Tuberculosis notification and treatment outcome among migrant boat arrivals in Malta, 2007-2011.

The annual incidence of tuberculosis (TB) in Malta has remained low, at <20 per 100 000 population per year. However, TB notification among vulnerable groups is on the rise and is a matter of public health concern. We measured the TB notification rate, which ranged from 470 to 880/100 000 among migrant boat arrivals 1 year after arrival, highlighting the need to maintain high treatment success rates. Early case detection and high treatment success were observed due to post-arrival screening; however, the need for pragmatic, patient-friendly approaches that will encourage self-referral and access to treatment among migrant groups could play a significant role in preventing the re-emergence of TB in low-incidence settings.

Role of group-specific component (vitamin D binding protein) in clearance of actin from the circulation in the rabbit.

The possible role of group specific component (Gc) (vitamin D-binding protein) in the clearance of cellular actin entering the circulation was examined with 125I-labeled Gc and actin injected into a rabbit model. Although filamentous F-actin is depolymerized primarily by plasma gelsolin, greater than or equal to 90% 125I-actin injected in either monomeric G- or F-form became complexed eventually with Gc (1:1 molar ratio). Clearance of Gc complexes was much faster (greater than 90% within 5 h) than that of native Gc (t1/2 = 17.2 h). Nephrectomy did not significantly alter the clearance of either Gc or actin. Since Gc complexes are dramatically increased in situations of tissue necrosis such as in fulminant hepatic failure, the current results suggest a crucial role for Gc in sequestration and clearance of released cellular actin.

Life-threatening asthma.

I review my experience with life-threatening asthma, defined as hypercapnia, need for intubation, or death, at a large municipal hospital during a ten-year period. Such severe illness is rare among asthmatics and predicting its occurrence is difficult. Eighty patients had 111 admissions for life-threatening asthma; 773 patients were hospitalized for asthma 851 times during the study period. Only 15% of these 773 patients had experienced severe asthma previously and the duration of asthma and frequency of hospitalization was similar to that of the other patients admitted for asthma. Follow-up study of the survivors of life-threatening asthma has revealed a very high rate of recurrence. More than 35% had a recurrence in one to ten years, and those who had three to four episodes had a recurrence rate of 45% and 60%, respectively. Although life-threatening asthma is rare, unpredictable, and occurs only after many years of symptomatic illness, once it does occur there is a real risk of recurrence. Patients who have experienced such a severe episode of asthma require continuing careful supervision and management.

Relationship of wheezing to the severity of obstruction in asthma.

Ninety-three asthmatic patients were examined on 320 occasions for wheezing and peak expiratory flow rate (PEFR). The presence of a wheeze (either reported by the patient or found on examination) was associated with a significantly lower PEFR. Expiratory wheezing was usually accompanied by inspiratory wheezing; this biphasic wheezing was associated with a lower PEFR than only expiratory wheezing. Loudness and the high pitch of wheezing were associated with more severe obstruction. Most expiratory wheezing lasted throughout the entire expiration. Expiratory or inspiratory wheezing of high pitch, moderate to severe intensity, and spanning the entire phase of the breath was associated with a lower PEFR than wheezing without these characteristics. Although characterization of wheezing has a general relationship to the severity of airway obstruction, an objective measurement of expiratory flow rate is necessary for the evaluation of each patient's condition.

Apneusis.

Two cases of apneustic breathing that had several unusual features, as compared with experimental apneusis, are reported here. Both patients had intact vagal function. Respiratory rhythm showed mainly inspiratory apneusis, with a relatively smooth background rhythm. Frequency and duration of apneusis either decreased or were unaffected by breathing CO2, and increased, in one case, after hyperventilation. Both patients were alert and conscious. One had a long history of narcotic abuse, but had no other neurological or respiratory abnormality. Another had been deaf and mute since an episode of meningitis in childhood and had had apneusis for over 35 years, but suffered no other neurological abnormality. These unusual features suggest that the pathogenic mechanisms for apneusis are not the same in experimental models and patients.

