Excess subcutaneous tissue may preclude intramuscular delivery when using adrenaline autoinjectors in patients with anaphylaxis.

Intramuscular adrenaline is the gold standard treatment for anaphylaxis. Intramuscular injection provides more rapid and higher plasma concentrations than subcutaneous routes. Given the increasing epidemic of obesity patients are at increased risk of subcutaneous delivery, we therefore assessed the depth of subcutaneous tissue in a population of patients with anaphylaxis. Patients already prescribed adrenaline autoinjectors (AAIs) for anaphylaxis were examined with ultrasound, and measurements of skin-to-muscle depth (STMD) at anterolateral thigh and anterior thigh were performed. Twenty-eight patients (23 female, 5 male) with an age range of 18-75 took part in the study, and in 68%, the STMD was greater than AAI needle length (15.02 mm), using the anterolateral thigh as the recommended administration site. The key predictors for increased STMD were female gender (P=0.0003) and a BMI > 30 (P=0.04). AAIs require longer needles to ensure intramuscular administration, and ultrasound at point of prescription would aid needle length selection.

High-dose nedocromil sodium as an addition to inhaled corticosteroids in the treatment of asthma.

In a double-blind placebo-controlled trial nedocromil sodium in a dose of 8 mg four times daily or matching placebo was added to the treatment of 29 asthmatic patients. All patients were taking inhaled corticosteroids in a dose of up to 1000 micrograms daily. The trial agents were given for 6 weeks after a 2-week run-in period. Twenty-four patients completed the study, three withdrew because of adverse effects, two on placebo. Daytime asthma symptoms were significantly reduced on nedocromil compared to placebo (-0.46 vs. +0.09, P = 0.03). Night-time asthma and morning tightness were not changed significantly. Bronchodilator use in the night and day were lower on nedocromil but the differences were not significant. Morning peak flow rates were higher on nedocromil (+22.2 vs. +0.08, P = 0.06) and physicians opinions of overall effectiveness favoured nedocromil (U = 35.0, P = 0.04). These results confirm that nedocromil sodium may be a useful addition in asthma to low to medium doses of inhaled corticosteroids. The effects of 32 mg nedocromil daily were comparable to previous reports with lower doses.

Public water fluoridation in Ireland: twenty-five years on.

In July of this year, 1989, Ireland celebrates 25 years of fluoridation of the public water supplies. No other country has had such a long experience of a national mandatory public water supply fluoridation programme. There is good reason therefore to review experiences and attempt to draw some conclusions.

Fibreoptic bronchoscopy in the elderly.

To evaluate the efficacy and safety of fibreoptic bronchoscopy in the elderly, the bronchoscopy records of 1000 patients were retrospectively reviewed. Of these, 423 were in-patients aged 65 years or over. This population was further subdivided into 'young' elderly (65-74 years old) and 'old' elderly (75+ years old). The indications for bronchoscopy in each group were similar and included haemoptysis, chest radiographic changes suggestive of collapse or consolidation, and hilar or paratracheal shadowing. The results in each group were also comparable and bronchoscopy was not tolerated in only five. A visible tumour was present in 165 patients. We conclude that, like upper gastrointestinal endoscopy, fibreoptic bronchoscopy in the elderly is safe, well tolerated and has a significant diagnostic yield.

Life-threatening right ventricular thrombosis in association with phospholipid antibodies.

An 18 year old man presented with cough and dyspnoea caused by pulmonary infarction. A large friable mass of organising thrombus in an anatomically normal right ventricle was identified as an embolic source. The acute illness was associated with raised titres of anticardiolipin antibodies, one of the antiphospholipid group. This thrombus recurred after surgical removal but subsequently was dissipated after treatment with oral corticosteroids and long-term oral anticoagulation.

Unusual spinal tuberculosis after adequate chemotherapy for lymph node tuberculosis in an immunocompetent man.

A 35 year old man developed paraplegia due to an epidural mass 15 months after completion of a full chemotherapy course for pulmonary and lymph node Mycobacterium bovis infection. His cellular immune function was normal after treatment. It is suggested that the lesion was a granulomatous healing response rather than bacteriological recurrence.

Planning oral health care for the elderly in Israel for the years 2000 and 2025.

