Influence of a single oral dose of vitamin D(2) on serum 25-hydroxyvitamin D concentrations in tuberculosis patients.

SETTING: Newham Chest Clinic, London, UK. OBJECTIVE: To determine the safety and efficacy of the administration of bolus-dose vitamin D(2) in elevating serum 25-hydroxyvitamin D (25[OH]D) concentrations in tuberculosis (TB) patients. DESIGN: A multi-ethnic cohort of TB patients was randomised to receive a single oral dose of 2.5 mg vitamin D(2) (n = 11) or placebo (n = 14). Serum 25(OH)D and corrected calcium concentrations were determined at baseline and 1 week and 8 weeks post-dose, and compared to those of a multi-ethnic cohort of 56 healthy adults receiving an identical dose of vitamin D(2). RESULTS: Hypovitaminosis D (serum 25[OH]D < 75 nmol/l) was present in all patients at baseline. A single oral dose of 2.5 mg vitamin D2 corrected hypovitaminosis D in all patients in the intervention arm of the study at 1 week post-dose, and induced a 109.5 nmol/l mean increase in their serum 25(OH)D concentration. Hypovitaminosis D recurred in 10/11 patients at 8 weeks post-dose. No patient receiving vitamin D(2) experienced hypercalcaemia. Patients receiving 2.5 mg vitamin D(2) experienced a greater mean increase in serum 25(OH)D at 1 week post-dose than healthy adults receiving 2.5 mg vitamin D(2). CONCLUSION: A single oral dose of 2.5 mg vitamin D(2) corrects hypovitaminosis D at 1 week but not at 8 weeks post-dose in TB patients.

Delay in starting treatment for tuberculosis in east London.

In the United Kingdom there is little information about the delay between the onset of symptoms in patients with tuberculosis and the time it takes for them to be correctly diagnosed and treatment started. We have examined the duration and possible causes of such delay in our own district. The records of 93 patients were examined. Total delay in starting treatment was estimated as the time from the start of symptoms to commencement of chemotherapy. Patient delays were estimated from the time between the start of symptoms to the time taken to first attend their general practitioner (GP) with symptoms. Healthcare system delays were estimated from the interval between first being assessed by their GP and starting anti-tuberculosis treatment. Median total delay was 18 weeks (0-219). The time when patients first presented to their GP was determined for 64 patients: median patient delay was then estimated as nine weeks (range 0-104 weeks), and median healthcare delay five weeks, with a very wide range (0.5-210). Prolonged delay was seen in three patients with cervical lymph node disease. Patient delay was significantly longer than healthcare system delay (p = 0.019). Pulmonary disease was associated with shorter total delay in starting treatment compared with extra-pulmonary disease (p = 0.035). In patients with tuberculosis there were considerable delays in first presentation to medical services, in diagnosis and in starting treatment. Patient delays were longer than healthcare system delays. There is a need to improve awareness of the symptoms of tuberculosis both on the part of the general population and of health professionals, especially in areas of high incidence.

Influences on hospital admission for asthma in south Asian and white adults: qualitative interview study.

OBJECTIVE: To explore reasons for increased risk of hospital admission among south Asian patients with asthma. DESIGN: Qualitative interview study using modified critical incident technique and framework analysis. SETTING: Newham, east London, a deprived area with a large mixed south Asian population. PARTICIPANTS: 58 south Asian and white adults with asthma (49 admitted to hospital with asthma, 9 not admitted); 17 general practitioners; 5 accident and emergency doctors; 2 out of hours general practitioners; 1 asthma specialist nurse. MAIN OUTCOME MEASURES: Patients' and health professionals' views on influences on admission, events leading to admission, general practices' organisation and asthma strategies, doctor-patient relationship, and cultural attitudes to asthma. RESULTS: South Asian and white patients admitted to hospital coped differently with asthma. South Asians described less confidence in controlling their asthma, were unfamiliar with the concept of preventive medication, and often expressed less confidence in their general practitioner. South Asians managed asthma exacerbations with family advocacy, without systematic changes in prophylaxis, and without systemic corticosteroids. Patients describing difficulty accessing primary care during asthma exacerbations were registered with practices with weak strategies for asthma care and were often south Asian. Patients with easy access described care suggesting partnerships with their general practitioner, had better confidence to control asthma, and were registered with practices with well developed asthma strategies that included policies for avoiding hospital admission. CONCLUSIONS: The different ways of coping with asthma exacerbations and accessing care may partly explain the increased risk of hospital admission in south Asian patients. Interventions that increase confidence to control asthma, confidence in the general practitioner, understanding of preventive treatment, and use of systemic corticosteroids in exacerbations may reduce hospital admissions. Development of more sophisticated asthma strategies by practices with better access and partnerships with patients may also achieve this.

