Undetected hypertension in primary care – a public health iceberg?

Background

Hypertension is largely asymptomatic and contributes to considerable lifetime cardiovascular morbidity and mortality, costing the NHS £2.1 billion annually. The national prevalence of hypertension is 13.7 % and lack of a national screening programme, despite meeting aspects of the Wilson Junger criteria, adds to delays in detection and treatment. Earlier detection could mitigate future cardiovascular risk. We wanted to understand the potential of detection of prehypertension in primary care to see if this fits the Wilson and Junger criteria for a screening programme.

Methods

GP records of adult patients n = 2178 with a known diagnosis of hypertension on the hypertension register from a practice population of 10,000 patients (prevalence is 22%.) were analysed for the prevalence of prehypertension systolic 120-139 mm hg and diastolic bp of 80-89. The average length of prehypertension, the time delay in detection and treatment were assessed, alongside the prevalence of clinical and therapeutic inertia.

Results

A retrospective analysis of a sample size of 1809 patients out of 2178 patients (83.1%) with known hypertension across 3 primary care sites over 20 years was undertaken. Of these 1809 patients, we found that 1095 patients (60.5%) were prehypertensive prior to being diagnosed. The mean time interval between detection of prehypertension to a formal hypertension diagnosis was 10.6 years, with a standard deviation of 7.89 years with no variation with age or sex. However, 588 patients (32.5%) did not have readings within the prehypertensive ranges prior to diagnosis and were opportunistically detected. 51 patients (2.82%) never had readings recorded within the prehypertensive range.

Conclusions

Prehypertension predates hypertension by an average of 10.6 years. Offering annual screening nationally to patients of risk groups e.g., those with a family history, obesity, and alcohol excess, would enable earlier detection, treatment, and considerable cost saving.

Key messages

• Prehypertension predates hypertension; therefore, hypertension meets the Wilson Junger criteria for earlier detection by a screening programme, which is lacking in the UK.

• Offering a national scheme to screen for hypertension to those at a higher risk, can only be considered a benefit to the public and should be implemented.

Detection of microorganisms with antibacterial activities from different industrial wastes and GC-MS analysis of crude microbial extract

Many soil microorganisms' i.e., bacteria and fungi produce secondary metabolites called antibiotics. These are used for the treatment of some of the bacterial, fungal and protozoal diseases of humans. There is a need for isolation of a broad spectrum of antibiotics from microorganisms due to the emergence of antibiotic resistance. In the present study two antibiotic producing bacteria Klebsiella pneumoniae and Bacillus cereus were isolated from pharmaceutical and poultry feed industry of Hattar, Haripur Pakistan. Total 10 waste samples were collected from different industries (Marble, Ghee, Soap, Mineral, Steel, Poultry Feed, Pharmaceutical, Qarshi, Cosmetic and Glass). Thirty-three bacterial strains were isolated from industrial wastes of these ten different industries. Fourteen out of thirty-three bacterial strains exhibited antimicrobial activities against at least one of the test microbes considered in this study including Escherchia coli, Staphylococcus aureus and Salmonella typhi. The bacteria were isolated by standard serial dilution spread plate technique. Morphological characterization of the isolates was done by Gram staining. Nine bacterial isolates out of fourteen were initially identified as B. cereus and five as K. pneumoniae through biochemical characterization. The antibacterial activities were tested by well diffusion method. Maximum number of antibiotic producing bacteria were isolated from pharmaceutical and poultry feed industry based on the results of primary screening, the most potential isolates S9, S19, S20, S22 and S23 were selected for secondary screening. The maximum activity against E. coli and S. aureus was recorded by bacterial isolate S19 i.e zones of inhibition of 6.5mm and 9mm while S20 showed 7.5mm and 6mm zones respectively. Molecular identification was carried out on the basis of 16S rRNA sequence analysis. Finally, the isolates were identified as B. cereus accession number LC538271and K. pneumoniae accession number MT078679. Analysis of bacterial extract S20 through GC-MS indicated the presence of 8 compounds of diverse nature and structure. Present study suggests that wastes of pharmaceutical and poultry feed industry may have antibiotic producing bacteria. These bacteria could be utilized for the production of antibiotics. B. cereus and K. pneumoniae isolated from wastes of poultry feed and pharmaceutical industries have the potential to produce antibiotics and could be used to control the microbial growth.

