Acute asthma exacerbations: tips from the shop floor.

Asthma places a significant burden on acute and non-acute services and is frequently encountered in the emergency department and the medical take. The UK has one of the highest asthma mortality rates in Europe. The National Review of Asthma Deaths has identified multiple factors that have contributed to preventable asthma deaths and solutions to these factors, including a better understanding and implementation of asthma guidelines. The British Thoracic Society and Scottish Intercollegiate Guidelines Network have recently updated their guidance on the management of asthma. This article outlines the guidelines for junior doctors managing patients with acute exacerbations of asthma. It highlights key areas of the initial assessment, establishing severity and initiating and escalating treatment. Furthermore, the discharge process from discharge criteria to promoting patient safety, education and ongoing self-management is discussed. This process, in particular education and personalised asthma action plans, can make a significant difference to the patient's outcomes and day-to-day burden of symptoms.

Haemodilution-induced enhancement of coagulation is attenuated in vitro by restoring antithrombin III to pre-dilution concentrations.

Moderate haemodilution enhances coagulability in vitro and in vivo as measured by thrombelastography (TEG). The mechanism has never been established. We have conducted an in vitro study to determine whether the effect can be moderated or prevented when the reduction in antithrombin III caused by dilution is prevented by supplementation. Blood from 20 volunteers was divided into four samples. One sample was not diluted and served as control (C). Another was diluted (by 20%) with saline (S). The third was diluted by 20% with saline plus two units of antithrombin (AT III) (SA). The fourth remained undiluted, with two units of added AT III (CA). Coagulation was measured in all four samples using the TEG. In a separate laboratory study, the levels of AT III were measured in control samples and compared with levels after 20% dilution, and 20% dilution with two units of AT III added to the diluent. Enhanced coagulation was demonstrated in saline-diluted samples (S) by shortening of r- and k-times, and increased alpha angle. In the SA samples, r-time shortening was prevented; k-time shortening and alpha-angle increase persisted, but to a reduced degree (difference from saline-only dilution P<0.051). There were no differences between samples C and CA. A predictable drop of AT III (24.2%) occurred with saline dilution, while AT III levels in the AT III/Saline group were similar to the undiluted control. Haemodilution-induced coagulation enhancement is attenuated, but not prevented, if AT III levels are maintained in the normal range. This is in keeping with the established concept of an antithrombin threshold preventing positive coagulation feedback into the intrinsic pathway.

The detection of Mycobacterium tuberculosis in bone marrow aspirate using the polymerase chain reaction.

SETTING: Tygerberg Hospital, South Africa. OBJECTIVE: Bone marrow aspirate and biopsy were obtained from 37 patients who were in-patients at the Tygerberg hospital. The specificity and sensitivity of the polymerase chain reaction (PCR) in the detection of Mycobacterium tuberculosis in bone marrow aspirate was evaluated. DESIGN: The PCR was compared to standard culture as well as to clinical and bone marrow biopsy data in 24 patients with suspected tuberculosis (TB). RESULTS: 12 of the 24 patients eventually had definite or probable TB and in these 12 patients the detection incidence was 42% for PCR and 25% for culture. CONCLUSION: This study confirms that it is possible to use PCR to detect M. tuberculosis in bone marrow aspirate material and that this technique is more sensitive than culture methods. The PCR technique has the added advantage of being a rapid test yielding results within 2 days of sampling. Overall sensitivity for the detection of M. tuberculosis in bone marrow aspirate may be improved to 58% [corrected] by using both culture and PCR techniques.

[Coronary embolism revealing mitral valve stenosis]. / Embolie coronaire révélatrice d'un rétrécissement mitral.

We report a case of myocardial infarction with normal coronary arteriography in a 39-year-old woman presenting with tight mitral stenosis complicated by atrial extrasystoles and spontaneous atrial contrast at echocardiography. The diagnosis of coronary embolism was most probable. Coronary embolism is a rare disease, usually due to a blood clot or, less frequently, to a vegetation of endocarditis starting in a heart valve. The left network is usually involved, with typical myocardial necrosis. Coronary arteriography is sufficient to make the diagnosis. Preventive treatment is essential.

Haematological changes associated with miliary tuberculosis of the bone marrow.

The peripheral blood and bone marrow findings in 25 patients found to have tuberculous granulomata on bone marrow examination were examined to determine whether specific haematological findings are associated with tuberculous infiltration of the bone marrow. All the patients had one abnormality or more on their full blood count. The presence of a peripheral lymphopaenia was the single factor common to all 25 patients studied. The peripheral lymphopaenia was only associated with bone marrow lymphopaenia in 14% of patients. Other findings of note were an association of peripheral monocytopaenia and absence of giant cells in the granulomata, and decreased iron stores in almost a third of the total number of patients. The relevance of the lymphopaenia, monocytopaenia and decreased iron stores are discussed and we propose that the absence of a peripheral lymphopaenia makes it very unlikely that there will be tuberculous localization in the bone marrow.

CD4+, CD33-, CD13-, CD14- acute monoblastic leukaemia.

We report a case of acute monoblastic leukaemia in which the expression of the CD4 antigen occurred in the absence of myeloid and monocytic lineage specific markers. Unexpected marker profiles have biological and diagnostic implications and we also suggest that the inappropriate expression of the CD4 antigen may be implicated in the poor prognosis of this case.

Autosomal recessive polycystic kidney disease. Evidence for high frequency of the gene in the Afrikaans-speaking population.

Polycystic kidney disease was investigated in 28 families in which at least one member attended the paediatric nephrology clinic at a Johannesburg or Pretoria hospital. Twenty-five (89.3%) of the families had autosomal recessive polycystic kidney disease (ARPKD), and of these a significantly larger number than would have been expected (92%) were Afrikaans-speaking. There was a consanguineous marriage in the ancestry of 2 patients but 6 of the families (26%) had ancestors with one surname in common and 7 of the families (28%) had their origin in the western Transvaal. A point prevalence for ARPKD of 1:26,000 was estimated for the Afrikaans population (based on the age cohort 0 - 19 years) and the carrier rate for the gene was 1:83; on the basis of the live-birth rate for ARPKD of 1:11,000 the carrier rate is 1:53. These findings suggest that ARPKD may be unusually frequent in the Afrikaans-speaking population. A founder effect is probably responsible.

[A study of the health services and needs of the elderly (SENSORG)]. / Ondersoek na die gesondheidsdienste en behoeftes van bejaardes (SENSORG).

Our department was approached by various welfare organisations who experienced problems with the placing of the frail elderly in suitable homes. The SENCARE project was planned to ascertain the health needs of the white and coloured elderly living in old-age homes and in the community and to identify the existing health services available to them by using the questionnaire method of measurement. The study was done in 3 phases: phase I in an urban area, phase II in a large rural town and phase III in 5 small rural towns. In the urban area too many healthy white elderly people live in old-age homes. The availability of services is poorer in the rural areas. In all 3 phases social and economic impairment is the major cause of dependence in both the white and coloured elderly population groups.