Compliance with oral corticosteroids during steroid trials in chronic airways obstruction

BACKGROUND

Corticosteroid trials are an important part of the assessment of patients with chronic airways obstruction, but false negative results will occur if the treatment is not taken. To determine compliance low dose phenobarbitone has been used as a marker.

METHODS

Thirty six patients referred to a chest clinic for assessment of their airways obstruction were studied. They were instructed to take eight capsules (each containing 5 mg prednisolone and 0.5 mg phenobarbitone) per day for two weeks. The response was assessed by home peak flow monitoring and clinic spirometric tests. Plasma phenobarbitone levels were measured after the trial to enable calculation of the dose to plasma concentration ratio (level to dose ratio, LDR) and the result was compared with the reference range for fully compliant individuals.

RESULTS

Five patients defaulted from follow up, 23 had LDR values within the expected range, and eight had low LDR values consistent with poor compliance. The nine patients with steroid responsive disease (> 20% improvement in peak flow or spirometric parameters) all had LDR values in the expected range.

CONCLUSION

Excluding those who defaulted whose compliance must be questionable, eight (26%) patients did not fully comply with the steroid trial. Not all patients who fail to respond to a two week home steroid trial have a steroid "unresponsive" disease.

Low incidence of red cell and HLA antibody formation by bone marrow transplant patients

BACKGROUND

Bone marrow transplant (BMT) patients, although immunosuppressed, are at risk for the development of red cell (RBC) and HLA antibodies, and they often are given filtered blood in an effort to prevent the latter complication. This study attempts to determine the rate of formation and the specificity of both RBC and HLA alloantibodies in this patient population.

STUDY DESIGN AND METHODS

BMT patients (148 received autologous marrow; 45 received allogeneic marrow) from an 18-month period, including patients with leukemia (57 patients), lymphoma (54), breast cancer (68), myeloma (8), myelodysplastic syndrome (5), and aplastic anemia (1), were studied to determine the rate of alloantibody formation to RBC and HLA antigens. A total of 2,410 RBC antibody screens were performed. The patients received 3,921 packed RBCs and 5,915 single-donor platelet units; all were irradiated and administered via white cell-reduction filters.

RESULTS

Seven (3.6%) of 193 patients had RBC antibodies upon hospital admission. Four (2.1%) of 193 developed RBC antibodies during the course of BMT: 3 patients had one RBC antibody and 1 patient had two RBC antibodies. RBC antibodies included anti-E (n = 2), anti-M (n = 1), anti-Jkb (n = 1), and anti-Lu14 (n = 1). Thus, 98 percent of patients (189/193) did not develop new (182/186) or additional (7/7) RBC antibodies during BMT. BMT patients were also screened weekly for HLA antibody formation (60-cell panel). Upon admission, 170 (85%) patients were negative. Of these, 8 (4.7%) developed persistent HLA antibodies (mean panel-reactive antibody score, 33 +/- 29%) and 9 (5.3%) were variably positive. Thus, in our setting and population, RBC antibody formation was 0.1 percent per unit transfused, and the HLA alloimmunization rate was 5 to 10 percent.

CONCLUSION

As RBC antibody screens are done every Monday, Wednesday, and Friday on this BMT service and as RBC antibody formation is low in these patients, screening for unexpected antibodies might be possible on a more infrequent basis. Also, the rate of HLA alloimmunization in this population receiving filtered blood components is low.

Childhood cancer in Britain: the National Registry of Childhood Tumours and incidence rates 1978-1987

The National Registry of Childhood Tumours contains population-based data on childhood cancers diagnosed throughout Great Britain from 1962 onwards. This paper describes the methodology of the Registry, presents incidence rates for 1978-1987 and describes other uses of the data. Total age-standardised annual incidence was 118.3 per million. The most frequent diagnostic groups were leukaemias (age-standardised rate 39.8), brain and spinal tumours (27.0), lymphomas (11.1), sympathetic nervous system tumours (8.3), kidney tumours (7.7) and soft-tissue sarcomas (7.5). Incidence rates were similar to those reported from other Western industrialised countries. The data are also used for a wide range of epidemiological and other studies. These include analyses of geographical variations in incidence, trends in survival, health of long-term survivors and their offspring and the genetics of childhood cancer. Information is frequently provided for clinicians and research workers, and series of specific types of cancer are compiled for further study. The Registry depends for the completeness and accuracy of its data on a wide range of organisations and individuals, and it is essential that this cooperation continues if the Registry is to be maintained.

Nasal surgery for snoring

Snoring is a common disorder usually presenting to otolaryngologists. Most patients who have any nasal symptoms would normally be offered nasal surgery, but there is a significant incidence of failure to control the snoring (approximately 25%). We analysed a group of patients, all having nasal surgery for snoring, with the aim of assessing whether any pre-operative factors would predict success or failure of the surgery. We found symptoms of excessively loud snoring, witnessed apnoeic episodes and hypersomnolence, or obstructive sleep apnoea diagnosed by overnight oxygen saturation measurements to be statistically associated with failure of nasal surgery to improve snoring.