Factors influencing the distribution of tuberculosis cases in an inner London borough.

The incidence of tuberculosis (TB) has increased throughout London, especially in inner city boroughs. Ethnicity, poverty, and the success of TB control measures all affect the distribution of cases between boroughs. This study was conducted to see which factors affect the distribution of cases between electoral wards within an inner London borough. The Borough of Newham in the East End of London is made up of 24 electoral wards and has one of the highest notification rates in the United Kingdom. Our analysis showed that the percentage of the population who were non-white made a strong contribution to the variance in TB rates between wards (p < 0.0001), but the age distribution of the population and Jarman scores for poverty did not, the latter because the entire borough is deprived. Measures to control TB should be targeted at those areas where members of the community are most at risk.

Bone density in asthmatic patients taking inhaled corticosteroids: comparison of budesonide and beclomethasone dipropionate.

We assessed bone mineral density (BMD) in 20 asthmatics who had been taking inhaled budesonide (BUD) (median daily dose 800 micrograms) for over a year, 13 of whom had taken previous courses of systemic steroids. Their results were compared with those of 20 patients receiving inhaled high-dose beclomethasone dipropionate (BDP) (median daily dose 1,000 micrograms), all of whom had received previous courses of systemic corticosteroids, and with those of 17 mild asthmatics who had never taken either inhaled or systemic steroids. Mean (standard deviation) (SD)) BMD in the patients taking BUD was 139.5 (28.6) mg/ml. This was significantly lower (p < 0.05) than in the control patients who had never taken inhaled or systemic steroids (160.4 (27.4) mg/ml). Mean BMD in the patients taking BUD did not differ significantly from that observed in patients taking BDP (127.5 (22.6) mg/ml). Although the reduction in BMD in the asthma patients taking regular high-dose BUD could have been due to previous courses of corticosteroid, the magnitude of bone loss is similar to that seen in patients taking high-dose inhaled BDP and intermittent corticosteroids.

Oilseed rape and bronchial reactivity.

OBJECTIVES: To investigate atopy and changes in symptoms, peak flow rate, and bronchial reactivity in people complaining of symptoms during the oilseed rape flowering season. METHODS: 37 people who had given positive answers to questions about the presence of symptoms in relation to the flowering season of oilseed rape and 24 controls with no such symptoms were studied, although not all took part in all parts of the study. All had been previously identified in a cross sectional survey of a random sample of a rural population. Atopy was assessed by means of skin prick tests, total immunoglobulin E (IgE), and radioallergosorbent test (RAST) assays. Bronchial reactivity (PC20) was measured by histamine challenge. Total IgE and bronchial reactivity were measured both before and during the oilseed rape flowering season. Day to day changes were monitored by subjects who kept a record of their symptoms and peak flow morning and evening, starting before the flowering season and continuing during it and into the grass pollen season. RESULTS: Only two cases, of 23 tested, showed evidence of allergy to oilseed rape and only 10 of 23 tested, including these two, were atopic. Eye, nasal, and headache symptoms increased in the season in cases, which validated the questionnaire used in the previous cross sectional survey. 12 of 16 cases tested and seven of 15 controls showed a seasonal fall in PC20; the fall in the cases was significantly greater than in the controls. Peak flow charts showed no evidence of fall or of increased variability during the season. CONCLUSIONS: People who complained of symptoms in relation to the flowering of oilseed rape were rarely allergic to the plant and fewer than half were atopic. Nevertheless, they usually showed increased bronchial reactivity during the season, which may have been due in some cases to other allergens but in others to non-specific irritant effects of the air. Whether these are due to chemicals released by the crop, to rising summer ozone levels, or to other factors remains unclear.

Rates of change in peak expiratory flow and in diurnal variation in peak flow in patients recovering from acute severe asthma.