Update on transcobalamin deficiency: clinical presentation, treatment and outcome

Transcobalamin (TC) transports cobalamin from blood into cells. TC deficiency is a rare autosomal recessive disorder usually presenting in early infancy with failure to thrive, weakness, diarrhoea, pallor, anemia, and pancytopenia or agammaglobulinemia. It can sometimes resemble neonatal leukemia or severe combined immunodeficiency disease. Diagnosis of TC deficiency is suspected based on megaloblastic anemia, elevation of total plasma homocysteine, and blood or urine methylmalonic acid. It is confirmed by studying the synthesis of TC in cultured fibroblasts, or by molecular analysis of the TCN2 gene. TC deficiency is treatable with supplemental cobalamin, but the optimal type, route and frequency of cobalamin administration and long term patient outcomes are unknown. Here we present a series of 30 patients with TC deficiency, including an update on multiple previously published patients, in order to evaluate the different treatment strategies and provide information about long term outcome. Based on the data presented, current practice appears to favour treatment of individuals with TC deficiency by intramuscular injections of hydroxy- or cyanocobalamin. In most cases presented, at least weekly injections (1 mg IM) were necessary to ensure optimal treatment. Most centres adjusted the treatment regimen based on monitoring CBC, total plasma homocysteine, plasma and urine methylmalonic acid, as well as, clinical status. Finally, continuing IM treatment into adulthood appears to be beneficial.

Treatment of ovalbumin-induced experimental allergic bronchitis in rats by inhaled inhibitor of secretory phospholipase A(2)

BACKGROUND

The pathophysiology of asthma involves the action of inflammatory/allergic lipid mediators formed following membrane phospholipid hydrolysis by phospholipase A(2) (PLA(2)). Cysteinyl leukotrienes are considered potent inducers of bronchoconstriction and airway remodelling. Ovalbumin (OVA) induced bronchoconstriction in rats is associated with increased secretory PLA(2) (sPLA(2)) activation and cysteinyl leukotriene production, together with suppression of cytosolic PLA(2) and prostaglandin E(2). These processes are reversed when the animals are pretreated systemically with an extracellular cell impermeable sPLA(2) inhibitor which also suppresses the early allergic reaction to OVA challenge. In this study we examine the capacity of the sPLA(2) inhibitor to ameliorate inflammatory and allergic manifestations (early and late bronchoconstriction) of OVA induced allergic bronchitis in rats when the inhibitor was administered by inhalation to confine it to the airways.

METHODS

Rats sensitised with OVA were treated with the sPLA(2) inhibitor hyaluronic acid-linked phosphatidyl ethanolamine (HyPE). The rats were divided into four groups (n = 10 per group): (1) naïve controls (no sensitisation/no treatment); (2) positive controls (sensitisation + challenge with OVA inhalation and subcutaneous injection of 1 ml saline before each challenge; (3) sensitisation + challenge with OVA and HyPE inhalation before every challenge; and (4) sensitisation + challenge with OVA and treatment with subcutaneous dexamethasone (300 mug) before each challenge as a conventional reference. Another group received no treatment with HyPE during the sensitisation process but only before or after challenge of already sensitised rats. Pulmonary function was assessed and changes in the histology of the airways, levels of cysteinyl leukotrienes in BAL fluid, and the production of nitric oxide (No) and tumour necrosis factor alpha (TNFalpha) by BAL macrophages were determined.

RESULTS

Inhalation of HyPE markedly suppressed OVA induced early and late asthmatic reactions as expressed by bronchoconstriction, airway remodelling (histology), cysteinyl leukotriene level in BAL fluid, and production of TNFalpha and NO by BAL macrophages. OVA induced bronchoconstriction in sensitised non-pretreated rats was also inhibited by inhalation of HyPE either before or after the challenge.

CONCLUSIONS

These findings confirm the pivotal role of sPLA(2) in the pathophysiology of both the immediate allergic response and the inflammatory asthmatic process. Control of airway sPLA(2) may be a new therapeutic approach to the treatment of asthma.

Fine particles and meteorological conditions are associated with lung function in children with asthma living near two power plants

Fine particles are thought to pose a risk to health, especially for vulnerable groups such as children with asthma. These children are also known to be affected by meteorological and seasonal changes. We assessed the association between air pollution and lung function via peak expiratory flow (PEF), controlling for seasonal changes, meteorological conditions and personal physiological, clinical and sociodemographic measurements, in a panel of schoolchildren with asthma living near two power plants in Israel. Two hundred and eighty-five children with confirmed asthma performed PEF tests and completed a respiratory symptoms diary twice a day. Particulate matter <10 microm in diameter (PM10), particulate matter <2.5 microm in diameter (PM2.5) and meteorological conditions were measured at six fixed stations. Data were analysed using time series analysis-generalized linear model and generalized estimating equations. The models were built under the assumption that any health outcome belongs to a multivariate hierarchical system and depends on meteorological, geophysical and sociocultural variables and pollution factors. No significant differences were found in the demographic (age, gender, mean parental education level, parental smoking habits, place of birth and housing density), physiological (body mass index) and clinical factors (illness severity) between the communities participating in the study. A significant direct effect of PM2.5 on the PEF was found in Ashdod (P=0.000). In Sderot, this effect was through an interaction between PM10 and the sequential day of the year (P=0.000). The main conclusion of this study is that children with asthma are at risk from air pollution and geophysical conditions. Policy makers should take these results into consideration when setting thresholds for environmental protection.