Monitored conditional release of persons found not guilty by reason of insanity.

This article reviews the recent literature documenting changes that have taken place in the management and treatment of insanity defense acquittees with the development of conditional release and monitored community treatment. The review demonstrates that conditional release is particularly important as a means of balancing the protection of society with the treatment of insanity defense acquittees in the least restrictive environment. The review also highlights the development of community programs based on treatment models for the chronically mentally ill. In addition, monitored community treatment programs appear cost-effective when compared with hospital-based programs. These factors point to the development in the 1990s of program standards for the release of insanity defense acquittees.

Psychiatric consultation to a state board of medical examiners.

This article describes the evolution of psychiatric consultation to the Oregon Board of Medical Examiners. The board is charged with the licensing and regulation of physicians in the state of Oregon in order to protect the public and uphold the standards of the medical profession. Psychiatric consultation has focused on the board's investigations of physicians with mental illness and/or substance abuse and physicians who inappropriately prescribe psychoactive drugs or sexually abuse patients. Each of these physician groups is described, and remedial programs for each group are discussed. The authors conclude that psychiatric consultation to medical boards is a feasible and productive activity that can make a positive contribution to the lives of a large number of physicians and patients.

Effect of odors in asthma.

Many patients complain that some odors worsen their asthma. Perfume and cologne are two of the most frequently mentioned offenders. Four patients with a history of worsening of asthma on exposure to cologne underwent challenge with a cologne, and their pulmonary function was tested before, during, and after the exposure. Forced expiratory volume in one second declined 18 to 58 percent below the baseline period during the 10-minute exposure and gradually increased in the next 20 minutes. Saline placebo pretreatment did not affect the response to subsequent challenge. Single-blind pretreatment with metaproterenol and atropine prevented decline in one-second forced expiratory volume in three of four patients and blunted the response in the other. Cromolyn sodium prevented decline in one of four, and occlusion of nostrils prevented decline in one of three. A survey of 60 asthmatic patients revealed a history of respiratory symptoms in 57 on exposure to one or more common odors. Odors are an important cause of worsening of asthma.

Aerosol beclomethasone in patients with steroid-responsive chronic obstructive pulmonary disease.

Some patients with chronic obstructive pulmonary disease have favorable responses to treatment with oral corticosteroids with increase in one-second forced expiratory volume of 30 percent or more above the baseline. The benefit of long-term steroid therapy may be outweighed by the side effects. Twelve patients who had previously demonstrated a response to oral corticosteroids were studied in a double-blind randomized crossover trial comparing prednisone (30 mg daily) with beclomethasone (metered-dose inhaler, 16 puffs daily) for two weeks each with a two-week washout period between the two regimens. Those who were taking prednisone tapered the dose to 5 mg daily and those taking beclomethasone discontinued it for two weeks before the beginning of the study. History, physical examination, and pulmonary function were monitored. The mean one-second forced expiratory volume increased from 0.65 to 1.00 liter after prednisone therapy and it increased from 0.63 to 0.81 liter after aerosol beclomethasone (difference significant, p less than 0.01 by paired t test). Only five of 12 patients had an increase in one-second forced expiratory volume with steroid aerosol, an increase that was at least 50 percent that achieved by prednisone. In most patients with steroid-responsive chronic obstructive pulmonary disease, aerosol beclomethasone is not an adequate substitute for oral steroids.

Comparison of oral aminophylline and aerosol metaproterenol in asthma.

