65.0-mg/kg per day treatment groups. Prevalence and multiplicity for the control group were 54.8%; 0.74 HC/animal. Hepatoadenoma (HA) prevalence and multiplicity were significantly increased (p < or = 0.05) at all chloral hydrate concentrations: 43.5%; 0.65 HA/animal, 51.3%; 0.95 HA/animal and 50%; 0.72 HA/animal at 13.5, 65.0, and 146.6 mg/kg per day chloral hydrate compared to 21.4%; 0.21 HA/animal in the untreated group. Altered foci of cells were evident in all doses tested in the mouse, but no significant differences were observed over the control values. Hepatocellular necrosis was minimal and did not exceed that seen in untreated rats and mice. Chloral hydrate exposure did not alter serum chemistry and hepatocyte proliferation in rats and mice or increase hepatic palmitoyl CoA oxidase in mice at any of the time periods monitored. It was concluded that chloral hydrate was carcinogenic (hepatocellular neoplasia) in the male mouse, but not in the rat, following a lifetime exposure in the drinking water. Based upon the increased HA and combined tumors at all chloral hydrate doses tested, a no observed adverse effect level was not determined.

Time- and dose-dependent development of potassium bromate-induced tumors in male Fischer 344 rats.

Potassium bromate (KBrO3) is a rodent carcinogen and a nephro- and neurotoxicant in humans. KBrO3 is used in cosmetics and food products and is a by-product of water disinfection by ozonization. KBrO3 is carcinogenic in the rat kidney, thyroid, and mesothelium and is a renal carcinogen in the male mouse. The present study was designed to investigate the relationship of time and dose to bromate-induced tumors in male Fischer 344 (F344) rats and to provide some insight into the development of these tumors. KBrO3 was dissolved in drinking water at nominal concentrations of 0, 0.02, 0.1, 0.2, and 0.4 g/L and administered to male F344 rats as the sole water source for 12, 26, 52, 78, or 100 wk. Renal cell tumors were present after 52 wk of treatment only in the high-dose group. Mesotheliomas developed after 52 wk of treatment on the tunica vaginalis. Mesotheliomas were present at sites other than the testicle after 78 wk of treatment, indicating that their origin was the testicular tunic. Thyroid follicular tumors were present as early as 26 wk in 1 rat each from the 0.1- and 0.2-g/L groups. The present study can be used as a basis for the determination of dose-time relationships of tumor development for a better understanding of KBrO3-induced cancer.

Serological characteristics of peanut allergy.

BACKGROUND: Peanut is the most common cause of severe or fatal food-associated anaphylaxis. Studies indicate that peanut extracts contain many allergenic proteins. The identification of major and minor allergenic components is necessary for standardization of experimental and diagnostic extracts. OBJECTIVE: To identify further major and minor allergenic components of peanut extract using a large population of peanut allergics, and to relate serological findings to clinical parameters. METHODS: The crude peanut extract was fractionated by fast protein liquid chromatography and the IgE binding proteins identified by sodium dodecyl sulphate polyacrylamide gel electrophoresis followed by western blotting. Serum from 89 peanut allergics with a positive history of peanut allergy and elevated specific IgE and control serum from four atopic and four non-atopic, non-peanut allergics were used. RESULTS: Nineteen peanut proteins were found to bind IgE from peanut allergic sera. Over 70% of subjects reacted to protein bands of 63 and 17 kDa (consistent with Ara h 1 and Ara h 2, respectively), confirming the importance of these two proteins as major allergens. A high proportion of patient sera also bound proteins at 15, 10, 30, 18 and 51 kDa in decreasing order. The percentage of cases with sensitivity to a 15 kDa protein was found to be higher in patient groups with severe reactions to peanut. CONCLUSION: This study highlights the diversity of peanut allergens. Diagnostic extracts containing a high proportion of the 15 kDa component may aid in diagnosis.

Carcinogenicity of potassium bromate administered in the drinking water to male B6C3F1 mice and F344/N rats.