[Adnexal torsion: a report of 135 cases]

OBJECTIVES

To evaluate the clinical findings and therapeutic options following adnexal torsion.

STUDY DESIGN

A retrospective series of 135 patients presenting with adnexal torsion between January 1992 and December 2001 in Sousse- Tunisia- a university teaching hospital.

RESULTS

Adnexal torsion accounted for 14.8% of surgically treated adnexal tumors. Pregnancy was associated in 17% of cases and diagnosis was accurate at first clinical examination in only 57.8% of cases. Ultrasound allowed visualisation of Adnexal Diseases in all cases. Operative laparoscopy was successfully achieved in 34% of patients. Conservative management was used in 57% of the premenopausal patients. No major postoperative complication was noted.

CONCLUSION

Clinicians must be aware of a possible adnexal torsion in women with acute pelvic pain. Ultrasound is a useful tool in these situations. Laparoscopy allows diagnosis and surgical management even during pregnancy.

Solid phase microextraction: measurement of volatile organic compounds (VOCs) in Dhaka City air pollution

A solid phase microextraction (SPME) technique was applied for the sampling of volatile organic compounds (VOCs) in ambient air polluted by two stroke autorickshaw engines and automobile exhausts in Dhaka city, Bangladesh. Analysis was carried out by capillary gas chromatography (GC) and GC-mass spectrometry (MS). The methodology was tested by insitu sampling of an aromatic hydrocarbon mixture gas standard with a precision of +/-5% and an average accuracy of 1-20%. The accuracy for total VOCs concentration measurement was about 7%. VOC's in ambient air were collected by exposing the SPME fiber at four locations in Dhaka city. The chromatograms showed signature similar to that of unburned gasoline (petrol) and weathered diesel containing more than 200 organic compounds; some of these compounds were positively identified. These are normal hydrocarbons pentane (n-C5H2) through nonacosane (n-C29H60), aromatic hydrocarbons: benzene, toluene, ethylbenzene, n-propylbenzene, n-butylbenzene, 1,3,5-trimethylbenzene, xylenes, and 1-isocyanato-3-methoxybenzene. Two samples collected near an autorickshaw station contained 783000 and 1479000 microg/m3 of VOCs. In particular, the concentration of toluene was 50-100 times higher than the threshold limiting value of 2000 microg/m3. Two other samples collected on street median showed 135000 microg/m3 and 180000 microg/m3 of total VOCs. The method detection limit of the technique for most semi-volatile organic compounds was 1 microg/m3.

Nasal potential difference measurements in patients with atypical cystic fibrosis

The diagnosis of cystic fibrosis (CF) is based on characteristic clinical and laboratory findings. However, a subgroup of patients present with an atypical phenotype that comprises partial CF phenotype, borderline sweat tests and one or even no common cystic fibrosis transmembrane conductance regulator (CFTR) mutations. The aim of this study was to evaluate the role of nasal potential difference (PD) measurements in the diagnosis of CF patients with an atypical presentation and in a population of patients suspected to have CF. Nasal PD was measured in 162 patients from four different groups: patients with classical CF (n = 31), atypical phenotype (n = 11), controls (n = 50), and patients with questionable CF (n = 70). The parameter, or combination of nasal PD parameters was calculated in order to best discriminate all CF patients (including atypical CF) from the non-CF group. The patients with atypical CF disease had intermediate values of PD measurements between the CF and non-CF groups. The best discriminate model that assigned all atypical CF patients as CF used: e(response to chloride-free and isoproterenol/response to amiloride) with a cut-off >0.70 to predict a CF diagnosis. When this model was applied to the group of 70 patients with questionable CF, 24 patients had abnormal PD similar to the atypical CF group. These patients had higher levels of sweat chloride concentration and increased rate of CFTR mutations. Nasal potential difference is useful in diagnosis of patients with atypical cystic fibrosis. Taking into account both the sodium and chloride transport elements of the potential difference allows for better differentiation between atypical cystic fibrosis and noncystic fibrosis patients. This calculation may assist in the diagnostic work-up of patients whose diagnosis is questionable.

