Occurrence of multidrug-resistant Enterococcus faecium isolated from environmental samples.

Enterococcus species are present in the microbiota of humans and animals and have also been described in the environment. Among the species, Enterococcus faecium is one of the main pathogens associated with nosocomial infections worldwide. Enterococcus faecium isolates resistant to different classes of antimicrobials have been increasingly reported, including multidrug-resistant (MDR) isolates in environmental sources, which is worrying. Therefore, this study aimed to characterize E. faecium isolates obtained from soil and water samples regarding antimicrobial resistance and virulence determinants. A total 40 E. faecium isolates were recovered from 171 environmental samples. All isolates were classified as MDR, highlighting the resistance to the fluoroquinolones class, linezolid and vancomycin. Furthermore, high-level aminoglycoside resistance and high-level ciprofloxacin resistance were detected in some isolates. Several clinically relevant antimicrobial resistance genes were found, including vanC1, ermB, ermC, mefAE, tetM, tetL, ant(6')-Ia, ant(4')-Ia, aph(3')-IIIa and aac(6')-Ie-aph(2″)-Ia. Three virulence genes were detected among the MDR E. faecium isolates, such as esp, gelE and ace. The results of this study contribute to a better understanding of MDR E. faecium isolates carrying antimicrobial resistance and virulence genes in environmental sources and report for the first time in the world the presence of vanC1-producing E. faecium isolated from soil.

Isolation of human mesenchymal stem cells from amnion, chorion, placental decidua and umbilical cord: comparison of four enzymatic protocols.

OBJECTIVE: To compare four enzymatic protocols for mesenchymal stem cells (MSCs) isolation from amniotic (A-MSC) and chorionic (C-MSC) membranes, umbilical cord (UC-MSC) and placental decidua (D-MSC) in order to define a robust, practical and low-cost protocol for each tissue. RESULTS: A-MSCs and UC-MSCs could be isolated from all samples using trypsin/collagenase-based protocols; C-MSCs could be isolated from all samples with collagenase- and trypsin/collagenase-based protocols; D-MSCs were isolated from all samples exclusively with a collagenase-based protocol. CONCLUSIONS: The trypsin-only protocol was least efficient; the collagenase-only protocol was best for C-MSCs and D-MSCs; the combination of trypsin and collagenase was best for UC-MSCs and none of tested protocols was adequate for A-MSCs isolation.

New STs in multidrug-resistant Acinetobacter baumannii harbouring ß-lactamases encoding genes isolated from Brazilian soils.

AIMS: We investigated the resistance profile, presence of ß-lactamases encoding genes and the clonal relationships in Acinetobacter baumannii isolated from Brazilian soils. METHODS AND RESULTS: Soil isolates of A. baumannii were subjected to antimicrobial susceptibility testing by disk diffusion and minimum inhibitory concentration methods. Different ß-lactamases encoding genes were screened by PCR and the molecular typing of these isolates was performed through the multilocus sequence typing. Non-susceptibility to different antibiotics was found, since environmental isolates were classified as multidrug-resistant. The blaSHV gene was the most prevalent, followed by blaGES. All sequence types (STs) found (ST1584, ST1607, ST1608, ST1609, ST1610, ST1611 and ST1612) were described for the first time in this study. CONCLUSION: The wide variety of new alleles and new STs detected in the present study indicates a divergent population compared to studies that are carried out in the clinical environment and points to an even larger genetic diversity within the species than was anticipated. SIGNIFICANCE AND IMPACT OF THE STUDY: A number of the environmental isolates represented multidrug-resistant strains, a phenotype that has been more commonly reported for clinical isolates of A. baumannii; the detection of several ß-lactamase encoding genes in the investigated isolates is of great concern suggesting that there is a large reservoir of these resistance genes in the environment.