1. The rates of change in mean peak expiratory flow and in diurnal variation in peak flow were compared in 14 patients recovering from acute severe asthma. 2. Peak expiratory flow was measured on hospital admission, and at 6-hourly intervals for the next 3 weeks. 3. Diurnal variation in peak flow was assessed by measuring the following: amplitude (the highest minus the lowest peak expiratory flow during any given 24 h period), amplitude % mean (the highest minus the lowest peak expiratory flow during any given 24 h period divided by the mean peak expiratory flow over that period) and residual amplitude (the maximum variation about the mean peak expiratory flow during any given 24 h period). 4. Plots of diurnal variation in peak flow and peak expiratory flow against time were constructed for each patient. To enable comparison of changes in peak expiratory flow and diurnal variation in peak flow the data were transformed. 5. The rate of change for mean peak expiratory flow and for the three measures of diurnal variation in peak flow was assessed by fitting an exponential function to each set of data, and calculating the slope of the exponential curve halfway through the period of observation (10.5 days). 6. Median (range) slope for peak expiratory flow was 0.055 (0-2.57). The comparable value for amplitude was -3.15 (-1.27 to -4.22) (absolute median values compared, P = 0.0029), for amplitude % mean was -1.87 (-0.18 to -5.95) (P = 0.012) and for residual amplitude was -1.43 (-0.62 to -3.09) (P = 0.033).(ABSTRACT TRUNCATED AT 250 WORDS)

Spontaneous sternal fractures in four patients with chronic airflow obstruction taking corticosteroids.

Four patients with chronic airflow obstruction developed spontaneous sternal fractures. All had received repeated courses of high dose corticosteroids and three were receiving long term treatment with low dose corticosteroids. It is important to consider sternal fracture in the differential diagnosis when patients with chronic airflow obstruction present with chest pain.

Bone density in asthmatic patients taking high dose inhaled beclomethasone dipropionate and intermittent systemic corticosteroids.

BACKGROUND: Asthmatic patients taking low to moderate doses of inhaled topical corticosteroids have been shown to have lower bone density than those taking bronchodilators only. There is little information on bone density in asthmatic patients taking high dose inhaled corticosteroids. METHODS: Bone mass was studied in three age matched groups of asthmatic patients. These comprised: 17 asthmatic patients who had never taken inhaled or systemic corticosteroids (group 1); 20 patients who had taken beclomethasone diproprionate in a dosage of 1000-2000 micrograms daily for at least a year, who had also received courses of systemic corticosteroids in the past (group 2); and 20 patients who were taking both high dose inhaled corticosteroids and regular low dose prednisolone, at a median dose of 7 mg daily (group 3). Vertebral bone density was measured by quantitative computed tomography. Biochemical indices of bone formation and resorption were also measured. RESULTS: Mean bone density in group 2 (127.5(22.6) mg/ml) was similar to that in group 3 (114.5 (36.0) mg/ml). Bone density was significantly lower in both of these groups than in group 1 (160.4 (27.4) mg/ml). There were no significant differences between groups for any of the markers of bone formation and resorption. CONCLUSIONS: Asthmatic patients receiving high dose inhaled beclomethasone and intermittent courses of systemic corticosteroids have reduced vertebral bone density. The bone loss is similar in degree to that seen in patients taking high dose inhaled topical corticosteroids and continuous low dose systemic corticosteroids.

Changes in spirometry during consecutive admissions for infective pulmonary exacerbations in adolescent and adult cystic fibrosis.

Changes in spirometry during consecutive admissions for treatment of pulmonary infective exacerbations were studied in 45 patients (24 males, 21 females) with cystic fibrosis (CF) who had required five or more such admissions. Over the overall study period there was a mean (SD) decline in FEV1 of -112.1 (188.0) ml yr-1 (P less than 0.001) and in FVC of -47.9 (82.4) ml yr-1 (P less than 0.001). FEV1 and FVC increased during each admission with treatment; however, the magnitude of this change became less over consecutive admissions by a mean value of -33.3 ml (45.0) (P less than 0.001) for FEV1, and -26.0 (72.2) ml (P less than 0.05) for FVC. In the majority of patients that died or underwent transplantation, FEV1 at the time of the last admission did not rise above 800 ml despite full treatment.

Cardio-respiratory responses to exercise following treatment of acute severe asthma.