The prevalence of gastroesophageal reflux in children with tracheomalacia and laryngomalacia

OBJECTIVE

We conducted a retrospective study to determine the relationship between gastroesophageal reflux (GER) and large airways malacia in infancy.

METHODS

One hundred sixteen children referred for chronic respiratory problems who were between the ages of 3 and 28 months were investigated. All of them underwent flexible bronchoscopy and chest radiography. Eighteen children had laryngomalacia, 13 had tracheomalacia, and 23 had combined laryngotracheomalacia. During bronchoscopy, BAL was performed. An analysis of macrophages in the BAL fluid for lipid content was performed. Fifty-four children with laryngomalacia and tracheomalacia constituted the study group, and 62 children were in the control group. Reflux studies were obtained for 40 children from the study group and 41 from the control group.

RESULTS

In the study group, 28 children (70%) had GER documented by reflux studies compared with 16 children (39%) in the control group (p < 0.01). In the control group, GER was found mainly among those with recurrent bilateral pneumonia. The lipid-laden macrophage score was correlated with the documented GER.

CONCLUSION

GER is prevalent among infants with large airways malacia, and treatment of this group with antireflux therapy should be considered.

Differences in lung function among school children in communities in Israel

Differences in lung functions of school-age children who lived near two electrical power plants in the Ashkelon district of Israel were studied. Lung-function tests were performed, and the American Thoracic Society questionnaire was administered in three study periods during the following years: (1) 1990, (2) 1994, and (3) 1997. Measurements of air pollutants (i.e., sulfur dioxide, nitric oxides, ozone) were also taken during the aforementioned study periods. Statistical analysis included an estimation of a series of fixed-effects regression models. A total of 2,455, 1,613, and 4,346 observations were included in the analyses for study years 1990, 1994, and 1997, respectively. The authors controlled for age, sex, height, weight, parents' education and smoking status, and being born out of Israel, and, consequently, substantial differences in lung function across the different communities and study periods were demonstrated in the study area. No robust association with air pollution was demonstrated. The cause of these differences in the respiratory health of children remains unknown.

Rare Jatropha multifida intoxication in two children

Two children were admitted to the Emergency Department (ED) after ingesting a large amount of fruit of a plant identified as Jatropha multifida. They were mildly obtunded, had intractable vomiting, and seemed dehydrated. Intravenous fluid replacement and urine alkalinization were initiated. After stabilization, their 5-day hospital stays were uneventful except for a subclinical rise of liver enzymes. Jatropha species contain the toxalbumin ricin, which causes severe vomiting and diarrhea, dehydration, shock, and renal and hepatic impairment. Ricin also has cardiotoxic and hemolytic effects and several deaths have been documented. Children are attracted by the shape and the color of the Jatropha fruits. Mortality can be prevented by immediate fluid and electrolyte replacement.

Two new triterpene lactones from Centaurium pulchellum

Two new triterpene lactones, centauriol (1) and centaurione (2) were isolated from the whole plant of Centaurium pulchellum. Their structures were determined by spectral data.

[Evaluation of asthmatic children presenting at the emergency room at Barzilai Hospital]

Bronchial asthma in the pediatric age group has become prevalent recently. Many children who suffer from asthma arrive at the emergency room (ER) with exacerbations which did not respond to medical treatment at home. Between July and December 1997, 136 children 8 months to 14 years of age (61% below 3 years), were studied in our pediatric ER. Investigation included physical examination and pulse oximetry, which were used as guidelines for scoring the children on arrival and post-treatment. Spirometry was done in those who could cooperate. For each patient a detailed questionnaire about medical and sociodemographic factors was filled. Primary pediatricians used mainly beta-agonist and corticosteroid inhalators, while pediatric pulmonologists used mainly inhaled steroids. There was no relationship between severity of attack on arrival at the ER, mode of treatment and speed of recovery in the ER. More children treated by a general pediatrician more were admitted to hospital. Low parental education and paternal smoking were risk factors for recurrent hospital admissions. Our results indicate that parents must be educated to stop smoking, especially those with asthmatic children, and primary pediatricians should be updated with regard to proper treatment and follow-up of asthma.

Transcobalamin II deficiency with methylmalonic aciduria in three sisters

Transcobalamin II (TC II) is a plasma protein that binds vitamin B12 (cobalamin, Cbl) and facilitates cellular Cbl uptake by receptor-mediated endocytosis. In autosomal recessive TC II deficiency, intracellular Cbl deficiency results in an early onset of megaloblastic anaemia that may be accompanied by neurological abnormalities. Inadequate treatment may lead to neurological abnormalities. We describe three sisters, the daughters of first cousins of Moroccan origin, with TC II deficiency requiring continuous and long-term vitamin B12 treatment. The diagnosis was suspected from the finding of low unsaturated vitamin B12 binding capacity and confirmed by absence of detectable TC II by radioimmunoassay and by inability of cultured fibroblasts to synthesize TC II.