Electrocardiographic abnormalities in the early stage following traumatic spinal cord injury.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: Although cardiac arrhythmias are relatively well recognized in the chronic stage after spinal cord injury (SCI), little is known regarding its occurrence during the early stage. The objective of this study was to examine electrocardiogram changes within the first 72 h after acute traumatic SCI. SETTING: Acute spine trauma center, Toronto, Ontario, CanadaMethods:This study included all consecutive patients with spine trauma admitted to our institution from January 1998 to June 2007 who had an electrocardiogram within the first 72 h post trauma. Patients were divided into four groups: (I) patients with motor complete SCI at T6 or above; (II) patients with motor incomplete SCI at T6 or above; (III) patients with spine trauma but no/minor SCI at T6 or above; and (IV) patients with SCI below T6. RESULTS: There were 69 men and 20 women with mean age of 53.8 years (16-88 years). All groups were comparable regarding age, sex, pre-existing comorbidities and cause of SCI. There were no significant differences among the groups regarding predominant rhythm, PR interval, atrial-ventricular conduction, ventricular rate, QRS axis and intraventricular conduction abnormalities. Nonetheless, patients in Group I had longer RR interval (P=0.016), longer QTc (P=0.025) and more prolonged duration of the longest QRS (P=0.017) in comparison with the other groups. CONCLUSIONS: Our results indicate that electrocardiogram abnormalities are more common within the first 72 h following acute traumatic, motor complete, cervical or high-thoracic SCI. This may represent early manifestations of autonomic dysfunction due to disruption of descending cardiovascular pathways in individuals with severe SCI at T6 or above.

Acute ischemic stroke and abnormal blood hemoglobin concentration.

OBJECTIVES: This study examines whether low or high blood hemoglobin concentration (HGB) is associated with stroke severity, worse clinical outcomes, and poorer prognosis after acute ischemic stroke (AIS). METHODS: This retrospective cohort study included data from the Ontario Stroke Registry on consecutive patients with AIS who were admitted between July 2003 and March 2008. We excluded patients taking anticonvulsants or iron supplement; patients with cancer, renal failure, history of gastro-intestinal or genitourinary bleeding, and pregnancy. Patients were divided into groups as follows: low HGB, normal HGB, and high HGB. Outcome measures included the frequency of greater degree of disability at discharge (modified Rankin score: 3-6), 7-day, 30-day and 90-day mortality, and length of stay in the acute stroke care hospital. RESULTS: Hemoglobin levels higher than the upper limit of normal are associated with a greater disability at discharge (OR = 1.49, 95% CI: 1.03-2.15, P = 0.0331), and higher 30-day mortality (HR = 1.98, 95% CI: 1.44-2.74, P < 0.0001) after adjustment for major potential confounders. The Kaplan-Meier curves indicate that abnormal HGB levels are associated with higher mortality after AIS (P < 0.0001). HGB levels below the lower limit of normal are associated with longer lengths of stay in the acute care hospital (OR = 1.11, 95% CI: 1.02-1.22, P = 0.017). Elevated HGB was associated with greater neurological deficit on admission (OR = 1.45, 95% CI: 1.06-1.95, P = 0.0195). CONCLUSIONS: Our results suggest that an elevated HGB on the initial admission is associated with more severe strokes, greater disability at discharge, and higher 30-day mortality after AIS. A low HGB on admission is associated with longer stay in the acute care hospital.

Treadmill walking differently affects body composition and metabolic parameters of female rats from normal or small litters.

This work assessed whether walking affects bodily development and metabolic parameters of female rats raised in small litters (three pups, group S) or control litters (nine pups, group C). After weaning, some of the rats had five sessions per week of a 30-min treadmill walking (CE and SE), while the others remained sedentary (CS and SS) until the age of 120 days. Exercise caused a reduction of body weight (CS/CE = 1.18), Lee index (CS/CE = 1.04), fasting blood glucose (CS/CE = 1.35), mesenteric (CS/CE = 1.23), and ovarian fat (CS/CE = 1.33) in CE, but only glucose was decreased in SE (SS/SE = 1.16). The diameter of adipocytes decreased to a half in the small-litter groups. Exercise increased subcutaneous (CS/CE = 0.88 and SS/SE = 0.71), but decreased retroperitoneal adipocytes (CS/CE = 1.2 and SS/SE = 1.3). Litter size reduction had little impact on females at the age of 120 days, but the light physical activity seemed insufficient to counteract all the effects of lactational overfeeding. On the other hand, pups from exercised mothers had a decrease in their biometric and glycemic indexes, demonstrating the transgenerational action of regular, although light, exercise.

Exercise partially reverses the inhibitory effect of caffeine on liver gluconeogenesis in type 1 diabetic rats with hypoglycemia.

