Investigation of outbreaks of Pneumocystis jirovecii pneumonia in two Scottish renal units.

Pneumocystis jirovecii is recognized as an opportunistic pathogen. In recent years, human-to-human transmission of P. jirovecii has been demonstrated. However, outbreaks of P. jirovecii infections are not well defined because the epidemiological setting that facilitates transmission is not fully understood. This article describes two outbreaks of P. jirovecii pneumonia (PCP) in renal transplant patients in the West of Scotland. In total, 25 patients in two geographically contiguous locations were affected. Allele B was identified as the dominant type, along with allele A3. It was not possible to determine the exact reason for clustering of cases, although the outpatient clinic setting featured in one of the outbreaks. The outbreaks ceased with the use of trimethoprim-sulphamethoxazole prophylaxis; the target populations that received prophylaxis were different in the two outbreaks. Infection control teams should be alert to the possibility of outbreaks of PCP.

Mass carbon monoxide poisoning.

The largest occurrence of carbon monoxide poisoning in Britain demonstrates the potential for mass accidental poisoning. It emphasises the need for strict public health controls and the importance of good liaison between emergency services to ensure that such events are quickly recognised and that the necessary resources are organised.

Medical cover at Scottish football matches: have the recommendations of the Gibson Report been met?

OBJECTIVES: To determine if doctors providing medical care at Scottish football stadiums meet the standards recommended by the Gibson Report. METHODS: A postal questionnaire and telephone follow up of doctors involved with the 40 Scottish League teams. RESULTS: 47% of the doctors had not attended any relevant resuscitation courses and 72% had no training in major incident management. CONCLUSIONS: The recommendations of the Gibson Report with regard to medical cover at football stadiums have not been fully implemented in Scotland.

Cimetidine-theophylline interaction in patients with chronic obstructive airways disease.

The effect of cimetidine on the elimination of theophylline was studied in six patients with chronic obstructive airways disease, who were receiving maintenance therapy with theophylline. The administration of cimetidine resulted in a decrease of 25% in the interdose clearance of theophylline, which led to an increase in "steady-state" theophylline levels in five of the patients. Prescribers should be aware of this potential interaction and reduce theophylline dosage where appropriate.

Oral contraceptive steroids impair the elimination of theophylline.

The influence of OCS and sex differences on the disposition of theophylline has been studied in 12 healthy young men (29 +/- 4 years old), 13 healthy young women (29 +/- 12), and 10 healthy young women (24 +/- 3) receiving OCS for a period greater than 6 months. The elimination t1/2 was longer in women taking oral contraceptives (523 +/- 110 min) than in women not on oral contraceptives (386 +/- 157). Weight-normalized plasma clearance of theophylline was less in women taking oral contraceptive steroids (0.70 +/- 0.15 ml X min-1 X kg-1) than in women not on oral contraceptive steroids (0.98 +/- 0.32). Plasma binding and volume of distribution were not different between the two groups of women. Weight-normalized clearance, weight-normalized volume of distribution, plasma t1/2, and plasma binding were not different between men and women not taking OCS.

PIP: The influence of oral contraceptives (OCs) and sex differences on the disposition of theophylline has been studied in 12 healthy young men (29 +or- 4 years old), 13 healthy young women (29 +or- 12), and 10 healthy young women (24 +or- 3) receiving OCs for a period greater than 6 months. The elimination 1/2-life was longer in women taking OCs (523 +or- 110 minutes) than in women not taking OCs (386 +or- 157). Weight-normalized plasma clearance of theophylline was less in women taking OCs than in women not on OCs. Plasma binding and volume distribution were not different between the 2 groups of women. Weight-normalized clearance, weight-normalized volume of distribution, plasma 1/2-life, and plasma binding were not different between men and women not taking OCs.

Cimetidine impairs the elimination of theophylline and antipyrine.