The methodology and conclusions of this workshop are reported here because the problems requiring solution are not unique to Israel. They will increasingly have wide geographical and political application. The population of Israel since its establishment in 1948 has increased about sixfold. The numbers of the elderly (65+) have increased about tenfold. The current situation must be examined and estimates obtained for the next ten years. Only thus can the system be enabled to cope with the problem as it develops. The chosen method was a carefully preplanned, multisectorial workshop. Recommendations were discussed, amended and finalised. The recommendations of the workshop included: Baseline national data is urgently required. Guidelines are required for selecting specific target populations to which priority should be given. The current favourable situation of adequate oral health manpower in Israel makes it possible to encourage providers of oral health care towards treatment for the elderly. It is essential that the appropriate health authorities allocate sufficient funds for the following urgent purposes: the conduct of a national survey of the elderly population; the establishment of oral health units on a trial basis in some selected hospitals; support institutions of higher education to facilitate training in geriatric dentistry. CONCLUSIONS. The workshop was multidisciplinary because it was necessary to include all the expertise and experience available as vital elements of the policy making process. This type of workshop was found to be an effective tool for planning oral health services.

Does single dose salmeterol affect exercise capacity in asthmatic men?

The aim of this study was to investigate whether the long-acting beta-agonist salmeterol affects athletic performance in patients with asthma. The effect of 50 micrograms salmeterol on the cardiorespiratory responses to a progressive maximal cycle exercise test and on endurance capacity (defined as the exercise duration at 70% maximum oxygen uptake), was compared with 200 micrograms salbutamol and a matched placebo in eight asthmatic men. Both salmeterol and salbutamol improved pre- and postexercise forced expiratory volume in one second (FEV1) for maximal and endurance exercise. Following active treatment, patients exercised from a significantly high baseline FEV1, with both salmeterol (3.58(1.16)l) (mean (SD)) and salbutamol (3.55(1.24)l) compared with placebo (3.29(1.35)l). Similar improvements preceded endurance exercise. Cardiorespiratory, haemodynamic or subjective responses to the progressive maximum exercise tests were not different with salmeterol, salbutamol or placebo, nor did endurance capacity change with any treatment modality. Blood lactate levels, after 15 min exercise, were significantly higher with salbutamol (3.64 (1.83) mM), but not with salmeterol (3.03 (1.64) mM), compared with placebo (2.95 (1.69) mM). These results demonstrate the absence of significant cardiorespiratory or metabolic effects during exercise after a single dose of salmeterol, together with a lack-of ergogenic effect, as measured by maximal or endurance exercise performance, in patients with asthma.

Occupational asthma due to glutaraldehyde and formaldehyde in endoscopy and x ray departments.

BACKGROUND: Glutaraldehyde is the best disinfectant for fibreoptic endoscopes. It is also used in the processing of x ray films. A number of studies have reported eye, nose, and respiratory symptoms in exposed workers. Three individual case reports of occupational asthma in endoscopy workers and a radiographer have also been published. We describe a further seven cases of occupational asthma due to glutaraldehyde in endoscopy and x ray departments, together with exposure levels measured during the challenge tests and in 19 endoscopy and x ray departments in the region. METHODS: Eight workers were referred for investigation of suspected occupational asthma following direct or indirect exposure to glutaraldehyde at work. They were investigated by serial measurements of peak expiratory flow (PEF) and specific bronchial provocation tests. Glutaraldehyde levels were measured using personal and static short and longer term air samples during the challenge tests and in 13 endoscopy units and six x ray darkrooms in the region where concern about glutaraldehyde exposure had been expressed. Three of the workers investigated with occupational asthma came from departments where glutaraldehyde air measurements had been made; the others came from other hospitals or departments. RESULTS: The diagnosis of occupational asthma was confirmed in seven workers, all of whom had PEF records suggestive of occupational asthma and positive specific bronchial challenge tests to glutaraldehyde. Bronchial provocation testing was negative in one worker who was no longer exposed and who had a less clearcut history of occupational asthma. Three workers also had a positive specific bronchial challenge to formaldehyde. The mean level of glutaraldehyde in air during the challenge tests was 0.068 mg/m3, about one tenth of the short term occupational exposure standard of 0.7 mg/m3. The levels obtained in the challenge chamber were similar to those measured in 13 endoscopy suites and six x ray darkrooms where median short term levels were 0.16 mg/m3 during decantation in endoscopy suites and < 0.009 mg/m3 in darkrooms. CONCLUSIONS: Glutaraldehyde can cause occupational asthma. The exposure levels measured in the workplace suggest that sensitisation may occur at levels below the current occupational exposure standard.