The bronchodilator efficacy of oral aminophylline and aerosol metaproterenol was compared in 18 asthmatic patients in a stable clinical condition. Treatment consisted of four regimens in a double-blind random sequence on four different days after withholding bronchodilators: (1) the administration of aminophylline tablets, 0.4 to 0.6 g, orally, (2) 3 puffs of aerosol metaproterenol administered in a sequential manner, (3) a combination of both, (4) placebos. Both oral aminophylline and aerosol metaproterenol produced significant bronchodilatation measured by forced expiratory volume in 1 second (FEV1). After the administration of aerosol metaproterenol, there was a more prompt and larger improvement in FEV1 than after the administration of aminophylline (p less than 0.01). The combined therapy produced a response which was larger, but not significantly, than the effect of metaproterenol. Side effects were frequent after the administration of aminophylline but absent after aerosol metaproterenol. The advantages of the aerosol adrenergic agonists are the prompt onset of action and efficacy, small dosage preferentially delivered to the bronchial tree and lack of side effects.

Evaluation of the severity of asthma: patients versus physicians.

It is clear that accurate assessment of the severity of asthma requires a measurement of airway obstruction, such as peak expiratory flow rate. In this study, physicians were quite inaccurate in estimating the peak expiratory flow rate by examining patients, whereas the patients themselves were far more accurate in guessing the measurement. In addition, they were able to tell whether the peak expiratory flow rate was better, the same or worse from day to day. Patients' symptoms are important indices of the severity of airway obstruction which should be exploited in management.

The adequacy of inhalation of aerosol from canister nebulizers.

Thirty patients hospitalized with asthma who had been taking aerosol bronchodilators from canister nebulizers were evaluated for their aerosol inhalation technique. Fourteen patients (47 percent) used an incorrect technique. The most frequent mistake was to inhale first, then to actuate the canister and breathhold. These patients were taught the correct technique. Some learned it easily but others had difficulty. With a teaching aid, incorporating a horn which is actuated by inspiration, all 14 patients learned to inhale the aerosol correctly. When retested five of the 10 patients had reverted to the old incorrect technique and required another lesson. Physicians who prescribe aerosol medication from a canister nebulizer should evaluate each patient for the aerosol inhalation technique. Those who inhale incorrectly should be taught repeatedly until they learn the correct technique and retain it. The teaching aid, utilizing an audio signal, is helpful in this training.

Bronchodilator response to oral aminophylline and terbutaline versus aerosol albuterol in patients with chronic obstructive pulmonary disease.

Bronchodilator efficacy of oral administration of aminophylline (400 mg) and terbutaline sulfate (5 mg) was compared with inhalation of three puffs of albuterol sulfate in 17 patients with stable chronic obstructive pulmonary disease in a double-blind crossover study. Two hours after either form of therapy, the patients were treated again with three puffs of albuterol. Forced expiratory volume in one second (FEV1) increased significantly more from the baseline value after albuterol aerosol than after oral medication at 30, 60, and 120 minutes (paired t test, p less than 0.01). After three puffs of albuterol at 120 minutes, FEV1 increased to similar values an hour later on both days in 14 of 17 patients. Thirteen patients complained of side effects during oral therapy and none during aerosol therapy. Maximum bronchodilatation was achieved by albuterol aerosol in 14 of 17 patients, and addition of oral therapy produced no further increase of flow rate in these patients. Bronchodilator aerosol is the logical choice for treatment of chronic obstructive pulmonary disease because it is more effective than oral therapy and because it is free from side effects.

Lactic acidosis in severe asthma.

Twelve patients with severe asthma in whom lactic acidosis developed are presented. All had an arterial blood pH level lower than that expected for the measured partial pressure of arterial carbon dioxide, all had an abnormally large anion gap, and the blood lactate level exceeded 2.8 mmol/liter. Respiratory acidosis subsequently developed in eight patients, and six required intubation. Lactic acidosis can develop in patients with severe asthma. Such patients are in danger of the development of respiratory failure and must be treated vigorously and observed closely.

Relationship of coping style to affective state and perceived social support in asymptomatic and symptomatic HIV-infected persons: implications for clinical management.