The purpose was to determine the possible effects of exercise and/or caffeine on hypoglycemia and liver gluconeogenesis in diabetic rats. These were divided into four subgroups: (a) intraperitoneal insulin only, (b) exercise bout before insulin, (c) caffeine after insulin, and (d) exercise bout before and caffeine after insulin. The marked glycemic drop 45 min after insulin (0 min = 229.00, 45 min = 75.75) was considerably reduced (p < 0.05) by caffeine or exercise (45 min: exercise = 127.00, caffeine = 104.78). However, this systemic effect was lost (p > 0.05) when they were combined (45 min: exercise + caffeine = 65.44) (Mean, in mg·dL-1). Caffeine alone strongly inhibited liver glucose production from 2 mM lactate 45 min after insulin (without caffeine = 3.05, with caffeine = 0.27; p < 0.05), while exercise + caffeine partially re-established the liver gluconeogenic capacity (exercise + caffeine = 1.61; p < 0.05 relative to the other groups) (Mean, in µmol·g-1). The improved hypoglycemia with caffeine or exercise cannot be explained by their actions on liver gluconeogenesis. As their beneficial effect disappeared when they were combined, such association in diabetic patients should be avoided during the period of hyperinsulinemia due to the risk of severe hypoglycemia.

White blood cell count is an independent predictor of outcomes after acute ischaemic stroke.

BACKGROUND AND PURPOSE: In patients with ischaemic stroke, elevated white blood cell count (WBC) has been associated with stroke severity on admission and poor functional outcome. However, previous studies did not control for confounding factors. We hypothesized that higher WBC is an independent predictor of stroke severity, greater degree of disability and 30-day mortality after acute ischaemic stroke. METHODS: Data from the Registry of the Canadian Stroke Network on consecutive patients with acute ischaemic stroke admitted between July 2003 and March 2008 were used. Patients were divided into groups as follows: low WBC (0.1-4 × 10(-9) /l), normal WBC (4.1-10 × 10(-9) /l) and high WBC (10.1-40 × 10(-9) /l). Primary outcome measures were the frequency of moderate/severe strokes on admission (Canadian Neurological Scale ≤ 8), greater degree of disability at discharge (modified Rankin score 3-6) and 30-day mortality. Regression analyses were performed adjusting for confounders. RESULTS: In total, 8829 patients were included. After adjustment for major potential confounders, every 1 × 10(-9) /l increase in WBC was associated with stroke severity on admission [odds ratio (OR) 1.09; 95%CI 1.07-1.10; P < 0.0001), disability at discharge (OR 1.04; 95%CI 1.02-1.06; P = 0.0005) and 30-day mortality (hazard ratio 1.07; 95%CI 1.05-1.08; P < 0.0001). The Kaplan-Meier curves indicate that elevated WBC is associated with higher mortality after acute ischaemic stroke (P = 0.001). CONCLUSIONS: In patients with acute ischaemic stroke, higher WBC on admission is an independent predictor of stroke severity on admission, greater degree of disability at discharge and 30-day mortality. These results reinforce the need for further studies focused on immunomodulation therapy targeting inflammatory response following acute ischaemic stroke.

Blood alcohol concentration as a determinant of outcomes after traumatic spinal cord injury.

BACKGROUND: Pre-clinical studies indicate a potential detrimental effect of ethanol on tissue sparing and locomotor recovery in animal models of spinal cord injury (SCI). Given this, an examination of whether blood alcohol concentration (BAC) is a potential determinant of survival and neurological and functional recovery after acute traumatic SCI was carried out. METHODS: All patients who were enrolled in the Third National Spinal Cord Injury Study (NASCIS-3) were included. The study population was divided into 'non-alcohol' (BAC equal to 0‰), 'legal' (BAC greater than 0 up to 0.8‰) and 'illegal' (BAC greater than 0.8‰) subgroups. Outcome measures included survival, NASCIS motor and sensory scores, NASCIS pain scores and Functional Independence Measure (FIM) determinants at baseline and at 6 weeks, 6 months and 1 year post-SCI. Analyses were adjusted for major potential confounders: age, sex, ethnicity, trial protocol, Glasgow coma score, and cause, level and severity of SCI. RESULTS: Among 499 patients (423 males and 76 females; ages from 14 to 92 years), the mean BAC was 0.054 ± 0.006‰ (range 0-1). The survival at 1 year (94.4%) was not associated with the BAC (P = 0.374). Moreover, BAC was not significantly correlated with motor recovery (P > 0.166), sensory recovery (P > 0.323), change in pain score (P > 0.312) or functional recovery (P > 0.133) at 6 weeks, 6 months and 1 year post-SCI. CONCLUSIONS: Our results, for the first time, show that the BAC at emergency admission does not adversely affect the patients' mortality, neurological impairment or functional disability over the course of the first year after SCI.