Seasonal variation in systemic onset juvenile rheumatoid arthritis in Israel

OBJECTIVE

To determine whether there is a seasonal peak onset of systemic juvenile rheumatoid arthritis (SOJRA) suggestive of an infectious etiology. We examined the seasonal variability of SOJRA in Israel.

METHODS

A multicenter retrospective chart review of 59 patients with SOJRA, enrolled from 10 rheumatology units or pediatric departments in Israel. All patients met defined criteria of SOJRA.

RESULTS

Fifty-nine patients (31 female, 28 male) were followed from 1982 to 1997. Their mean age was 7.1 +/- 4.3 years (range 0.9-16). Forty-six were Jewish and 13 were Arabs or of Bedouin origin. Eighteen patients (31%) had disease onset in the winter, 16 (27%) in the spring, 12 (20%) in the summer, and 13 (22%) in the fall. Twenty-eight patients had a monophasic disease subtype, while 31 had a chronic or cyclic subtype. The seasonal onset in the patients with the monophasic type versus the chronic or the cyclic type shows 7 versus 11 in the winter, 7 versus 9 in spring, 8 versus 4 in summer, and 6 versus 7 in fall, respectively.

CONCLUSION

There is no seasonal pattern to SOJRA disease onset in Israel. However, the disease onset of patients having the chronic or the polycyclic subtype tends to be more common in winter and spring. Since patients with this type have more severe disease, it is possible that another specific infectious agent is one of the factors involved in the pathogenesis of the disease. Larger sampling and multicenter studies are required to clarify this point.

Treatment with hypertonic saline versus normal saline nasal wash of pediatric chronic sinusitis

BACKGROUND

Chronic sinusitis (CS) is a common disease in children, especially those with allergies, that is caused by impaired drainage from the sinuses. Hypertonic NaCl solution has been shown to increase mucociliary clearance and ciliary beat frequency.

OBJECTIVE

We performed a randomized double blind study to compare the effect of nasal wash with hypertonic saline (HS) (3.5%) versus normal saline (NS) (0.9%) on CS.

METHODS

Thirty patients with CS aged 3 to 16 years were studied. They were randomly divided into two treatment groups matched by age and severity of the disease. Each individual was treated with either HS or NS for 4 weeks. All patients were evaluated by two clinical scores (cough and nasal secretions/postnasal drip [PND]) and by a radiology score at the beginning of the study and after 4 weeks.

RESULTS

The HS group improved significantly in all scores (average +/- SD): cough score, from 3.6 +/- 0.51 to 1.6 +/- 0.74; nasal secretion/PND score, from 2.86 +/- 0.35 to 1.6 +/- 0.74; and radiology score, from 8.06 +/- 1.28 to 2.66 +/- 1.04. The NS treatment group showed significant improvement only in the PND score (from 2.66 +/- 0.49 to 1.53 +/- 0.83) but no significant change in both the cough score (from 3.53 +/- 0.52 to 3.33 +/- 0.49) and the radiology score (from 8.13 +/- 1.25 to 7.86 +/- 0.91). Clinical observation 1 month after the end of the study showed no change compared with the end of the study in both groups.

CONCLUSION

HS nasal wash is an efficient treatment of CS.

[Sudden death from asthma in childhood, is it preventable?]

Sudden death from asthma is rare but occurs in the young age group. We recently faced this rare situation when 3 asthmatic children were dead on arrival at the local emergency room. All 3 had been treated with beta-2 agonist inhalation on a regular basis, without anti-inflammatory treatment, 2 of the children died while inhaling the beta-2 agonist. It is important that there be clear guidelines and full education about the management of asthma, during and between exacerbations, to prevent such deaths.

[Pediatric flexible bronchoscopy]

Between 1993-1996, 200 pediatric flexible bronchoscopies were performed. Indications were: chronic cough (158 children), persistent pulmonary infiltrates (89), recurrent stridor (28), suspected tracheobronchial foreign body (20), suspected tuberculosis (17) and hemoptysis (3). Some children had more than 1 indication. 124 patients were boys (mean 4.18 +/- 2.86 years; range 1 month-15 years) and 76 were girls (mean 4.39 +/- 2.7 years; range 4 months-15 years). The procedure included direct vision recorded by video-camera and bronchoalveolar lavage; the lavage fluid was sent for culture, Gram and Ziehl-Nielsen strains and for cytology. There were a few minor side effects: mild stridor which resolved within a few hours (10 children) and transient fever (3). This simple, flexible instrument was effective and helpful in the diagnosis and treatment of children with respiratory symptoms in a secondary hospital facility.