Ozone has been proposed for water disinfection because it is more efficient than chlorine for killing microbes and results in much lower levels of carcinogenic trihalomethanes than does chlorination. Ozone leads to formation of hypobromous acid in surface waters with high bromine content and forms brominated organic by-products and bromate. The carcinogenicity and chronic toxicity of potassium bromate (KBrO3) was studied in male B6C3F1 mice and F344/N rats to confirm and extend the results of previous work. Mice were treated with 0, 0.08, 0.4, or 0.8 g/L KBrO3 in the drinking water for up to 100 wk, and rats were provided with 0, 0.02, 0.1, 0.2, or 0.4 g/L KBrO3. Animals were euthanatized, necropsied, and subjected to a complete macroscopic examination. Selected tissues and gross lesions were processed by routine methods for light microscopic examination. The present study showed that KBrO3 is carcinogenic in the rat kidney, thyroid, and mesothelium and is a renal carcinogen in the male mouse, KBrO3 was carcinogenic in rodents at water concentrations as low as 0.02 g/L (20 ppm; 1.5 mg/kg/day). These data can be used to estimate the human health risk that would be associated with changing from chlorination to ozonation for disinfection of drinking water.

An evaluation of the sensitivity of subjects with peanut allergy to very low doses of peanut protein: a randomized, double-blind, placebo-controlled food challenge study.

BACKGROUND: The minimum dose of food protein to which subjects with food allergy have reacted in double-blind, placebo-controlled food challenges is between 50 and 100 mg. However, subjects with peanut allergy often report severe reactions after minimal contact with peanuts, even through intact skin. OBJECTIVE: We sought to determine whether adults previously proven by challenge to be allergic to peanut react to very low doses of peanut protein. METHODS: We used a randomized, double-blind, placebo-controlled food challenge of 14 subjects allergic to peanuts with doses of peanut ranging from 10 microg to 50 mg, administered in the form of a commercially available peanut flour. RESULTS: One subject had a systemic reaction to 5 mg of peanut protein, and two subjects had mild objective reactions to 2 mg and 50 mg of peanut protein, respectively. Five subjects had mild subjective reactions (1 to 5 mg and 4 to 50 mg). All subjects with convincing objective reactions had short-lived subjective reactions to preceding doses, as low as 100 microg in two cases. Five subjects did not react to any dose up to 50 mg. CONCLUSION: Even in a group of well-characterized, highly sensitive subjects with peanut allergy, the threshold dose of peanut protein varies. As little as 100 microg of peanut protein provokes symptoms in some subjects with peanut allergy.

Clinical characteristics of peanut allergy.

BACKGROUND: Current clinical advice regarding peanut allergy is based on small series of patients. OBJECTIVE: To determine, in a large group of peanut allergic subjects, the patterns of clinical severity, symptom progression and availability and use of rescue medications. METHODS: Questionnaire study of 622 self-reported allergic subjects. RESULTS: A total of 406 patients (66%) reported symptoms on contact with peanut. Only 121 (19%) had been knowingly exposed to peanut before the first documented reaction, implying a high frequency of occult sensitization. Severe symptoms were more common in adults. Abdominal symptoms were significantly associated with collapse. Fifty per cent reported reactions in the previous year. Only 82 (13%) had been admitted to hospital because of a reaction. Adrenaline was carried in some form by 65% though only 78 subjects (12.5%) had ever received injected adrenaline. Only 18/43 subjects (41%) who collapsed were given adrenaline. Skin-prick test weal size correlated weakly with severity but there were large overlaps between the groups. Peanut-specific IgE peaked in the teenage group, but did not correlate with severity. CONCLUSIONS: Peanut allergy is characterized by more severe symptoms than other food allergies and by high rates of symptoms on minimal contact. Skin-prick testing and peanut-specific IgE levels do not predict clinical severity. Avoidance of peanut is difficult. Many people suffering severe relations are inadequately treated. Sufferers need education and training in the use of rescue medication.

Responses of free-ranging coyotes to lures and their modifications.

Several chemical modifications of a synthetic fermented egg (SFE) lure were field tested on free-ranging coyotes (Canis latrans) to determine the effects of odor intensity and quality on their behavioral responses. SFE was modified for testing by (1) enhancing one of the four basic odor components (fruity, sulfurous, sweaty, or fishy), (2) deleting one of the basic components, (3) individually testing an odor component, and (4) addition of aldehydes and indoles to SFE. Most behavioral responses, especially visitation, increased with odor intensity. Widely different odors elicited similar visitation. Specific odor quality influenced response rates such as urinating, defecating, digging, scratching, rolling, and pulling.