Management of anticoagulation following central nervous system hemorrhage in patients with high thromboembolic risk.

SUMMARY BACKGROUND: Patients who present with central nervous system (CNS) hemorrhage while on anticoagulation (AC) for thromboembolic (TE) risk factors are a challenge to manage. OBJECTIVE: We sought to inform decisions surrounding the timing and intensity of AC resumption by performing a systematic review. METHODS: Three reviewers screened publications from Medline and EMBASE and extracted data. Hemorrhagic and TE adverse events that occurred subsequent to the index hemorrhage were recorded, as was their timing relative to presentation and covariates that might influence their occurrence. RESULTS: Data were extracted from 63 publications detailing 492 patients; 7.7% of patients experienced hemorrhagic complications and 6.1% experienced TE complications. Hemorrhagic complications were more common within 72 h of presentation while TE complications were more common thereafter. Patients restarted on AC after 72 h were significantly more likely to have a TE complication (P = 0.006) and those restarted before 72 h were more likely to hemorrhage (P = 0.0727). Factors associated with re-hemorrhage included younger age, traumatic cause, subdural hematomas and failure to reverse AC. TE complications were more common in younger patients and those with spinal hemorrhage, multiple hemorrhages, and non-traumatic causes of the index hemorrhage. Re-initiation of AC at a lower intensity also significantly increased the risk of TE complications. INTERPRETATION: Our results suggest that it may be prudent to re-initiate AC earlier than previously thought, with the timing and intensity modified based on predictors of TE and hemorrhagic complications. These findings must be explored in a prospective study because of limitations inherent to the analyzed studies.

Attitudes towards the older patients with spinal cord injury among registered nurses: a cross-sectional observational study.

STUDY DESIGN: Cross-sectional observational study. SETTING: Acute-care unit and tertiary rehabilitation centre in Ontario, Canada. OBJECTIVE: To evaluate attitudes towards older patients among nurses caring for individuals with spinal cord injury (SCI), and examine potential determinants of ageist attitudes. METHODS: Using Kogan's Old People Scale, this questionnaire-based survey assesses attitudes towards older patients among registered nurses working in an acute-care unit, registered nurses working in a rehabilitation centre and individuals with chronic SCI. RESULTS: Although individuals with SCI and nurses working in the rehabilitation setting were statistically comparable regarding their attitudes towards older patients, nurses working in the acute-care unit hold more ageist attitudes than their rehabilitation-nursing counterparts (P=0.003). Among nurses, a higher level of education and working in the rehabilitation setting were associated with fewer ageist attitudes (P<0.03). There was a trend for an association between older age and more positive attitudes towards older patients (P=0.069). CONCLUSIONS: Our questionnaire-based survey, which appears to represent the population of interest, identified significant differences in the attitudes towards older patients between nurses working in the acute-care setting versus rehabilitation setting who showed similar attitudes towards individuals with SCI. The most reliable factor associated with the nurses' attitudes was their level of education. Given that the practice of ageism has the potential to prejudice service provision and ultimately recovery of patients with SCI, further research and knowledge dissemination activities for nurses caring for elderly patients with SCI should be sought.

Optimal treatment for severe neurogenic bowel dysfunction after chronic spinal cord injury: a decision analysis.

BACKGROUND: When conservative management fails in patients with chronic spinal cord injury (SCI) and neurogenic bowel dysfunction, clinicians have to choose from a variety of treatment options which include colostomy, ileostomy, Malone anterograde continence enema (MACE) and sacral anterior root stimulator (SARS) implantation. This study employed a decision analysis to examine the optimal treatment for bowel management of young individuals with chronic refractory constipation in the setting of chronic SCI. METHODS: A decision analysis was created to compare the four surgical strategies using baseline analysis, one-way and two-way sensitivity analyses, 'worst scenario' and 'best scenario' sensitivity analyses, and probabilistic sensitivity analyses. Quality-adjusted life expectancy (QALE) was the primary outcome. RESULTS: The baseline analysis indicated that patients who underwent the MACE procedure had the highest QALE value compared with the other interventions. Sensitivity analyses showed that these results were robust. CONCLUSION: The MACE procedure may provide the best long-term outcome in terms of the probability of improving bowel function, reducing complication rates and the incidence of autonomic dysreflexia, and being congruent with patients' preferences. The analysis was sensitive to changes in assumptions about quality of life/utility, and thus the results could change if more specific estimates of utility became available.