The effects of indomethacin on the refractory period to hypertonic saline-induced bronchoconstriction.

The purpose of this study was to determine the effect of pretreatment with indomethacin on the refractory period to hypertonic saline-induced bronchoconstriction. In a double-blind, placebo-controlled, randomized trial nine asthmatic subjects underwent two hypertonic saline challenges, 60 min apart, on a control day and after premedication with indomethacin 50 mg or matching placebo, twice daily for three days. Premedication with indomethacin did not change airway responsiveness to the initial hypertonic saline challenge. The mean maximal % fall in specific airway conductance (sGaw) was 40.3, 44.1 and 47.6% on the control, placebo and indomethacin days, respectively. Subjects were significantly less responsive to the second hypertonic challenge as compared to the initial challenge on all three study days. There was a variable effect of indomethacin pretreatment on the refractory period. Five subjects lost their refractory period after indomethacin, when the variability of the test was taken into account. This suggests that there may be contributory mechanisms to the refractory period other than the release of protective prostanoid metabolites.

Manchester air disaster.

On 22 August 1985 a fire occurred on a Boeing 737 jet airliner at take off at Manchester Airport. One hundred and thirty seven passengers and crew were on board. Fifty two passengers died on the aircraft, 85 escaped. Most survivors had minor physical injuries, but 15 required admission to hospital because of smoke inhalation and two of these had severe burns. At presentation only one survivor required ventilation but within 12 hours a further five required ventilation. Although initially patients suffering from smoke inhalation may seem relatively well, lung function may deteriorate rapidly in the first 24 hours. Careful organisation and regular practice of procedures to deal with a major accident are essential to be able to respond adequately to such an event.

Pathogenetic mechanisms of exercise-induced asthma and the refractory period.

Exercise is a powerful stimulus to the development of asthma. In most asthmatic subjects the airways obstruction recovers spontaneously within 60 minutes, but in some subjects there is more prolonged airflow obstruction which requires bronchodilator treatment. Approximately 40-50% of subjects with EIA will show a refractory period of two to four hours after an initial exercise task, during which time an identical exercise task will evoke significantly less (less than 50%) bronchoconstriction. In some patients, particularly children, EIA will be followed three to nine hours later by a further episode of bronchospasm, termed the late asthmatic response. There remains considerable debate about the pathogenesis of EIA the refractory period and the late asthmatic response.

Airway responsiveness to histamine and leukotriene E4 in subjects with aspirin-induced asthma.

Airway responsiveness to histamine and leukotriene E4 (LTE4) has been compared between five subjects with aspirin-induced asthma (AIA) and 15 asthmatic subjects without aspirin sensitivity (non-AIA). In the AIA group, the geometric mean doses of histamine and LTE4 causing a 35% fall in specific airway conductance (PD35) were 0.31 mumol and 0.17 nmol, respectively, and LTE4 was 1,870 times more potent than histamine. In the non-AIA group, the histamine and LTE4 PD35 doses were 0.40 mumol (non-AIA versus AIA, NS) and 2.8 nmol (non-AIA versus AIA, p = 0.002), respectively, and LTE4 was 145 times more potent than histamine in eliciting bronchoconstriction (non-AIA versus AIA, p = 0.001). After desensitization to aspirin the geometric mean histamine and LTE4 PD 35 in the AIA group changed to 0.19 mumol (NS) and 3.3 nmol (p = 0.007), respectively, and there was an average 33-fold reduction in the responsiveness of the airways to LTE4 relative to histamine (p less than 0.001). In five non-AIA subjects. Ingestion of 600 mg of aspirin daily did not lead to any significant change in airway responsiveness to histamine or to LTE4. These results demonstrate a selective and marked increase in airway responsiveness to LTE4 in subjects with AIA. The efficacy of desensitization may relate in part to a selective down-regulation of LTE4 receptors within the airways.