Epidemiology of childhood tuberculosis in the Ashkelon region in Israel, 1958-1994

The incidence rates of tuberculosis (TB) in Israel decreased steadily up to 1984, but rose again between 1985 and 1991, mainly due to immigration waves from Ethiopia. The epidemiology of TB in children was surveyed in the Ashkelon region. The regional TB register of Barzilai Medical Centre, kept since 1958, was used as the source for our data. Two hundred and fifty TB cases in children were reported between 1958 and 1994, constituting 9.7% of the total 2565 cases reported in the whole population of Israel's southern Mediterranean coast. While in the late 1950s and early 1960s the majority of reported cases occurred in children of North African origin, reflecting the large wave of immigration from North Africa at that time, in 1985-94 at the time of the Ethiopian immigration wave, Ethiopian children constituted the majority of the patients. They were diagnosed up to 9 years after arrival. None of the reported cases was HIV-positive.

[Tuberculosis in early childhood]

The incidence of tuberculosis (TB) has been increasing worldwide. While the incidence in the young is lower than in adults, it mirrors that of the adult population. Infants do not exhibit typical symptoms, and may present with only a low-grade fever and a mild cough which resolves within a few days. Often physical examination is within normal limits. Over the past year we diagnosed TB, confirmed by culture and histology, in 6 children under 2 years of age. We wish to increase awareness among pediatricians of the clinical forms of this disease in children.

[Intussusception: diagnosis and treatment with saline enema under ultrasound]

Intussusception is the most common abdominal emergency of early childhood. In the past 100 years intussusception has been treated by both surgical and nonsurgical methods. The last few years have brought improved nonsurgical methods of treatment. We present the results of ultrasonic diagnosis, and of treatment by saline enema under ultrasound, in the first 7 infants in our series.

Intratracheal N-acetylcysteine use in infants with chronic lung disease

To evaluate the effect of intratracheal administration of N-acetylcysteine (Mucomyst) on the clinical status, pulmonary function and gas exchange in premature infants with chronic lung disease, we conducted a randomized, placebo-controlled, crossover trial. Ten mechanically ventilated infants (gestational age 27 +/- 1 week; postnatal age 22 +/- 6 days) with clinical and radiological evidence of chronic lung disease and increased airway secretion were enrolled in the study. Each infant received tracheal administration of 5% N-acetylcysteine for one week and saline placebo every 4 h for another week. N-acetylcysteine was associated with a 59 +/- 26% increase in total airway resistance by the third day of treatment (p less than 0.01). A two-fold increase in airway resistance associated with an increased frequency of bradycardia and cyanosis spells was seen in two of the infants following three days of N-acetylcysteine administration, with a rapid improvement in their condition when subsequently switched to saline. Overall, N-acetylcysteine administration had no effect on the variables measured. We conclude that intratracheal administration of N-acetylcysteine to liquefy airway mucus neither improves the clinical condition nor hastens recovery in premature infants with chronic lung disease and its administration may lead to increased total airway resistance and cyanotic spells. The present data do not support the use of N-acetylcysteine as a mucolytic agent in premature infants with chronic lung disease.

Relationship between response to inhaled salbutamol and methacholine bronchial provocation in children with suspected asthma

Fifty children (27 females, 23 males) ages 6-15 years who were referred for evaluation of suspected asthma had baseline FEV1 and FEF25-75 of greater than or equal to 80% and FEF50 greater than or equal to 70% of predicted values. All had these tests repeated on the same day, after inhaling salbutamol. On a subsequent day PC-20 (methacholine) was determined as an index of bronchial hyperreactivity (BH). Fourteen age-matched healthy children (6 females, 8 males) were studied in a similar manner. There was no significant relationship between the PC20 and the change in FEF25-75 or FEF50 following salbutamol. There was a negative correlation between the initial FEV1 (% predicted) and the percent change in FEV1 following salbutamol (P less than 0.01). An increase in FEV1 of greater than 6% occurred in 7/12 (58.3%) patients with PC20 less than or equal to 0.25 mg/mL (Group I); in 7/24 (29.2%) patients with PC20 = 0.26-2.0 mg/mL (Group II); in only 1/14 (7.1%) patients with PC20 greater than 2.1 mg/mL (Group III) and in none of those asymptomatic (control) children with PC20 greater than 8.0 mg/mL (Group IV). All subjects who had a change in FEV1 greater than 6% after salbutamol had a PC20 less than 8 mg/mL and this test detected the majority of patients with severe BH. However, although the sensitivity of the test was 100%, the predictive value was only 36%. We conclude that in the presence of a normal baseline FEV1 a change of greater than 6% following salbutamol inhalation is indicative of bronchial hyperreactivity.