Localization of the superior laryngeal nerve during carotid endarterectomy.

Knowledge of the topographic anatomy is essential to prevent iatrogenic damage of the superior laryngeal nerve (SLN) in carotid endarterectomy (CEA). The purpose of this study was to analyze the anatomic relationship between the SLN and carotid arteries in order to prevent iatrogenic nerve injury. Anatomic dissections similar to CEA were performed bilaterally in 50 fresh human adult cadavers. The topography of the SLN was analyzed regarding its relationship with the carotid arteries. Furthermore, the distance between the external branch of the SLN and the point of bifurcation of the common carotid artery (dCAB) was analyzed regarding effects of gender, ethnicity, individual stature and side of the neck. The SLN was always located adjacent and posterior to the carotid arteries.The dCAB ranged from 20.3 mm below the point of bifurcation of the common carotid artery to 50.9 mm above this level (average 10.3 mm above). Most dissections (75%) showed the external branch of the SLN emerging from behind the carotid artery above the arterial bifurcation; in only 10% of cases did this nerve emerge from the artery below that anatomic reference. Based on Student's t-test, there were no significant differences in the dCAB between genders ( P=0.237), ethnicities ( P=0.410) and sides of the neck ( P=0.872). Moreover, tall stature was not significantly correlated with a shorter dCAB (linear regression: R(2)=0.009, P=0.357). We conclude that most SLNs were located above the carotid artery bifurcation, but anatomic variations occurred in 25% of the dissections. The dCAB was unaffected by gender, ethnicity, individual stature and side of the neck.

Anatomical study applied to anesthetic block technique of the superior laryngeal nerve.

BACKGROUND: The topography of the internal branch of the superior laryngeal nerve (ibSLN) was prospectively studied to evaluate the greater horn of the hyoid bone (ghHB) and the incisura of the thyroid cartilage (iTC) as anatomical repairs in laryngeal anesthetic block. Factors such as gender, ethnicity and side of the neck were also analyzed concerning their influence in the ibSLN position. METHODS: One hundred neck dissections were performed in 50 human cadavers bilaterally identifying the ibSLN, the ghHB and iTC. The distance between the ghHB and ibSLN in the cranio-caudal direction (dHB), and the distance between the iTC and the ipsilateral thyrohyoid membrane ostium (dTC) were measured. Furthermore, the results were statistically analyzed according to ethnicity, gender and side of the neck. RESULTS: The ibSLN was juxtaposed to the apex ghBH in 31 out of 100 dissections. The mean dHB was 2.4 mm, and mean dTC was 33.4 mm. The statistical analysis did not identify any significant difference regarding those distances between the groups in terms of ethnicity, gender and side of the neck. CONCLUSION: The ibSLN was often dissected very close to the ghHB, and this result was not influenced by any factor studied. Therefore, the ghHB can be considered a good anatomical repair to localize the ibSLN in the local block of the larynx. Furthermore, the dTC could frequently be reached by routinely used nerve block needle. However, a few anatomical variations may occur, resulting in a low failure rate of this anesthetic procedure.

Biologic basis for the treatment of microscopic, occult well-differentiated thyroid cancer.