Asthmatic patients are encouraged to adopt a normal and active life-style. However, following treatment of acute severe asthma, patients may ask for advice about taking exercise. Serial measurements of the cardio-respiratory responses to continuous work load exercise, were made in asthmatic patients convalescing following hospital treatment of an acute exacerbation. Eighteen asymptomatic patients, (seven male) aged 18-48 years, were studied. The first test was performed within 1 week of admission, when the mean (SD) peak expiratory flow rate (PEFR) was 88 (20)% predicted normal and the arterial oxygen tension (PaO2) was 13.1 (1.4) kPa. No significant differences in the mean cardio-respiratory responses, from the last minute of exercise, were found during the 4-week study. There were no significant differences in the four tests, between the resting PEFR, lowest post-exercise PEFR or % change in PEFR. Also, there were no significant differences in the pre-exercise, end of exercise and recovery (10 min after exercise) PaO2, between the four tests. However, taking the four tests as a whole, significant relationships were found between the recovery PaO2 and the lowest post-exercise PEFR, expressed in absolute terms (r = 0.515, P less than 0.001), and as a percentage of predicted normal (r = 0.533, P less than 0.001); and also between the recovery PaO2 and the % change in PEFR after exercise (r = 0.299, P less than 0.05). It is suggested that a formal exercise test should be performed in convalescent asthmatics wishing to participate in active sports. Patients with exercise-induced asthma may then be identified and treated appropriately.

Group G streptococcal bacteraemia--a review of thirteen cases in Grampian.

Thirteen cases of group G streptococcal bacteraemia are described. All subjects were hospital in-patients between 1980-1988, and were either middle-aged or elderly. A primary site of infection was identified in 11, of whom nine had soft tissue infection and two had infections derived from the gut/biliary tree. Seven patients had underlying disease, two of whom had malignancy. One patient died of septicaemia. In the majority of patients early institution of treatment led to prompt recovery.

The effect of sustained-release theophylline in nocturnal asthma.

Nocturnal symptoms are common and often disabling in asthmatic subjects. Furthermore, they often persist, in spite of appropriate dosages of inhaled beta 2-agonists and topical steroids. In such a clinical situation, theophylline preparations may have a therapeutic role. This double-blind, placebo-controlled, cross-over trial was designed to evaluate the effectiveness of a twice-daily Bioavail slow-release theophylline capsule in a group of out-patient asthmatics, with a history of nocturnal and/or early morning wheeze or chest tightness. Theophylline was initially prescribed and monitored in an 'open' phase to obtain the drug dosage required to achieve a serum level in the therapeutic range of 10-20 mg/l. In the ten patients who completed the study, serum theophylline levels were stable throughout. During active treatment there was an improvement in morning peak expiratory flow rate (PEFR), and a reduction in measurements of diurnal variation. In addition, the bronchodilator response to an inhaled beta 2-agonist was preserved. Bioavail theophylline has thus been shown to be an effective agent in the management of adults with nocturnal asthma.

Acute myocardial infarction caused by intravenous amphetamine abuse.

A man aged 27 years presented with an acute myocardial infarction after injecting himself intravenously with amphetamine. Soon after admission ventricular fibrillation developed. This was successfully cardioverted. Coronary arteriography was normal.

Effects of exercise on gas exchange in patients recovering from acute severe asthma.

The effect of exercise on gas exchange was studied in 17 patients (seven male and 10 female) recovering in hospital from acute severe asthma. On admission the patients (mean age 26 (SD 8) years) had a mean peak expiratory flow (PEF) of 26.8% (5.7%) predicted, a mean arterial oxygen tension (PaO2) of 8.63 (1.26) kPa, and a mean alveolar-arterial oxygen difference (A-aDO2) of 5.98 (1.34) kPa. Once resting symptoms had resolved (after 3.7 (1.6) days) patients performed a constant load exercise test (100 watts for men, 75 watts for women) on a bicycle ergometer for five minutes. PEF was measured before exercise and at five minute intervals for 30 minutes after exercise. Blood gas tensions were measured on capillary blood before, during, and 10 minutes after exercise. Treatment was not interrupted for this study. Mean PEF at rest was 87.6% (21.1%) predicted and showed no significant change after exercise. Mean PaO2 was 13.13 (1.37) kPa before exercise; it showed no significant change during exercise (13.93 (1.34) kPa) or 10 minutes after exercise (13.50 (2.15) kPa). Mean A-aDO2 also showed no change, being 1.82 (1.31) kPa before exercise, 1.79 (1.27) kPa during exercise, and 2.53 (0.93) kPa after exercise. It is concluded that moderate exercise carried out shortly after treatment for acute severe asthma is unlikely to result in worsening gas exchange during or after exercise if resting PEF, PaO2 and A-aDO2 have attained normal or near normal values.