The authors describe the relationship of three coping styles to affective state (mood) and perceived social support in 29 human immunodeficiency virus (HIV)-infected homosexual/bisexual men between the ages of 18 and 45 years. Active-behavioral coping was significantly related to enhanced mood and greater perceived social support. Avoidance coping was significantly related to greater mood disturbance and lower social support. No relationships were found for active-cognitive coping. Recommendations for clinical management of HIV-infected persons and their traditional and/or nontraditional family follow from the findings.

Treatment of asthma with triamcinolone acetonide aerosol.

Thirty-five steroid-dependent asthmatic patients have been treated with an aerosol of triamcinolone acetonide for periods ranging from 8 to 26 months. Fourteen patients discontinued the oral use of steroids for the first time in from 2 to 19 years and throughout the period of treatment with aerosol, have not required any other steroid medication. Fifteen patients were able to discontinue oral use of steroids but have required one or more short supplemental courses of oral steroid treatment for exacerbations of asthma. Six patients have either continued to require oral steroid therapy, or their symptoms have been incompletely controlled by the aerosol. Steroid aerosols represent an important advance for the treatment of asthma. Small doses which do not suppress adrenal function and do not produce hyperadrenocorticism make it possible for most patients to eliminate or substantially reduce their requirement for oral steroid therapy.

Streptokinase in a loculated pleural effusion. Effectiveness determined by site of instillation.

A patient with a large loculated pleural effusion had streptokinase instilled into the loculation, and this was ineffective; however, when the same amount of streptokinase was instilled into the space around the loculation, there was rapid lysis of the loculation, resulting in the drainage of purulent fluid through the chest tube.

Cough and wheezing from beclomethasone aerosol.

Cough and wheezing are frequent side effects of inhaling beclomethasone dipropionate aerosol (BA) in patients with asthma. Twenty percent of our outpatient asthmatic subjects are unable to take BA due to these side effects. Twelve patients with history of severe cough and wheezing after inhaling BA were tested. Three puffs of either BA or placebo (Plc) were administered from a metered dose inhaler (MDI) in a double-blind crossover design. They coughed a mean of 31 times after BA and 19 times after Plc. Forced expiratory volume in one sec (FEV1) declined a mean of 22.6 percent after BA and 22.0 percent after Plc. Pretreatment with albuterol attenuated both the cough and the drop in FEV1. Follow-up study showed that regular pretreatment with bronchodilator enabled seven of 12 patients to tolerate BA therapy. The remaining five required a short course of increased dose oral steroid therapy. Cough and wheezing are frequent side effects of BA therapy that interfere with regular compliance. Pretreatment with a bronchodilator is effective in attenuating these side effects in some patients; in others, a short course of oral steroid therapy may be necessary.

Lack of effect of hydration on sputum production in chronic bronchitis.

Patients with chronic lung disease productive of sputum are generally encouraged to drink a large amount of fluid to facilitate sputum production. This clinical practice has not been tested systematically. Twelve outpatients with chronic obstructive pulmonary disease in clinically stable condition who had daily sputum production were asked in random sequence: 1) to drink one glass of fluid every waking hour after supper and upon waking the next morning (hydration), 2) to drink no fluid after supper and upon waking the next morning (dry), and 3) to drink fluid ad lib (ad lib). Each morning sputum collection was started upon waking and continued for four hours. The differences in volume, elasticity of sputum, respiratory symptoms, and ease of expectoration were not significant. We conclude that moderate hydration and dehydration have no effect on volume expectorated, the elasticity of sputum, respiratory symptoms or forced expiratory volume in one second.

Bullous pulmonary damage in users of intravenous drugs.

Among a large group of users of illicit intravenous drugs, the incidence of bullous pulmonary damage was noted to be 2 percent (6/387). Bullous damage was significantly different in the drug users than in those who did not use drugs. The drug users were significantly younger than the nonusers, their bullae were large and confined to the upper lobes, and alpha 1-antitrypsin deficiency was very unlikely. These features strongly implicate intravenous drug abuse in the pathogenesis of these patients' bullous pulmonary damage.