BACKGROUND: Management of thyroid microcancer or occult well-differentiated thyroid cancer (OWDTC) is controversial. Our present study compared some clinical features of OWDTC and gross well-differentiated 10-mm thyroid carcinoma (GWDTC), which may offer a basis for treatment policy. METHODS: From 1964 to 2000, 1000 patients underwent thyroidectomy for thyroid cancer. We randomly selected 428 cases for study in which node sampling was carried out in 88% of GWDTC and 60% of OWDTC and who were demographically comparable. All data were obtained by chart review and analyzed by chi-square test. RESULTS: With the maximum limit of 10 mm for defining OWDTC, we found 113 such cases with a mean size of 6.1 mm and 315 GWDTC cases with a mean size of 27.6 mm. The incidence of metastatic nodal disease was 16.8% in OWDTC cases and 25.7% in GWDTC cases (P = .057). Distant metastases occurred in 1 of 113 (0.9%) cases of OWDTC and 11 of 315 (3.5%) cases of GWDTC (P = .149). After a mean follow-up time of 55.8 months, neck metastatic recurrent disease occurred in 3 of 113 (2.7%) cases of OWDTC and 7 of 315 (2.2%) cases of GWDTC (P = .770). OWDTC was found in 11.1% of the GWDTC group undergoing an operation. Multicentricity occurred in 31.9% of OWDTC cases and 35.9% of GWDTC cases (P = .447). No cause-specific death occurred. CONCLUSIONS: One cannot be dogmatic in treatment of microcancer, but one is justified in extending similar treatment principles for OWDTC as in GWDTC, which in our center usually indicates near-total thyroidectomy and consideration for radioactive iodine ablation.

[Surgical treatment of infections involving arterial prosthesis in aorto-femoral position]. / Tratamento cirúrgico de infecções comprometendo próteses arteriais em posição aorto-femoral.

This article is to evaluate the results of surgical treatment of aorto-femoral graft infections. The records of 20 patients with aorto-femoral graft infections were reviewed. The patients were submitted mostly to a combination of surgical procedures. They were: a) conservative treatment; b) partial removal of the infected graft and c) total removal of the infected graft. The removal of the prosthesis, partial or total, was followed by a new arterial reconstruction in some patients. The final treatment was: total removal of the infected graft in 11 (55%) patients, total removal plus arterial reconstruction in six, partial removal in two and partial removal plus arterial reconstruction in one. The results of treatment were presented as the survival rate and the effective palliation (patient alive, lower limbs preserved and infection cured). The survival rates after one month, 12, 24, 36 and 48 months were respectively: 80%, 60%, 53%, 42% and 27%. The effective palliation rates after one month and after 48 months were respectively 50% and 27%. The highest effective palliation rate was obtained when the infected prosthesis was removed and a new arterial reconstruction performed. We conclude that the treatment of choice of aorto-femoral graft infections seems to be the total removal of the graft followed by new arterial reconstruction.

[Ambulatory treatment of asthma in adults]. / Ambulantno lecenje astme u odraslih.

In the introduction the approach to the treatment of asthma has been classified into preventive measures and drug therapy. By both methods especially by drugs the inflammation in the airways should be decreased. According to the modern concepts of pathogenesis of asthma the bronchial hyperresponsiveness might be reduced together with the causes of the symptoms of asthma. For the preventive treatment of all but mild forms of asthma in most asthmatics the therapy of three parallel ways should be applied: bronchodilators in aerosol and/or perorally, anti-allergic inflammatory drugs as well as corticosteroids in aerosol only in exceptional cases per os. According to the clinical effect and lung function (measurement of PEF at home) the drugs and doses are changed. In acute aggravation of asthma when bronchodilators are not sufficient the corticosteroids should be added parenterally in high doses with special attention on beta agonists in inhalation of increased doses after the corticosteroids had been applied.

The effect of food on the bronchial response in adult asthmatic patients, and the protective role of ketotifen.

The bronchial response and haemolytic complement were monitored for 8 hours after challenge in 24 asthmatics giving positive oral provocation tests (OPT) to various food. Double-blind oral provocation tests were carried out in 16 asthmatics and open food challenge in 8. The food in question was milk (10 patients), flour (5 patients), eggs (4 patients), potatoes (2 patients), beans (1 patient), tomatoes (1 patient) and beer (1 patient). Five patients gave an immediate type bronchial response, the reduction in PEFR being greatest in the first hour. Eighteen patients showed a non-immediate type response, the maximum decrease in PEFR being observed in the second hour in 8 patients, in the third hour in 7 patients and in the fourth hour in 3 patients. In 4 of the asthmatic patients a dual type of bronchial reaction was observed. The onset of bronchial response and the time to maximum change in PEFR did not depend on the food ingested. An open study with Ketotifen was carried out in 14 asthmatics. The mean reduction in PEFR in response to repeated OPT was smaller than the reduction induced by the initial OPT (p less than 0.001). The results indicated that Ketotifen afforded effective protection against the bronchial response to food challenge in asthmatics. The study confirmed that ingested food, i.e. flour, milk and eggs, may provoke asthmatic dyspnoea in chronic adult asthmatic patients.