Typhoid fever diagnosed by isolation of S. typhi from gastric aspirate

The diagnosis of typhoid fever (TF) is usually established by culturing S. typhi from the blood or by serology. In this report we describe three patients in whom the diagnosis of TF was made by the isolation of S. typhi from gastric contents, despite negative blood urine and stool cultures. Culture of gastric contents has not previously been recognized as a diagnostic tool in this disease.

Home measurement of oxygen saturation during sleep in patients with cystic fibrosis

Feasibility and reproducibility of home measurement of arterial oxygen saturation (SaO2) were evaluated in 14 clinically stable patients with cystic fibrosis (CF). Changes in SaO2 during sleep were compared to the clinical status and pulmonary function while awake to identify predictors of nocturnal oxyhemoglobin desaturation. Each patient was assessed by clinical score, spirometry, and arterial blood gas analysis within 72 hours of the overnight study. Eight patients were studied on more than one occasion to assess dependence of SaO2 on position and reproducibility of overnight studies. A pulse oximeter stored up to 8 hours of nocturnal SaO2 measurements in its memory. Off-line analysis of trend data provided the proportion of sleep with SaO2 less than 90% and less than 85%. We found that patients with daytime PaO2 less than 60 mm Hg spent greater than 80% of their sleep with SaO2 less than 90%, while those with PaO2 greater than 70 mm Hg spent less than 20% of the night with SaO2 less than 90%. Patients with daytime PaO2 of 67-70 mm Hg were desaturated to less than 90%, from 0 to 98% of the night. No consistent body position dependence of daytime SaO2 was found. Home measurement of SaO2 during sleep was reproducible, with a difference on two repeat occasions of 4% +/- 2 (mean +/- SEM) for %time with SaO2 less than 90% and 3% +/- 2 for %time with SaO2 less than 85%. The severity of hemoglobin desaturation during sleep could not be reliably predicted from clinical scores or awake pulmonary function.(ABSTRACT TRUNCATED AT 250 WORDS)

Erythrocyte glutathione peroxidase activity in asthmatic children

Erythrocyte glutathione peroxidase (GPX) levels were determined in 56 asthmatic children. Lowest levels were found during acute asthmatic attack (13.53 +/- 2.94 IU) which were significantly less than controls (20.4 +/- 5.44 IU) (P less than .001). Post-attack levels 1 week later rose significantly (16.77 +/- 2.63 IU), but were still less than normal values (P = .001). GPX levels (16.96 +/- 3.28 IU) were less than controls (P less than .03) even in patients with mild symptomatology. Asymptomatic patients receiving theophylline had normal levels. Low GPX activity in asthmatic patients may play a role in the pathogenesis of the disease.

Pediculosis capitis: why prefer a solution to shampoo or spray?

Two hundred and sixty-eight children with pediculosis capitis took part in a comparative study to test the efficacy of five different pediculocides commonly used in Israel. The preparations used were pyrethrin shampoo, pyrethroid spray, malathion solution, carbaryl shampoo and carbaryl lotion. Carbaryl lotion and malathion solution were much more efficient when compared to the shampoo and spray preparations.

Racial or ethnic variation in spirometric lung function norms. Recommendations based on study of Ethiopian Jews

It is widely known that different ethnic (or racial) groups do not appear to have lung function test results which fit the same prediction formulae. Israel, with ethnic minorities from many countries, is faced with a dilemma as to what to use as a basis for normative estimates. We studied 146 Ethiopian Jewish immigrants (68 males and 78 females), all nonsmokers with no evidence of any chronic disease. The FEV1 and FVC were analyzed separately by sex and age (those less than 25 and those 25 years or more of age). Standard prediction formulae based on height overpredicted the values found by from 15 to 29 percent. Logarithmic formulae based on sitting height provided a good fit for values for children (less than 25 years). Compared to other populations the sitting height-standing height ratio was low for this population, (0.48 vs 0.52) reflecting their relatively long limbs and shorter thoracic height. Our findings suggest that as a guideline, ethnic groups with deviant standing height-sitting height ratios either use ethnic-group specific prediction formulae or derive prediction formulae using sitting height.