Changes in nocturnal oximetry after treatment of exacerbations in cystic fibrosis

Sleep related arterial oxygen desaturation has been described in clinically stable young adults with cystic fibrosis. The incidence and severity of nocturnal oxygen desaturation in children during infective exacerbations and the changes that occur with treatment were examined. Forty five children with proved cystic fibrosis, median age 8.9 years, admitted to the Regional Cystic Fibrosis Unit underwent clinical evaluation, spirometry, and measurement of peak flow and nocturnal oxygen saturation on admission and after 10 days' treatment. There was a significant improvement in all the above measurements, with the averaged overnight saturation changing from a mean (SD) 92.7 (2.7)% to 94.3 (2.0)%, mean (SE) difference 1.58 (0.37). The time spent with a saturation 4% or more below their clinic value showed a marked improvement from 122 (152) minutes on the first night to 21 (30.7) on the second, mean (SE) difference 101 (22.4). Eight young children could not perform pulmonary function tests, all desaturated on the admission night. Nocturnal hypoxaemia is a common finding in young cystic fibrosis patients during infective exacerbations but improves with treatment. Overnight oximetry is simple to perform, well tolerated, and identifies patients with marked nocturnal desaturation.

Pulmonary and cutaneous vasculitis following hepatitis B vaccination

The case history is presented of a previously healthy non-atopic woman who developed cutaneous vasculitis, confirmed by biopsy, and pulmonary problems after inoculation with recombinant hepatitis B vaccine.

Pancoast syndrome: an unusual presentation of adenoid cystic carcinoma

We report on a patient with primary pulmonary adenoid cystic carcinoma presenting with Pancoast syndrome. Pancoast syndrome has not previously been described with this tumour. Other unusual features of this case include the peripheral origin and mediastinal involvement, with lack of proximal endobronchial spread.

Salbutamol output from two jet nebulizers

Nebulized bronchodilators are commonly used in the management of patients with airflow obstruction, although there is little information available on the bronchodilator output from the nebulizer unit. We have examined the fluid and salbutamol outputs of a single jet nebulizer from two commercial manufacturers at 1 min intervals up to 12 min. The drug and fluid output continued throughout the study period, with a greater fluid output leading to an increase in the concentration of salbutamol remaining within the nebulizer unit. This suggests that weight change is not a good indicator of drug output. Furthermore, there was a marked difference in peak salbutamol output between the two nebulizer units, being 2.9 mg (55%) with the Micro-Neb unit and 1.98 mg (38.7%) with the System 22 unit.

Pancoast syndrome: an unusual presentation of adenoid cystic carcinoma

We report on a patient with primary pulmonary adenoid cystic carcinoma presenting with Pancoast syndrome. Pancoast syndrome has not previously been described with this tumour. Other unusual features of this case include the peripheral origin and mediastinal involvement, with lack of proximal endobronchial spread.

Accuracy and significance of scoring hypopneas

We previously reported that the best definition of hypopneas in the sleep apnea/hypopnea syndrome (SAHS) is based on reduction in thoracoabdominal movement. However, the repeatability of scoring hypopneas from thoracoabdominal movement has not been assessed, nor has the need to record flow as well as thoracoabdominal movement. Thus, two polysomnographers independently scored both apneas and hypopneas on all-night polysomnograms of patients with SAHS. There was close agreement between the polysomnographers for the number of hypopneas (r = 0.98; mean difference 11%) and for the number of apneas (r = 0.99; mean difference 8%). The agreement was similar for the durations of both hypopneas (r = 0.99; mean difference 13%) and apneas (r = 0.99; mean difference 11%). There was also close agreement between the total number of respiratory events scored with and without reference to the flow signal (r = 0.99; mean difference 1.4%) with a maximum under-recognition of 18 events per night in a subject with 237 apneas per night. Thus, hypopneas can be scored reproducibly. In addition, the value of always recording and scoring flow as well as thoracoabdominal signals is questioned.

Obstructive sleep apnoea in adults presenting with snoring

Snoring is a common disorder, and may be associated with obstructive sleep apnoea, although there is little published information on the incidence of apnoea in snorers. This study aimed to assess the upper airway and to relate the findings to sleep study data in a population of patients referred by their general practitioners with loud snoring. Each patient had a full history, weight and height measurements, nasal examination, rhinomanometry, peroral grading of the oropharyngeal features, and fibreoptic pharyngoscopy with a modified Muller manoeuvre, followed by a sleep study. The results in our group of 35 patients demonstrate a high incidence of obstructive sleep apnoea (46%). Factors which correlated well with apnoea were excessively loud snoring, a narrow oropharynx, and marked obesity; 94% of patients with one or more of these features had evidence of sleep apnoea.