In 7 healthy subjects theophylline and antipyrine elimination were determined before and during a course of oral cimetidine in a dose of 1 g/day. Plasma clearance of theophylline was reduced from 71.2 +/- 10.1 ml/min to 56.0 +/- 18.5 ml/min and the plasma clearance of antipyrine from 53.7 +/- 14.2 ml/min to 48.1 +/- 11.7 ml/min. Elimination half-life of theophylline was prolonged from 5.1 +/- 1.6 to 8.1 +/- 1.4 h. All these changes were statistically significant. Volume of distribution of theophylline (31.7 +/- 8.4 L before and 39.2 +/- 5.6 L during cimetidine administration) and plasma binding of theophylline (44.7 +/- 3.8% before and 44.3 +/- 3.1% during cimetidine administration) were not significantly different. Similarly, volume of distribution of antipyrine (45.8 +/- 14.0 vs. 47.6 +/- 17.9) was not significantly affected by cimetidine administration. We conclude that cimetidine impairs the elimination of theophylline and antipyrine in healthy subjects.

Cholestatic liver disease associated with diphenylhydantoin therapy. Possible pathogenic importance of altered bile salt metabolism.

A ten-year-old boy persented with a prolonged cholestatic liver disease 5 weeks after starting diphenylhydantoin therapy. The initial phase of his illness was characterized by hepatocellular damage with swollen liver cells and centrilobular cholestasis. Severe hyperlipoproteinemia with eruptive xanthomata developed within 3 weeks of his initial jaundice. The second phase of his illness was characterized by portal tract inflammation with bile ductular proliferation and chronic cholestasis gradually resolving over a period of 15 months. It is postulated that diphenylhydantoin sensitivity produced swollen hepatocytes with hypertrophy of the smooth endoplasmic reticulum, reducing hepatic sinusoidal blood flow and the clearance of secondary bile salts. A fall in clearance of lipoproteins, including the cholesterol precursor of primary bile acid synthesis, may have been responsible for a reduction in serum bile acid concentration. High levels of serum lithocholic acid, largely unsulfated presumably due to decreased hepatic uptake, may have produced the prolonged second phase of this illness when histological changes resembled that seen in experimental animals following lithocholic acid administration.

The measurement of sulphated and non-sulphated bile acids in serum using gas-liquid chromatography.

A method is described to assay sulphated and non-sulphated bile acids in serum using gas-liquid chromatography. Previously described techniques have been substantially modified to allow analysis of free and conjugated salts of the four major bile acids with particular care to ensure quantitative recoveries of lithocholic acid, its conjugates and sulphate esters. Losses of lithocholic acid inherent in some methods have been reduced by avoidance of column chromatography with alumina and extraction of lipid contaminants into heptane. Assay of the proportion of serum bile acids present as sulphate esters is achieved by the routine use of column chromatography to separate sulphated bile acids from non-sulphated bile acids followed by solvolysis of the sulphated bile acids before deconjugation. Careful selection of the conditions of strong alkaline hydrolysis ensures deconjugation of all bile salt conjugates including lithocholic conjugates which are not completely hydrolysed in weaker alkaline solutions. The trifluoroacetate derivatives of the methyl esters of the bile acids are chromatographed using 5-beta-cholanic acid as an internal standard with clear separation of the four major bile acids from the internal standard. In 10 fasting control subjects the mean serum total bile acid concentration was 5.3 muM (RANGE 1.1-16.4) including 0.7 mum sulphated bile acid (range 0-1.8). In 10 patients with acute viral hepatitis the total bile acid concentration was elevated in some but normal in others (mean 44.9 muM, range 2.7-80.3). The percentage of the total bile acid sulphated was not significantly different in the hepatitis patients compared to controls (controls 13%, range 0-35; hepatitis 23%, range 0-52). Lithocholic acid made up 13% of the total bile acid in controls (0-32%) and 18% in hepatitis patients (0-53%). Most of this lithocholic acid was sulphated (controls 81%, range 30-100; hepatitis 67%, range 37-100). Unconjugated bile acids were demonstrated in the serum of a few patients with acute viral hepatitis but in no control subjects.