Allergen-specific leukocyte adherence inhibition (LAI) assay: sensitivity, specificity and mechanism

An allergen-specific tube leukocyte adherence inhibition (LAI) assay has been developed in order to study the mechanism by which leukocytes lose their normal property of adherence to glass. Peripheral blood leukocytes (PBL) from 27 individuals allergic to Dermatophagoides farinae (DF), 10 with seasonal rhinitis not induced by DF and 49 non-allergic healthy volunteers were challenged in vitro with DF and a non-relevant allergen, Artemisia vulgaris (AV) and then assayed for the ability to adhere to glass tubes. Challenge by DF, but not by AV, resulted in loss of adherence by PBL from patients allergic to DF, but not in those of normal controls. The specific LAI response was dose-dependent and occurred only when a critical dose of 0.5 X 10(3) was employed. Following in vitro challenge with DF, radio-immunoassay using an antiserum to LTC4 detected immunoreactive material in supernatants of PBL from DF-allergic individuals. When highly enriched mononuclear cells from non-allergic individuals were armed with cytophilic allergen-specific IgE and challenged with the specific allergen, they lost the property of glass adherence and released a substance that was immunoreactive with LTC4. The results suggest that the chain of events leading to the LAI response in PBL from allergic individuals involves primary recognition of the allergen by specific IgE antibodies bound to receptors on mononuclear cells. The cells are thus triggered to synthesize cysteinyl-containing leukotrienes which mediate the LAI phenomenon. The results suggest that this assay may be used to study allergen-antibody interaction and the subsequent events leading to the clinical picture of atopic diseases.

Ketotifen, disodium cromoglycate, and verapamil inhibit leukotriene activity: determination by tube leukocyte adherence inhibition assay

Peripheral blood leukocytes (PBL) from asthmatic individuals lose their former ability to adhere to glass when incubated with leukotriene C4 (LTC4). A modified leukotriene-induced leukocyte adherence inhibition (LAI) assay was therefore used to study the ability of anti-asthmatic drugs to abrogate such activity. Ketotifen, disodium cromoglycate, Verapamil, and dimethpyridene, all at concentrations of 2 X 10(-6) M, were co-cultured with 2 X 10(-7) M LTC4 and their effect on the LTC4-induced LAI determined. Verapamil, Ketotifen, and disodium cromoglycate all inhibited the LTC4 activity while the H1 antagonist, dimethpyridene, did not. These results suggest that the beneficial effect of Verapamil, Ketotifen, and disodium cromoglycate in bronchial asthma is probably as calcium antagonists that cause the inhibition of leukotriene activity.

Interferon modulates the leukotriene C4-induced non-adherence properties of leukocytes: acquisition of an asthmatic phenotype

We have previously shown that peripheral blood leukocytes (PBL) of asthmatic patients acquire non-adherence properties after challenge with leukotriene C4 (LTC4), whereas PBL of normal individuals do not. Hence the use of the LTC4-induced leukocyte-adherence-inhibition (LAI) assay enables one to recognise an asthmatic phenotype on the basis of the ability of PBL to respond in vitro to LTC4. To examine the possibility that alpha interferon (IFN alpha) may have relevance to the pathogenesis of bronchial asthma, various concentrations of IFN were incubated with normal PBL and the acquisition of non-adhering properties was measured. We found that following 24 h incubation with 500 U/ml IFN, normal PBL were induced to respond to a standard dose of LTC4, and this reaction was abrogated by FPL 55712 and cyclohexamide.

Leukotrienes (LTC4, LTD4) confer glass non-adherence on leukocytes of asthmatic individuals. Dependency on cyclooxygenase products and calcium ion

It has been suggested that cysteinyl-containing leukotrienes (LT) are important mediators in bronchial asthma. Since leukotrienes have been shown to mediate the leukocyte adherence inhibition (LAI) phenomenon observed in cancer-bearing host we have devised a modified LAI assay which determines the acquisition of non-adherence properties of leukocytes following a challenge with pure synthetic LT. Our results demonstrate that peripheral blood leukocytes of asthmatic individuals acquire non-adherence properties when challenged with pure synthetic leukotriene C4 and D4, a property not shared by peripheral blood leukocytes of control healthy individuals. Furthermore, we demonstrate that LT activity as manifested by the LAI assay is dependent on cyclooxygenase products, since 2 X 10(-6) M Indomethacin abrogated the LT-induced LAI and is restored by the addition of 2 X 10(-6) M prostaglandin E2 which is also synergistic to LT activity. Our results further suggest the possibility that leukotriene activity is dependent on calcium ions since it was negated by known calcium antagonists. It is thus suggested that the LT-induced LAI may serve as a tool for the study of the interrelationship between the metabolic pathways of arachidonic acid and calcium ion homeostasis.